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Michael. C. Goldman, DDS
Sleep Apnea and Snoring...
............or, What's often noisy and can literally Kill you in your sleep?
What is Sleep Apnea and Snoring?
...........................AND WHY IS IT A VERY BIG DEAL!
Snoring is something we are all aware of as a range of sleep noises ranging from cute and funny to absolutely maddening! It is the result of obstructed breathing in the nose or throat causing the tissues in the airway to vibrate similar in a way to a vibrating reed in a musical instrument, but with a very different end sound.... not very musical at all! Often - but not always - heavy snoring is a sign of obstructive sleep apnea.
Sleep apnea -often called Obstructive Sleep Apnea - results from obstructions in the airway causing, not just irritating sounds, but stoppage of life-sustaining breathing itself. People with sleep apnea stop breathing during sleep for anywhere from 10 seconds to 2 MINUTES ...or longer. And this cessation of breathing can happen anywhere from a few times a night to over a THOUSAND times a night!!! It can be FATAL! People with sleep apnea most often do snore heavily, but people that snore heavily don't always have apnea.
When a person stops breathing his blood oxygen level goes down. If it's just once, the oxygen level only goes down a little bit. Normally, our blood oxygen level is in the high 90% range, like 96% to 99%. But if there are repeated episodes of breathing stopping fairly close together, then the blood doesn't have a chance to get back to normal and with each episode the oxygen level gets lower and lower. It is not uncommon for the blood oxygen level to get into the 80's % or even into the 70's. To put that in perspective so it has some meaning, if you're in the hospital for anything and your oxygen is being monitored as it normally would be, when your level gets DOWN TO 90%, they immediately put an oxygen mask on you! Why? Because it gets dangerous at 90% or below.
Your brain and heart and other tissues need oxygen to MAINTAIN LIFE. So, when your blood oxygen starts to get low, your body tries to compensate by making your heart pump faster and faster to pump more and more blood to your brain. If you have any predisposition to heart disease, or if your arteries are not as flexible and open as they should be, you can easily have a heart attack or a stroke. A heart attack is usually the result of the heart muscles not getting enough blood and oxygen. A stroke is not getting enough blood and oxygen to a part of your brain. While the human body is pretty tough generally, lack of oxygen is a very critical thing!
Our tolerance is pretty critical even when we are young and healthy. As we age and our heart and blood vessels are not as forgiving for many "normal" reasons, so lack of oxygen becomes more and more dangerous as we age and as we develop the kinds of medical conditions that we are accustomed to seeing with aging. High blood pressure, plaque formations and scarring in our blood vessels, inflammation, diabetes, overweight and obesity all contribute to making lowered oxygen levels even more dangerous.
All this is to make the single point that SLEEP APNEA CAN BE FATAL! It's not something to dismiss lightly! When you hear of someone dying in their sleep - especially someone that seems otherwise pretty healthy - there's a very good chance they died because of sleep apnea. Usually undiagnosed - and untreated - sleep apnea.
What are the symptoms if a person has Sleep Apnea?
Probably the most common symptom is fatigue and tiredness during the day. Sleep quality is so poor that you never feel like you got a good night's rest so you just don't feel good. Need for "naps" and falling asleep too easily even while driving or just sitting at a desk.
Heavy snoring is often seen .... or, more importantly.... HEARD!
Chronic headaches and cluster headaches are often a factor.
Esophageal Reflux (GERD) is sometimes seen because the struggle to breathe results in squeezing the stomach and at the same time there can be a suction in the esophagus. These actions push and pull stomach acid up into the esophagus causing GERD.
High Blood Pressure is observed in 50-70% of patients with apnea independent of other predisposing factors (like obesity, smoking, alcohol use). Studies have shown the blood pressure often decreases with treatment of the apnea.
Weight Gain and Obesity are both predisposing factors for having apnea and also consequences of it. Chronic fatigue and tiredness results in a less active lifestyle. There is often a compulsion to eat sugars and carbs for short term energy boosts to help stay awake during the day. Also, Leptin, a natural appetite suppressant is released by the body during deep (Stage 4) sleep. People with apnea have poor, fragmented sleep patterns and as a result get very little, if any, deep sleep and as a result many hormones and proteins are not released into the body. Weight gain also results in more fat deposits in the neck, resulting in more obstruction to normal breathing.
Diabetes: Multiple studies have shown that patients with apnea have increased glucose levels and increased insulin resistance.
Alzheimer's: This is still being debated but there seems to be a high correlation (up to 80%) between Alzheimer's and sleep disordered breathing.
Heart attack as discussed above can result from lowered oxygen levels from apnea. A 2005 study showed a significant increase in sudden death between midnight and 6am! Approximately 50% of heart failure patients experience sleep disordered breathing.
Stroke : As many as 63% of stroke patients also exhibit sleep disordered breathing.
How is it Diagnosed and how is it Treated?
The Epworth Sleepiness Scale is often a starting point to get an objective look at degree of tiredness compared to the general population. A high score suggests you should seek medical attention.
EPWORTH SLEEPINESS SCALE
The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire and widely used by sleep professionals in quantifying the level of daytime sleepiness.
(Johns, M.W. “A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale.” Sleep 14 (1991): 540-545.)
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze 2 = Moderate chance of dozing
1 = Slight chance of dozing 3 = High chance of dozing
CHANCE SITUATION OF DOZING
Sitting and reading ______
Watching television ______
Sitting, inactive in a public place (e.g. theatre, meeting) ______
As a passenger in a car for an hour without a break ______
Lying down to rest in the afternoon when circumstances permit ______
Sitting and talking to someone ______
Sitting quietly after lunch without alcohol ______
In a car, while stopped for a few minutes in traffic ______
- 0-7: It is unlikely that you are abnormally sleepy
- 8-9: You have an average amount of daytime sleepiness
- 10-15: You may be excessively sleepy, depending on the situation, and may want to consider seeking medical attention
- 16-24: You are excessively sleepy and should consider seeking medical attention
The only way to properly, and scientifically diagnose sleep apnea is with a computerized sleep study. So if someone is a heavy snorer or not, but there is a suspicion of possible sleep apnea, that person is hooked up to a special kind of computerized tester for the night. The person goes to sleep and his or her breathing, heart rate, and oxygen levels are constantly monitored along with several other functions depending on the particular testing monitor. The monitor records all these functions for the entire night. The medical doctor or dentist then connects the monitor to his computer and he downloads the recorded data. Software in the computer organizes and interprets the data and creates graphs and written text reports of the results of the overnight test. A medical doctor trained in "sleep medicine" then examines the printout and makes a diagnosis based on the overnight test data.
This computerized testing is usually done one of two ways. The patient goes to a "sleep lab" and is hooked up to a "Polysomnography" system of wires and contacts in a simulated bedroom in the lab. The patient is told to go to sleep and the recording process begins.
This kind of test is very sophisticated and a great many body functions can be measured and recorded and it is very accurate in its measurements. The downside is that the sleeplab is not your real bedroom and the sounds, smells, and strangeness of the place may not allow you to sleep as you normally do at home. This may result in different data than what normally happens when you sleep in your own bed or with your sleeping partner.
Another way to do the testing is with a "Portable" monitor. This way you take a small, less complicated monitor home from the medical doctor or dentist, hook it up yourself - it's very simple to hook yourself up - and go to sleep in your own bed, in your own home, with your own sleepmate if you have one. While the testing is not quite as complex and sophisticated, it may in fact be more accurate because you are sleeping in your normal environment . There are no stick-on electrodes to stick onto your face and body like the sleeplab testing. The "lines" in the drawing going up to the patients face shown to the right, are not electrodes. They are soft thin air-hoses that go to up around your ears to little breath sensors just at the nostril openings. The monitor is pretty small and light and is held by the center body-strap. The upper and lower body-straps are soft elastic with sensors built in to record expansion and contraction of your chest and abdomen areas as you breathe. You should be aware also that testing with the portable "take-home" monitors is a lot less expensive than going to a sleeplab! Normally, medical insurance will pay for either kind of testing. But there is variation between insurance plans. Dental insurance will not pay for it, but any dentist doing this kind of testing should be able to submit medical insurance claims for you.
If you are diagnosed with Obstructive Sleep Apnea, it is divided into "mild, moderate, and severe" depending on the number of times per hour you stop breathing and for how long. The treatments that we have available today include:
1. Surgery of several types, depending on the location of the "obstruction"
2. CPAP - Continuous Pressure Air Pressure - in which a small air pump is used to pump room air into a face mask that covers either the nose, or nose and mouth, or entire face. One type of mask that covers the nose is shown here from a very good website www.cpap.com if you should need to purchase a CPAP or mask or supplies.
3. Lifestyle Modifications can sometimes be all the treatment needed. These include weight loss and exercise and forcing yourself to sleep on one side or the other, rather than on your back. These modifications are often too difficult to do, but it can work for some people.
4. Oral Appliances, made by a dentist can often take the place of cumbersome CPAP machines and masks by simply repositioning the lower jaw temporarily, during sleep, to hold the tongue further forward so it doesn't close up the throat during sleep. While these appliances vary in design, they all work essentially the same way. The trick - if there is one - is not in picking the right appliance so much as it is in fitting and critically adjusting that appliance to hold the jaw in just the right place, balancing comfort and function. Too far one way or the other and it is either too uncomfortable or it is useless. Fortunately there are some scientific devices that can help the dentist find that "sweet spot". Most dentists do not get involved in this kind of treatment, but some do if they have taken specialized training in this area of "sleep medicine". Medical Doctors, on the other hand do not normally get involved in making oral appliances. They normally just prescribe CPAP machines. So here is a good opportunity for medical and dental specialists to work together to help you! Here's one of many appliances made by Orthodent Laboratory for dentists. www.ortho-dent.com.
Note: If you do decide to try a CPAP machine and mask, I can tell you from personal experience and from many comments on the web that most of the masks are too large, too claustrophobic, too uncomfortable and leak too much, causing both discomfort and noise. Masks like shown above tend to need to be tightened too much for comfort and leave red marks and irritations on your face the next day - if you have managed to wear it long enough during the night!
Possible exceptions are the Swift FX mask made by www.resmed.com , and the SleepWeaver Advance Nasal CPAP Mask with Zzzephyr Seal, made by www.circadiance.com . Both are far smaller, lighter and can be much more comfortable, but both take a good amount of "playing around with" to find how to best adjust it and use it. There are several "nasal pillow" type of masks somewhat similar to the Swift FX, but the Sleepweaver is in a class by itself with no others like it. Circadience, at least at this time - September 2011 - allows you to try it for 30 days with a full refund if not pleased! Worth a try! Worth a look!
The Sleepweaver mask can be purchased directly from www.circadiance.com or either mask can be purchased from many web-based businesses, such as www.cpap.com , www.secondwindcpap.com , and many other sites. Good luck!
Obesity is considered a major contributing factor in the development of Obstructive Sleep Apnea due to the increased fatty tissue deposits in the neck - as everywhere else in the body. This extra tissue in the neck makes it more likely that the airway will be compressed and that the tongue - which also becomes fatter - will more easily obstruct the airway and interfere with proper breathing. The statistical increase of obesity in the United States is alarming, increasing very rapidly over the past 20 or so years, with no letup in sight. If only for that reason, apnea is thought to be increasing at an exponential rate! The stresses of modern life and the increase in chronic diseases like diabetes and inflammatory diseases of the arteries, bowels, GI tract and many other body tissues all likely play a role in the increase of sleep apnea.
Pregnant women often have apnea before pregnancy, but the body changes in pregnancy probably increase the occurrence of apnea. Not only is this dangerous for Mom, but her oxygen-starved blood is going to the developing baby, too! Could this be a major contributory factor in the incredible increases in childhood ADD, ADHD, learning difficulties, and autism? When you consider the increasing obesity in women (as in men) before pregnancy, it seems to me, something to think about.
Then there's the tremendous increase in obesity among children.... Sleep apnea does occur in children, too, so perhaps their tiredness and inability to concentrate in school is more than ADD, ADHD, or a learning disability. Perhaps they are not able to get regenerative, restful sleep at night! Treating these kids with stimulants or other treatments, or letting them fail is possibly missing the point for many of them. Something to think about.....
An additional issue related to learning disorders in children, but not so often discussed, is Grief and Loss . My wife is an author of several books on the topic and lectures widely to graduate students and educators at Johns Hopkins University, Georgetown University in Washington DC, King's College in Ontario, Canada, and elsewhere. To learn more, see her website which contains a lot of helpful information and resources: www.childrensgrief.net
I hope this has been helpful in explaining this somewhat complicated and very important topic.
Michael C. Goldman, DDS
General and Cosmetic Dentistry
3815 East-West Highway
Chevy Chase, Maryland 20815
Phone (301) 656-6171
HOME TOPICS / INFO ABOUT DR.GOLDMAN TO EMAIL ME CONTACT OFFICE
Holism in dentistry is an approach to dental treatment, primarily caring for patients' health and safety from both a conventional as well as "alternative healthcare" point of view. It is sometimes called "biological" dentistry or "biocompatible" dentistry. In it's fullest sense, I believe it acknowledges and deals with the mind, body and spirit of the patient, not just his or her "teeth". See Topics / Info.....
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