Special Article 2, Issue 13.3
Questionnaire-Based Outcomes in Patients with Sleep Disorders
http://dx.doi.org/10.15331/jdsm.7462Michael Simmons, DMD, MScMed, MPH, MSc, FAASM, FAAOP
Disclaimer: The use, mention or depiction of any product, device, service or appliance shall not be interpreted as an endorsement, recommendation or preference by the AADSM. Any opinion expressed is solely the opinion of the individual, and not that of the AADSM.
INTRODUCTION
If the AHI has lost credibility and burden based measures of sleep have not come of age, how do dentists measure success with any interventions they provide for their patients in sleep healthcare?
As dentists practicing in the sleep medicine field, we often see patients carrying a diagnosis of obstructive sleep apnea (OSA), elevated apnea-hypopnea index (AHI), decreased oxygen saturations, or intolerance to positive airway pressure (PAP) therapy. Of course, these findings are often not the true starting point of the patient’s sleep health journey. Increasingly, patients also arrive after self-screening with over-the-counter sleep technologies, wearable sleep trackers, smartphone applications, or direct-to-consumer home sleep apnea testing devices. Some self-testing patients present with anxiety generated by nightly sleep scores, oxygen saturation recordings, or perceived sleep inefficiency despite limited clinical correlation. We may have witnessed a phenomenon increasingly described as “orthosomnia1” a term stemming from the Greek word orthos (á½ρθÏς), meaning straight, correct, proper, or upright, and the Latin word somnus, meaning sleep.
More commonly, patients seek help because of symptoms they associate with or surrounding “poor”, “terrible” or “horrible” sleep. Common complaints are sleepiness/fatigue; delayed/ unrestful/ interrupted/ insufficient sleep; waking symptoms such as headaches/impaired concentration/poor mood; interrupted breathing/snoring/excessive movement identified by nearby sleepers; diminished quality of life or concerns regarding long-term health consequences of poor sleep.
Validated sleep questionnaires provide an important bridge between objective sleep testing and the patient’s lived experience. Importantly, no single questionnaire captures the entire sleep experience, none are foolproof, and each requires time to complete and analyze. In the recent past a few sleep questionnaires have been developed and the AASM just released a new subjective measure of sleep (PLATO-11) that reportedly took over 5 years to validate but is now ready for application in clinical studies and clinical practice. Table 1 summarizes some well-validated and emerging questionnaires of the many that are available.2 Determining which sleep related questionnaire(s) to use may depend on who you are trying to help and what their chief complaints are.
Clinical Utility and Limitations of Some Sleep Questionnaires for Consideration by Dentists Working in the Field of Sleep Medicine
PLATO-11
Patient-reported Longitudinal Assessment Tool for OSA is a recently developed patient-reported outcome measure designed to assess treatment response in adults with obstructive sleep apnea (OSA). Historically, clinicians have relied heavily upon physiologic metrics such as AHI, ODI, and T<90, along with symptom scales such as the Epworth Sleepiness Scale (ESS) and Insomnia Severity Index (ISI). PLATO potentially expands this framework by attempting to longitudinally assess broader aspects of patient experience, symptom burden, treatment response, and sleep-related quality of life. Although the ultimate clinical utility and long-term adoption of PLATO remain to be established, its development reflects an important conceptual shift toward multidimensional and patient-centered outcome assessment. Unlike screening instruments that identify OSA risk, PLATO-11 evaluates changes in symptoms, sleep quality, daytime functioning, and treatment effectiveness over time. For dentistry, PLATO-11 is particularly relevant because it was designed to assess outcomes across OSA therapies, including oral appliance therapy. Dental sleep medicine providers can use PLATO-11 to quantify patient-perceived benefits and monitor longitudinal treatment success beyond traditional metrics such as the (AHI).
Limitations
PLATO-11 is an outcome measure rather than a screening or diagnostic instrument and cannot establish the presence or severity of OSA. As a relatively new instrument, long-term validation across diverse populations and treatment modalities remains limited.
APSQ
Anxiety and Preoccupation about Sleep Questionnaire evaluates sleep-related worry, anxiety, and excessive cognitive preoccupation with sleep. Originally developed within the insomnia literature, the instrument quantifies concerns regarding the consequences of poor sleep as well as fears and perceived loss of control over one's ability to sleep. More recently, the APSQ has gained attention as a potential screening tool for orthosomnia, a condition characterized by excessive concern about achieving perfect sleep and unhealthy preoccupation with sleep-tracking data. In dental sleep medicine, the APSQ may be particularly useful when patients continue to report poor sleep quality, dissatisfaction with treatment outcomes, or persistent sleep concerns despite apparently successful management of OSA. The questionnaire may help identify individuals whose residual symptoms are driven more by sleep-related anxiety and cognitive hypervigilance than by ongoing sleep-disordered breathing.
Limitations
APSQ scores reflect subjective sleep-related anxiety rather than objective sleep physiology. Elevated scores may be influenced by generalized anxiety, depression, chronic pain, health-related worry, perfectionistic personality traits, or other psychological factors. Although recent literature suggests potential utility for identifying orthosomnia, the construct remains relatively new, and additional validation studies across diverse populations and cultural settings are needed before APSQ can be considered a definitive orthosomnia screening instrument. Furthermore, the current evidence base is derived from a limited number of psychometric studies. Orthosomnia is an emerging sleep-health construct characterized by excessive preoccupation with achieving optimal sleep, often driven by consumer sleep-tracking technologies. Although increasingly discussed in the sleep medicine literature, orthosomnia is not currently recognized as a distinct diagnosis in either DSM-5-TR or ICSD-3-TR. Current evidence suggests substantial overlap with insomnia-related cognitive hyperarousal, sleep-related anxiety, and maladaptive sleep beliefs.STAB
Standardized Tool for the Assessment of Bruxism is a comprehensive consensus-based framework developed to standardize the assessment of both sleep and awake bruxism using Axis A for evaluating bruxism status and consequences and Axis B for bruxism risk, etiologic factors and comorbid conditions. Unlike traditional single-question bruxism surveys, STAB evaluates behaviors, risk factors, psychosocial contributors, consequences, and comorbidities associated with bruxism. The instrument is highly relevant to dentistry because bruxism is strongly associated with tooth wear, restorative complications, temporomandibular disorders (TMD), muscle pain, implant complications, and sleep disturbances. STAB provides a modern framework for evaluating bruxism within clinical practice and research involving orofacial pain and dental sleep medicine populations.
Limitations
STAB is an evolving comprehensive assessment framework rather than a simple screening tool and may be too lengthy for routine clinical practice. While STAB is one of the most important recent developments in bruxism research, it is also one of the newest comprehensive questionnaires, and its clinical adoption is still in the early stages. Unlike the ESS, ISI, STOP-Bang or PSQI, there are not yet dozens of independent validation studies or large outcome studies.RU-SATED
Regularity, Satisfaction, Alertness, Timing, Efficiency, Duration is a brief multidimensional measure of overall sleep health that evaluates six core domains of healthy sleep rather than focusing on a specific sleep disorder. The instrument assesses sleep regularity, subjective satisfaction, daytime alertness, timing, efficiency, and duration. In dentistry, RU-SATED offers a broader perspective on sleep health that may help identify patients whose oral health, pain experience, or treatment outcomes are influenced by poor sleep habits. This is particularly relevant in patients with TMD, chronic pain, bruxism, or sleep-disordered breathing.
Limitations
RU-SATED measures overall sleep health rather than specific sleep disorders and may not identify the underlying cause of poor sleep. It should be supplemented by disorder-specific instruments when clinical sleep pathology is suspected.
PROMIS-SD
Patient-Reported Outcomes Measurement Information System is an NIH-funded initiative established in 2004 to develop standardized, psychometrically robust patient-reported outcome measures across multiple health domains. The “SD = Sleep Disturbance” measurement evaluates subjective perceptions of sleep quality, sleep depth, and sleep-related concerns. The questionnaire provides standardized scoring that allows comparisons across diverse patient populations. In dental research, PROMIS-SD may be useful for evaluating sleep-related symptoms in patients with TMD, chronic orofacial pain, and sleep-disordered breathing. Its integration within the broader PROMIS framework also facilitates comparison with other patient-reported outcomes such as pain, fatigue, anxiety, and depression. There are other PROMIS questionnaires developed in an NIH-funded measurement system that contains more than 300 item banks, short forms, and profile measures spanning physical, mental, and social health domains. The PROMIS system includes Sleep-Related Impairment (SRI) measures as well as pediatric versions of both Sleep Disturbance and Sleep-Related Impairment.
Limitations
PROMIS-SD assesses subjective sleep disturbance but does not identify specific sleep disorders such as OSA, insomnia, or circadian rhythm disorders. Scores may also be influenced by comorbid pain, mood disorders, and psychosocial stressors.
FOSQ-10
Functional Outcomes of Sleep Questionnaire is a shortened version of the Functional Outcomes of Sleep Questionnaire and assesses the impact of sleep disorders on daily functioning. Domains include activity level, vigilance, social interactions, productivity, and intimate relationships. For dental sleep medicine, FOSQ-10 is particularly valuable because it measures whether treatments such as oral appliance therapy improve a patient's ability to function during daily activities. It therefore provides clinically meaningful information that complements physiologic measures of OSA severity.
Limitations
FOSQ-10 measures the functional consequences of sleep disorders rather than the disorders themselves. It may show improvement despite persistent physiologic abnormalities or, conversely, remain impaired because of non-sleep-related medical conditions.
STOP-Bang
Snoring, Tiredness, Observed Apnea, Blood Pressure, BMI, Age, Neck Circumference, Gender is one of the most widely used screening tools for identifying individuals at risk for obstructive sleep apnea. STOP-Bang evolved from the original STOP questionnaire through the addition of anthropometric risk factors and both questionnaires were developed in Anesthesiology to address perioperative risk assessment. In dentistry, STOP-Bang is commonly used during routine examinations or prior to oral appliance therapy referrals to identify patients who may require formal sleep evaluation. Its ease of administration makes it an effective chairside screening tool in dental practices.
Limitations
The STOP-Bang is highly sensitive but has relatively low specificity, leading to a substantial number of false-positive screenings. It is intended for risk stratification and cannot diagnose OSA without confirmatory sleep testing.
ISI
Insomnia Severity Index evaluates the nature, severity, and impact of insomnia symptoms, including difficulties initiating sleep, maintaining sleep, and dissatisfaction with sleep. The questionnaire also measures the perceived impact of insomnia on daily functioning and quality of life. In dentistry, insomnia is increasingly recognized as a significant contributor to chronic orofacial pain, TMD, and central sensitization. The ISI may therefore help clinicians identify sleep-related contributors to pain amplification and treatment resistance.
Limitations
The ISI relies entirely on patient self-report and does not distinguish between primary insomnia and insomnia secondary to other medical, psychiatric, or sleep disorders. Objective sleep measures may be needed when diagnostic uncertainty exists.
ESS
The Epworth Sleepiness Scale measures subjective daytime sleepiness by asking patients to rate their likelihood of falling asleep in common daily situations. It is among the most widely used sleep questionnaires in clinical medicine, and some insurers may require minimum ESS score thresholds for reimbursement of certain sleep-related diagnostic tests or therapies. For dental sleep medicine practitioners, the ESS provides a simple method for assessing one of the hallmark symptoms of untreated OSA and monitoring improvements following oral appliance therapy. Persistent sleepiness despite treatment may also indicate inadequate therapy or coexisting sleep disorders.
Limitations
The questionnaire is not good for OSA screening as most subjects with OSA do not endorse sleepiness. The ESS may underestimate sleepiness in patients who do not routinely engage in the situations listed in the questionnaire, such as riding in a car, sitting quietly after lunch, or watching television. Patients with hyperarousal insomnia, highly motivated individuals, or patients who normalize chronic fatigue may also report falsely low scores despite significant sleep-disordered breathing. There are other less used subjective sleepiness scales with better applications in research such as the Stanford Sleepiness Scale. ESS measures subjective sleepiness and may not correlate with objective measures of sleepiness such as the Multiple Sleep Latency Test. Some patients with severe OSA report low ESS scores, while others report high scores for reasons unrelated to sleep-disordered breathing.
PSQI
Pittsburgh Sleep Quality Index is one of the most extensively validated measures of global sleep quality. It evaluates multiple domains including sleep duration, latency, efficiency, disturbances, medication use, and daytime dysfunction. In dentistry, PSQI is frequently used in studies involving TMD, chronic pain, bruxism, and sleep-disordered breathing because poor sleep quality is strongly associated with increased pain sensitivity and impaired treatment outcomes. The questionnaire provides a comprehensive overview of a patient's sleep experience over the preceding month.
Limitations
The PSQI provides a broad assessment of sleep quality but does not identify specific sleep disorders. Its retrospective one-month recall period may introduce recall bias and may not accurately capture short-term changes in sleep patterns.
FSS
The Fatigue Severity Scale (FSS) assesses the impact of fatigue on physical, social, and occupational functioning. Unlike excessive daytime sleepiness, which reflects an increased propensity to fall asleep, fatigue is characterized by persistent physical or mental exhaustion, reduced energy, and diminished capacity for activity that may occur despite apparently adequate sleep duration. In dentistry, fatigue is commonly reported by patients with chronic orofacial pain, temporomandibular disorders (TMD), fibromyalgia, autoimmune disorders, and untreated sleep-disordered breathing. Because many patients presenting to dental sleep medicine practices identify fatigue rather than sleepiness as their primary complaint, the FSS may provide a more clinically relevant measure of symptom burden and treatment response. Although effective treatment of sleep-disordered breathing often improves excessive daytime sleepiness, fatigue may improve less completely because it is influenced by multiple coexisting medical, psychological, and chronic pain conditions that may warrant additional investigation.
Limitations
The FSS measures fatigue rather than sleepiness and may be influenced by numerous medical, psychiatric, and pain-related conditions. Elevated scores do not necessarily indicate the presence of a sleep disorder.
MEQ
Morningness-Eveningness Questionnaire evaluates an individual's circadian preference, often referred to as chronotype. It classifies individuals along a spectrum ranging from "morning types" to "evening types." Circadian preference influences sleep timing, alertness, performance, and health behaviors. In dentistry, chronotype may affect patient adherence to oral appliance therapy, sleep hygiene recommendations, and pain perception. Emerging research also suggests that circadian factors may influence TMD symptoms, bruxism patterns, and responses to treatment, making the MEQ increasingly relevant in sleep and pain research.
Limitations
The MEQ assesses circadian preference rather than actual sleep behavior or sleep pathology. Chronotype classifications may also be influenced by age, occupational demands, and social schedules, which can obscure underlying biologic circadian tendencies.
Figure 1
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Table 1, part 1
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Table 1, part 2
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Table 2
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SUMMARY
The progression of questionnaire development over the past five decades demonstrates a paradigm shift from measuring sleep timing, quality, and daytime symptoms toward comprehensive assessment of sleep health, treatment effectiveness, behavioral phenotypes, and technology-related influences on sleep. This evolution parallels the expanding role of dentistry in sleep medicine, particularly in the assessment of bruxism, oral appliance therapy outcomes, and patient-centered measures of sleep-related quality of life. Each era reflects a distinct conceptual focus and a different underlying clinical question (Table 2).
CONCLUSION
Sleep medicine care by dentists is evolving beyond a purely airway-centered discipline toward a broader patient-centered model of care. Patients may present with an elevated AHI, PAP intolerance, or concerning wearable-generated sleep metrics, yet the underlying reason they initially sought care often relates to poor sleep and related symptoms, reduced quality of life or concern about future health risks such as dementia. Historically, much of the therapeutic literature in obstructive sleep apnea has emphasized physiologic outcomes and long-term health risks, including cardiovascular and all-cause mortality, while patient-centered outcomes have received comparatively less attention.
In this context, sleep health questionnaires provide an important complement to physiologic measures. Metrics such as AHI, oxygen desaturation, arousal frequency, or device-generated sleep scores do not always correspond closely with the patient’s lived experience of sleep. Patient-reported instruments (validated questionnaires) help characterize sleep quality, satisfaction, insomnia symptoms, fatigue, daytime function, treatment burden, and quality of life, while also supporting longitudinal assessment of treatment response. Their increasing use reflects the recognition that sleep health is multidimensional and that successful care should be judged not only by improved objective indices, but also by subjective outcomes that matter to patients.
CITATION
Simmons, M. Questionnaire Based Outcomes for Sleep Disordered Patients. J Dent Sleep Med. 2026;13(3).
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