All Posts Tagged: sleep apnea

It’s Just Snoring

 

While many people do snore, heavy or severe snoring isn’t part of a healthy sleep pattern. Snoring is a sign that you’re not getting enough air with each breath. Pauses in breathing mean that your airway has closed. This is Obstructive Sleep Apnea. Snoring can also be a symptom of a serious health condition like heart disease.

If anyone tells you that you pause in breathing, snort or gasp while sleeping, or you consistently feel unrested in the morning, you should be evaluated for Sleep Apnea.

Symptoms of serious snoring problems:

  • periodically stop breathing for a couple seconds at a time
  • high volume of snoring is a sign that your body is working really hard to get sufficient oxygen
  • excessive daytime sleepiness

Lifestyle changes that may help include:

  • losing weight
  • not sleeping on your back
  • avoid alcohol or drugs that relax your nervous system
  • quit smoking (It’s proven that stopping smoking immediately makes it easier for a person to breath better.)

Proper sleep stages throughout the night are important for the body to repair and restore different organs and systems while we sleep. We typically should go through 4 sleep stages every 90 minutes or so, throughout the night. Each sleep stage has its job of what gets restored. Snoring, restless sleep, gasping, frequent waking can all be signs that you have Obstructive Sleep Apnea; a potentially deadly condition.

In a study[1] of 744 college aged who had only mild/moderate obstructive sleep apnea and normal blood pressure at baseline were followed for high blood pressure. There was a strong association for young and middle-aged adults to develop high blood pressure because of their mild-moderate sleep apnea. They also had a higher statistical onset of metabolic syndrome (early diabetes). Older adults (over age 60) didn’t develop high blood pressure. Age seemed to be a benefit.

Custom and highly specific orthotic appliances are provided for differing TMD conditions and offer an alternative to CPAP for patients suffering from snoring and Sleep Breathing Disorders.

Credentialed Dentists in Dental Sleep Medicine and TMJ can work with your sleep doctor to design, adjust, and monitor your progress. Oral appliances are easy to wear and travel with. They require monitoring by a trained dentist periodically.

If you or someone you know has symptoms of sleep apnea, such as snoring, we can help get them diagnosed and treated before high blood pressure or pre-diabetes develop. The earlier it is diagnosed and treated, the healthier you will be over the decades.

[1] Mild-to-Moderate Sleep Apnea is associated with Incident Hypertension: Age Effect

Alexandros N Vgontzas, MD Yun Li, MD Fan He, MS Julio Fernandez-Mendoza, PhDJordan Gaines, PhD Duanping Liao, MD, PhD Maria Basta, MD Edward O Bixler, PhD

Journal SLEEP

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Why might I need a sleep study and how do I get one?

A sleep study would be indicated by consistent snoring, feeling unrested after a night’s sleep (frequently), clenching or grinding of the teeth (indicates a high probability of a sleep breathing disorder), or repeated waking throughout the night. Any treatment a Dentist might provide to diagnose or treat a sleep breathing problem, needs the patient’s physician to manage the process by written permission to the dentist.

If someone witnesses or hears you “stop breathing” or gasping, snorting, jerking awake, it’s almost certain that you have Sleep Apnea. There are several ways to evaluate if you have, or the severity of, a sleep-breathing disorder.

PSG: Polysomnogram:

A very sophisticated evaluation of your entire physiologic and neurologic system during sleep. This is important in cases where patients may have several health conditions that might be related to or affected by Sleep Apnea. It’s the best diagnostic test.

Home Sleep Test:

A much simpler evaluation of basic parameters of Sleep Apnea in healthier patients. It can measure heart rate, breathing pauses, oxygen saturation, some can assess basic brain waves too. These are often used to evaluate the effectiveness of Dental Sleep Appliances after the initial Sleep Evaluation was done.

Pulse Oximetry:

Basically, a medical-grade “Fit Bit” with better accuracy. Not often used and doesn’t pick up much data.

If you mention snoring or fatigue to your Physician, they may not suggest having a sleep study. A dentist trained in TMJ or Dental Sleep Medicine can identify oral and other facial features, historical information and 3D imaging evaluations that would strongly suggest the need for a sleep study.

A sleep study must be ordered by a Physician because of the wide-ranging medical problems that Sleep Apnea can directly cause or contribute to such as:

  1. Hypertension
  2. A-Fib
  3. Heart Attack Risk Factor
  4. Stroke
  5. Frequent Urination Overnight
  6. Clenching/Grinding of Teeth
  7. TMJ Damage from Clenching/Grinding
  8. Neck Pain or Stiffness
  9. Nighttime Headaches/Migraines
  10. Feeling of Fatigue Despite Sleeping 7-8 Hours

A simple “pulse oximetry” test, or information from your “Fit Bit”, may miss critical information that could identify some of these risks based on your medical history and exam by your physician. Most of these conditions are out of the scope, licensure, and experience of Dentist’s to evaluate.

Over my years, we have seen patients who had heart conditions, blood pressure spikes (stroke risk) during sleep that weren’t picked up in their normal medical visits.

For a dentist to provide a Sleep Study, we must contact the Physician and get a written order to dispense a home unit or pulse ox. Dentist’s aren’t legally permitted to diagnose or test for, fabricate a “Snoring” or “Sleep Apnea” appliance without a written prescription from the patient’s Physician or Sleep Physician, which we always obtain.

Snoring IS a form of sleep disorder and must be approached as such.

In our practice, we have different sleep study devices that can be used to assess for the presence of a sleep breathing disorder or assess the success of a Dental Sleep Appliance in treating Sleep Apnea, snoring or other sleep-breathing problems involving oral appliances.

I always notify the patient’s Physician and discuss my findings that would suggest evaluation of a sleep breathing condition. The Physician makes the decision on the type of study that is done.

We work with many physicians and can provide fast, easy, home screenings with physicians written RX of patients we see to for TMJ or facial pain conditions, if indicated.

Contact us today for more information.

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Dehydration, Nighttime Urination, Bedwetting and How It Relates to Obstructive Sleep Apnea

Dehydrated? Get more sleep….Tired? Drink more water….it’s all connected.

This article reviews what we already know about proper sleep time and quality: if your sleep is disrupted it affects our entire body chemistry. Kidney function is also impacted by Sleep Apnea and other sleep breathing problems.

Proper length and depth of sleep is known to affect judgment, executive functioning, attention, mood, as well as a significantly affect our heart health, blood pressure, and increases risk for type 2 diabetes.

It’s been known for decades that children who bed-wet and adults who need to urinate 2-3 times at night likely have Sleep Apnea or one of a couple sleep-breathing problems.

Rosinger & colleagues analyzed 2 large database studies from China, looking at over 20,000 healthy young adults. Sleeping (16-59% more likely) less than 6 hours was correlated with dehydration by symptoms (thirsty) and measuring urine concentration and amount.

What’s the relationship?

Disturbed or shortened sleep disrupts the release of vasopressin, a hormone released at night when sleep quality and duration is normal. This hormone is released later in the sleep cycle in greater quantities and with increasing frequency the longer you sleep. WHY???? Without vasopressin, our kidneys would continue to “fill” throughout the night, causing us to wake up and urinate 2-3 times over a normal 8-hour sleep period. Vasopressin is released throughout the lateral stages of sleep and, with increasing release later in the sleep cycle. This makes sense…if you’re sleeping a “normal” 8 hours and entering all the stages of sleep such as REM and Stage lll, the body releases Vasopressin in those deeper sleep stages to slow the kidneys from filling up and causing you to wake up, go to the bathroom and, have to go back through the sleep stages…it’s disruptive to the body/brain repair sequence as we sleep.

Children with enlarged adenoids and tonsils can’t breathe well in deep sleep, so the body makes them restless and deprives their brain of REM sleep…all the while allowing their kidneys to fill. The result: bedwetting.

Adults who snore, have sleep apnea or women with sleep anxiety or frequent waking also don’t release as much Vasopressin, causing us to wake 2-3 times to urinate. Typically the 1st waking is just after midnight…

By morning, the body has dehydrated itself by the continued water loss and can cause long term dehydration symptoms such as muscle weakness, headaches, fatigue (similar symptoms as sleep apnea contribute to)…

Amazing how our physiology is so intricately designed!

Sleep Deprivation May Cause Dehydration

Published Wednesday 7 November 2018,  

Medical News Today

By Ana Sandoiu

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You, The Well-Informed Parent: Advocate for Your Children and Teens!

In my last post, it was my intention to pay attention to how your children are sleeping (or not). If YOU are awake much of the night…perhaps you need a screening for a sleep breathing disorder!

A variety of symptoms can present when children/teens don’t get the proper quantity and quality of sleep regularly. Children and teens will typically present with nighttime symptoms of bedwetting, restless sleep (kicking and banging around) or are twisted in the sheets when you go in to wake them. Hyperactivity, trouble focusing on quiet tasks, impaired growth, avoiding dry, chunky, or more difficult to swallow foods may also present.

The lack of parasympathetic sleep (restful and restorative- think “rest and digest” for parasympathetic) has an immediate and long-lasting effect if deep sleep is impaired. Early in growth it is typically the consequence of enlarged adenoids and/or tonsils. It can also be related to being “tongue tied’. This will also affect the types of foods your children will trend away from; dry foods, hard to chew foods. They may swallow without a closed lip seal or “smack” when eating. Myofunctional therapists and speech therapists trained in MFT can evaluate this condition and, once the frenum is released and airway cleared, begin to retrain the brain improper tongue positioning, speech, swallowing, etc.

If the airway isn’t cleared or isn’t developing properly due to those effects, it can be very difficult to “re-train proper swallowing or speech” until the physical barriers are dealt with.

Orthodontic treatment for under-development of the maxilla (upper jaw) may be needed to get the maxilla back towards normal size to allow the tongue and airway to properly function.

Clinical evaluation as well as radiographic of the airway, jaw growth and size, deep tonsils and adenoids and proper nasal/ maxillary growth can clearly show the physicians the medical necessity they are required to provide that “justifies” tonsil/adenoid removal.

As I tell my patients, nothing can stand in the way of a well-informed parent when advocating for their child’s wellbeing.

A list (downloadable PDF) of common signs and symptoms and visuals that parents can look for that will suggest your child or teen has an airway problem are located on our website under the Sleep Breathing Disorders tab.

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A Note From The Experts of TMJ/Craniofacial Pain

I attended the annual conference of the leading TMJ/Craniofacial pain organization this past month in which I hold a Fellowship status (AACP). After hours, I was able to spend more time with friends and mentors, often we learn as much sharing ideas and techniques as in the actual conference.

There is an increasing awareness and focus on the importance of proper nasal breathing, management of sleep disordered breathing problems such as Sleep Apnea, subtler Upper Airway Resistance Syndrome (typically in women who have poor sleep and excess fatigue without snoring or obvious apnea) and sleep breathing signs/symptoms and effects on growing children that are often missed. I am Board Certified in Dental Sleep Medicine by the American Academy of Craniofacial Dental Sleep Medicine.

Later this summer, I’ll be attending a similar conference with another organization I hold a Mastership status in (ICCMO) and look forward to spending time with those colleagues, many of which are the same experts.

I look forward to expanding my knowledge base, clinical tips and techniques, and comparing notes with my friends who are also leaders in the field of TMJ and Dental Sleep Medicine.

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Waking the Dead (and grumpy): Teenagers and Sleep

Why is it that getting our teenagers up and going is sometimes such a battle?

We nag them to get up, they want to sleep longer

We’re in a hurry- they can’t seem to get out of bed

They stay up too late…

Actually, it’s not totally their fault.  As kids enter teenage years their circadian rhythm, as well as the rest of their physiology, begins to change. All parents know that for sure! Teens are known for staying up late and sleeping in. During teenage years, melatonin’s release (the sleep hormone) is delayed. Teenagers start getting sleepy (melatonin release) around 11pm and need more time to fall asleep.  8-10 hours of sleep is ideal for teens according to the American Academy of Sleep Medicine. They need to sleep until around 7:30 AM.

There is a growing pressure on school systems to change school start times based on research in the sleep literature. It’s being met with resistance because of our work schedules, after school programs/sports and parent’s time schedules. It’s a clash between physiology and a society that has, for decades been on a schedule that seems to have trended earlier over the decades.

According to an article in this month’s American Academy of Sleep Medicine journal:

Short sleep in adolescents is associated with poor school performance, obesity, metabolic dysfunction and cardiovascular morbidity, increased depressive symptoms, suicidal ideation, risk-taking behaviors, athletic injuries, and increased motor vehicle accident risk.917 Increased motor vehicle accident risk is particularly concerning because young, novice drivers have a higher crash risk when sleep deprived, and motor vehicle crashes account for 35% of all deaths and 73% of deaths from unintentional injury in teenagers.1820

Importantly, a delay in school start time has beneficial impacts on teenage students. Studies show that implementation of later school start times for adolescents is associated with longer total sleep time, reduced daytime sleepiness, increased engagement in classroom activities, and reduced first-hour tardiness and absences.7,2123 Delayed school start times also are associated with reduced depressive symptoms and irritability.21,22 Reaction time improves, and crash rates decline by 16.5%, following a school start time delay of 60 minutes.12,13 Extension of sleep time also facilitates behavioral weight loss interventions in adolescents.24.

There isn’t an easy solution to this clash between physiology and society’s needs. But recognizing it can take some of the stress off families. Let the kids schedule relax on the weekends for sleep, talk to them about “sleepy driving” and remaining alert. Perhaps a nap after school would help some of them. If they seem overly tired, they should be screened by a qualified Dentist in sleep/breathing disorders for airway obstructions and altered craniofacial growth that may be a contributing factor.

Read more about sleep disorders in kids here. 

Citation: Watson NF, Martin JL, Wise MS, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Olson EJ, Ramar K, Rosen IM, Rowley JA, Weaver TE, Chervin RD. Delaying middle school and high school start times promotes student health and performance: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2017;13(4):623–625.

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Why is High Blood Pressure a symptom and side effect of Obstructive Sleep Apnea?

Every time you have an apnea (a total block of air for 10 seconds) or hypopnea (partial breathing block) the “fight or flight” reflex is triggered.

With each event, the heart rate and blood pressure increase.  It’s the same feeling you get when you’re scared suddenly; a little sweating, hard to catch your breath, and your heart pounds for a few seconds.

  1. Apneic’ s have this sympathetic response many times per hour, all night long. The body begins to be in a constant state of alert.
  1. With Sleep apnea, the body is chronically low on oxygen. Oxygen is needed to produce nitric oxide in our sinus’ and blood. Nitric oxide is a potent vasodilator- it relaxes the blood vessels and decreases the work of our heart. In sleep apnea the blood vessels chronically tighten and don’t get to relax and repair. The higher blood pressure causes damage to the inside of the artery. This contributes to plaque and more narrowing. As the arteries get narrower it places a higher burden on the heart which leads to heart attacks, strokes, and chronic high pressure.
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A Good Night’s Sleep

Walking through the airport I saw a cover of Consumer Reports regarding how to sleep better.

It reviewed all types of mattresses, pillows, sleep positions, etc. suggesting that this is the primary cause of poor sleep. Not most likely.

While discomfort in your neck, back, or hips can disturb your sleep, the PRIMARY cause of sleep issues in America today is BREATHING. You’re not breathing well. Sleep Apnea, Upper Airway Resistance, Reactive Airway conditions are the most likely culprits robbing you of restful, restorative sleep.

If you have neck, back, shoulder or spinal disease or pain, the pressure and position you sleep in can cause progressive pressure on discs and nerves as you sleep. As you enter deeper stages of sleep your joints may become “irritated” enough to cause a signal to the brain to move or change positions to lessen the pressure. If it happens often enough you will feel that you’re not sleeping well. These are the conditions that pillows and mattresses can improve.

Most sleep disturbances in adults result from Obstructive Sleep Apnea, Snoring, or other conditions involving airway collapse during sleep. If you snore, there’s a near 70% chance that you have Sleep Apnea or that your oxygen is dropping to levels that increase risk of stroke or heart attacks. That is the first consideration to rule out.

Narrowing of the throat (such as with snoring, gasping, jerking) is a reaction to significant drops in the oxygen in your blood and brain. The brain reacts by sending a “flight or fight-like” surge of adrenaline to jerk or twitch us awake and take a breath (but not awake enough to remember) This can happen many time per hour and rob our body of sleep it needs to be mentally sharp.

Another stage of sleep causes all body muscles to be “paralyzed” and completely relaxed. This is believed to be so that our joints, vertebral discs, and cartilage discs, ligaments can have time to repair and heal from the day’s jarring. The oxygen drops associated with Sleep Apnea episodes (snorts, snoring, gasps) are micro-arousals (mentioned above) that re-engage the muscles and interrupt the joint repair periods of sleep. This can lead to joint discomfort, muscle aches and pains, etc. in the morning. Especially if we already have some “wear and tear” on our joints from sports or activities.

If you suffer from poor sleep, achy tired joints in the neck, back or TMJ in the morning, make sure to have your Physician or a Dental Sleep Specialist evaluate you for potential Sleep breathing problems, in addition to finding comfort with pillows and mattresses.

Our website has a convenient, private self-assessment that you can take and have instant feedback as to risk factors for  a Sleep breathing disorder. TMJ problems are also associated almost 70% of the time to a sleep disorder. Clenching and bruxing are also activities triggered by breathing interruptions that eventually damage the joints and discs, in addition to our teeth.

I work with local Sleep Specialists and Physicians to help determine whether patients with TMJ pain, neck pain, or other symptoms should be screened for a sleep disorder.

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Sleep Disorder Categories and AHI

There are 7 categories sleep disorders as outlined by the American Academy of Sleep Medicine. One of those categories involves all the Sleep Breathing Disorders that Dentists treat under the prescription of a Physician.

Sleep Apnea and UARS (Upper Airway Resistance Syndrome – considered a variant or pre-cursor to sleep apnea) are what we will most often see oral evidence of. Benign Snoring is also under the Sleep Breathing disorders heading. Dentists cannot treat any sleep disorder, including snoring without a physician diagnosing it and writing a prescription for a Dental Sleep Appliance.

Sleep Apnea is scored by a number called the AHI, Apnea-Hypopnea Index. What is that?

Apnea is defined as not breathing for 10 seconds or more with a measured drop in the blood oxygen (the airway is completely blocked). Hypopnea is when the airflow of breathing drops by 50% (because the airway is partially blocked) and blood oxygen drops a certain amount. That’s what defines the AHI.

It’s generally considered normal to have up to 5 AHI’s per hour if you don’t have any other symptoms such as tiredness, heart or blood pressure problems, etc. in adults. If an adult is tired or feels unrested, then the sleep disorder is treated even if the AHI is normal. In children, ANY apnea or hypopnea is considered critical to treat, even grade 1. Their developing brains and bodies need full oxygenation with every breath.

 

The AHI is graded as;
0-5/ events/hour = normal
5-15/hour = mild sleep apnea
15-30/hour= moderate sleep apnea
30+/hour =severe sleep apnea.

 

Urgency develops when we can’t breathe; our brain recognizes that something is wrong…a “fight or flight response” increases the heart rate, blood pressure rises, and anxiety will begin to creep in. That sense will increase as the apnea event lasts longer. Many apneic’s have events lasting 30 seconds or longer. Hypopnea’s cause the same physiologic response, it’s just not as dramatic.

Apnea scoring is tightly regulated for the scoring physicians and technicians, somewhat like periodontal disease. Probing 4mm without bleeding may not qualify for treatment. Same as OSA; An AHI of 5 without sleepiness may not be allowed to get treated. If the patient only stops breathing for 9 seconds, it isn’t apnea. If the oxygen doesn’t drop by 3% in a certain amount of time, it isn’t a hypopnea (partial apnea). Patients may have many non-qualifying breathing events that don’t get scored as sleep apnea. Yet they feel unrested, clench or grind their teeth, have sleep anxiety, etc. Those are the conditions that can be discussed with the sleep physician and have them prescribe a sleep appliance.

We sometimes see a mild sleep apnea worsen when patients start using an oral appliance. Why? They are sleeping better and go in the deeper stages of sleep where more apnea occurs. We screen for those clinical signs at regular follow up visits and have scheduled overnight pulse oximetry testing in our process. We can re-evaluate their mandibular position using pharyngometry and 3D cone beam imaging to assess how they are doing and whether a different jaw position is indicated. Throughout the process, we communicate with the patient’s physician to keep them informed about the process.

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