Sleep Apnea Could Really Be Stressing You Out!

raised hand saying "need sleep"Inhale, then exhale, but don’t inhale right away. Count out 10 seconds until your next breath.

Take that breath. How do you feel?

Relieved, probably. Maybe you even noticed the tension releasing from your whole body as you inhaled again.

Now imagine experiencing that over and again through your night’s sleep. That’s a bit of what obstructive sleep apnea (OSA) is like. Not getting the oxygen it needs to survive, the body perceives a threat and reacts accordingly. You wake with a gasp, taking in as much air as you can.

Then you go back to sleep only to wake once the airway is again blocked – by excess tissue around the top of the windpipe, for instance, or the tongue or lower jaw slipping backwards.

New research in the Journal of Clinical Endocrinology & Metabolism shows just what an impact this has on the body as it sleeps.

Now, most studies on OSA collect data during the day, when patients are awake. But

“This is one of the first studies to show real-time effects of sleep apnea on metabolism during the night,” says Jonathan Jun, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine and the paper’s senior author.

Jun and his team collected a range of metabolic data from patients while they slept both with and without CPAP – the usual treatment for OSA symptoms, which uses continuous positive airway pressure to keep the airway open. They measured free fatty acids in the blood, glucose, insulin, and the stress hormone cortisol. They measured brain waves, blood oxygen levels, heart rates, and eye and leg movements.

Jun and colleagues found that CPAP withdrawal caused recurrence of OSA associated with sleep disruption, elevated heart rate and reduced blood oxygen. CPAP withdrawal also increased levels of free fatty acids, glucose, cortisol and blood pressure during sleep. The more severe the OSA, the more these parameters increased. In addition, glucose increased the most in patients with diabetes. Increases in fatty acids, glucose and cortisol have all been linked to diabetes. The Johns Hopkins team also found that blood pressure increased and the arteries showed signs of stiffness in the morning without CPAP. Over time, increased blood pressure and vascular stiffness can contribute to cardiovascular disease.

That’s the very picture of a body under stress. It also suggests that OSA may be more than just a manifestation of obesity and related health issues. It may actually aggravate them.

CPAP is hardly the only solution, though – and it’s a good thing, too. Many people find reasons to quit it. Compliance rates are notoriously low. But there are other effective options for dealing with mild to moderate sleep apnea – from lifestyle changes to oral appliance therapy.

In fact, according to the most recent American College of Physicians guidelines for managing sleep apnea, the first recommendation is to encourage overweight and obese OSA patients to lose weight. Other research suggests that exercise can likewise have a big impact on at least some OSA symptoms.

And these, of course, can be pursued in tandem with oral appliance therapy, in which custom appliances are used to keep the tongue from blocking the airway or gently repositioning the lower jaw to keep the airway free and clear.

One 2016 study found that airflow may be greatly improved by appliance therapy.

Our findings suggest that oral appliance therapy not only improves the upper airway collapsibility but also improves the upper airway compensatory effectiveness. Thus, oral appliances appear to unload the upper airway, thereby enabling patients to exhibit more effective compensatory dilator muscle responses for improved airflow.

OSA is much more common today than just a couple decades ago. According to one study, between 1993 and 2010, OSA diagnoses jumped 14.6-fold! But many more treatment options and tools have been developed during that same period – and continue to be developed – offering options beyond CPAP.

And you just might find some of those options in your dentist’s office.

Image by Dmitry Kugarov

Sleep Apnea Solutions

As we mentioned before, more than 18 million Americans are believed to suffer from obstructive sleep apnea (OSA), a disorder in which breathing is interrupted during sleep.

OSA can lead to insomnia and irregular sleep patterns, teeth grinding (bruxism), chronic allergies, earaches, acid reflux and hypertension. And it’s more than just a nuisance. It can be life-threatening. After all, when the upper airway is blocked, oxygen can’t get to the brain! This, in turn, affects other parts of your body – both organs and muscles (and your heart is one big muscle). It has been linked with conditions such as heart attack and stroke.

Clearly, doing nothing about it is NOT a great option.

cpapOne of the most common treatments for it is the use of a CPAP machine, where CPAP stands for “continuous positive airway pressure.” It consists of three parts: a mask to cover your mouth and nose, a tube to connect the mask to the machine, and a machine which creates air to blow into the patient’s airway.

Suffice it to say, CPAP has its drawbacks, which contribute to notoriously low compliance rates with the therapy. Some patients complain that the machine is cumbersome or makes them feel claustrophobic. Some complain of stuffy noses, dry mouth and skin irritation.

And a new case report, published in the journal Bipolar Disorders, suggests that it may trigger manic symptoms in those diagnosed with that condition. The extreme euphoria associated with bipolar disorders – the total opposite of the extreme depression on the other end of the pole – brings behavioral changes, such as talking too fast and erratically, shopping excessively and uncontrollably and acting impulsively. It’s not hard to see how this could easily mess with one’s ability to perform basic day-to-day tasks.

While more research on this potential side effect of CPAP, the authors of the case report caution that

Clinicians need to monitor patients with bipolar disorder closely for worsening of manic symptoms when they are started on CPAP for underlying OSA.

Of course, there are alternatives for dealing with OSA. In fact, new guidelines from the American College of Physicians indicate that weight loss should be the first treatment where obstructive sleep apnea is suspected.

“Not everyone with sleep apnea is overweight, but most patients are,” [Dr. Molly] Cooke says. Losing weight gets rid of fat that blocks the windpipe. It would “not only fix your sleep trouble, it would help your cholesterol, it would help your knees, your clothes would fit better and you would be a happier person,” she says.

Patients who still have symptoms at that point might need to go to a sleep clinic and do an overnight test for apnea.

For people who are diagnosed by a sleep clinic, the No. 2 treatment of choice is CPAP, or continuous positive airway pressure.

At least when it comes to conventional medicine. Many consider oral appliance therapy (OAT) to be the frontline treatment at least for mild to moderate OSA – or for those who cannot use CPAP for whatever reason. (At least one study has shown that it may be “effective in controlling…more severe forms of OSA.) These custom-fit devices “reposition the lower jaw, tongue, soft palate, and uvula,” and strengthen the tongue, keeping it from falling back when relaxed, obstructing the airway.

Another alternative is myofunctional therapy, which involves exercises to retrain the muscles of the face and oral cavity, restoring them to proper function. Research continues to support the usefulness in dealing with sleep apnea and a host of other issues. Both the International Association of Orofacial Myology and the Academy of Orofacial Myofunctional Therapy provide online directories of therapists worldwide.

Dietary changes can also prove helpful.

For more on how the dentists here at Pride Dental can help, visit our sleep apnea page – or contact us today.

Image by Brandon, via Flickr

Another Match Not Made in Heaven: TMD & Sleep Apnea

Of course, depression isn’t the only problem that can occur simultaneously with TMJ disorders (TMD), as another recent study reminds us.

The aim of the study – published earlier this month in the Journal of Dental Research – was to test for an association between obstructive sleep apnea (OSA) and TMD. Analyzing data from a large, ongoing study of orofacial pain (OPPERA, or Orofacial Pain: Prospective Evaluation and Risk Assessment Study), the authors found that “a significant association of OSA symptoms and TMD, with prospective cohort evidence finding that OSA symptoms preceded first-onset TMD.”

In other words, yes, OSA and TMD often occur together, with sleep apnea symptoms showing up before any TMJ issues become apparent.

Osa_cycleObstructive sleep apnea is the most common form of the disorder, in which the airway becomes blocked during sleep, disrupting normal breathing. According to the National Sleep Foundation, more than 18 million Americans have the condition. Most who do probably don’t know it. (A survey conducted in the Netherlands found that 4 out of 5 people who have sleep apnea are unaware that they do.)

And what blocks the airway? The tongue, the tissues lining the airway and muscles around the airway all relax during sleep. If they fall back and block the airway, the attempt to keep breathing creates the sound of snoring. Obese people are more at risk than others (more surrounding tissue), as are older people (loss of muscle tone).

But while snoring can be an obvious sign of OSA, not all with the condition snore. Here are some of the other signs of disrupted breathing during sleep:

  • Choking or gasping during sleep
  • Waking up tired
  • Waking suddenly
  • Morning headaches
  • Fatigue and sleepiness through the day
  • Decreased productivity
  • High blood pressure

OSA can lead to insomnia and irregular sleep patterns, teeth grinding (bruxism), chronic allergies, earaches, acid reflux and hypertension. And it’s more than just a nuisance. It can be life-threatening. After all, when the upper airway is blocked, oxygen can’t get to the brain! This, in turn, affects other parts of your body – both organs and muscles (and your heart is one big muscle). It has been linked with conditions such as heart attack and stroke.

Clearly, doing nothing about it is NOT a great option.

But great options are available, including alternatives to CPAP, the commonly prescribed remedy that involves wearing a mask that blows air into the upper airway. The device works well, but many find it cumbersome and uncomfortable, and stop using it after a time.

When OSA is mild to moderate, oral appliance therapy may be used instead. In our office, in fact, it’s the first line of treatment in such cases. These custom appliances help hold the jaw low enough so that the upper airway is kept clear and oxygen can flow to the brain easier. There are “invisible” daytime appliances, as well, which help the tongue to rest as it should against the palate.

There are other things you can do, as well, to get the better of OSA, such as avoiding alcohol, quitting smoking (as if you needed one more reason to quit, right?), sleeping on your side and losing weight. In fact, the National Sleep Foundation considers weight loss the most important thing you can do in treating OSA.

And, of course, the healthy eating that brings about real and lasting weight loss should give your oral and overall health a boost, as well! (For more on fad diets vs. lifestyle change, read this excellent post over at The Healthy Omnivore.)

Learn more about sleep apnea and how we can help you sleep and breathe better