Screening for Sleep Apnea – Helpful or Not?

nodding offThere’s a new report on sleep apnea in JAMA, and it has us a little…well, restless. We think it may send the wrong message and prevent people from getting the help they need to get a good night’s sleep.

The report sought to find if screening for obstructive sleep disorder (OSD) or obstructive sleep apnea (OSA) is effective. All in all, it said, there’s not enough evidence to suggest that it is.

“There is uncertainty about the accuracy or clinical utility of all potential screening tools,” wrote the group led by Daniel Jonas, MD, MPH, an associate professor of medicine at the University of North Carolina at Chapel Hill.

It’s estimated that over 18 million people have some form of obstructed sleep disorder, many of whom go undiagnosed. OSA itself has been linked to a number of serious health conditions, including heart disease, type 2 diabetes, and stroke. Hence, the recommendation that dentists and doctors screen their patients.

The current study reviewed 110 studies with more than 46,000 patients. The goal was threefold:

  1. To evaluate primary care-relevant evidence on screening adults for OSA.
  2. To evaluate test accuracy and treatment.
  3. To inform the U.S. Preventive Services Task Force.

While they found that multiple treatments for OSA were able to reduce AHI, Epworth Sleepiness Scale scores and blood pressure, they couldn’t establish if these reduced mortality or improved other health outcomes. But they did find evidence of a modest improvement in sleep-related quality of life.

Results based on insufficient evidence concern Susan Redline, MD, MPH, who noted in an editorial in the same issue of JAMA,

While the USPSTF found insufficient evidence on screening for OSA in asymptomatic adults, high priority should be given to additional studies that generate rigorous evidence that will serve to improve the recognition and treatment of OSA in the population and reduce its attendant morbidity. However, the current recommendations, if misinterpreted, could negatively influence public health if they are used to discourage direct questioning or deployment of short screening questionnaires for identifying patients at high risk for OSA. Encouraging patient and clinician discussion of relevant symptoms and signs of OSA is one way to help address early recognition.

We agree.

As we noted just a couple weeks ago, we dentists we are in a unique role to not only screen and treat patients with OSD, but we see the positive results in our patients. And we believe that even the “modest” improvements noted by the study are beneficial to overall health and well-being.

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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: Not Just Some Annoyance

painting of sleeper in stormSleep apnea isn’t just some annoyance. It can be life-threatening. Literally. But is it associated with cancer?

Earlier research had suggested that intermittently limiting oxygen intake – as happens repeatedly through the night for those with sleep apnea – encouraged abnormal cell growth. New research from Canada, however, suggests that there is, in fact, no relation.

The scientists analyzed 6 years of health data from more than 10,000 people with sleep apnea.

At the start of the study, about 5 percent of the patients had cancer. Over an average of nearly eight years of follow-up, an additional 6.5 percent of the participants developed cancer. Most common were prostate, breast, colorectal and lung cancers, the researchers said.

The findings were published last week in the Canadian Medical Association Journal.

But while there may be no cancer connection, sleep apnea still plays a role in many other health issues. On the milder side, there are things like fatigue, headaches, sexual dysfunction and depression.
 

How sleep apnea occurs

 
But research has shown it to be link to a number of quite serious health problems, as well – cardiovascular disease, for instance. Data from the National Commission on Sleep Disorders Research shows that 38,000 deaths each year

relate to cardiovascular problems that in one way or another are connected to sleep apnea. These problems include high blood pressure, hypertension and stroke, among others.

Sleep apnea can affect anyone at any age, with similar effects. A study published this month in the Journal of Behavioral Sleep Medicine found that 13% children studied had signs of obstructive sleep apnea and ADHD or another behavioral disorder. A slightly earlier study looked at the connections between blood pressure, white matter change (WMC), and sleep apnea.

A reverse dipping pattern, characterized by higher night-time blood pressure (BP) than daytime BP, is associated with the increased risk for cerebrovascular disease, cardiovascular events and all-cause mortality.

WMC, also known as leukoaraiosis, is a vessel disease that may be a sign of impending strokes and cognitive declines. The researchers found that unusual blood pressure was strongly connected to WMC. And while the researchers didn’t find conclusive evidence that sleep apnea directly contributes to WMC, we do know that sleep apnea does increase blood pressure.

As for cancer, although no link was found, some experts note that sleep apnea can make the going tougher for a cancer patient. As Dr. Yosef Krespi, director of the Center for Sleep Disorders at Lenox Hill Hospital in New York City recently told HealthDay,

The quality of life of sleep apnea patients with cancer and their ability to tolerate treatments such as chemotherapy and radiation can be very different than those without the condition.

It may even make healing tougher. For sleep, as we’ve seen, isn’t just about getting a break. It helps your body strengthen, regroup, and recover. A habitual lack of it, science is finding, can mean chronic health problems down the line.

If you suspect that you or a family member suffer from sleep apnea, seek treatment soon. Each case is different, so make sure to talk to your dentist about your individual needs. There are options beyond CPAP

Image by Dara Skolnick

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