**6. Assessment of sleep-pain interaction**

While diagnostic aspects and evaluation of pain were discussed along this chapter and assessment of sleep was also detailed elsewhere in this book, it is important to consider some important diagnostic tools for an adequate assessment of the sleep-pain patient, such as self-reported questionnaires and polysomnography.

#### **6.1 Self-reported measurements**

An optimal use of self-report measures depends on the clinician's degree of expertise and on the specific goal. There are several screening, diagnostic, and follow up tools which can be used to properly evaluate and manage patients with sleep-pain interaction conditions.

Sleep evaluation involves several dimensions and patterns which should be differently assessed according to the main complaint and prior clinical suspicion. A sleep diary is the gold standard for subjective sleep assessment and is always a simple good way to start understanding better the usual sleep pattern of the patient. There is a consensus sleep diary (CSD) [61] that resulted for the collaborative work of both insomnia experts and potential users. This instrument is unique regarding the important related methodological issues that allow to evaluate insomnia in the research field and practical arena.

Other self-reported instruments commonly used are the Pittsburgh sleep quality index [62], to evaluate sleep quality, the Epworth Sleepiness Scale [63] to evaluate sleepiness which could be intended as an indirect measure of inadequate sleep, the Sleep Questionnaire to characterize sleep depth, and dreams and a the Sleep Disturbance Questionnaire to assess mental anxiety and physical tension. The Global Sleep Assessment Questionnaire (GSAQ ) probably represents the best available screening tool for primary care practice. The chronotype as it could impact the sleep timing and the vulnerabilities for some pain sleep-wake cycle related impairments can be measured by the Morning-Evening Questionnaire [64], while states of sleepiness may be addressed by using the Stanford Sleepiness Scale [65] or the Karolinska Sleepiness Scale [66]. Visual analog scales oriented to sleep quality, sleepiness, or any other qualitative-measured dimension of sleep can also be used

**97**

*Sleep and Orofacial Pain: Physiological Interactions and Clinical Management*

[68] for sleep apnea and the Insomnia Severity Index [69], for insomnia.

suspicion for OSA remains, a second PSG should be considered [70].

**7. Treatment of sleep-pain interaction**

symptom relief is associated to a better quality of life.

disturbances should be objectives to pursue.

pharmacological characteristics).

**7.1 Nonpharmacological interventions**

first option approach to both conditions.

ness, and anxiety.

and could provide important insights on the patient's status. For screening of specific high prevalent sleep disorders like sleep apnea or insomnia, there are available simple validated questionnaires as the Berlin Questionnaire [67] or the Stop-Bang

Polysomnography is the gold standard for sleep evaluation if movement disorders during sleep or parasomnias are suspected. In the case of disorders of central hypersomnolence, a Multiple Sleep Latency Test should be made after a PSG night in order to properly diagnose. Although PSG remains the gold option also to diagnose sleep disordered breathing, several simplified sleep studies are accepted and available. The American Academy of Sleep Medicine however recommends that PSG or home sleep apnea testing be used for diagnosis of uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. Important to note is that if a single home testing for sleep apnea is negative, inconclusive, or technically inadequate, PSG should always be performed for diagnosis in OSA. Furthermore, if a first PSG is negative and clinical

The orofacial pain diagnosis is clinical, but sleep studies may contribute to the

Differential diagnosis could be difficult because of the occurrence of multiple sleep disturbances, which may mimic some aspects of pathological interaction between sleep and pain, either clinically or in a laboratory-based evaluation.

In patients with acute conditions, the efforts should be directed to the improvement of nocturnal complaints in order to avoid chronicity. In chronic patients,

Whenever possible, identifying the primary disturbance allows an approach directed to the etiological factors and sleep hygiene as well as management of sleep

Pharmacological management not only should always attend to the possible interaction with pain- and sleep-related mechanisms, but also to the influences of circadian oscillations in the symptoms and in the treatment effect (chrono-

Although medications have been widely used for managing both pain and insomnia, such drugs are not free from adverse effects which many times may actually worsen one or both conditions or even be responsible for therapeutic withdrawal symptoms. Cognitive behavioral therapy is largely used for insomnia (CBT-I) and for pain (CBT-P) related conditions and is recognized as an effective

objective establishment of orofacial pain interference with disturbed sleep. The patient's evaluation should include the identification of risk factors as higher levels of anxiety, alcohol consumption habits, use of long-term medication, sedentarism, stress, and a compromise in the quality of life. Patients commonly complain from non-restless sleep and higher levels of fatigue, headaches, sleepi-

*DOI: http://dx.doi.org/10.5772/intechopen.86770*

**6.2 Objective assessment**

and could provide important insights on the patient's status. For screening of specific high prevalent sleep disorders like sleep apnea or insomnia, there are available simple validated questionnaires as the Berlin Questionnaire [67] or the Stop-Bang [68] for sleep apnea and the Insomnia Severity Index [69], for insomnia.
