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Feature Article

The Sleep Connection – Sleep Disordered Breathing

By Gale Skousen, MD

The Importance of sleep

Adequate sleep is vital for your body’s processes to work properly. The average person needs 6-8 hours of sleep. According to the NIH, sleep deprivation increases the risk of obesity, heart disease and diabetes. Sleep deprivation decreases the level of the hormone leptin which tells the brain when your stomach is full. Sleep deprived individuals tend to compensate for their tiredness by eating more. Improvements in sleep quantity and quality have shown benefits in cognitive functioning, a decrease in coronary artery events, a reduction in risk for stroke, improved memory and increased safety as a driver on the road.

Sleep Disordered Breathing

Your dentist deals with two kinds of Sleep Disordered Breathing – snoring, with which you are probably familiar, and sleep apnea, which you may not have heard of. As you get older and gain weight, the soft tissues in your pharynx (the back of your throat) vibrate as the air is forced through a passage that is too small - resulting in snoring. Snoring is very common, it is estimated that 45% of men and 30% of women over the age of 40 snore on a regular basis. Many couples report that snoring is a problem with their relationship and can result in sleeping in separate rooms. But snoring itself is not dangerous to your health.

Between 20% and 50% of snorers actually have obstructive sleep apnea. When they snore, their throat tissues completely collapse causing a temporary obstruction of the airway, temporarily cutting off all breathing. Obstructive Sleep Apnea’s severity is measured by how many instances of Apnea (stopping breathing) or hypopnea (shallow breathing) happen in one hour.

Risks of Sleep Apnea

Apart from the bothersome nature of a sleeping partner listening to loud snoring and periods of absent breathing, wondering if their partner is going to take the next breath - sleep apnea has many significant health consequences. The recurrent episodes of apnea produce lowered oxygen levels and elevated intra-thoracic pressures. These physiologic changes contribute to increases in Hypertension, Coronary Artery Disease and Stroke events. Sleep apnea contributes to daytime sleepiness, diminishes job performance and leads to an increase in the frequency of motor vehicle accidents. The cognitive capabilities of patients with sleep apnea decline as well. If you suffer from Obstructive Sleep Apnea:

· You are 4 times as likely to have heart attack

· You are twice as likely to die in your sleep

· You are seven times more likely to have a motor vehicle accident

· You have a 40% greater risk of having depression

· You are more likely to have sexual impotence and develop diabetes

· You are 2 to 3 times as likely to have a stroke

Diagnosis and Treatment

Many different factors can cause snoring and sleep apnea. These include: an abnormal enlargement of the soft tissues in your throat such as the uvula or tonsils, excess fat in the neck associated with obesity, brain injury, and a small jaw. If your snoring is a relatively recent phenomenon for you, correlated with weight gain, the first step would be to get on a weight loss program. This will help lower your risks for diabetes and heart disease as well.

The good news is that simple snoring, without sleep apnea, is treatable. Positioning yourself to sleep with your mouth closed, breathing through your nose and sleeping on your side rather than your back will help to avoid the collapsing of throat tissues that causes snoring. Dental devices, which often resemble the mouth guards worn by athletes, can help open your airway by bringing your lower jaw or your tongue forward during sleep.

However, if you snore, it is vital to determine if it is “just snoring” or serious obstructive Sleep Apnea. A major problem in our society is that the diagnosis and treatment has been expensive and required specialty evaluation. As a result, 85% of sleep apnea in the United States is undiagnosed.

ARES Unicorder Model 600 New - on subject 021.jpg An initial indication that you have sleep apnea is given by the Epworth Sleepiness Study, which asks questions about when and where you become drowsy. If the study is positive, Obstructive Sleep Apnea is diagnosed by the Apnea Hypopnea Index (AHI), a measure of the number of pauses in breathing while sleeping. Historically the AHI was calculated through overnight sleep studies away from home in a “Sleep Lab”. Today these measurements can be done in the comfort of one’s own bed. Advancements in technology with the use of microchips and tiny sensors in contained devices allow for the simultaneous measurement of air flow, brain waves, oxygen levels, intra-thoracic pressure changes and sound measurements with a device worn on the patients head (the ARES device from Watermark Medical). The ability to perform a comprehensive sleep evaluation at home drastically lowers the cost of the procedure and provides an opportunity for an increased role by dentists in the evaluation and management of results.

The use of a facemask with variable rate and air pressure delivery (CPAP) has been the most commonly used treatment. However, many patients find the facemask and air blowing into their face and nose to be excessively noxious and limit the frequency of it’s use. Other treatment options for sleep apnea include the creation of an oral appliance - used to move the jaw forward, that opens the airway and reduces the obstruction and Uvulopalatine surgery used to remove excess tissue at the back of the throat that is obstructing the airway during sleep.

device in mouth.jpg Of interest, formal sleep laboratories are only able to treat sleep apnea with CPAP. All other treatment modalities require consultation with either dentists, oral surgeons or ear nose and throat surgeons. The unique relationship of the linkage between a sleep lab and a treatment device has too often left patients that might be treated in other ways – untreated or at best only partially treated. In addition, the costs for a sleep study and long-term CPAP use are significant. Now, with the development of a relatively inexpensive, in-home diagnostic tool, and the use of dental Mandibular Repositioning Devices a dentist can work in cooperation with physicians to evaluate and treat many of the affected patients at relatively low costs. The in-home diagnostic tool also allows the dentist to see if the Mandibular Repositioning device decreases apnea so patients and health care professionals can compare before and after AHI readings to confirm efficacy. As this is a medical treatment, medical insurance companies are billed by your dentist and often provide excellent coverage for this evaluation and treatment.

In Summary, if you snore tell your dentist – it could help your most important relationship and add years to your life.

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