Breathing’s Important…Right?

The Nose Knows

What is the first thing that we do as humans when we are born?

What is the last thing we do as humans before we leave this earth?

BREATHE!!!!!

Breathing is the most fundamental of needs. It trumps the need for food and water. Some might argue that your beating heart or brain function are more important. The reason you have a heart is for the purpose of pumping blood throughout the body. Blood provides oxygen to your organs, oxygen obtained by breathing. Your brain will not function if deprived of oxygen for more than 6 minutes. Where does this oxygen come from? Breathing! It all comes back to breathing.

If breathing is SO essential, shouldn’t you be doing it correctly? This might seem like a ridiculous question given that breathing is something we, as humans, do automatically. However, most of us DO NOT breathe correctly.

By not breathing correctly, you are not optimizing oxygen consumption. This might sound like a silly question, but why is oxygen important? It comes down to every cell in your body. They must have oxygen—if they don’t, they die.

So what does proper breathing look like? If you are breathing properly, then you are breathing comfortably through your nose with your lips together, teeth apart, with your tongue at the roof of your mouth. It also includes using your diaphragm, as well as your back and stomach, not your shoulders and neck. Sounds simple right? Unfortunately, many people do not breathe in this manner.

​Let’s dissect a breath. Sit, or stand tall and pay attention to your posture. Now breathe in, making sure that your lips are together, your teeth are apart, and your tongue is touching the roof of your mouth. After focusing on your mouth position and breathing through your nose, focus on your upper body. When you breathe in, make sure your stomach, lower back, and chest expand. When you breathe out, make sure these areas contract. DO NOT breathe in by raising your shoulders or extending your neck. This qualifies as shallow closed breathing and does not optimize your air intake.

Feels good, right? Breathing in this manner gives you a feeling of relaxation—every yoga instructor out there encourages you breathe this way. So, why is it that most people don’t? It’s not your fault. There are many anatomical and/or genetic characteristics that prohibit healthy breathing. Let’s discuss them.

1. The nose contains ridges called turbinates (we will discuss their function shortly.) If these​ turbinates or ridges become enlarged due to chronic inflammation or poorly positioned turbinate bones, they will obstruct airflow into the nose which will promote mouth breathing.
2. Allergies cause sinus congestion, which makes it difficult to breathe through the nose and will lead to mouth breathing.
3. Chronic sinus infections will lead to mouth breathing.
4. ​Large tonsils and/or adenoids (also called the Pharyngeal tonsil) decrease the ability to get air from the nose to the lungs.
5. If the middle of the nose is shifted to the left or right (called a deviated septum) this obstructs one side of the nose and decreases the ability to breathe properly.
6. ​Polyp formation in the nasal passage decreases the size of the nasal airway.
7. The shape of the nose can prohibit proper breathing. For example, some people have narrow nostrils or have a bridge of the nose that is flat.
8. The shape and/or size of the jaw can affect the ability to breathe through the nose.
9. Stress promotes shallow, rapid, abnormal breathing that is easier to accomplish by breathing through the mouth.
10. Chronic health conditions such as asthma, COPD, pulmonary hypertension and anemia will cause mouth breathing because the body feels it needs to get air in faster than nasal breathing can provide.

Why is it so important to breathe through your mouth as opposed to your nose?

1. The nose is your FIRST defense against bacteria and viruses that can make you sick. Remember the turbinates that were mentioned above? They are essential in this process. It is the job of these ridges, along with hair-like projections in the nose called cilia, to keep as many germs, dust, and debris out of your lungs as possible. Your sinuses produce mucous, otherwise known as snot. This mucous also assists in the capture of unwanted air debris and germs. By breathing through the mouth, this first line of defense is eliminated.
2. The turbinates also humidify and warm the air we breathe. This is important so that the airway does not shrink making it more difficult to breathe. This can be particularly bad for people with asthma.
3. Mouth breathing can cause the airway to not function at its normal capacity because the air is cold and dry. A dry airway leads to poor oxygen exchange.
4. Dryness due to mouth breathing can also cause dental diseases such as decay, misaligned teeth, and gum disease.
5. By exhaling through the nose, the process of breathing is slowed down and a back pressure develops in the airway. This allows more oxygen to be transferred from the lungs to the bloodstream.
6. Mouth breathing in children can lead to facial deformities that will cause a small airway as an adult. A lower chin, longer face, less pronounced cheekbones, and narrow jaws will predispose a child to a lifetime of difficult breathing.

​​WHY DOES ALL OF THIS MATTER?

Oxygen is ESSENTIAL for cellular activity. Since EVERY PART of your body is made up of cells, and cells dictate the function of your organs, your body relies on oxygen in order to function properly. Proper breathing allows for optimum oxygen consumption and is one of the best things we can do for our cells.

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Why Can’t You Breath Properly at Night?

Diana is sure her brother Robbie loves her dearly . . . or at least he does NOW. But when he challenged 8-year-old Diana to ‘The Great Snorkeling Competition,’ she should have known to suspect he was up to mischief. As they sunk below the surface of the pool, Robbie managed to breathe effortlessly into his snorkel. Diana, on the other hand, was struggling to pull the air through the snorkel and into her lungs. “Why is this so difficult for me?” she thought. Her brain was telling her body to resurface NOW…and so, despite her best efforts, Robbie won by a landslide. Diana licked her wounded ego and vowed never to snorkel again—after all they were underwater choking hazards!​

Little did Diana know that Robbie, like most big brothers, had rigged the challenge...and given Diana a half-pinched-off snorkel! Her life-line had been compromised from the start.​

When we go to sleep at night our brains have the important job of maintaining our life-lines. If our ‘snorkels’ or airways become compromised it will affect how well we rest. But HOW do our airways get blocked? What keeps the air from getting into our lungs?

It depends! We’ll start by assuming your older mischievous siblings have nothing to do with it! The point or points of blockage may be different for each person. Let’s go through these from the top to bottom.

​​1- THE BRAIN. Our brain may stop telling our body to breathe. This looks like long pauses in breathing without ANY effort by the chest and belly to pull air in and is called central sleep apnea. It is not really a physical blockage, BUT it does result in the same decreased oxygen to the brain.

2- ​​​THE NOSE. Have you ever noticed how hard it is to sleep when you have a stuffed-up nose? The nose is ideally where we pull the air from the outside world into our body. It acts as both a filter and a moisturizer for the air. If our nose is plugged up, we will have less volume of air coming into the lungs… which means less oxygen to the brain. Some of the common reasons our nose becomes clogged include: chronic allergies, polyps (or outgrowths within the nose as described in chapter 1), deviated septum (the wall separating the right and left side of the nose is bent, also described in chapter 1), or the sides of the nose may collapse inward when you inhale...​​ .

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3- ​THE MOUTH. Our mouths house a lot of soft stuff that, once relaxed, can fall back into our airway during sleep. Some of these structures include: the tongue, the soft palate (the soft ceiling behind your back teeth), and the dangling uvula we all know from the opera-singing cartoons.

​What makes these tissues slump backwards? Gravity! When we begin deep sleep, the muscles in our body relax so that we don’t act out our dreams. Gravity then goes to work, especially when we sleep on our back, pulling the soft tissues towards our throat and limiting our airway.

​If you snore, this is where all that noise comes from! The soft tissues vibrate as the air is being forced between these floppy tissues. Both the condition and size of these tissues can also affect their tendency to cause a blockage. For example, if these tissues are BIGGER due to fat deposits or inflammation, they already take up more of the airspace. Or, if these tissues lack tone (meaning they don’t hold their structure while relaxed) they will fall inwards more easily as well.

What about the teeth and jaws? Let’s imagine that the teeth and jaws are a garage and the tongue is the car. If the teeth are crowded and the jaws are narrowed, like a compact-sized car space and the tongue is a full sized SUV, then we are going to struggle to keep the tongue out of the airway. This is important to recognize ASAP, especially in children, because we may be able to up-size the garage space to make breathing easier! More on how this is done later!

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4- ​THE THROAT. Our throat is the main pipe through which all this air will travel to reach the lungs. This may be blocked by everything upstream (the nose and mouth) OR by other structures located along this tube. Big adenoids and tonsils are a common suspect, especially in children.

​These tissues tend to enlarge in response to inflammation from three issues:

• Chronic environmental and food allergies… like grasses, dust, dairy and wheat.
• Snoring… the chronic vibration causes the tissues to become swollen.
• Mouth breathing… air breathed in through the mouth is not filtered, warmed or moisturized by our nose, so it tends to irritate and dry out all the soft tissues downstream in the throat and the tubes leading to the lungs and then the lungs themselves (see Asthma in Chapter 9).

Short-term conditions like sickness may also cause the tonsils and adenoids to get bigger as the body is fighting off the illness.

Wow, that’s a lot of ways our ‘snorkels’ can get clogged! You can see why it is SO important to find out WHERE the obstruction is for YOU!

Our team of brain, nose, mouth and throat experts are ready to help guide you on your journey towards your BEST night’s rest.

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Signs of Sleep-Disordered Breathing

In Adults and Children

“Knowing is half the battle.” -GI Joe

The goal of this chapter is to give you some tools so you can help yourself and your loved ones seek proper evaluation and treatment. The signs and symptoms of sleep apnea are like stars in a constellation. Once you start identifying the stars, you can see the constellation.

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• Adults with sleep-disordered breathing will often have some of the following symptoms:
• Waking up tired and unrefreshed, no matter how many hours of sleep you get, excessive daytime sleepiness or fatigue
• ​​Insomnia. Seems strange, but your body is actually trying to keep you awake so you don’t stop breathing while asleep.
• ​​Waking up frequently during the night to go to the bathroom.
• ​While asleep, gasping for breath or pauses in breathing.
• ​Waking up gasping or choking
• ​Heartburn or waking up with stomach acid in your mouth.
• ​Frequent napping.
• ​Loss of interest in life, hobbies and intimacy.​

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• ​High blood pressure (adults)
• ​Hyperactivity/Attention Deficit Disorder (children)
  Snoring loudly​
  
• Morning headaches
  
• Trouble concentrating
• ​Depression & Anxiety
• ​Sleep difficulties

The American Dental Academy directed all dentists to screen patients for sleep-disordered breathing in 2017—just like dentists have been asked for years to screen every patient for oral cancer. When your dentist screens you for sleep-disordered breathing, here are a few things they should be looking for (be prepared for a yucky tongue picture below, haha!):

• Difficulty lying back to receive dental procedures
• Tooth wear from grinding or clenching (flat spots on the pointy parts of your teeth)
• Looking at the back of your throat for a congested airway
• Scalloped tongue (see the “pie crust” looking ridges on the sides of the tongue?)

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After reading through all those symptoms you are probably wondering if you have a sleep-disordered breathing disorder! Here is a quick screening tool you can use at home. For each question that you answer yes, give yourself 1 point.​

1. Do you snore?
2. Are you frequently tired, or feel sleepy?
3. Has anyone seen you stop breathing in your sleep?
4. Do you have high blood pressure?
5. Are you overweight?
6. Are you over the age of 50?
7. Is your neck circumference larger than 15.75 inches?
8. Are you male or a post-menopausal female?

What’s your score?

If you scored 0-2 you have a low risk of having sleep-disordered breathing, 3-4 means you have moderate risk, and 5 or more indicates you are at very high risk. Please keep in mind this only estimates your risk. Even people with a low risk can have sleep apnea. This is not a substitute for speaking with your doctor.

What about Children?

Identifying sleep-disordered breathing in children is crucial for their wellbeing and development. We will address this in depth in Chapter 7.

If a child snores—AT ALL—they need to be evaluated for sleep-disordered breathing by a sleep professional. Children have some of the same symptoms as adults, but also have a few others as well. Watch for these in child:

• Snoring
• Pauses in breathing during sleep
• Snorting, coughing or choking sounds
• Mouth breathing
• Bedwetting
• Sleep Terrors
• Restless sleeping
• Circles under the eyes (these can often look slightly pink or purplish)
• Grinding their teeth at night

Untreated sleep-disordered breathing will often result in many areas of life being challenging for children. If a child is experiencing difficulty in the some of the following areas, it could be a symptom of untreated sleep-disordered breathing:

• Difficulty paying attention
• Learning problems
• Behavioral problems
• Hyperactivity
• Poor weight gain or growth
• Poor school performance

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It is essential that if you think you or a loved one is at risk that you seek medical help. Do not let your fear of the test or treatment prevent you from getting evaluated and diagnosed.

This is a matter of life and breath.

Are You At Risk?

If you were to imagine the typical person who is at risk for Obstructive Sleep Apnea (OSA) who would come to mind?

You would be in good company if you first think of someone who is overweight, middle aged, male, and who snores like a banshee—perhaps this description even applies to your spouse, family member, or friend who has already been diagnosed with OSA(or who you suspect may have it).

This commonly held mental image of the stereotypical sleep apnea patient is based in truth—multiple scientific studies confirm that middle-aged, obese males who snore loudly are indeed among those at highest risk for this serious and potentially deadly condition. Our medical community has long focused on this type of patient as it has struggled to manage this epidemic.

A recent discussion with a primary care physician reinforced this. As we discussed that clinic’s methods of identifying those at risk for sleep apnea, this physician quipped, “Well, we don’t miss many of the fat old men!” This was an illuminating statement, as we have become aware that sleep apnea can potentially affect just about every age group, and both sexes, depending on individual circumstances.

It is now well understood that OSA is a complex, chronic condition that is influenced by MULTIPLE factors. The Mayo Clinic has stated that some of those factors are:

• Being male​
• Excess weight
• Being older
• Thick neck circumference
• A narrowed airway
• Family history
• Use of alcohol, sedatives, or tranquilizers
• Smoking
• Nasal congestion

Right off you can see that the first three factors listed DO describe our stereotypical OSA patient! But this is not the whole story; so let’s tackle these risk factors individually to gain a better understanding of who is truly at risk for OSA…

BEING MALE

Multiple studies confirm that men are two to three times as likely to suffer from sleep apnea compared to women, and this may be due to several reasons.

First, men tend to report more classic signs of OSA such as heavy snoring and excessive daytime sleepiness, whereas women more often complain of OSA-related symptoms such as insomnia, anxiety, and headaches/TMJ related pain (this may result in fewer sleep testing recommendations from family physicians for females). Second, females are generally more aware of their partner’s sleep problems, so they more frequently witness their partner’s apnea events and then perhaps encourage their male bed partners to get testing. There also appears to be an airway protecting function of the female hormone estrogen that may account for this lower prevalence among women.

This may explain why some studies show that men tend to have more severe OSA and longer apnea events than females. It may also explain why women’s risk for sleep apnea increases dramatically after menopause.

EXCESS WEIGHT (and a THICK NECK CIRCUMFERENCE)

As of 2019 approximately 42% of the American adult population are considered obese, and sleep apnea is more common in obese patients compared to those of normal body size. This really makes sense if you think about it; as we get bigger on the outside—especially if fat deposits occur in the neck and in tissues surrounding the upper airway—our airway gets smaller and less able to resist collapse. As obesity rates have increased over the past few decades, so has the prevalence of sleep-disordered breathing.

Obesity is such a key factor in OSA that many people who lose significant amounts of weight may find their sleep apnea reduced from severe to a milder condition, or that their OSA is even fully resolved. Weight loss may be easier to achieve with active therapy such as CPAP or Oral Appliance Therapy due to the therapies’ positive effect on the hormones that regulate hunger. A more rapid weight loss can occur for severely obese patients that have bariatric surgery.

BEING OLDER

As we age, two things tend to happen that increase our risk for OSA: we tend to gain weight, and we tend to lose muscle tone. Loss of muscle tone can directly affect our airway because the airway now collapses more easily. In general, rates of OSA are higher for older (over age 40) versus younger adults. However, sleep apnea can affect people of ALL ages, including teens and children, although at lower rates.

A NARROWED AIRWAY/FAMILY HISTORY

A narrowed airway is the crux of the whole problem—almost all the other risk factors mentioned here relate to this! It is easy to understand that if the airway is physically smaller due to the presence of excess fat or large tonsils, even a small degree of collapsing during sleep would further compromise your airway. Dentists are occasionally asked if there is a genetic or family history component to sleep apnea, and the answer is… yes!

Your family genetics may mean you’re more likely to have smaller jaws, or to have a high palate, or are prone to obesity—all of which increases your risk for OSA. Studies now suggest very strong genetic foundations for this condition. narrowed airway is one of the most common causes of sleep apnea in children—in this instance due to large or swollen tonsils or adenoids that cause a physical narrowing of the airway as opposed to the collapsing airway more commonly seen in adults.

USE OF ALCOHOL, SEDATIVES, AND TRANQUILIZERS

These substances are often used for insomnia, but they may also affect your airway and worsen your​ OSA. Many people drink alcoholic beverages in the evening, sometimes with the mistaken thought that it helps them sleep better. However, research shows that alcohol doesn’t really help you sleep better but instead, creates more of a sedative effect. Alcohol may also cause you to wake up in the middle of the night as it is processed by your liver. This could be because the chemical byproducts have been shown to promote a more awake state, or because it is a diuretic which promotes awakening to urinate. We all know that alcohol is a relaxant, and it can cause a direct relaxation of your airway muscles, thereby promoting or worsening underlying sleep apnea. It has even been suggested that some hangover symptoms are due to the increased level of sleep apnea caused by alcohol’s effects on the airway.

Because other sedatives such as Benzodiazepines (Valium, Xanax, etc.) and tranquillizers also cause muscle relaxation, they may also worsen your sleep apnea. Newer sleep aids such as Ambien and Lunesta seem to have less direct effect on the airway, but come with their own unique and challenging side effects.

SMOKING

The ill health effects of smoking are so well documented that everyone is aware of its inherent dangers, but less known are the potentially damaging effects on your sleep from tobacco use. Smoking has been shown to disrupt your normal sleep cycles and damage the function of your very important upper airway muscles. And, the inflammation smoking causes in your throat means the upper airway may be more swollen which in turns makes the overall airway smaller.

NASAL CONGESTION

Nasal congestion is common among those of us who suffer seasonally or through the year with allergies, commonly referred to as Allergic Rhinitis. Because nasal congestion can cause swelling in your upper airway, it may worsen both snoring and underlying sleep apnea. Nasal congestion can be so profound that it promotes mouth breathing, which has also been shown to worsen airway collapsibility (this could also be caused by a physical blockage in the nasal anatomy such as the deviated septum mentioned earlier). If you do suffer from chronic nasal congestion, you will likely suffer from dry mouth while sleeping which also increases risk of dental decay and gum disease.

Fortunately, solutions do exist: you can use an over-the-counter (OTC) nasal decongestant spray such as Flonase, an OTC allergy medication such as Zyrtec, or consider consulting with an Ear, Nose and Throat specialist (ENT) to determine whether a minor surgical procedure could improve your nasal breathing long-term. There are also numerous remedies for dry mouth we can help you with!

As you may now realize, there are MULTIPLE risk factors for OSA –how many of these apply to you or your loved ones?

If risk factors exist, a consultation with your primary care doctor or a sleep physician is warranted. The bottom line, however, is there are many of us who lack these common risk factors but may still suffer from sleep apnea. For example, we now know that many otherwise healthy, slender, young females without any of the above risk factors are prone to UARS (Upper Airway Resistance Syndrome), thought by some to be a milder form of OSA but that can cause many of the same symptoms as sleep apnea. While it is important to understand these common risk factors, anyone who suffers from poor sleep in general is encouraged to discuss their issues with a medical professional.

Your Sleep Apnea Could Be Causing...

THE BIG 3: Heart Disease, Diabetes and Stroke

We all agree that snoring can be super annoying to listen to, especially if YOU are trying to sleep next to that snoring person. But, how many of us realize the person snoring next to us may also be suffering from OSA, which puts them at a much higher risk of suffering from a heart attack, diabetes and stroke?

By ignoring snoring and OSA we may unknowingly be putting ourselves into higher risk categories. A study from The Journal of Clinical Sleep Medicine in 2008, found patients who have OSA increased their risk of cardiovascular disease by 140%,stroke by 60%,and coronary heart disease by 30%.

What is especially worrisome is that heart disease is already the #1 cause of death in the United States. Strokes are responsible for 1 out of 20 deaths per year according to the Center for Disease Control (CDC) and are also the leading cause for long-term disability in the U.S. To tie it all together, diabetes is an underlying condition for all of them. Wow! Hats off to modern medicine and research for discovering this information.

So how does OSA increase a person’s risk for all of these conditions?

When your body has trouble breathing, either because of snoring or apneas (stopping breathing), the​​ oxygen level in your blood starts to decrease.95% to 100%oxygenis considered ideal and below 90% is considered low.

When oxygen levels drop into the low range, it’s actually the increased levels of carbon dioxide that will trigger a response from your brain to increase the oxygen level.

The body accomplishes this by increasing your heart rate. Your heart will begin to beat harder and faster by pumping more and more blood through your lungs as your body tries to get more oxygen to your brain.

But remember with OSA, the airway is obstructed or blocked. Your heart, not in a restful state, will need more energy to do this. Insulin is released into the body to convert sugar (glucose) into energy for fuel to power the heart. While this happens, your glucose levels remain high to power the body under stress.

Studies have shown long-term high levels of insulin actually cause the cells to become immune to the insulin further increasing blood sugar levels.

As the brain senses lower oxygen levels it releases a stress hormone called Cortisol. Cortisol is part of the “fight or flight” response released under stressful conditions, such as not being able to breathe. Cortisol also works to increase your glucose levels and increases blood pressure by tightening blood vessels. Tightening blood vessels increases blood pressure and an increase of blood pressure is a risk factor for heart disease, heart attack and stroke. (We will discuss the “fight or flight” response in greater detail in the next chapter). 

In the meantime, consistent elevated glucose levels contribute to diabetes. Frequent urination is a common symptom of increased levels of glucose in the blood. It’s difficult to get a good night’s sleep while having an obstructed airway. So if you have diabetes or know someone that does, nowt he additional burden of having to wake up often to urinate compounds the problem.

There are two types of strokes. The most common stroke is called an ischemic stroke, which accounts for about 85% of strokes. Ischemic strokes occur when a blood clot or a fatty deposit called “plaque” blocks blood flow to the brain in an artery. The less common type of stroke is called a hemorrhagic stroke. Hemorrhagic strokes happen when a blood vessel in the brain has become weakened and bursts, leaking blood into the brain itself, or into the space between the skull and brain.

As mentioned earlier, the effects of OSA increase blood pressure and lower blood oxygen concentration. The body responds with the “fight or flight“ response. In scientific terms, we call this the sympathetic nervous response.

The response is not designed to last hours on end, like sleeping (or trying to sleep) at night. Rather, as the name suggests, it’s designed to help you survive. Stay and “fight” or leave the scene to survive, “flight.” In short durations of increased heart rate and supporting hormone levels, this response works rather well.

But, when the sympathetic switch is left on (a person with sleep apnea) the long-term effects of this response are unhealthy. It leads to high blood pressure(hypertension) and an irregular heartbeat called arrhythmia(atrial fibrillation). Two well-known risk factors of both types of strokes are hypertension and atrial fibrillation.

Chronic increases in blood pressure weakens the blood vessels over time. These blood vessels are most susceptible to developing clots and fatty plaques, called atherosclerosis. Atherosclerosis increases the risk of having a stroke. It also contributes to lower blood flow to the brain. When a person with atherosclerosis wakes up and gets out of bed, it takes longer to restore the proper amount of blood to the brain, compared to a person without atherosclerosis.

​Now imagine this scenario playing out night after night, week after week, month after month, and year after year. We can quickly understand why treating OSA should be a priority to not only treat and lower risk factors, but to also maintain a healthy lifestyle. As we learn more and more about sleep apnea and its overall effects on the human body, it becomes quite clear that treating this condition should be a top priority.

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And by the way, as if the big 3 aren’t enough, the same process described above, has been postulated to be a root cause of Alzheimer’s disease. We’ll go into more of the unfortunate consequences of sleep apnea in the next few chapters.

Sleep Apnea AND MORE TROUBLE?

Depression, High Blood Pressure, Obesity and Liver Disease​​​​

Pictured here is Francis Grose (1731-1791). He was an English antique collector/dealer and gifted storyteller. His friend, Rev James Douglas, drew this portrait depicting Grose as a thick-necked man asleep with his mouth partially open. If you close your eyes, you can almost hear his snoring thundering through a meeting he was attending with fellow antique dealers. He was known as a great drinker, eater and of course, he loved his sleep. He ultimately died suddenly of an assumed stroke at the age of 60 (one of the big 3 mentioned in the previous chapter).

This sketch is thought to be the first illustration of obstructive sleep apnea syndrome. While Grose never had the chance to have a home, or lab sleep test done, it is not a far leap to assume he had some form of obstructive sleep apnea. Taking it a step further, we could also guess that Grose also suffered from high blood pressure and as the picture depicts, he was obese as well. In fact, Grose was thought to be 5 feet tall and 22 stone or 308 lbs. At this weight and height his body mass index, or BMI, would have been 60 (between 18.5 and 24.9 is considered healthy). Grose possesses some common risk factors for sleep apnea as discussed in Chapter 4.

​​DEPRESSION, HIGH BLOOD PRESSURE, OBESITY AND LIVER DISEASE

Some other illnesses associated with sleep apnea outside of the Big 3 are depression, high blood pressure, obesity (see Grose above) and liver disease. All these conditions are due to the body’s inability to regulate itself correctly.

Sleep apnea, as described in other chapters, deprives the body of oxygen. The lack of oxygen stresses your body out. .​Have you ever been swimming in the ocean and unexpectedly been pushed down to the bottom by a wave? When you finally make it to the surface, your heart is beating 90 miles an hour, you can’t catch your breath and you’re shaking. Your fight or flight system that we talked about in the last chapter has kicked in. Sleep apnea causes that same response because your body cannot breathe. Only it’s at night, in the comfort of your own bed and not in the ocean. You are fighting to stay alive.

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NO OXYGEN -> YOU DIE

And, your brain wants to keep you alive. So, you wake up, disrupting your sleep and all the important stuff that happens while you sleep.

High blood pressure is known as the silent killer because you have no obvious symptoms until it has done significant damage to your body. Increased blood pressure can cause a heart attack or like in our friend Grose’s case a fatal stroke (one of the BIG 3, mentioned in the previous chapter).

The activation of fight or flight is responsible for increasing your blood pressure. Your body is pumping blood faster because it senses danger. Only in the case of obstructive sleep apnea, it’s not lack of oxygen because of ocean waves on top of you.

The stress hormone cortisol also increases in the fight or flight response. Struggling to breathe every night encourages your body to store fat. See Francis Grose as exhibit 1 of this phenomenon.

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Other metabolic conditions such as Nonalcoholic Fatty Liver Disease (NAFLD) and insulin resistance are affected by your flight or flight response. Over 20 studies have linked Obstructive Sleep Apnea and Nonalcoholic Fatty Liver Disease due to the low nighttime oxygen levels. The liver can try to repair itself from this condition, causing scarring and reducing its ability to function.

Pinpointing the exact link between sleep apnea and depression has proved complex for researchers. It has been found to involve the relationship of serotonin that is both involved in depression and the upper airway. Although we don’t need to worry about the exact relationship of what receptors or other scientific jargon are involved, we do need to understand that sleep issues increase the likelihood of depression.

As many as 46% of adults with confirmed obstructive sleep apnea also report symptoms of depression. Lack of sleep is associated with the inability to regulate our mood. We have all heard the phrase “waking up on the wrong side of the bed.” Sometimes we say this in good fun to our family members or bed partners, but lack of good quality sleep can do real damage to our thoughts and our ability to deal with our emotions. E. Joseph Cossman captured the relationship of sleep and emotion with this quote, “The best bridge between despair and hope is a good night’s sleep.”

Depression, high blood pressure, obesity and liver disease are all linked with obstructive sleep apnea. Some sleep sufferers will develop one of these illnesses while others will develop one or two on top of the Big 3. Increasing good quality sleep will not magically cure these illnesses but it will give your body the necessary rest to begin repairing itself.

Save the “fight or flight” response for the ocean and not for your bed.

Wait, There’s Even MORE!
Acid Reflux, ADHD & Sleep-Disordered Breathing in Children

Sleep-disordered breathing can be expressed anywhere on the severity spectrum between “simple snoring” to the daddy-of-them-all OSA (obstructive sleep apnea). These conditions, and everything in between, are sleep-disordered breathing issues that affect your overall health.

By this time you are seeing that sleep-disordered breathing creates chaos, not just in the infant, not just in the older child, not just in the young adult, not just in older adult, but it selfishly affects the entire human age spectrum. Sleep-disordered breathing doesn’t limit itself to any one age group, ethnicity, gender or body type. It’s not picky. In fact, it is really difficult to think of many other diseases that are so indiscriminate.

Let’s start with attention-deficit/hyperactivity disorder (ADHD). In a nutshell a person with ADHD may be disorganized; have difficulty focusing, difficulty paying attention to details and make careless mistakes; he/she may have trouble staying on topic or become forgetful. Just remember the last time that you were sleep deprived. You likely experienced some or all these symptoms.

WHAT ABOUT CHILDREN?

In children the symptoms may be similar, their school performance may suffer; their behavior and​ attention in school is questionable; they can become irritable and very often they present with the hyperactive component of ADHD. Have you ever seen a child that stays up past their bedtime? They just get crazy and wild. They are irrational and unable to follow directions and then BOOM they knock right out. Just like that. How is a child with ADHD treated with a typical drug prescription? With a stimulant!

Wait a minute…won’t that make them more hyper? Intuitively that is what you would think but in actuality, it wakes the child up and he becomes more manageable; more human as one might say. This can be illustrated best by reading Connor’s Story, which you’ll read in chapter 24.​

Not all children with ADHD need drugs but likely more than 50% are simply sleep deprived. We could treat more than 50% diagnosed cases of childhood ADHD with just proper sleep!

Here is another thought. ADHD can be caused by sleep deprivation and by now you realize that sleep-disordered breathing can deprive you of much needed restorative sleep. There is strong evidence that now links sleep-disordered breathing to dementia and Alzheimer’s (the end game for brain function).

​What is the number one nutrient we need? What is the nutrient that if we are without for a few minutes or more can cause death? It is oxygen and proper breathing supplies us with that oxygen. IDEAL breathing supplies ideal oxygen for the entire body and brain but there is something that we can refer to as an “oxygen diet”.

We may receive just enough Oxygen to stay alive and function, but it may not be enough to optimize the much needed demands for our bodies to thrive. If you have a sleep disorder then might you be on an “oxygen diet”. Could night after night of this “diet” be harmful? Could night after night of oxygen deprivation be harmful to an adult’s developed brain or a child’s developing brain? The answer is an obvious YES! ​

Now let’s talk about headaches. By no means should we think that every headache is caused by sleep-disordered breathing. However, they can occur more frequently when you have a breathing problem. Let’s explore.

Chances are that headaches that are experienced upon waking in the morning are related to a sleep-disordered breathing problem. In fact, in many studies it is shown that lack of REM sleep (our deep dreamy sleep) is shown to increase the incidence of migraine headaches.

Sleep-disordered breathing causes pauses in what we would consider normal breathing. They can last longer than 10 seconds causing the oxygen level in our blood to drop or they can be short pauses with little affect on our oxygen levels. What the pauses have in common is that they can lead to more frequent disturbance to your sleep and fragmentation of your precious sleep cycles. Poor sleep quality is the result.

Your inability to get deep sleep can stress your entire nervous system and increase it’s sensitivity. This may be your involuntary nervous system over-reacting to stimuli. You may experience migraine headaches as a result. A person suffering a hangover has similar symptoms of nausea, vomiting, brain fog and sensitivity to light and sound. A night of alcohol indulgence also causes compromised breathing as they sleep it off. Ever seen how loudly an individual may snore after a night of consumption?

Many people think a large majority of sinus headaches are from disturbed sleep caused by a breathing disturbance. Lack of healing sleep can also result in muscle tension, spasms and pain, especially in head and neck muscles. Many people experience TMJ pain (jaw joint pain) as well.

Someone with normal sleeping patterns will sleep with their teeth apart, coming together lightly with occasional swallowing. But in many individuals with a sleep-breathing disorder the body reacts with an episode of squeezing the teeth firmly and tightly for hours at a time with all the force it can muster. Ouch!

​​And then there’s acid reflux—yet another symptom. What in the world does acid reflux have to do with sleep-disordered breathing?

We see it in children and adults. It can be a subtle acid reflux experience or a more acute, “Oh my gosh, I’m choking! experience. Many adults report suddenly awakening with a mouthful stomach acid, choking and gasping for air—a truly awful and scary feeling. Others afflicted with acid reflux may not even notice acid in their mouths, but we dentists can see erosion on their teeth in the form of pitting or missing (dissolved) tooth structure. This is commonly seen in children and we often see small divots on the chewing surfaces of their molars caused by acid reflux.

Some scientists suggest that morning congestion of the nose and sinuses is caused by acid aerosols

​​ that are produced from the reflux; this mist is what irritates our sinuses & causes sinusitis and congestion in the mornings, many times mistakenly confused with allergies. Measurements of acid have confirmed more acidity is seen when a sleep-breathing disorder is present.​

During episodes of forceful breathing, negative pressure is produced in our breathing tubes (our breathing tubes collapse, and our bodies struggle to breathe). This creates a phenomenon like a vacuum cleaner tube sucking up acid from the stomach into the breathing tube. The end result is more acid making its way into our esophagus, mouth and sinuses. As noted in previous chapters, many patients grind their teeth when they sleep. When you couple this with acid reflux, more abnormal wear on your teeth will be noted.

We need good quality sleep for our physical health, our biochemical processes, our brain and memory function, our bodily repair, our immunity, and our emotional stability (among lots of other things). We should focus not just on getting the proper quantity of sleep but just as importantly, quality. Good sleep is a major pillar of health.

Without good sleep our lives are doomed.

TMJ and Sleep

It is estimated that more than 10 million people in the United States suffer from TMJ problems and jaw pain related headaches. Most of those people spend years and thousands of dollars searching for answers. Some are prescribed one or more medications with significant side effects. Often, many are​ told that it’s a psychological problem, and they need to learn to live with it. In fact, many dentists and even doctors have very little to no education regarding TMJ in dental or medical school, and the information they might have received was probably outdated.

Thankfully, if YOU fall into this category, you’re not alone. You can have HOPE and find SOLUTIONS.

The latest research indicates that many TMJ problems are caused by untreated sleep apnea. As your body struggles to breathe at night, it activates jaw muscles to keep the airway open—sort of doing its own CPR. You may have experienced this and wakened with your jaws clenched. Or maybe you were told that you grind your teeth at night. This behavior, once attributed to stress, could actually be your body’s way of keeping you alive by preventing suffocation.

Talk about stress! Depending on the severity of your sleep apnea, this can happen more than a hundred times a night, creating damage to jaw joints and causing muscle overload. Some people can even end up with severe joint disease or even a locked jaw. Your jaw can be stuck in an open position, so it can’t be fully closed, or stuck closed, so that you can’t open up wide.

Do you have to smash down a sandwich in order to take a bite? If you do, you might have a TMJ​ problem. A normal opening would allow you to place 3 vertical fingers in your mouth—just wash your hands first please!

The great news is that a dentist with extensive training in sleep-disordered breathing and orofacial pain can recognize this problem and provide treatment that will manage both sleep apnea and TMJ problems.

There are many clues in your mouth that allow an experienced dentist to suspect your TMJ problems are related to sleep problems such as tongue shape, size, and posture; teeth wear; upper and lower jawbones shape and size; and soft tissues inside and outside the mouth. All these structures are evaluated by a knowledgeable dentist to help them design a proper course of action for YOUR specific needs.

A properly designed, custom oral appliance can stabilize the jaw, optimize the flow of air, take the load of the joints and allow the muscles to relax at night, all at the same time. Talk about multi-tasking! This way, you can help both TMJ and sleep problems with one device!

It’s also important to know that a mouthguard made without these considerations can actually make it harder for you to breathe at night and should be avoided. If you are suffering from TMJ and jaw pain, don’t be surprised if your experienced dentist talks to you about your sleep quality. You might be overusing your jaw at night as your body struggles to prevent choking.

It is always best to treat the cause of the problem and not just the symptom. If your jaw pain is caused by sleep apnea, both of these conditions should be treated for the best results—no more pain and better, more restful, refreshing sleep.

Sleep-Disordered Breathing and Asthma

Asthma is a condition where your lungs react to things that normally shouldn’t affect you, making it difficult to breathe.

As we’ve discussed, obstructive sleep apnea (OSA) occurs when your muscles relax and the soft tissues in your mouth, throat and nose interrupt your breathing during sleep.​

You might not see the relationship immediately, but asthma and obstructive sleep apnea are closely linked to each other. People with asthma are much more likely to have OSA and for those who do have OSA it makes their asthma worse.

OSA is a serious health risk and if left untreated often leads to death. A partial airway blockage produces a sound: snoring. A completely blocked airway will not make any sound and is completely silent. Sleep apnea is a combination of both obstructions that occur during sleep. Aside from sleepiness, it can create a higher risk for high blood pressure, heart attack, stroke and insulin resistance.

If you suspect you have sleep apnea, you should seek treatment right away, especially if you have asthma. Schedule a consultation with your qualified dentist who can then refer you to a physician for an evaluation, diagnosis and treatment. The physician may direct your dentist to fabricate an oral appliance if it’s appropriate and you are a candidate.

Both sleep apnea and asthma are life threating and have inflammation in common. Let’s explore more so you can see how they are connected.

There are 2 key factors that play a role in the asthma and obstructive sleep apnea connection:

• Mouth-breathing
• Inflammation

Mouth Breathing and Asthma

Mouth breathing is a huge factor in the development of asthma and obstructive sleep apnea. The nose (not the mouth) should be used during breathing. This is what is known as nasal breathing. As stated in chapter 1, the nose has better air conditioning capacity.

​By enlarging the nostrils a person’s nasal breathing improves drastically in the majority of people. Studies show that when people suffering from nighttime or morning asthma enlarged their nostrils during sleep they reduced their nighttime asthma. Any inexpensive nasal dilator such as Nozovent or Mute (or even Breath Right Strips) will help keep the nostrils enlarged while sleeping.

Mouth breathing leads to the drying and cooling of the lining of the lungs causing the airway ducts to constrict and the asthma to worsen.

Inflammation in Asthma and Obstructive Sleep Apnea

Inflammation is an immune response in which white blood cells produce chemicals to fight a foreign substance and occurs in both asthma and obstructive sleep apnea. Obstructive sleep apnea produces a low level of inflammation in an adult or child. Factors such as hereditary, lifestyle and your environment are capable of increasing this level of inflammation to epic proportions.

Belly fat produces inflammation that occurs before the start of obstructive sleep apnea. This same inflammation may also affect the lungs and cause asthma. Even as early as puberty, metabolic factors such as having a large waistline, high blood pressure, high levels of fat, cholesterol and sugar in the blood are driving the development of sleep apnea, just as we see in adults.

Researchers have found that inflammation in the lining of the upper airway results in it being more collapsible and makes OSA worse. Inflammation causes the inner lining of the airways to swell and produce mucus. This makes the airway more sensitive to asthmatic triggers.

Likelihood of asthma developing into obstructive sleep apnea according to the Centers for Disease Control and Prevention Report:

​- Risk—having asthma was a risk factor for an asthmatic patient developing obstructive sleep apnea. Asthma patients face an almost 40% greater risk for sleep apnea than asthma-free patients. This risk depends on the degree of therapeutic control of the patient’s asthma: controlling asthma meant reducing the risk for being diagnosed with sleep apnea. The more uncontrolled the asthma is the more severe the sleep apnea is.

- Severity—people with obstructive sleep apnea and asthma also appear to have more severe asthma symptoms than people with asthma without obstructive sleep apnea.
- Duration—the longer a patient had bronchial asthma, the more likely that the patient would develop obstructive sleep apnea.
- Obesity—people with a BMI of 30 (obese) or more have a much higher risk of having asthma than those with a lower BMI. It is thought that belly fat tissue produces inflammatory substances that might affect the lungs and cause asthma.
- Gender—evidence suggests that the effects of asthma and obstructive sleep apnea may be worse in women.

Asthma and Obstructive Sleep Apnea Overlap:

- They occur together at the same time in a high number of cases

- They share risk factors including

1. Rhinitis—runny nose, sneezing, and stuffiness.
2. Obesity
3. Acid reflux
4. The worse the asthma severity the worse the obstructive sleep apnea severity and vice versa
5. Inflammation exists both inside the body and the airway
6. Both have an effect on the immune system
7. Asthma-controlling medications (corticosteroids) can cause patients with asthma to develop obstructive sleep apnea.
8. If obstructive sleep apnea is not adequately controlled it becomes harder to control the asthma because irregular lack of oxygen during sleep causes airway inflammation and prevents formation of healthy tissue.

Steps to Take Now:

1. If you are not sure if you have asthma or OSA let your dentist know so you can be referred to the right physician for an evaluation.
2. If you or a loved one has asthma make sure you also get checked for OSA especially children.
3. Patients with both conditions should strive for the best control of asthma, which in turn can​ improve your OSA or decrease chances of getting OSA.
4. If you have OSA continue to use your CPAP (continuous positive airway pressure).
5. If you have both OSA and asthma, CPAP use has shown to improve asthma-specific quality of life especially in older patients.

What To Do if You Cannot Tolerate Wearing Your CPAP:

1. Let the physician who prescribed the CPAP know and inform your dentist.
2. Ask for and discuss other options to treat your sleep apnea.
3. The physician will request an evaluation by your dentist to see if you are a candidate for oral appliance to treat your OSA.

Covid-19, Pandemics and Sleep Apnea

Ah yes, “COVID-19”, the “novel corona virus”! Just reading the name most likely evokes thoughts and emotional responses in your body, which are then followed by a string of hormonal reactions that are likely inducing a decrease of your immunity as we speak. You don’t even have to be infected by the virus to be affected by it!

Our thoughts alone can affect our immune systems. That’s the power of our brains. That’s why it’s often referred to as the control center.

We’re told: wash your hands, cover your cough, don’t touch your face, don’t worry about a mask, it won’t help…WAIT! Then we’re told that you need to wear a mask AND gloves, stay 6 feet apart, don’t leave your house but make sure you “get out” and exercise and eat healthy. Clean everything in your house, and keep it clean, manage your stress (sure…)! It’s dizzying!

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Did you hear the part about sleep?

Sleep 7-8 hours EVERY night or your immune system will be as non-existent as toilet paper was? In case you missed it, like most people did, here’s the scoop.

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Think of your immune system like a giant military defense force, the largest you could ever imagine and one that never rests. Every night when you sleep, your personal defense system is especially hard at work. For instance, remember the last time you had the flu (or maybe you had the COVID-19)? All you likely wanted to do was curl up in bed and sleep for days. Well, there is good reason for that!

Sleep fights against sickness by deploying your immune military and its arsenal of protection. While you rest, your body is waging war on the enemy infiltrators to make you well again. Destroying viruses, killing bacteria, and even obliterating cancerous tumor cells, is what your immune system does best, mostly while you sleep!

This process is so necessary to keep you alive, that your immune system continues to set off alarm signals of exhaustion, bringing in more troops until you’re better. The more sleep you get, the faster you will recover.

Your body needs sleep in order to fight illness, but it also needs sleep in order to stay healthy.

If you reduce your sleep by just a few hours for one night, your military defense system dramatically falls apart. Natural killer cells, the Navy Seals of your immune system, identify dangerous enemies, such as COVID-19, and eliminate them. Studies show that healthy people who had slept only 4 hours for a SINGLE night, had their natural killer cells reduced by 70%.

That’s seven deaths for every ten Navy Seals you have in your body after just one night of bad sleep! What’s even worse is trying to regenerate them. Once you miss out on sleep, you can’t just “catch up” by trying to sleep more the next night. The damage is already done. In fact, so much so that evidence of a damaged immune system from just a short disruption of sleep is still present up to a year later!

Studies have proven again and again that adults need 7-8 hours of sleep each night to bolster their immune system, while children and teenagers need at least 10, if not more.

So the next time you find yourself in the middle of a pandemic, or any other time you want to keep from getting sick, consider the immense value of sleep.

Recommendations such as washing your hands and wearing a mask help keep the virus away, and are definitely a good idea (think of that as a partial wall around your body). But if just one virus gets through that wall, who is left to defend you?

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How many Navy Seal cells are on your team? How many do you want to still be there in the morning?

Breathing Isn’t Just for Nighttime!

Mary just gave birth to a baby girl, her first child. She had some minor sleep issues during her pregnancy, but the baby, Caroline, was perfect. Of course, babies take a lot of work and Mary insisted on breastfeeding too. She was always on call for Caroline, so it wasn’t unusual for Mary to feel tired.

When Caroline was 2 years old, Mary was no longer breastfeeding and was able to sleep through the night, but she still found herself tired. She thought it was her new normal—she was a mom to a toddler, after all.

One day, Mary developed a terrible pain in her jaw that radiated into her ear. She went from dentist to​ dentist, but none were able to find out what was wrong. She finally went to an Ear, Nose and Throat doctor, who gave her a sleep questionnaire. That questionnaire showed that she might have sleep apnea so a home sleep study was recommended. It showed only very mild evidence of sleep apnea, with an AHI score (you’ll read about AHI in chapter 16) was 4. She didn’t qualify for any treatment.

Mary’s primary care physician had diagnosed her with Epstein Barr and Fibromyalgia but that didn’t explain the jaw pain, so Mary kept searching.

She finally made her way to a dentist who was well trained in both dental sleep medicine and TMJ. It turned out that Mary suffered from a syndrome called UARS, Upper Airway Resistance Syndrome, which is very hard to diagnose by standard methods and tests.

As mentioned before, most people (including many doctors) think that a typical sleep apnea patient is an overweight, older male. We refer to this as “confirmation bias.” We see what we know. We don’t see what we don’t know. Excess weight is a common finding among people with sleep apnea and it is also more common in men and older people in general. Most of us are unaware that there is another phenomenon primarily affecting thin, young women, usually with thin noses and narrow faces.

You see, breathing is something that is done all day long, not just a night (obvious, I know!). Sometimes people with smaller airways can have a hard time getting airway to the lungs in a way that is efficient and allows for the proper absorption of oxygen. We refer to this kind of airflow as “turbulent.” In such a circumstance, the body will try and maneuver itself to get a smoother flow by positioning the head, neck, and jaw in different positions. Doctors refer to this as “posturing.” Really, it’s just a way for the body to adapt to get the oxygen it needs.

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Such “better air” positions might be responsible for these people getting bad backs, muscle aches, headaches and even TMJ problems like Mary had. As we’ve seen in previous chapters, when the body has to work hard to get oxygen, it goes into a “fight or flight” mode. Cortisol is made that keeps the body UP. But, that’s not only unsustainable, it’s unhealthy and leads to many of the symptoms we see.

Because people with this phenomenon, called UARS, also have problems getting adequate air moving from their lungs to their organs at night, they often have all of the symptoms of people with Sleep Apnea:

• Difficulty initiating or maintaining sleep (Insomnia)
• Snoring – but not always
• Chronic Fatigue
• Cognitive impairment (brain fog)
• Anxiety
• Depression
• Headaches
• Non-refreshing sleep
• Excessive daytime sleepiness
• And many others.

Many people like Mary also complain of not being able to sleep on their backs. They need their bedroom environments just right: the right temperature, the right pillow, and minimal sounds or a noise machine. These people tend to not get adequate amounts of deeper sleep so they attempt to accommodate by altering their bedrooms in an attempt to improve their quality of sleep.

UARS is an ALL DAY problem, as we breathe all day long.

Mary wound up getting a night-time sleep appliance and a daytime, jaw repositioning appliance, that she wore on her lower teeth. These repositioned her jaw so that she was able to breathe better. The flow of air became smoother and gentler on her lungs. The pain in her jaw went away. Mary is now considering orthodontics so her jaw can be properly positioned without the use of an appliance.

UARS is often overlooked. If you suspect you might suffer from this, please find yourself a dentist who understands both dental sleep medicine as well as TMJ issues because, as mentioned before, they are often connected!

Mary is now happy, energetic, and pain free. She’s undoubtedly a better mommy to Caroline as well.

It’s Just Snoring!” Right?

A Blessing or a Curse?

The above quote is a rather typical review from people who eventually get treated by the right sleep dentist.

What is also typical is the underlying reason someone may have to search for 12 years to find a solution for their snoring! So many people are desperate to find snoring solutions. And when you get to the root of why they are searching for a solution, you inevitably find that it is to get back into the bedroom with their spouse (or to get back into the good graces of their spouse).

​

A 2017 survey by the National Sleep Foundation showed that almost one in four married couples slept in separate beds. Yes, you read that right. Almost one in four. There were many reasons for this stated in the survey, but among the most common was snoring, as you could have probably guessed. Especially if you are reading this chapter as a victim of secondhand sleep deprivation due to a partner’s snoring.

For many of those partners who have yet to be asked to leave the bedroom, you may suffer from bruised rib syndrome. Beware, it may be the ribs or the opposing elbows causing the damage that could eventually lead to the exit. In either case, nobody prefers to bring snoring into a relationship.

While dentists are not marriage counselors, sleep dentists do find themselves intervening in relationships every day.

There’s one dental sleep colleague who happens to be married to a marriage counselor and he always says “My wife’s job is to keep couples in the same house, and my job is to keep them in the same bedroom.” What is it that keeps someone on a journey for 12 years to fix a problem that often doesn’t “bother” him or her personally? What leads a person like the one who wrote the review above to continue looking for solutions even when surgery failed? The answers to these questions happen to be one reason you might consider snoring somewhat of a blessing. Seeing what spouses will do for each other is a blessing in and of itself.

But the real blessing of this obnoxious situation is that our body is giving us an audible clue of an underlying problem. A clue that is tough to miss if we just have someone listen to us. As much as sleep dentists enjoy helping couples with their relationships, it takes a back seat to helping people improve their health and wellness.

With our health in general, many devastating problems go unnoticed until it is far too late. Take high blood pressure for example. Many people don’t know they have had a long-term problem until they are hit with a major heart attack. Think about cancer. Without routine exams, cancer often goes undetected until it has spread so much that there are limited treatments and often a very poor prognosis.

Once a pain point has occurred in these other situations, many times the problems have done so much damage that the chances of returning to normal are minimal. Fortunately, in the realm of sleep-breathing disorders we often have clues to catch things early. Yes snoring, as ugly as it sounds, can be one of these obvious clues.

All we must do is listen and choose to act. In his book, “Sleep Interrupted”, Dr. Steven Park gives the following statistics: “It’s estimated that about 20% of men and 5% of women in their thirties snore, but these figures rise to 60% of men and 40% women in their sixties. About 35% of habitual snorers are estimated to have obstructive sleep apnea. However, of most concern is the fact that about 80-90% of people with obstructive sleep apnea are not diagnosed, implying that a significant number of snorers have undiagnosed obstructive sleep apnea.”

This simply shows that if you or a loved one are suffering from snoring—you are not alone! As we have discussed in this book, snoring sits on a continuum of breathing issues and can be a sign of more detrimental things occurring, or even signs of things to come.

Increasingly, research shows that there is an elevated chance of stroke associated with snoring alone. That means that we can no longer ignore this common problem.

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So, while many consider snoring a curse, let’s reframe that thought. Let’s consider it a blessing. It’s a chance to catch a major health problem before it’s too late…before our relationships, or even worse, our lives, are affected. Let’s also consider that it is a blessing that the treatment for snoring can be so simple.

In the next chapter we’ll discuss more about the affect snoring (and sleep apnea) has on your bed partner.

Second Hand Sleep Apnea?

I’m sleeping with a grizzly bear—how your BED PARTNER’s snores can affect your health!

In many bedrooms across the country (and world), there is a competition. Sometimes it’s a battle for the blankets. Other times it’s a tiff over the temperature. But on any given night, in as many as 50% of bedrooms, it’s a fight to fall asleep first. He or she who falls asleep first, wins. There is no trophy for the winner in this game. Instead, the prize is: NOT having to listen to the other partner snore. All. Night. Long.

The ability to sleep through the night with a snoring bed partner is actually pretty rare. When someone in the family snores, no one gets much sleep. The non-snoring partner goes to bed with a human and is awakened to the sound of a grizzly bear or a chainsaw (worst case is a bear WITH a chainsaw) sleeping next to them. And now they are doing anything BUT sleeping. They try earplugs, but they don’t stop the noise. They throw a hard elbow to their partner’s ribs, but that only helps for a few minutes. They might even kick their partner out of bed or move to the couch themselves. All of these might be temporary fixes but none are long term solutions.

So what’s the big deal? Why is it so bad to have a snoring bed partner? There are 2 big ways that having a bed partner with snoring or sleep apnea is harmful to the non-snoring bed partner. Poor sleep quality will not only affect the physical and mental health of the non-snoring partner, but it can also be detrimental to the couple’s relationship.

For 40+ years, we have known that secondhand smoke is deadly. Even though only one person is actually smoking the cigarettes, the other family members are exposed to the smoke and are at high risk for lung disease and cancer. Similarly, secondhand sleep apnea can also cause severe problems. As shown in earlier chapters, sleep disorders have serious and deadly health consequences. Although having a snoring bed partner doesn’t cause you to have pauses in breathing or drops in oxygen levels, it does cause major sleep disruption. Chronic sleep disruption and/or deprivation can easily lead to weight gain and mood disorders, such as anxiety and/or depression. It also causes excessive daytime sleepiness, which is the leading cause for car accidents and poor job performance.

In addition to serious physical and mental health risks, permanent damage can be done to the​ relationship between the partners. Sleep disruption can lead to moodiness, anger and conflict that extend well beyond the walls of the bedroom. Tired and cranky people are quicker to disagree or respond in anger, often saying things they don’t really mean or wouldn’t normally say. But like toothpaste squeezed out of a tube, hurtful words cannot be taken back once they are said. Many of these couples end up in costly therapy or counseling.

“Laugh and the world laughs with you.
Snore and you sleep alone.”
~Anthony Burgess​

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Dr. Oz told a story on The Today Show about “Sleep Divorce,” where couples sleep in different rooms in order to get more restful sleep. As mentioned in the previous chapter, The National Sleep Foundation reports that up to 25% of American couples are already sleeping in separate rooms, and even more wish they were. But who enters into a long-term relationship with the goal of sleeping in different bedrooms? Intimacy can suffer when physical walls are between partners, thus setting the stage for emotional walls to develop. And though it may help temporarily, this physical separation is more of a band-aid rather than a solution to the underlying problem.

Worst-case scenario? Your partner awakens you because they are having a sleep apnea-induced heart attack. Or you wake up in the morning to find they’ve passed in their sleep. Both are very real possibilities for someone with sleep apnea. That’s a nightmare no one should have to live, and yet it happens all the time.

When a person is snoring or has sleep apnea, everyone suffers: the one doing the snoring, the one hearing the snoring, and the relationship between them. But there is great news! There are easy and effective ways to treat it; resulting in everyone getting deep and restful sleep, which not only saves lives but also relationships.

Sleep and Pregnancy

Pregnancy and sleep-disordered breathing. Is that really a thing? One more item to add to the list for women to worry about! ​

Pregnancy is full of so many emotions and concerns: excitement, hope, being fulfilled, love, fear, and anxiety to name just a few. The point, however, is not to add one more reason for anxiety, but to have the ability and knowledge to provide a more restful and healthy environment for women and their little ones on the way.

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In fact, a healthier sleep with proper breathing decreases stress and anxiety. Quality sleep helps our hormones regulate better so we can be calm, think through our fears, eat healthier, and function better. As a result, expectant mothers feel more confident about this beautiful but sometimes uncertain time of their life, and the baby benefits as well.

Although we have already covered the definition of sleep-disordered breathing and sleep apnea in previous chapters, it is well worth repeating here so we can see how it affects pregnancy…

The phenomenon of sleep apnea is when the airway begins to collapse, either partially or fully, creating an obstruction in breathing. When this happens, the “fight or flight” response that we’ve mentioned before triggers a host of reactions, creating great stress on the body. Breathing gives us oxygen. A dip in oxygen levels when we are not breathing creates a spike in blood pressure which is part of that fight or flight response. As this happens over and over again during the night, the whole cardiovascular system is put in a state of distress.

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For pregnant mothers this causes a very high risk of preeclampsia and pre-term delivery. These babies are twice as likely to have low birth weights and be placed in the NICU (neonatal intensive care unit). Pregnant women who might live at high altitude such as in Colorado live with chronically low oxygen levels and may already be predisposed to blood pressure disorders.

The feeling of a fight or flight response is usually not something any of us enjoy (except maybe on a roller coaster or those who like skydiving). Adrenaline and cortisol are the hormones that rush through the body to create that feeling, with cortisol being the primary stress hormone.

The event of a breathing obstruction during sleep causes a surge in cortisol. Again, there is a domino effect as that imbalance of hormones increases blood sugar levels and leads to a high risk of gestational diabetes in pregnant women. In fact, if there is a severe level of sleep apnea during mid pregnancy, the chance of gestational diabetes is twice as high.​

Expectant mothers have been under-recognized as a group at risk for apnea. Mothers need a restful sleep for themselves and their babies. However the research is clear and the prevalence of obstructive sleep apnea can be as high as 26% in the third trimester.

With this knowledge, what can be done about it?

CPAP is often prescribed for sleep apnea and has been shown to be effective. It works by pushing air into the airway at whatever pressure is needed to blow open and prevent collapse of the airway that occurs during an oxygen-depleting event. CPAP works! Unfortunately, many people find it cumbersome or claustrophobic. It is hard enough to find a comfortable position during pregnancy without adding a machine to the mix!

Dental appliances also treat sleep-disordered breathing and are easy to wear and get used to. The additional bonus is that it also helps relieve the extra snoring, which often occurs during pregnancy too. ​

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Dental appliances for sleep apnea have grown in popularity over the years and have been verified by many research studies as to their effectiveness. These appliances gently hold the lower jaw in a position that keeps the airway open, providing the restful night sleep that is so crucial especially for pregnant women. Your medical insurance carrier might even cover it!

The expectation of new life sparks a level of love and a protective role in women that is undeniable. A good night's sleep can only enhance that miracle.

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Sleep Apnea and Menopause

Sleep apnea awareness is growing all around us. Most people appreciate the need for a good amount of restful sleep. Yet, many people fall short of national recommendations or even their own personal expectations. Thankfully, more and more people are being tested and, when appropriate, treated for sleep-disordered breathing.

Unfortunately, sleep apnea is often stereotyped as mostly affecting older, overweight men and therefore, many women are not getting evaluated for the problem. As you’ve seen with Mary’s story in chapter 11, young women are not immune from sleep-disordered breathing problems. Older women aren’t immune either.

According to research, men are 8 times more likely to be tested for sleep apnea than women. One of the main reasons is that the “classic” symptoms of sleep apnea such as very loud snoring and excessive sleepiness during the day are more common in men. Women with sleep apnea often present with more subtle symptoms such as insomnia, fatigue and mood disorders.

Snoring might not be quite as loud and disruptive due to the shape and size of the female airway. Instead of being tested and treated for sleep apnea they are given medications and left with no help for the underlying problem. This is especially true for middle-aged women who are premenopausal or actually starting menopause.

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Insomnia, frequent awakenings, mood swings, hot flashes, memory loss, fatigue—all of those symptoms are often accepted as part of “normal aging” and leave a woman with no choice but to suffer from a lack of restful sleep.

What is often ignored is the fact that many of these symptoms are, in fact caused by developing sleep apnea. Studies indicate that more than 20% of women will develop sleep-disordered breathing in midlife.

Why do women develop sleep apnea later in life?

It turns out that to some extent, women are protected from sleep apnea by female hormones—estrogen and progesterone. The hormones maintain the airway’s muscle tone and keep it from collapsing.

As the level of these hormone begin to decline, the incidences of sleep apnea in women increase. In fact, older women have the same risk of developing sleep apnea as their male counterparts.

Women who have hysterectomies and similar surgeries that affect their hormones have the same issues. They too are more prone to sleep apnea.

And, it seems that women who have sleep disturbances are also more prone to depressed mood and clinical depression.

The good news is that with proper treatment, sleep quality can be dramatically improved. In fact, there are several studies that found when women were treated for a sleep disturbance, that sleep treatment enhanced their other treatments for depression or alleviated their depressed symptoms altogether.

​​But if sleep apnea is due to a hormonal imbalance in these women’s midlife years, then what about hormone replacement therapy?

Good question, and a complex one.

According to a well known sleep doctor, “The decision to use HRT is a highly individualized one, a decision women should make in consultation with their physicians, and with consideration of their health and family medical history, age, where they are in the menopausal transition, the severity of their menopause symptoms and the effectiveness for them of non-hormonal therapies in relieving those symptoms.”

It turns out that use of estrogen and progesterone for longer than 5 years is linked to an increased risk of breast cancer.

Because of the complexity of hormone replacement therapy (HRT), a more conservative approach to resolving sleep apnea might be preferable. Oral appliance therapy (OAT), might be part of the solution. It might allow a lower dose of HST or negate its need at all. Certainly, it’s worth a try?

There are so many things that are out of our control. Seeking help for sleep problems is a choice, as is choosing the treatment that is right for YOU!

How is Sleep Apnea Diagnosed?

How do you know if you have obstructive sleep apnea? We’ve gone over many of the symptoms, and probably by now you are “sure” you have it! But just in case you’re in doubt, let’s repeat some of them here with some more “in depth” explanations.

Symptoms like snoring, silent pauses in breathing followed by choking and gasping sounds are all very common and obvious. Interestingly, people who suffer from sleep apnea are often unaware of just how much their sleep is disrupted. It is usually a bed partner or a family member that brings it to their attention as their own sleep is disrupted by the loud and often scary sounds.

Other symptoms like unrefreshing sleep, fatigue, morning headaches, memory loss, and daytime sleepiness are also common. However, since most people suffer from sleep apnea for many years (and some of its effects come on gradually), they might think that these symptoms are “normal”—they don’t even know what a good night's sleep feels like! Even worse, they often label themselves as lazy or unmotivated without realizing that they just never get a good night's rest and have to power through the day because of their disease.

It is estimated that more than 15 million people in America suffer from undiagnosed sleep apnea. Many of these symptoms are so common that we, as a society, consider them “normal”. In truth, it might currently be “normal” to drink 4 cups of coffee and a Monster drink just to get through the day because so many people do it, but that doesn’t mean it’s right or healthy, or makes sense.

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But to a doctor or dentist who is trained in sleep-disordered breathing, it does all make sense. Through asking the right questions and gathering information they can suspect that you have a disease and recommend a sleep test that will study your nighttime breathing, detect the abnormalities and determine if you have a disease. The sleep test will also determine the extent of the problem. Depending on how often the breathing is disrupted while you sleep, sleep apnea is classified as mild, moderate or severe. This information is crucial to develop successful personalized treatment recommendations.

A sleep test is a non-invasive study of your nighttime breathing and some other body functions. Depending on your needs and doctor’s recommendations, the sleep test can be a polysomnopraph (performed in a clinic) or at your own home with a home sleep test. Polysomnography

​Polysomnography is a very detailed study of your sleep. You will spend a night in a sleep laboratory. There will be a private bedroom and you can bring your own nightclothes. After you arrive and check-in, a specially trained technician will attach small adhesive electrodes and other monitoring equipment to your body. These will help to record brain activity, heart rate and rhythm, oxygen levels in your bloodstream, and leg and other muscle movement. After the technician is done, you will be left alone to relax in your room. After you fall asleep the technician will monitor the instruments in a nearby control room. All the data from the instruments and electrodes will be recorded. Later on, a medical doctor who specializes in sleep disorders will evaluate the data and provide an accurate diagnosis based on the results of the test.

Since children’s sleep is complex, they can only be tested for sleep apnea with polysomnography. When a child is tested, 2 bedrooms are usually provided—one for the child and an adjoining room for the parent.

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HOME SLEEP APNEA TEST is another option to diagnose obstructive sleep apnea.

A home sleep test is performed in your own home. You will receive a kit with instructions and before you go to sleep at night you will set it up yourself. There are many different kits available but most will include a nasal cannula (a tube that goes under your nose to monitor airflow), pulse oximeter to monitor heart rate and blood oxygen level (usually a comfortable clip on your finger), a chest belt to monitor breathing pattern and a recorder to gather all the data. After you return the kit, the data will be analyzed by a sleep doctor.

With a home sleep test, only airflow and oxygen are measured and the numbers are sometimes affected by the lack of monitoring of the other functions and parameters. However, there is an obvious convenience to this test as it can be done at home. Home sleep tests should be used in people that have a fairly significant level of obstructive sleep apnea as they tend to often overlook subtle changes in breathing.

If your home sleep test says you DO NOT have sleep apnea, that may NOT be true and your results should be discussed with your doctor to see if an in-lab study would be appropriate to diagnose more complex sleep-disordered breathing. If your home sleep test says you DO have sleep apnea it is always correct.

The sleep test is a non-invasive and easy way to diagnose obstructive sleep apnea. Many people are surprised to find out just how bad their sleep quality is. They also feel relieved to find out that some of the vague symptoms that they have suffered with through the years are actually caused by a very real disease.

The best news is, once the disease is identified, there are non-invasive treatments available to help you to get a better night's rest and ultimately a better quality of life.

What Do the Numbers Mean?

The information gathered during your sleep study—either a home study (HST) or an in-lab study (PSG)—are used to determine your problem and the severity of it. And, while the numbers do tell your doctor a lot, there’s more to helping you than JUST the numbers.

During the study the number of times you stop breathing(apnea)or breath too shallowly(hypopnea)are recorded. Reduction in the level of oxygen(oxygen desaturation)in your blood is also noted. This information is used to classify the presence and severity of obstructive sleep apnea (OSA).

Types of airway obstructions:

• Apnea—a complete collapse of the airway, breathing stops for 10 seconds or more and airflow to the lungs is blocked.
• Hypopnea—a partial collapse of the airway, breathing is reduced for 10 seconds or more and airflow to the lungs is restricted.

The Apnea Hypopnea Index (AHI)is the number of apneas and hypopneas per hour of sleep. It is calculated by adding the apneas and hypopneas together and then dividing that number by the number of hours you slept, like this:

AHI= Apneas + Hypopneas
​Total hours of sleep

Once you have your AHI you can use this table to Classify your OSA severity:

Your sleep study results may also include another number called the Respiratory Disturbance Index (RDI). This number includes apneas, hypopneas and other additional breathing irregularities. So, the RDI is often higher than the AHI.

When having episodes of apnea or hypopnea during OSA, the level of oxygen in your blood may fall, depriving your body of much needed oxygen. This is known as oxygen desaturation, and is another number you will find on your sleep study.

At sea level, normal blood oxygen saturation is usually around 96-97%. During sleep a desaturation to 90% is generally considered mild, dips to 80-89% moderate and below 80% severe.

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The Oxygen Desaturation Index (ODI)is another index on your sleep study report. This index is measured by the number of times per hour that the oxygen level in your blood drops by a certain percentage from your baseline number. The American Academy of Sleep Medicine (AASM) counts a 3% drop as a desaturation and Medicare uses a 4% drop.

Once you have your sleep study results, you and your doctor can review them and then based on the presence, severity of the disease and individual factors can determine the best course of treatment for you.

Understanding your numbers is important, but they are only one part of the complex puzzle making up your sleep. The treatment decision that YOU and your doctor will make should take into account many different variables to help you achieve your ultimate goal of restful, refreshing and health-promoting sleep.

Do-It-Yourself Remedies

THE GOOD, THE BAD, AND THE COSTLY

I bet you are thinking that I will tell you there are no good Do-It-Yourself solutions for sleep apnea?? That is not the case! There are absolutely some great things you can do on your own to help yourself.​​​

Of course there are also some very dangerous things out there that can get you into a whole lot of hot water, be very costly to fix, and can even do quite a bit of damage— including not adequately treating your sleep apnea. That puts you at a very high risk for your overall health, as you have already learned in previous chapters. In addition, the degree to which DIY remedies will help varies depending on the severity of your sleep apnea and the type of sleep apnea you have. It is best to discuss these remedies with either your sleep physician or qualified dentist, to determine if any of them could be a benefit to you. This way you won’t waste your money or jeopardize your health.

THE GOOD

Some of the more obvious DIY remedies are:

• Avoid alcohol within 3 hours of bedtime.

• Avoid caffeine after 1 in the afternoon.
• Drink plenty of hydrating fluids.
• Get regular exercise.
• Maintain a healthy weight.
• Eat a balanced diet.
• Keep a consistent sleep schedule.
• Keep the room you sleep in dark and cool.
• Avoid electronics and screen time at least 2 hours before you go to bed.

These are also called “good sleep hygiene habits.”

Nasal dilators like Mute, Nozovent, and Breathe Right Strips can help by keeping the nasal passages open and enhance airflow. This can be particularly beneficial if you have a compromised or obstructed nasal airway.

Vitamin supplementation has shown to be beneficial as well. For instance, low levels of vitamin D are associated with poor sleep quality and sleep quantity. Additionally, several studies demonstrate a lack of vitamin D may also affect the severity of sleep apnea, with lower D levels linked to more severe cases of OSA.

A 2009 study showed that a combination of Vitamin C (100 mg) and Vitamin E (400 IU) taken twice daily reduced episodes of apnea, the interrupted breathing that is the hallmark, or main symptom, of OSA. This C and E combination also improved sleep quality and decreased daytime sleepiness.

There’s evidence that B6 also aids sleep—and affects our dreams. The role of Vitamin B12 is interesting. Several studies have demonstrated that this vitamin is involved in regulating sleep-wake cycles by helping to keep circadian rhythms in sync. More research is needed, however.

Some people have what is called a “positional component” to their sleep apnea. For some people, staying off of your back will, essentially, cure your sleep apnea. For other people, staying off your back will only improve your sleep apnea but not completely cure it.

If you do not have what is called a “positional component” to your sleep apnea, then positional aides that help keep you off your back will not help you at all and will be a waste of money.

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If you do have a “positional component” to your sleep apnea, you can purchase these positional aides online. Many are available on Amazon. Some examples are the Slumberbump and Zzoma. They are essentially pillows that you wear like a belt and if you try to roll onto your back, they don’t let you. Or make your own with a t-shirt, a tube sock, a few tennis balls and some large safety pins.

There are also devices that you wear either around your head, your neck or your midsection that vibrate if you roll onto your back. The fancy term for these devices is “vibrotactile” stimulation. They are similar to a doggie shock collar on the lowest levels. I don't think anyone needs to worry about yelping in the middle of the night if you roll on your back, but it will certainly wake you up to get you off your back! Pricing varies quite a bit, ranging typically between $100 and $300 and they do require a prescription from your sleep physician.

THE BAD

One could argue that the vibrotactile stimulation devices could be in this category. They don't actually hurt you, but they have the potential to be “uncomfortable,” shall we say? And they wake you up if you roll on your back which is something we’re trying to minimize.

Another device that is readily available online is a tongue retaining device, or TRD, which were mentioned in the previous chapter. A TRD is a little suction cup that holds the tongue forward while you sleep. Again they don't hurt you, but they are not exactly comfortable and few people who have teeth (and thus have other options) chose to use them. Imagine falling asleep with your tongue stuck to a frozen flagpole. The only people we have seen use these successfully are our Down syndrome patients.

THE COSTLY

The items mentioned here might be costly in several ways. They may hurt your pocketbook without delivering any value to your health, could actually harm your health as well as your pocketbook, or cause unwanted side effects that can be very costly to fix or manage.

Medications that claim to “fix” or “cure” sleep issues. Unless a medication was prescribed or​ recommended by your sleep physician, it should not be used. There are too many unsubstantiated claims out there to name, so unless it is recommended by your physician or other sleep professional that knows YOUR specific health history, do not take it.

Melatonin can be beneficial if you have trouble falling asleep or maintaining a consistent sleep schedule. I would recommend speaking with a sleep physician prior to starting this on your own, as there may be other non-medication ways to achieve the same results.

Myofunctional Therapy done by a skilled therapist can be a fantastic adjunctive treatment. But it requires proper initial evaluation and measurement of progress to be effective. Looking it up on YouTube will likely not give you the evaluation and guidance needed for this type of therapy to be effective.

Over-the-counter oral appliances are WAY bulkier than custom appliances, do not hold up well and have been proven to not adequately treat sleep apnea. They HAVE also been proven to really mess up many people’s teeth. This can be incredibly costly to fix via orthodontics, restorative and/or cosmetic dentistry and in some severe cases, jaw surgery.

A skilled, qualified dentist, who can discuss your particular situation and the risks ahead of time to help you make an educated decision, should provide YOUR oral appliance.

As you can see there are many things you can do at home to improve your health. Hopefully I have enlightened you to other things that, at best waste your time, and at the worst, can actually do harm. It is always best to consult with an expert when it comes to matters of your health. You have learned in previous chapters that untreated or inadequately treated sleep apnea can have very serious medical side effects—treatment for sleep apnea should not be taken lightly.

My Dentist Does What?

What Your Dentist Has to Do With Sleep-Disordered Breathing?

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The plain fact is that more people go to their dentist than go to their physician. So dentists have been trained, in the interest of public health to spot other diseases such as high blood pressure, oral cancer, and now sleep and breathing issues.

Plus, we know that what happens in the mouth, doesn’t stay there, it affects the entire body. Dentistry is progressing to become another sub-specialty of medicine. The doctors who have contributed to this book all appreciate that and incorporate it into their practices.

So, even your routine dental visit to the hygienist might not look as “routine” as it used to. It may include x-rays, oral cancer screening, nutrition counseling as well as a gum analysis and treatment to help remove bacterial deposits and instructions on how you can take care of these issues at home.

We might also have you fill out a questionnaire so we can help assess the quality of your sleep. Two of the more commonly used sleep screening forms are the STOP BANG and the EPWORTH Sleepiness Scale.

These questionnaires often spark discussion as people might be aware of a problem or perhaps even had a sleep test and have been told they have sleep apnea. Some might have even tried to use a CPAP but couldn’t find a mask they could tolerate. Even those people who don’t have sleep apnea always seem to know and love someone who does.

These discussions make many people aware that there are other solutions to sleep-disordered breathing that are effective, comfortable alternatives.

Dentists trained in TMJ and dental sleep medicine are also trained to spot the telltale signs of sleep-disordered breathing like worn and chipped teeth or ridges in your tongue. They know that “grinding” can mean a whole lot more and that jaw pain might be a sign of you not getting enough oxygen.

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Such specially trained dentists know the intimate relationship that exists between the mouth and the rest of the body and specifically between how you breathe and how the mouth and jaw are positioned and function. Sadly, your dentist’s role in the breathing process (and hence the sleeping process) is not well-known or appreciated yet by many dentists since this cutting edge field is not really taught in many dental schools yet.

If your dentist suspects that you have an airway problem, you might be referred to your physician, an Ear, Nose and Throat doctor or even a sleep physician. You might be tested with either a home sleep test (HST) or be asked to sleep overnight in a special sleep center.

The important thing is that you get diagnosed so you can be treated properly. Dentists can play an important role in recognizing the problem, help you get the diagnosis, then help you use your CPAP or offer you a treatment option like an oral appliance to help solve the problem.

Breathing is something that involves the structure in and around the mouth. Why wouldn’t a dentist, who specializes in that part of the body, be involved?

Our current healthcare system has become too complex, polarized and specialized. Everyone seems to have his or her little niche. Specially trained dentists have been in the forefront of the collaborative movement to work with your entire healthcare team to achieve a common goal: YOUR EXCELLENT HEALTH AND WELLBEING.

Your Dentist and Your Physician

By now you know more about sleep-disordered breathing than almost everyone around you! But if you haven’t experienced the journey from suspected sleep apnea to effective treatment yourself, then you might be wondering what it looks like! What would a person expect when being seen for sleep apnea therapy?

This chapter will take you through the process of becoming healthier, happier and more refreshed by managing your sleep apnea with a custom oral appliance.

The first step on the journey is realizing you have a problem. Many people “self-refer” to a doctor or dentist because they think something is going on.

Others come at the insistence of their spouse who is probably suffering from “secondhand” snoring and sleep apnea, even though the offending person themselves reports sleeping well. Their spouse may actually fear going to sleep, feeling they need to stay awake watching their loved one stop breathing for more than half a minute multiple times through the night so they can poke them to start breathing. When the exhausted spouse does finally fall asleep, they doze off only to be awakened by loud disruptive snoring.

Not all people snore and not all people visibly or audibly stop breathing and then gasp to start breathing again, but many do and their bed partners suffer along with them. A person can arrive for help expressing a combination of embarrassment, irritability and/or exhaustion. After all the yare sometimes in the office “for the spouse” but likely they know something is just not right.

At a consultation appointment you will be asked about underlying medical conditions such as Type II​ Diabetes and High Blood Pressure among others. Vitals will be taken to determine your neck size, height, weight and BMI (body mass index).

If you self-refer and have never had a sleep study, the doctor or dentist will discuss a sleep study with you and then send out a request or referral for one. Once a sleep study is done you will discuss the results with your medical doctor. If you are diagnosed with sleep apnea, you will either be put on CPAP therapy or you will be referred back to your dentist to see if you are a candidate for an oral appliance. If you think you won’t be able to tolerate CPAP for some reason and you want to try an oral appliance, you may need to advocate for yourself and talk to your medical doctor to let them know you want to try oral appliance therapy first. When your doctor refers you back to your dentist, the process of beginning your journey to healthy sleep using an oral appliance has begun!

The next step is a thorough dental examination and digital scans of your mouth and teeth (or​ standard “trays of goo” impressions) are collected. Digital scans, when available and possible, offer advanced technology and accuracy, and eliminate the need for the “trays of goo” you may have experienced in the past. This examination, although thorough, is painless and easy to tolerate.

At this appointment your dentist will discuss different oral appliances that might work for you, depending on your nighttime patterns, condition of your teeth and gums, and many other factors. Together you will select one that will work best for you.​

Your sleep dentist then takes over while you return home or to work and your custom oral appliance is designed and made just for you. It is customized around your unique teeth, fillings, crowns and any teeth you might be missing.

Where else are you able to have a medical device made just for you?

The custom device is generally available for fitting and delivery within 2-4 weeks. At your fitting appointment your oral appliance will be adjusted for comfort and you will learn how to take care of it. Any questions you have will be answered and you will place and remove the appliance by yourself. Printed instructions will also be provided for take home reading and reference.

Your dentist knows how important it is to keep your medical doctor informed on your progress. Letters are sent to them after your consultation appointment, your fitting appointment, and various other appointments. When needed your dentist will reach out to your doctor to discuss your case as well. A team approach is definitely the best approach!

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Now that you have your appliance it is very important that you check in with your dentist at follow-up appointments to make sure the appliance is working well for you and is taking care of your sleep apnea. The most expensive therapy is one that doesn’t work as well as it should!

The frequency and number of follow-up visits will vary depending on you and how your treatment is progressing. Some people are able to wear their appliance through the night from the time they put it in. For others it may take between a few nights and a few weeks before they put in their appliance and not even notice it’s there.

Once you are able to wear the appliance all night, you will need to keep track of your symptoms. Are you still sleepy? Do you still doze off at red lights? Does your spouse report that you are still snoring? Your dentist will want to adjust your appliance until you have a resolution of your symptoms. Depending on the appliance you and your dentist select, your dentist may be able to give you the ability to do some small adjustments yourself (to how far forward the appliance is set), making in-office visits less frequent. Over the course of a few weeks to a few months you and your dentist will find the position where your symptoms are resolved. How long it takes will depend on the response of your airway. Every airway is unique, and its response will vary based on what it needs and the condition it’s in when treatment starts (how much healing has to take place). But you’ll get there! WAHOO!!!

Here are some things you can watch for as you progress on this journey:

• Most people report that their appliances are comfortable, easy to use and easy to care for.
• The majority of people report they are sleeping better, snoring less and have resolved the daytime fatigue and sleepiness they previously thought were “normal.”
• They also often report their spouse is sleeping better too and are incredibly grateful.
• They can wear their appliance every night, all night and would miss wearing it since they feel so much better. Some people even get a spare appliance for travel or for a second home, not wanting to ever be without it.
• They report that since they have more energy, they are exercising more, craving bad food choices less, and have lost weight.
• Their physicians are happy knowing their patients have found a therapy they wear well and is helping them sleep better and live better.

Of course, the only way to REALLY KNOW the effectiveness of your oral appliance is to have a follow-up sleep study. These might be recommended by your dentist or doctor while you are trying to find the perfect position of your appliance or once you and your dentist think you’ve found the spot, based on your symptoms.

Letters are again sent to your referring physician, and will include any subjective improvement reports and progress home sleep studies with your appliance in (if your dentist is allowed to do those in your state). And now that you are sleeping better and snoring less, your sleep dentist will recommend returning to meet with your medical doctor to discuss possibly adjusting any medications you’re on to manage medical conditions that could have been improved through the treatment of your sleep apnea.

Finally, you will be on a yearly appointment schedule. At these annual visits your dentist will check for wear and tear on your appliance, tighten and adjust anything that needs to be addressed and make sure your appliance is still performing as it should.

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Great results are possible! The vast majority of patients improve their sleep apnea with a custom oral appliance and for most it is truly a blessing and a life-saver!

Potential Complications

When it comes to complications, it’s important to put things into perspective. The complication of NOT being treated for sleep apnea is DEATH! Or, if your sleep apnea is causing you to be tired during the day, then when you’re driving and fall asleep at the wheel, it could also result in other peoples’ DEATHS as well. This scenario happens every day in America!

You hear of people dying in their sleep all the time. Some even look at it as the “best” or “natural way to go.” There’s nothing good about gasping or choking for breath and nothing natural about dying in your sleep.

Do you think that putting a plastic bag over your head is a natural or good way to die? That’s what it’s like to die from Sleep Apnea.

Most people who die in their sleep do so because of sleep apnea related issues like heart attack and stroke.

Think about it. You can understand someone dying when they’re shoveling a foot of snow or doing other hard labor that puts a strain on their heart. But shouldn’t sleep be a time when the heart relaxes???

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Indeed, it’s only when the heart is over-taxed, over worked and lacks enough oxygen, as happens during a sleep apnea event, that it can succumb and stop working. Death during sleep is NOT NORMAL. That’s a pretty serious and sad consequence to leaving your sleep apnea untreated.

OK, with that in perspective, let’s talk about the potential complications of various treatments.

Many treatments for snoring, sleep apnea, UARS and even TMJ have been discussed. Every treatment can have negative, sometimes unintended consequences. EVERY SINGLE ONE!

Even the do-it-yourself ones can have unforeseen, sometimes severe complications including giving a person the false sense of security that they are actually solving their problem, when in fact, they might be making it worse. The most important thing to remember is that because DEATH is the ultimate complication, YOU should do everything YOU can to make certain that any treatment YOU decide to use is EFFECTIVE at solving the problem.

US Supreme Court Justice, Antonin Scalia, had sleep apnea which was treated with a CPAP. Yet, when he died, the CPAP was on his nightstand, unused. He suffered the ultimate consequence of treatment that wasn’t used properly.

Get diagnosed properly, get treated adequately and get followed-up with properly to ensure that the problem has been resolved. And, just because it was resolved a few years ago, doesn’t mean that it hasn’t come back!

When you have been diagnosed with Sleep Apnea, you need monitoring FOREVER.​

Want to know about the other complications?

CPAP—The complications involved with CPAP therapy include:

• Runny nose, earache, sore eyes
• Sore or inflamed skin
• Feeling claustrophobic
• Dry mouth
• Difficulty tolerating forced air, including air leak out the mouth or eyes
• Sleep interruptions of bed partner
• Stomach filling with air
• Side Bar—Recently some doctors are recommending people who have COVID-19 should not wear a CPAP to avoid spreading the virus to others.

Dental Oral Appliance—The possible side effects of wearing a sleep apnea mouth device include:

• Bite changes (the upper and lower teeth may seem to align themselves differently in the morning)
• Developing spaces between teeth leading to food getting stuck between them
• Dry mouth
• Excessive saliva
• Tooth and/or jaw discomfort
• Side Bar—Keep in mind that dogs LOVE these appliances—they make for very expensive chew toys. When you get one, keep it out of Fido’s reach.

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Inspire—This is a “pacemaker” like device that is surgically implanted in your chest. Side effects and risks include:

• All the complications of a surgery under anesthesia
• Tongue soreness and/or weakness
• Infection
• Damage to the nerve
• Discomfort from stimulation
• Extremely Expensive (although this isn’t a side effect, it is definitely something to consider)
• Side Bar—The Inspire requires periodically replacing batteries, which means additional surgeries.

Health/Wellness—

• In some cases weight loss can help sleep apnea symptoms for obese individuals. Overweight people often have thick necks with extra tissue in the throat, which may block the airway. There is no guarantee that losing weight will eliminate the sleep apnea although it may help, and will certainly improve overall health.
• Side Bar - This approach is unlikely to make a difference in people with a narrow nasal passage or airway.

Some additional notes:

Oral Appliances: when these are made well, adjusted properly and monitored, there are few complications. The most common ones are bite shifts and teeth shifting. Your Dentist should be showing you how you can prevent these and how YOU can monitor your mouth for slight changes.

Jaw or TMJ discomfort: can occur whenever muscle and jaw positions are changed. These are usually due to the body’s adjusting to the new positions and are temporary. They should, however, be brought to your dentist’s attention.

Remember, little problems are usually easy to fix. When they grow and become bigger, its harder and often more costly to fix.

Surgery: There are many surgical procedures other than Inspire (the pacemaker type surgery) that can be used to help resolve these problems. Each has its own set of complications, which should be thoroughly discussed with the surgeon BEFORE a commitment is made to proceed.

Before doing an invasive, irreversible procedure you should always ask yourself, “Is there a more conservative way to solve this problem?”

CPAP: While this is still considered the “gold standard” of sleep apnea care, there are issues to be aware of. Like Justice Scalia, if you don’t wear it, it can’t work. And many people find it uncomfortable and inconvenient, especially when they travel or have a cold.

Plus, CPAPs are very hard (some say impossible) to clean, and during the covid-19 pandemic, the American Academy of Sleep Medicine recommended people not use their CPAP in certain circumstances. What did these dedicated CPAP users do if they didn’t have an oral appliance as a back up?

All treatments CAN have negative consequences. That’s why they have to be done properly, checked to see if they’re working properly and monitored regularly to see that they continue to serve the function that they were intended to serve—TO SAVE YOUR LIFE.

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Performance Enhancing Sleep

Three hundred yards to go! The four athletes had broken away from the main peloton of cyclists at mile 70. Working as a ‘team of competitors,’ they take turns pulling and drafting to stay out front. The years of sweat-fueled conditioning has propelled them up sharp climbs and over miles of cobblestones to find themselves now staring at the finish line. . . their camaraderie over the last 30 miles, suddenly a distant memory. Now they slow and watch. . .who amongst them will start the final attack towards the finish line?

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Who has enough fuel left in the tank to sprint for the win? Who has the mental sharpness to decide when and how to lead the attack towards the podium? Was it the athlete that logged only 5 hours of sleep? Was it the athlete that got 8 hours of poor quality sleep?

The endurance and sport specific judgments needed for these cyclists to grab the win rely on three pillars: DIET, TRAINING, AND SLEEP. A lot of energy and money is typically funneled into supporting athletes with the most well-planned nutritious meals, and the most sophisticated training regimens…all custom designed to meet the athlete’s personal strengths and weaknesses.

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But what about the third pillar…SLEEP? Could concentrating on a personalized sleep-training regimen translate into improved sports performance and sleep recovery?

We’ve learned that a significant percentage of our general population has an underlying sleep-disordered breathing issue, like snoring, upper airway resistance syndrome, or obstructive sleep apnea. We also have learned that these conditions lead to decreased decision making skills, decreased release of hormones that support immune function, muscle recovery from damage and fatigue, and lead to poor food choices. So, what percentages of our athletes fall inside this pool of undiscovered sleep-breathing issues? Probably more than we may think!

In the world of an elite athlete, oftentimes the separation between 1st and 2nd place can be a mere 1-2% difference in power output between you and your opponent. So as we’re testing an athlete's VO2 max, fluid dynamics through air or water, and power output…let us add in a sleep screening. Let us find out IF and WHAT underlying sleep issue may be keeping this athlete from their best performance. Let us use the techniques outlined in this book to clear the airway for these athletes to maximize sleep-related recovery!

And, speaking of performance, there are other types of performance that getting the proper quality and quantity of sleep helps too…if you get the drift!