Dr. Jamison R. Spencer
Dr. Claire-Marie Bender
Dr. Kip Covington
Dr. Elizabeth Duling
Dr. Frank Henrich
Dr. Chiarina Iregui
Dr. Chuck Jelinek
Dr. Erica Johannes
Dr. Tanya Kushner
Dr. Gemma Kwolek
Dr. Angela Lunn
Dr. Alfred Marquez
Dr. Sharnell Muir
Dr. Kevin Postol
Dr. Anitha Prasanna
Dr. Jessica Sabo
Dr. Ashley Smitherman
Dr. Trish Takacs
Dr. Amy Thompson
Dr. Keith Valachi
Dr. Joan Werleman
Dr. Kathi Wilson
Editor in Chief: Dr. Michael Goldberg, Assistant Editor: Jennifer Spencer
This book is dedicated to Ellen. 42 years as my college classmate, wife, mother to Alanna, Mike, Conor, and Murray, Co-Founder and Chief Financial Officer of Boston Center for Oral Health. Thank you for no longer tolerating my snoring and encouraging me to find a solution to my poor sleep. It has led to a new level of physical wellness and professional fulfillment that this book represents. Sharing your life’s journey with me – that has made all the difference.
I gratefully recognize two people who have helped to make this book possible: Dr. Noah S. Siegel, and Dr. Jamison. R. Spencer – first by introducing me to dental sleep medicine at the Tufts University School of Dental Medicine’s Dental Sleep Medicine Residency (TUSDMDSMR), and then guiding me to this day with their care, skill, and judgement.
Noah’s role as an otolaryngologist (ENT) took me beyond people’s teeth, gums, and tongue to a deeper understanding of the structures of the airway, which allow us to breath. It is the foundation of my dental sleep medicine practice and of this eBook – Breathe Well, Sleep Well, Live Well.
The ability to build on this foundation has been made possible by Jamison, first in the TUSDMDSR by demystifying the Temporomandibular Joint (TMJ), its function, issues that occur with this joint, and predictable ways to solve the problems in this part of our bodies. Then, with the confidence to “do no harm”, he taught me how to help people with sleep disordered breathing through creating custom Oral Appliances. The multitude of challenges to overcome; implementing, maintaining, and growing a Dental Sleep Medicine practice requires the daily and consistent attention of experts. The Spencer Study Club (SSC), led by Jamison, brings together 100s of dental professionals committed to dental sleep medicine each day in our online community. Sharing our challenges and solutions is a state of creativity that has allowed us to successfully help people all over the world in finding restful and restorative sleep.
I am delighted to record here publicly – and in a permanent fashion – my gratitude and appreciation with Breathe Well, Sleep Well, Live Well
Noah Siegel, MD
The more I learn about sleep, the more I am enchanted by its restorative powers and the more I am motivated to better understand its mysteries. How is it that ‘shutting down’ for 7-8 hours per day provides the foundation of so many of our essential bodily functions? Sleep clears waste products from the brain, consolidates our memories, refreshes our muscles, regulates hormones, and synchronizes our organ systems. At the end of the day, my mind feels dull, I am more moody, and my muscles feel fatigued. Yet, in the morning, after a good night’s sleep, I can focus better, my body aches less, and I am ready to attack another day. Therein lies the miracle of sleep!
Despite the fact that sleep is essential to optimal functioning, the majority of us have sleep problems. Those sleep problems may be as straightforward as not getting enough of it, or having difficulty falling asleep. There are also very common intrinsic sleep disorders such as obstructive sleep apnea (OSA) which is the focus of this book. It is well known that individuals with sleep apnea commonly have poor sleep quality.
Sufferers of OSA don’t thrive because they don’t breathe well at night. As a result, their sleep is less restorative. It is often challenging for individuals with SOA to accomplish simple daily tasks. Many sufferers are not productive at work or lack adequate energy to optimally interact with family members. Furthermore, untreated OSA is stressful to the body and increases risk for hypertension, irregular heart rhythms, stroke, and neurocognitive decline such as Alzheimer’s disease.
By now, I may have convinced you that untreated sleep apnea is bad and sufferers need therapy. While continuous positive airway pressure (CPAP) therapy is effective, this treatment approach is often difficult to tolerate. By 1 year, approximately half of people prescribed CPAP therapy are no longer using it. The good news is that there is no longer a ‘one treatment fits all’ approach. In this new era of personalized healthcare, doctors are much better able to match health history, physical examination, medical conditions, and desires with the treatment that makes the most sense for that individual. Treatment options also include oral appliance therapy, airway surgical procedures, positional therapy, weight loss therapy, and surgically implantable devices.
For several years, I have partnered with Dr. Morreale and the Boston Center for Oral Health to care for many individuals with sleep disordered breathing. Their comprehensive and caring approach has resulted in countless success stories of people achieving optimal sleep. You are in very capable hands with Dr. Morreale.
In closing, I would like to congratulate you on taking the proactive step of picking up this book. Let this be the first in a rewarding journey toward unlocking the restorative powers of your sleep.
Noah S Siegel, MD
Harvard Medical School
Director of Sleep Medicine and Sleep Surgery at Massachusetts Eye and Ear
Medical Director of Otolaryngology at Massachusetts Eye and Ear, Longwood
I’m not only the BCOH Director, but I’m also a patient.
Carmine L. Morreale, D.M.D., M.A.G.D., Diplomate ABDSM
When does it hit you? When they finally demand you sleep on the couch because you have ruined another good night’s sleep with your snoring? When another annual physical with your doctor ends with a demand by them for you to deal with your elevated blood pressure? Is it when you finally see a photo of yourself, in living color – at the party honoring the birth of your grandchild (Figure 1)? Or perhaps it may even take a pandemic!
As I write this eBook, our world has changed in unimaginable ways: mandatory face mask use, quarantining, curfews, greeting friends and family with nods and air hugs, and saying goodbye to people with the phrase, “Be safe!”
You are reading this eBook because you finally realize that you need help with sleep, whether it is for your spouse/partner, your family, or yourself. We have the ways to help, but first, let me share a secret. I used to snore. Not just your heavy breathing type snoring. I’m talking about rattle-the-dishes, hear-it-through-the-walls, dog-running-away kind of snoring. As my father would say, “to beat the band,” kind of snoring. But now each night before I go to bed, I do one thing different. Let me explain. For over 35 years, we at Boston Center for Oral Health, have helped people prevent dental disease and improve the health and appearance of smiles. In the last several years, we have developed and implemented the expertise that allows us not only to prevent dental disease, but prevent and reverse systemic disease with our dental sleep medicine program. Helping people reach their optimal health by getting restful, restorative sleep is the foundation to overall wellness. (Image bellow – just two years after using Oral Appliance Therapy myself.)
When most people think of sleep apnea, they think of heavy, older men – usually bald too. Even medical doctors tend to only consider sending heavier, older men for sleep studies, even though younger, thinner people may present with similar symptoms. In this book, we will describe the basics of sleep, many of the important things that sleep impacts, how to get a good night’s sleep, and what happens if we don’t. Our brain sometimes has to make a decision between what’s good in the long term and what’s necessary immediately. Breathing MUST be maintained, or there will be no more “long term”. So why am I, as a dentist, involved in this field?
Because we’ve learned that some people will clench and/or grind their teeth while they sleep due to an unconscious attempt to keep their airway open.
Because we’ve learned that such clenching and grinding can not only lead to damaging the teeth and any “restorations” (like crowns, bridges, and dental implants, etc.), but it can also contribute to TMJ problems, facial pain and headaches.
Because we’ve learned that even periodontal disease, or “gum disease” seems to be worse in people with sleep apnea.
And because we as dentists have a simple and easy to use therapy that is effective for most people with sleep disordered breathing issues, called “oral appliance therapy.”
Oral appliance therapy, in a nutshell, involves wearing a small, custom made device on the teeth that keeps the lower jaw from falling back and obstructing the airway. I wear one every night! I started the process to spare my wife from my horrible snoring. Now I wear it because I cannot tolerate sleeping without it!
If you’ve ever taken a CPR course you probably remember “head tilt, chin lift.” This procedure is performed to help open the airway on the unconscious person so that when air is blown into them it actually goes into their lungs.
Several of the main muscles of the tongue attach to the lower jaw, just on the inside of the chin. Bringing the lower jaw forward has a tendency to open the airway.
You can experience this yourself. Make a snoring noise in the back of your throat (plug your nose to make sure it’s in your throat and not in your nose). Now thrust your lower jaw forward and see if changes how hard it is to make the noise. For most people, it will be harder to make the noise. This is because the airway is now more open.
The problem is, you can’t just hold your jaw forward all night by yourself.
As you’ll learn in this book, in dream sleep our muscles become “more floppy,” sort of paralyzed, and this makes it even easier for the airway to become even smaller or collapse. Sleeping on our backs also makes it easier for the airway to become restricted.
CPAP, or continuous positive airway pressure, is an excellent treatment for sleep apnea in which the patient wears a mask attached to a machine that blows air to keep their airway open in all dimensions. For those who can tolerate its use, it’s fantastic and can absolutely change their life. As dentists we always encourage our patients to stay on their CPAP if they can use it, and we prefer for patients with more severe sleep apnea to at least try CPAP.
CPAP is AWESOME…
UNLESS YOU CAN’T USE IT
When this eBook was written we were in the midst of the COVID-19 Pandemic – along with the rest of 2020!
This global crisis affected almost everyone physically, emotionally, and financially, and we will feel the ripple effects for many, many years to come, and certainly never forget the experience for the rest of our lives.
As doctors and scientists looked to keep people safe from COVID-19, all manner of things were deployed: from simple reminders about hand washing, to social distancing, to wearing masks and other protective gear. Such proactive devices and practices were intended to reduce the spread of the virus.
One area that could have easily have been overlooked was the use of CPAP therapy in the hospital, as well as in the home.
Doctors with the American Academy of Sleep Medicine published the following guidance on their website:
There were also concerns regarding using CPAP in the hospital. One sleep physician that we spoke with referred to CPAP as a possible “viral sprinkler,” and we discussed ways that oral appliances could be used during the period that the patient wasn’t able to use their CPAP.
That same sleep physician mentioned how the COVID-19 crisis had made him reconsider putting all of his patients on CPAP and that moving forward he was more likely to recommend oral appliance therapy, particularly for his mild and moderate patients.
It is highly likely that the companies that manufacture CPAP machines will quickly develop a way to keep the machine from being “a viral sprinkler,” and possibly by the time you read this that will no longer be a concern.
However, if you use CPAP you know that there are times when it is difficult, or maybe even impossible, to use your CPAP the way you’re supposed to.
Such times might include:
Having an oral appliance as a backup to your CPAP just makes sense.
If you wear glasses you probably have more than one pair. And just like your vision is critical to your health and happiness, so is a good night’s sleep.
Perhaps one of the unexpected benefits of using an oral appliance as a CPAP backup is that any potential side effects, such as minor tooth movement or transient discomfort, tend to be eliminated since the device is only used from time to time.
We have had many people over the years use an oral appliance as a CPAP backup. Some people choose to use their CPAP several nights a week, and their oral appliance a few nights a week, thus eliminating any of the potentially annoying side effects they may experience over time with nightly use of either therapy. In some cases, patients will combine CPAP with an oral appliance to improve the results of the CPAP by keeping the airway open and reduce the pressure setting.
Oral appliance therapy is not just for people who can’t use their CPAP. CPAP is an excellent treatment for obstructive sleep apnea, but even the best treatment is completely ineffective if it cannot be tolerated. And going even one night without therapy is not a good idea.
You may recall a few years ago that US Supreme Court Justice Antonin Scalia was found dead in bed, with his CPAP sitting on the night stand next to him, not even plugged in.
Related to this, Dr. Nancy Collup, a sleep physician and then Editor-In-Chief of the Journal of Clinical Sleep Medicine, wrote:
If you, or someone you love, is using CPAP, please consider having an oral appliance as a backup. Going without treatment for even a single night is not a good option, and with oral appliance therapy being easy, effective and affordable getting a backup is super simple to do.
I hope that you will enjoy this book. Please feel free to jump around. It’s not a novel. Look for the topics in the Table of Contents that interest you the most right now, whether you are looking for information for yourself or a loved one. Mark it up and tag the pages that you want to talk to us about. The more you read the more likely you’ll start to see signs and symptoms of sleep disordered breathing in those around you. This is an EXTREMELY common problem, with the vast majority of those with the problem undiagnosed and untreated—many of whom are being treated for other presumed issues, rather than the core issue.
We wrote this book to be informational. It is not designed to be a summary of current research. It is based on clinical experience and research evidence, with a strong leaning toward the day to day practical experience of helping literally thousands of people suffering with sleep-disordered breathing. Perhaps it can help you or a loved one too.
(Heart Disease, Diabetes and Stroke)
Depression, High Blood Pressure, Obesity and Liver Disease
I’m sleeping with a grizzly bear—how your BED PARTNER’s snores can affect your health!
“That awkward moment when you can’t sleep at night and continue to change positions like a mentally challenged walrus.”-Anonymous.
THE GOOD, THE BAD, AND THE COSTLY