Exploring the impacts of daytime sleepiness on gait, physical balance, and the occurrence of orofacial trauma: a narrative review

3.1. The possible effects of daytime sleepiness on balance and mobility

Daytime sleepiness has been consistently correlated with variables that directly influence gait and balance [10]. This study, published in 2017, showed a significant association between self-reported DS, a slower gait speed, and low balance confidence in community-dwelling older adults. Moreover, it stressed that subjective sleep assessment should be considered when evaluating balance and implementing interventions to improve balance in older adults. Therefore, it emphasized the need for further research to identify potential contributors to DS, such as insomnia or sleep apnea, and to examine the effect of treating these conditions on mobility. Furthermore, the study highlighted the importance of delving deeper into the complex interactions involving the central nervous system, medication use, balance, and mobility [10].

3.2. The possible impacts of sleep-disordered breathing on balance, gait, and risk of falls

This review study [11] investigated the relationship between obstructive sleep apnea (OSA) and balance, gait, and the risk of falls. It was reported that increasing rates of hospitalization [12] and fall-related injuries are a global concern, primarily due to the aging population and associated health problems that increase the risk of falls [11]. One of these health problems is OSA, a common disorder characterized by repeated obstruction or cessation of airflow during sleep. Additionally, some analyzed studies [11] mentioned that subjective sleep quality and the presence of OSA are associated with a higher risk of falls. Therefore, mechanistic studies are needed to understand how OSA can affect posture, balance, and gait, mainly due to nocturnal hypoxemia, a common consequence of OSA [11].

Furthermore, it was mentioned that although treating OSA with continuous positive airway pressure (CPAP) may improve gait, its impact on posture and balance remains uncertain. Moreover, the complexity of balance control was emphasized, involving various physiological systems such as vestibular, muscular, visual, and cognitive, all potentially affected by OSA. Additionally, it was mentioned that nocturnal hypoxic burden plays an essential role in this impact on posture and balance. Therefore, future large-scale randomized controlled trials are needed to determine the efficacy of OSA treatment in reducing the risk of falls [11].

The analyzed cohort and review studies examined the effects of DS and sleep-related breathing disorders, indicating a potential association with changes in motor coordination, balance, and increased risk of falls. However, despite these concerns, no direct link was found to establish the influence of these associations on the incidence of events such as orofacial fractures and, consequently, hospitalization and dental surgical interventions. This suggests a gap in the theme, highlighting the need for new studies to understand this relationship better. Additionally, this investigation may lead to the development of more effective preventive strategies, improving existing treatments and patients’ quality of life.

4.1. Analysis of the results in the light of the study objectives

This research highlighted the gaps in understanding the relationship between DS and gait/balance and the approach to potentially effective treatments for this population [4, 11]. The case studies and analyses presented illustrate how large-scale randomized controlled trials and investigations are critical to identifying and treating the underlying causes of DS and SDB, preventing its adverse consequences, and determining the efficacy of treatment, consequently promoting greater effectiveness of treatments [10, 11].

4.2. Implications and benefits of daytime sleepiness interventions for gait, balance, and fall prevention

Daytime sleepiness (DS) can impair motor coordination and reaction times [16], affecting the ability to walk steadily and maintain balance. According to Umemura et al. [17], sleep disturbances that generate daytime sleepiness may harm brain areas that could be responsible for the real-time adjustment of gait and sustained attention. This inability increases the risk of falls and compromises mobility and independence [17]. By addressing daytime sleepiness through interventions such as improving sleep hygiene [4, 18], treating sleep disorders, or implementing strategic nap schedules [18, 19], individuals may experience improvements in gait and balance, leading to a reduction in the risk of falls and related injuries [18]. Furthermore, recent research has shown that interventions targeting the root cause of DS, such as cognitive-behavioral therapy for insomnia [20] or personalized pharmacological [13, 21] treatments, have significantly improved balance and motor coordination.

Improved daytime sleepiness and its effects on gait and balance also directly affect fall prevention in seniors and other vulnerable populations [2, 4, 6, 9-11]. Falls are one of the leading causes of injury and hospitalization [10, 12] in the elderly and are often associated with severe consequences such as fractures and functional disability [10, 14]. The risk of fractures is related to the higher likelihood of falls in patients with DS-associated OSA [1, 11] and the adverse effects on motor coordination and balance. When a person is tired, their ability to perceive and react to dangerous situations is reduced, which can lead to falls [22, 23] and, consequently, an increased risk of bone fractures, especially in older people, whose bones tend to be more fragile due to the natural aging process. Studies, such as those conducted by Tyagi et al. [11], have shown that OSA [1, 11] and DS are associated with an increased risk of fall-related fractures, resulting from the difficulty in maintaining vigilance over the adverse effects on motor coordination and balance [17, 22, 23].

In this context, the implementation of targeted interventions can significantly reduce the risk of falls and promote the safety and autonomy of individuals, especially older people.

4.3. Interdisciplinary integration in the management of daytime sleepiness and sleep disorders

The interdisciplinary integration among public health, medicine, dentistry, and others yields significant benefits in treating and researching sleep disorders [2, 6, 10, 12, 14]. Studies, such as those by Lobbezoo et al. [15], indicate that dental sleep medicine traditionally focuses on sleep-related breathing disorders like snoring and obstructive sleep apnea. However, clinical practice reveals that dentistry intersects with other sleep disorders, including sleep-related orofacial pain, xerostomia, hypersalivation, gastroesophageal reflux disease, and bruxism. Recognizing this, a new definition encompassing all aspects of diagnosing and treating these conditions has been formulated for dental sleep medicine.

Moreover, while treatments offer benefits, it’s crucial to consider the challenges associated with DS and SDB-related pathologies and how they can impact treatments [10-13] and, consequently, patient improvement with existing therapeutic interventions. Exploring alternative therapeutic options, such as Integrative and Complementary Practices, may also be significant in treatment and become necessary for various associated pathologies.

In addition, this collaboration can drive innovation in health, such as the development of awareness programs on sleep hygiene, promoting healthy sleep habits from childhood to adulthood. Furthermore, the development of public health policies that promote early detection, as well as the formulation of evidence-based policies aiming to improve access to sleep-related health services and reduce disparities in care provision.

This interconnection among different fields has the potential to positively impact the health of the general population by promoting a culture of healthy sleep and improving healthcare systems as a whole.

4.4. Study limitations

Some limitations of this study merit consideration. Firstly, the methodology employed involved a narrative review of the literature, wherein the examples and case studies presented reflect the research available up to the analysis date without a formal assessment of the included studies' quality. Additionally, it's crucial to note that grey literature was not considered in this review, potentially overlooking valuable insights. Consequently, it’s plausible that recent advancements and applications may not have been addressed in this study.

Moreover, it's worth mentioning that only two articles were analyzed in this narrative review, which inherently restricts the breadth of conclusions drawn. Nevertheless, this caveat does not diminish the topic's significance or the importance of encouraging further research by other scholars.

4.5. Opportunities for research

Future research opportunities encompass longitudinal studies aimed at comprehending the intricate relationship between DS, gait/balance, falls, and associated pathologies, including the risk of trauma such as orofacial fractures. Moreover, investigations should extend to other age groups, mainly focusing on vulnerable populations such as older adults or individuals with underlying medical conditions. This necessitates a meticulous examination of preventive interventions to mitigate risks linked to traffic accidents, encompassing vehicle drivers [17], pedestrians in public areas, machine operators, and school children in both academic and domestic settings.

Given the correlation between DS, fatigue, and other factors compromising cognitive capacity, attention, and risk perception, such research endeavors are pivotal in advancing our understanding and formulating tailored preventive strategies. Furthermore, it's imperative to address the physical, psychosocial, and environmental dimensions, assessing the effectiveness of multidisciplinary interventions involving healthcare, education, and public safety professionals. Notably, the collaboration between health professionals, the community, and research centers, facilitated by their researchers, holds promise in providing valuable insights to enhance the prevention and management of these adverse events, thereby promoting individuals' health and quality of life.