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 Like Your Health Depends on It (Because It Does)

bedA recent article over at CNN offers a good reminder that running a sleep debt can have far greater effects than daytime sleepiness and general grouchiness.

It can mean more accidents due to weakened reflexes and an unfocused mind. It can mean weight gain. It can mean a higher risk of depression, anxiety, diabetes, heart disease – in general, a shorter, unhealthier life span.

Recent research has also supported the suspected link between Alzheimer’s and sleep loss. A study in Brain, for instance, found that when sleep is constantly interrupted – as in cases of obstructive sleep apnea (OSA) – more of the proteins suspected to cause Alzheimer’s build up in the brain. (Normal sleep helps clear them.)

What’s more, research in the Annals of the American Thoracic Society found that those who are genetically susceptible to Alzheimer’s appear to be at greater risk of the cognitive decline that OSA and other forms of sleep disordered breathing can contribute to.

Many don’t realize that dentists are in a unique position to help identify sleep breathing problems and even, in mild to moderate cases, offer solutions that can enhance both oral and systemic health. Many signs of OSA can show up in the mouth, from inflamed tonsils to scalloping along the tongue, from tooth wear from bruxing (grinding the teeth during sleep) to headaches and other TMJ symptoms. If exam findings suggest OSA, a sleep test may be recommended for diagnosis.

Dental options for treating apnea provide welcome alternatives to CPAP. Most often, dental treatment involves appliance therapy – comfortable devices that typically keep the airway open by gently pulling the lower jaw forward. On the whole, research suggests that oral appliance therapy (OAT) can be at least as effective as CPAP, yet much more comfortable and well-tolerated.

We may also recommend diet, activity, and other lifestyle changes to support improved sleep, as well as additional therapies such as acupuncture or chiropractic care. As ever, everything depends on the individual and the specific causes of their symptoms. After all, it’s causes we want to address.

While tending to symptoms can bring short term relief, only attention to causes can bring about good long-term results.

Many people don’t even realize the impacts a little lack of sleep can cause. We all know those who like to brag of only getting four to six hours of sleep a night, almost like it’s a competition. Yet according to a 2003 paper in Sleep, such folks are likely unaware of what they’re losing in the course of gaining those extra waking hours.

Since chronic restriction of sleep to 6 h or less per night produced cognitive performance deficits equivalent to up to 2 nights of total sleep deprivation, it appears that even relatively moderate sleep restriction can seriously impair waking neurobehavioral functions in healthy adults. Sleepiness ratings suggest that subjects were largely unaware of these increasing cognitive deficits, which may explain why the impact of chronic sleep restriction on waking cognitive functions is often assumed to be benign.

For the sake of your health, happiness, and those around you, it is worth a quick conversation with your dentist to identify warning signs or offer suggestions for improving your sleep. And if dental factors aren’t at the root of your running a sleep debt, here are some great tips from Harvard Medical School on getting a better night’s sleep.

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Do Crooked Teeth Predict Your Death?

It’s a headline built to make parents freak out:

Daily Mail headline

And as is usually the case, the reality behind the headline isn’t quite so sensational. Impressive, yes. Sensational? No.

The reality is new research out of the University of Washington School of Dentistry, which “suggests that an asymmetric lower face is a novel marker that also captures early life stresses that occur after birth.” Those early stresses can lay the foundation for ill health later in life.

[Study author Philippe] Hujoel, a professor in the UW School of Dentistry, described a crooked, or asymmetric, bite as the teeth biting backward or forward on one side of the face and normally on the other side. Backward-biting asymmetries, the most common lower-face asymmetry in the U.S. population, were found to fluctuate randomly between the left and right sides of the face. Such randomness is evidence for early life stress, he said.

Hujoel emphasized that crooked teeth, overbites and underbites are different than an asymmetric bite. Those conditions can be associated with asymmetric and symmetric bites, the latter of which is largely a reflection of genetics, not environmental stress, he said.

So, no, crooked teeth don’t predict early death in and of themselves. It’s the bite that’s telling – how the teeth come together. Even then, an asymmetric bite isn’t a death warrant, particularly if you take action to support your health and lower your risk of all manner of chronic diseases.

malocclusionThere’s also plenty you can do to correct bite problems, whether they’re the result of early environmental stresses or later ones. In fact, correcting issues with the bite can lead to overall health improvements.

Consider bruxing, for instance – habitual clenching and grinding, often during sleep. While commonly associated with stress, it can also be an unconscious way of coping with a bad bite or even a compromised airway. Bruxing, in turn, is associated with sleep apnea in both adults and children.

And sleep apnea is associated with a wide range of chronic health problems, including heart disease, diabetes, and stroke.

Interventions like oral appliance therapy and appliance-free DTR can do wonders for correcting bite-related problems. Lifestyle changes – especially in the area of diet and nutrition – can likewise be of help. The specific approach, the best approach, depends on your specific health situation and how it got that way.

For above all, and always, we want to treat the cause, not just help you mask or “manage” symptoms.

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Help for Sleep Apnea from Your Dentist? Yes!

sleep apnea diagramMost people with obstructive sleep apnea (OSA) probably don’t know it. In fact, it’s often a sleeping partner who first notices the common signs. After all, the snoring’s not keeping you awake.

But there’s another person who can tell you if you may have OSA: your dentist.

According to a study published last year in the Saudi Medical Journal, dentists have a unique advantage to hone in on the signs of sleep apnea. Because they see into patients mouths more often than physicians do, they have more opportunities to notice indications of airway obstruction – specifically, enlarged tonsils and scalloping along the sides of the tongue.

Other research has suggested even more dental signs of possible OSA, including worn teeth, morning headaches, gum problems, and TMJ pain.

Of the more than 18 million adults in the US affected by sleep apnea, those who are obese are 10 times more likely to report symptoms than their slender counterparts. According to the National Sleep Foundation, many of those 18 million go undiagnosed. Without diagnosis and treatment, the sleep apnea issues compound. OSA has been linked to heart disease, diabetes, depression, memory loss, and more.

Once sleep apnea is diagnosed through a sleep test, dentists can play a role in effective treatment, as well.

Whether you have a history of OSA and use a CPAP device or are searching for help with a recent diagnosis, you may be interested to learn about how less invasive oral appliance therapy can treat mild to moderate cases of sleep apnea. Appliance therapy tends to be more comfortable than CPAP, while also effective in keeping the airway open.

In fact, oral appliance therapy is now the recommended treatment of the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine for adults who are CPAP intolerant or prefer an alternative.

“This evidence-based guideline reinforces the fact that effective treatment options are available for obstructive sleep apnea, a chronic disease that afflicts at least 25 million adults in the U.S.,” said AASM President Dr. Nathaniel Watson. “Although CPAP therapy is still the first-line option for treating OSA, oral appliance therapy is an effective alternative that is preferred by some patients. Sleep medicine physicians and dentists can promote high quality, patient-centered care by working together to identify the optimal treatment for each patient who has sleep apnea.”

Most appliances work by supporting the lower jaw in a slightly forward position. This forward position keeps the tongue from dropping back toward the throat. Over time, this helps tone the tissues that line the throat. Wearing an appliance can sometimes double and even triple the size of the airway opening.

These appliances are not “one-size-fits-all” devices. There are dozens of options available. Only a dentist well-versed in breathing disorders such as OSA can help determine the best choice for your unique situation and help get you on the path to better sleep – and better overall health for the long haul.

An Irregular Bite Can Affect Your Posture and Balance

cranial motionIf you have gaps between your teeth, crowded teeth, tooth wear, or missing teeth, it may be more than just a cosmetic issue. These things can affect how your teeth come together when you close your mouth – your occlusion.

Malocclusion – a bad bite – has its consequences, too.

Two recent studies indicate that when your dental occlusion is off, your posture and balance may be, too. Instability in balance and postural control may leave you at risk of falls or other injuries.

For the first study, published in Motor Control, researchers monitored dental occlusion and stability in 25 participants. They found that it’s likely that sensory information linked to the dental occlusion for balance comes strongly into effect if unstable conditions, such as malocclusion, are present.

The second study, published in Neuroscience Letters, considered the type of dental occlusion, control of posture, and physical fatigue in 10 physically active participants to determine if a relationship existed among any of these factors. The authors concluded that malocclusions had a greater negative impact when subjects were fatigued. When corrected, balance improved.

In our day to day life most of us don’t notice or associate dental occlusion relationship with posture and balance. But these studies indicate it may be a factor not only in in athletic performance and injuries, but also in the prevention of injuries in the general population.

When an irregular bite decreases postural control, the risk of falls and injuries such as sprains, strains, and fractures is increased. Fatigue appears to just make things worse and further decrease motor system response.

Researchers point out that postural control is the result of a complex system that gathers sensory and motor information from visual, somatosensory, and vestibular (inner ear) input.

The set of organs and tissues that allow us to eat, talk, chew, swallow, and smile – the stomatognathic system – and its effect on posture control has been the subject of increasing scientific interest. Specifically, research continues to explore the reciprocal influence between the trigeminal nerve and the vestibular nucleus that allow us to chew and control the muscles involved in the chewing function and of the neck.

While the studies stop short of saying correcting an irregular bite will improve balance and posture, we do know if you are experiencing head, neck, jaw pain, or postural issues, malocclusion is a likely component. But that doesn’t necessarily mean orthodontics are necessarily the answer.

In many instances, dental appliance therapy may offer the least invasive technique to correct postural and muscle irregularities that may be contributing to discomfort.

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Is Snoring Keeping You Awake?

insomniaIf you snore – or live with someone who does – it can be more than just irritating. If it’s associated with sleep apnea, it can put you at risk for some serious health problems

Sleep apnea is a condition that causes you to periodically stop breathing. Each pause can last 10 seconds or more, and in severe cases, these episodes can happen more than 30 times an hour. This can be frightening and fatiguing. More, it deprives your body of an essential nutrient: oxygen.

Fortunately, there are things you can do about it – including, new research suggests, exercise.

This review of the science, published online last month in Respiratory Medicine, analyzed data from eight sleep apnea studies that used exercise as a measure. Subjects – 180 in all, most in their 40s, all diagnosed with obstructive sleep apnea – were split between those who exercised, from two to seven days, and those who did not.

According to WaPo,

The studies lasted from two to six months. Among people who exercised, sleep apnea symptoms improved. It became less severe, according to a standardized scale based on the frequency of their breathing interruptions, and the participants reported better sleep overall and less daytime drowsiness. Improvements were similar regardless of the type of exercise people did and were determined to be independent of any weight loss.

Your Dentist Can Help

Improvement of symptoms is one thing, but you still may need additional support to help you get the best of sleep apnea – so it doesn’t get the best of you. And the clunky facial mask of CPAP is hardly your only option.

Oral Appliance Therapy can be a big help – and far more comfortable than CPAP. The best appliances are all designed to hold the lower jaw forward just a bit, enabling an open, unrestricted airway.

They also work to keep the tongue from falling back into a fleshy pile. This structural support helps create more tone in the tissues lining the throat.

If you suspect you, or someone you love may have obstructive sleep apnea, reliable home tests are available. And testing is worth your while. The American Academy of Sleep Medicine holds that as many as 80% to 90% of us with sleep apnea are still undiagnosed.

The benefits of finding the right treatment, and exercise to your routine can be dramatic. With deeper levels of sleep, many people experience lasting health benefits, including

  • Lower blood pressure.
  • Weight loss.
  • Improved insulin sensitivity.
  • Improved productivity.
  • Improved cognitive skills.
  • Reduced risk of depression.
  • Reduced medical expenses.
  • Increased energy and vitality.

But more than that, better sleep might just save your life – or the life of someone you love.

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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