CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 1 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy
Martha Cortes DDS
Wake up! Your SLEEP is KILLING YOU!!! YOUR SMILE YOUR HEALTH
SUMMARY:
Sleep apnea is a chronic sleep disorder that affects the ease of breathing during the sleep cycle. Restorative sleep is essential to health. A good sleep cycle regenerates body tissue, fights illness and infection and gives the body and brain restful energy. Breathing provides oxygen, a vital nutrient, to all the cells and tissues of the body, especially important to the brain, which is an energy glut. If left untreated sleep apnea can cause a wide range of health concerns ranging from the mildly irritating to life threatening.
An individual suffering from sleep apnea will experience intervals when breathing stops during the night. The sleep apneic is unable to sleep peacefully and thoroughly, as they are frequently aroused or awaken by a physiological need for air and will sooner or later become chronically sleep deprived. If this condition continues unabated the entire health of the individual will be at risk. Sleep apnea is not a one-time event – it is generally a lifetime condition that must be treated intelligently.
In the United States alone over 40 million cases are reported annually, yet, it is estimated that approximately 90% or more go without treatment as they remain undiagnosed and/or are misdiagnosed – resulting in under-treatment or non- treatment of this widespread condition. The risk for sleep apnea increases as we age. However, it can even affect children and teens, as it does not discriminate for age, color or gender. In children and teens, the disorder is generally linked to lower academic grades and problematic behavior at home and at school, as it is associated with inattention, fatigue and poor study skills.
The word apnea is derived from the Greek – without breathe. Apnea is a temporary absence or cessation of breathing. Sleep apnea is a temporary absence or cessation of breathing during sleep.
CAUSES OF OBSTRUCTIVE SLEEP APNEA:
When the body is awake and alert the muscles of the throat provide an open airway for oxygen to enter the upper airway and then down into the lungs providing oxygen for the entire body. During sleep, all our voluntary functions are suspended – the throat muscles, tongue and soft palate become relaxed and unfortunately may block the airway. In a healthy individual the airway remains open – ensuring proper oxygen distribution to the entire body. However, for a
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 2 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy person with sleep apnea, known as the sleep apneic, the pharyngeal airway (throat) may become blocked resulting in decreased oxygen to the brain and other key organs. A reduction of oxygen to the tissues and the brain will lead to a decrease in functional health.
There are three different parts of the throat – obstruction can occur in the nasopharynx (upper part of the throat behind and above the soft palate and behind the nose and sinuses), oropharynx (the middle throat that is below the soft palate and behind the oral cavity) and the laryngopharynx (lower throat below the base of tongue and behind the voice box). Under the right conditions, soft tissue in any of these areas can block air from entering the lungs during sleep. In the nasopharynx (including the nose and sinuses), mucus, nasal polyps, hypertrophied turbinates, or a deviated septum can block air from properly entering the upper throat. In the oropharynx, lymphatic tissue, such as, tonsils, adenoids or uvula can be infected or inflamed – reducing the overall airway space of the mid-throat (An enlarged tongue can also block the oropharynx). In the laryngopharynx, the base of the tongue can roll backwards – blocking air from entering the lower throat. In an over-weight or obese patient, accumulation of Fatty tissue throughout the pharynxes reduces the passage size all the way through the upper to lower throat without exception.
Anatomically, the jaws may be poorly positioned or even underdeveloped, due to mouth breathing, an improper swallow, allergies or environmental pollutants, leading to a decrease in size of any or all the pharynxes. The most common is to have the lower jaw poorly developed and positioned back towards the throat. Both the upper jaw (maxilla) and the lower jaw (mandible) can be underdeveloped or have not grown enough to match the size or the head (cranium). Genetically there seems to be is a size mismatch between the mandible and the maxilla, or a mismatch of the maxilla to the cranium and sometimes both jaws are divergent to the size of the head. This size divergence often leads to smaller airway spaces, as there is not enough anatomical size providing an adequate development of these associated structures. Small jaws are indicative of small airway spaces.
Obstructive sleep apnea can involve a small retruded mandible, deposits of fatty tissue throughout the throat, inflamed tonsils, an enlarged tongue and a deviated septum. Furthermore there is the relaxation of the throat muscles, which leads to collapse of some soft tissue of the pharynx and consequently an obstruction to
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 3 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy breathing of the upper airway. Treatment will as a result be – as complex as the obstruction.
When we sleep muscle tone throughout the body is lost – voluntary control to a large degree is also diminished. In order to survive an obstructive episode there has to be some sort of arousal from sleep that stimulates a muscular response to the lack of oxygen. Generally these are mini-arousals that allow the sleep apneic to fall back to sleep after each event. The mini-arousal activates the throat muscles, causing the airway to open. However, these mini-arousals can inhibit or pull the individual out of deep-sleep and back into light-sleep. (Deep-sleep is considered extremely restorative and restful – light-sleep is not.) Sometimes the arousals will be significant enough to fully awaken the sleep apneic. Making it difficult to fall asleep again and in some cases causing insomnia and panic in some predisposed individuals.
There are 4 phases of arousal involved in sleep apnea. In the first and second phase the length of obstruction results proportionally to an increase in the amount of hypoxemia (inadequate oxygen in the blood) and hypercapnia (an abnormally high level of carbon dioxide in the blood) In the third phase – the chemical changes caused by low blood oxygen and high carbon dioxide levels provokes an increased breathing effort. Lastly, the increased breathing effort against the obstructed airway causes an increased negative air-pressure in the airway. These phases alone or together cause an increase in brain activity that consequently arouses the sleep apneic, which produces (temporarily) the elimination of any and all soft tissue collapse, by restoring muscle tone to all tissues of the throat.
Even though the arousals are necessary and essential for survival, they have negative outcomes for the sleep apneic, as the autonomic nervous system is constantly being disturbed. Each arousal stimulates the sympathetic nervous system to kick-in hard; this is part of the nervous system that is active during stress or danger and is involved in regulating pulse and blood pressure, dilating pupils and changing muscle tone – used especially to survive a dangerous life event. Each and every night the sleep apneic unleashes a Herculean effort to survive, as it sets free mechanisms used only when there is the possibility of
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 4 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy bodily harm – such as running away from a grisly bear. Patients with obstructive sleep apnea (OSA) have a high level of sympathetic nerve traffic. Sympathetic nerve drive leads to the overuse and exhaustion of involved organs, such as the heart, kidneys, lungs and digestive system.
A healthy autonomic nervous system (ANS) is a balanced structure that constantly switches between two complimentary systems, the parasympathetic (rest and relaxation) and sympathetic (flight or fight response). A working ANS keeps the body fit and in homeostasis (balance). Ideally checks and balances prevent one of these from becoming dominant over the other – however once this occurs homeostasis can be lost. The ANS is an involuntary system that is programmed for survival. If the sleep apneic is not receiving enough oxygen it will activate certain bodily mechanisms to achieve arousal and as a direct result breathing. Once breathing is achieved it will then inhibit those mechanisms. If this occurs only occasionally, the body easily adapts, with no consequential changes to the central nervous system. However, if these powerful life-threatening events occur 40 to 300 times nightly, for many years or even decades, then there can only be maladaptation. Unable to respond in a healthy way the autonomic nervous system will begin to misfire in order to compensate for these life- threatening episodes.
Imagine that the ANS is like the thermostat in your house – keeping the environment cool or warm based on external temperature. If the thermostat for some reason or other is not able to determine the external temperature and thus adjust to it – and stays stuck in one mode only – it is considered a broken system. A system that is stuck in the stress response (sympathetic nervous system) is always on fight or flight mode – there is a permanent state of emergency that is not being inhibited by the parasympathetic nervous system. Hence those sleep apneics that do not inhibit or reduce the breathing obstruction that occurs hundreds of times nightly will eventually overwhelm the cardiovascular system, as the sympathetic nervous system is constantly stimulating it to compensate for the reduction in blood oxygen. The recurrent hypoxemia (inadequate oxygen in the blood) and hypercapnia (an abnormally high level of carbon dioxide in the blood) may eventually lead to both pulmonary and systemic hypertension (high blood pressure), cardiac arrhythmias (irregular rhythm of heartbeat) and consequently the potential for reduced survival despite a person’s genetic health potential. The risk to health is mediated by the complex interaction of the mechanical (obstruction of the throat) and the chemical (hypoxemia, hypercapnia) that devastates the balance of the nervous system and other compensatory systems, such as the cardiovascular and hormonal.
A chronic stress response itself is dangerous. It is correlated with high blood pressure, formation of artery-clogging deposits, obesity and changes in the brain that contribute to anxiety, depression and addiction. A prolonged stress response may chronically suppress the immune system – greatly increasing the
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chances for infections of the upper airway and the body. It also suppresses the digestive system, reproductive system and growth processes, which are especially important in growing children. The long-term activation of the stress response (sympathetic nervous system) – and the consequential overexposure to stress hormones of all varieties – can disrupt all the body’s natural processes and end in physical exhaustion of many systems. Yet an acute stress response is healthy – as it keeps us alive. It is only when this system that is meant merely as a short-lived response to a life-threatening event gets out of whack – that the problem begins. Apneas and hypopneas and sleep disordered breathing instigate persistent and continual stress response.
An apnea occurs when there is more than 90% loss of air due to an obstruction that lasts more than 10 seconds and it can be a complete cessation of breath even though the lungs are working hard to get air into the body (breathing effort). A hypopnea takes place when there is more than 50% loss of air due to an obstruction that lasts more than 10 seconds; it is never the cessation of air, only a diminishment of the amount of air being taken in during active breathing. The apnea–hypopnea index (AHI) is a formula to measure the severity (the amount) of apneas and hypopneas that occurs during sleep in a per-hour basis. Apnea can be seen as a complete or near-complete obstruction of breath, hypopnea can be seen as a partial obstruction of breathing. The index measures these as events or episodes per hour.
Mild is 5 to 15 events per hour. Moderate is 15 to 30 events per hour. Severe is greater than 30 events per hour.
However, 10 seconds is the minimum and not the maximal time involved in an episode. A rough average is between 20 to 40 seconds, however an obstructive event can easily last minutes, as the heartbeat can slow (bradycardia) due to the reduction in oxygen and not immediately triggering arousal. The longer the period without air the more physically taxing is the apneic event on the body. It is hard to imagine that some people are practically not breathing during sleep, as their breathing can be obstructed for 20 or 30 minutes of every sleeping hour; if they sleep 8 hours – that’s 2 1/2 to 4 hours of diminished oxygen intake. Blood oxygen is vital to all organs of the body, especially the brain – it is only by the blood that oxygen is distributed to all tissues and cells; without it the body cannot function or
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 6 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy survive. When we breathe the blood becomes saturated with oxygen – (normal oxygen blood saturation is 95% or better – using pulse oximetry) – a 5 to 10% drop in blood saturation is significant, as the cells of the body are unable to receive enough oxygen to fully function. Some sleep apneics can have blood saturation as low as 65% or lower, which is extremely precarious to survival. The brain, which forms only 2% of the body, requires about 20% of the body’s oxygen and energy; brain cells start to die within minutes if they do not get the oxygen or nutrients they need. The brain requires the most energy and oxygen than any other body part to function and survive.
Sleep apnea and other sleep breathing disorders can only be medically verified by a required laboratory sleep test (polysomnography). A dentist or M.D. can prescribe a sleep test to confirm or rule out sleep-disordered breathing (SDB). SDB can include sleep apneas and UARS (upper airway resistance syndrome). Although UARS does not follow the same pathophysiology of sleep apnea – it is cause for concern, as it has a minimal respiratory arousal index greater than 10 per hour. Many patients awaken as many as 30 times an hour as there is an obvious struggle to breathe, (although there is no frank obstruction). Some considered this a milder form of obstructive sleep apnea (OSA), while others consider it a different class of SDB. UARS mostly affects women (of all ages and sizes) and it too is under-treated, misdiagnosed and ignored by the dental and medical community.
It is important to restore restful sleep to the apneic because of oxygen’s impact on ATP (adenosine triphosphate) production, which is the cell’s main metabolic fuel. Without adequate ATP production the cell simply cannot function and will eventually perish. Oxygen depletion due to chronic obstructive sleep apnea stresses all the cells, tissues and finally all the organs of the body. Healthy oxygen levels are essential for overall wellbeing and a long life. Low oxygen levels in cells may also be an essential ingredient in the growth and spread of cancer. Without adequate cellular oxygen, cells will resort to a fermentation process that may promote cancer development. Without adequate oxygen cells will perish – yet if they switch to the fermentation process they stay alive but as non-functioning cells. These cells degrade and no longer serve the body. Instead they live to survive like a virus does. Moreover the lack of oxygen in cancer cells and tumors may promote its spreading and growing. Additionally persistent scarcity of oxygen in body tissues and cells can create a defect in red blood cells, which of course exacerbates the lack of oxygen in the body.
One can even say that the balance and evenness of craniofacial anatomy is due to how well an individual breathes while asleep. Facial form and structure are not always due to genetics; as they are also influenced by the function of breathing – both while sleeping and awake. Form follows function; so if something is not functioning well, this will have a direct impact on the shape and size, which is integral to form. If the muscles of the face do not function properly, the result will be altered form.
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If a child has sleep disordered breathing – their deficient breathing is in essence sculpting their facial form. Chronic mouth-breathers, for instance, almost always have crooked, misaligned teeth and a small lower jaw, as an open mouth does not allow the muscles of the face including the tongue to develop the proper facial anatomy. Once this facial form is locked-in during maturity, the form itself will inhibit fully functional breathing, especially during sleep. Anatomy, shape, form and size are all dependant on airway functioning, and airway space itself is dependant and proportional to an unobstructed airway.
Many children are in danger of becoming sleep apneics (or are already) because of upper-respiratory allergies, inflamed tonsils and adenoids, deviated septum, obstructing mucus, polyps and poor oral-habits. It is important to catch this early in a child’s life. Besides being deleterious to their physical health, poor facial outcomes can negatively influence how they feel about themselves and lower their level of confidence later in life. Moreover, their level of longevity is at risk, no matter the underlying genetic life potential they may have, as these are gene- regulating episodes with the capacity of altering gene expression in the individual. It is imperative that these childhood issues do not become translated into decades long survival issues for adults. Luckily these are easy to treat during the many years of childhood.
DAYTIME BREATHING VS NIGHTTIME BREATHING:
It is interesting to note that most sleep apneics experience little to no problems with their breathing or airway while awake. In fact, the great majority experience normal to adequate breathing when awake and are quite unaware of their nightly struggles. It is only by observing the sleep apneic during sleep that they become aware that they have an issue. This is especially important as breathless episodes can last seconds to minutes. It is usually the spouse or bed partner that is awaken or kept awake by snoring and/or snorting that rings the alarm about the sleeping disorder. If the sleep apneic is alone or single, it becomes that much more difficult to discover, as they are generally unawares that they regularly have obstructed breathing at night. If they go to the doctor, they are commonly misdiagnosed with some other condition or left completely untreated. Sleep apnea is rarely due to a single factor; it is generally affected by many risk factors; such as, age, neck circumference, excess weight, facial and head anatomy, gender, family history, unusual fatty deposits, a narrow airway, narrow and small mandible, race, use of alcohol-sedatives-tranquilizers, smoking, nasal congestion, sleep position, menopause, snoring and sleep hygiene.
Sleep hygiene, for instance, is key in either exacerbating or diminishing obstructive sleep apnea – as all the habits that we participate in daily affect the quality or quantity of our sleep. It is vital to keep regular sleep and waking patterns, (meaning going to bed at the same time and waking up at the same time daily). Drinking alcohol, coffee, tea and caffeinated beverages can affect the quality of sleep, as does smoking and other lifestyle habits. If the patient sleeps
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 8 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy prone (lying face down), drinks caffeinated beverages all day long and into the evening, is overweight, and a male over 40-years-of-age, consumes alcohol late at night and does not have regular sleeping and waking hours – can he be expected to have good quality sleep? Chances are he is already or eventually will be suffering from OSA. Although in his case many of the poor habits contributing to sleep apnea can be changed – especially if he is already suffering from OSA, he can, for instance, reduce the amount of caffeinated beverages he consumes, change his sleeping position (the side is preferred), lose some weight, stop drinking at night and start a more regulated sleep and waking pattern.
By itself good sleep hygiene will benefit many patients, it will especially help those with mild to moderate sleep apnea, but it will not help everyone. It is critical to understand that some people will have hundreds of episodes a night (of apneas or hypopneas) but will have them for less than the required 10 seconds an episode to be considered an apneic event. Treatment for these individuals will be quite different and insurance companies will not consider it a life threatening disease, and may therefore not compensate the insured sufficiently.
OSA and sleep disordered breathing (SDB) are damaging to health, as they undermine the individual directly and indirectly. Waking constantly is disturbing to sleep, as the individual may never reach stages of deep, profound sleep, which is critical to healing and regeneration. Moreover these events are exhausting to the nervous system, which then affects the functioning of the endocrine (hormonal) system and all related organs and functions of the body. The recurrent hypoxemia (inadequate oxygen in the blood) and hypercapnia (an abnormally high level of carbon dioxide in the blood) will eventually lead to acidosis of the blood, which will reduce the amount of oxygen that the blood cells can carry and deliver to oxygen deprived tissue cells. A vicious cycle will ensue; as oxygen starved cells attempt to produce sufficient cellular energy to keep the body healthy. Deprived of good sleep and cellular energy, daytime sleepiness and fatigue will follow as day follows night. Brain fog and fragmented behavior can result from prolonged sleep deprivation.
OSA and SDB can affect each and every system of the body including our mental and psychological wellbeing. Fatigue and daytime sleepiness can negatively affect the quality of our daily decisions, state of mind, behavior and interaction with others. It can worsen depression, fatigue, attention deficit disorder, impotency, reckless behavior and poor judgment. The risk for depression rises with the increasing severity of sleep apnea. OSA can exacerbate nightmares and post-traumatic stress disorder in some patients. What's more, attention-deficit disorder and hyperactivity are common in children with sleep apnea.
The psychological effects of sleep deprivation may affect the apneic on a rational, cognitive and emotional basis, as the interaction of these further affects
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 9 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy the state of wellbeing and the ability to perform focused mental tasks – such as driving a car. There is also the possibility of reduction of the natural alpha state (brain activity during a relaxed state) in the sleep deprived individual as they are driven and stressed and relying on sympathetic nerve drive to keep them awake and alive. Breathing is so important that it even forms part of the ABC’s of hospital emergency rooms – airway, breathing and circulation. OSA and SDB are often ignored because they mostly take place at night, when we are less conscious of others, our surroundings and ourselves.
Complexity of the Upper Airway:
The upper airway is a very complex structure. It must be able to simultaneously vocalize, breathe and swallow. The pharynx is basically a fibromuscular tube that has no rigid support apart from the upper and lower ends, where it is attached to bone and cartilage. It is a musculo-menbranous cavity that lies behind the nasal cavities, mouth and larynx (voice box) and is approximately 5 inches long and extends from the base of the skull (bone) to the esophagus (cartilage). And forms the passageway for the respiratory and digestive tracts and changes shape when forming various vowel sounds. It is composed of muscle that is lined with a mucous membrane, and divided into the upper (nasopharynx), middle (oropharynx), and lower (laryngopharynx) throat.
The pharynx communicates with four different cavities – nasal, oral, laryngeal, and esophageal and serves two major functions, breathing and swallowing and assists in a third, speaking. The size and shape of the pharynx is directly influenced by craniofacial development, as the throat is dependant on the size, breadth and functionality of the cavities that interact with the outside. Small jaws inevitably lead to a small airway. Small jaws, however, do not lead to a small tongue.
A newborn’s oral cavity is small and, in comparison, occupied by a fairly large tongue that is positioned forward and away from the pharynx. As the oral cavity enlarges with the growth of the lower jaw and a descending larynx, the base of the tongue gradually moves backwards – eventually becoming the frontal wall of the oral pharynx. Accordingly, to genetic potential, the length, width and thickness of the tongue doubles by the time a child reaches adolescence. If daytime and nighttime breathing is unobstructed and the tongue is used correctly – the size of the tongue and the size of the two jaws will correlate. However, if the tongue is misused (i.e., tongue thrusting, improper swallow) and there is daytime or nighttime obstruction or both – the tongue may not eventually fit the size of the oral cavity. This is especially true in those with nasal obstruction that eventually become mouth breathers.
Mouth breathing leads to functional weakening of the nasal cavity by inactivity, an altered tongue position and a change in activity of the orofacial and throat muscles that affect the shape and form (morphology) of face, head and neck.
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The main functions of the oral cavity are mastication, suckling, swallowing, speech and when necessary can be used for breathing.
Genetically, all these functions are programmed to be balanced under the right conditions, however, a significant disturbance in one oral function results in an abnormal growth and development of bony and soft tissue – affecting craniofacial morphology, and hence craniofacial function. A larger mandible, for instance, helps to anchor the tongue in a more forward position (away from the back of the throat), as it sits comfortably, without spilling-over the boundaries of the jaws. This allows the tongue to develop alongside the jaws and not at the expense of the jaws.
Unfortunately, mouth breathing, which is usually the consequence of upper airway disturbance, positions the tongue loosely and only in the lower jaw, where it exerts no muscular effort on any of the jaws. The jaws themselves are unable to help regulate each other, as they rarely come into contact. The lower jaw, in the healthy individual, develops in accordance to the growth and expansion of the upper jaw. The tongue actually helps to develop the upper jaw and arch when it is correctly positioned against the palate and upper jaw. The tongue is a powerful myofunctional (muscular) device, which helps to develop craniofacial balance and beauty in the child and adult.
The Negative Effects of Open Mouth Breathing:
Jon Heder – Open mouth breathing
The normal growth direction of the jaws is forward and occurs as a result of the forces exerted by the surrounding soft tissue, the lips, cheeks and tongue. This is a natural outcome with nose breathing and proper tongue placement and swallowing. All infants are obligate nose breathers and breast-feeding helps to develop nose breathing, swallowing and tongue placement. The correct position for the tongue is resting on the roof of the palate and is also the case when swallowing. The tongue helps to develop the size, shape of the upper jaw; the lower jaw takes its cues from the maxilla and proper use of the surrounding soft tissue.
Open mouth breathing is dysfunctional breathing. Nose breathing is natural and instinctual as long as there are no obstructions blocking the nose and sinuses. If it is temporary the child will instinctively go back to nasal breathing. If the tongue is not resting on the upper jaw it will not be able to guide the upper jaw forward,
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 11 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy as it exerts its gentle force forward and to the sides and giving it a natural U shape. Mouth breathing leads to an underdeveloped, V-shaped upper jaw with crooked crowded teeth.
In general those with long faces tend to have problems breathing properly as their sinus cavities are normally narrow. When air passes the nose it is cleaned of large particles, warmed and moistened. Mouth breathing causes dry mouth, increasing the risk of throat infections and reducing the sense of smell; it also allows pollution and germs to directly enter the lungs, without protection. Furthermore, dry cold air makes secretions in the lungs thicker, slowing the cilia and slowing the passage of oxygen into the blood stream. Mouth breathing can also decrease lung function in asthmatics and possibly irritate the tonsils and adenoids causing them to enlarge. Some believe that it can cause asthma, high blood pressure and heart disease.
Chronic mouth breathers often do not swallow correctly, due to the inefficient use of the tongue, they also have an increased gag reflex and increased mucus production. Children often have allergies, dry lips, pale skin and dark circles under the eyes. Some children may appear sickly, lacking energy and look underdeveloped for their age. Open mouth breathing is not sexy and should be discouraged in children and teens. If your child has difficulty easily closing their lips for a length of time – it may indicate a nasal breathing issue; or it may also imply that they are misusing their facial muscles and need to be trained in using them properly (myofunctional therapy). The sooner this is stopped and corrected in childhood the better. It becomes more difficult as they get older, however, not impossible to treat. See an ENT (ear, nose and throat) doctor to rule out upper airway obstruction in the nose, sinuses, mouth and throat, as these can worsen the blockage and symptoms involved in OSA and sleep disordered breathing.
SYMPTOMS of OSA:
1. Snoring 2. Loud, heavy snoring – (loud sounds point to airway blockage) 3. Fatigue/irritability 4. Choking/gasping for air during sleep 5. Restless sleep 6. Frequent awakening from sleep 7. Decreased energy and excessive daytime sleepiness 8. Morning headaches 9. Poor mental functioning (lack of focus, mood swings) 10. Decreased memory and poor work/school performance 11. Depression, decrease libido, irregular heart beats, high blood pressure, CHP, heart attack, and/or stroke
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THERE ARE THREE TYPES OF SLEEP APNEA:
CPAP Machine with Mask There are three kinds of sleep apnea to consider: obstructive, central, and mixed. Obstructive sleep apnea (OSA) is a mechanical blockage of the airway space. This is the most common kind and the one that we will mostly consider in this book. It occurs usually as a soft tissue blockage of the throat’s airway space. During sleep, the muscles of the throat, soft palate, tongue, and uvula relax and are no longer responsive to voluntary control that is present during the waking state; as a result, these tissues can block air from continuously entering the lungs. This decreased air intake will cause a signal to be sent to the brain that awakens the apneic enough to open the airway and breathe. These episodes typically last 20 to 40 seconds, directly leading to a decrease in blood oxygen saturation – that consequently leads to a reduction of oxygen to the brain and cellular tissue throughout the body. As a result, the heart is forced to work more diligently causing blood oxygen levels to drop and blood pressure to rise. OSA can be considered mild, moderate and severe – mild is 5 to 15 events per hour, moderate 15 to 30 and severe is more than 30 episodes per hour. OSA can be successfully treated with a CPAP (continuous positive airway pressure) machine, a mandibular advancing device or splint, the Full Breathe Solution and preferably by enlarging the size of the jaws with specific appliances, such as the DNA appliance.
Central sleep apnea (CSA) has very little to do with a collapsible airway space and more to do with a dysfunctional nervous system. Generally there is no obvious or frank soft tissue blockage of the pharyngeal airway space. Rather, the part of the brain responsible for the breathing process does not operate properly and fails to signal the muscles of respiration to engage. Breathing, as a result, is disrupted because of the dysfunction of the brain and not by the physical inability to do so. Instead breathing does not occur because there is little to no effort to breathe and no chest movements or struggle to breathe. This effort to breathe can be diminished or totally absent and occurs intermittently or in a cyclical fashion. A CSA episode is defined as a cessation of airflow for 10 seconds or more and without an identifiable effort to breathe.
CSA is a neurological condition and may develop as a result of head injury, stroke, chronic heart failure or nervous system failure. It is a rare form of sleep apnea. Since the airway is open, there is typically no snoring present. In order to treat central sleep apnea properly, as many stressors as possible must be eliminated from the central nervous system; including improving the posture of the head, neck and body, adequate exercise at rising, and a healthy life style and eating habits. Central sleep apnea is generally considered an imbalance of the
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 13 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy body’s feedback mechanism to control respiration during sleeping. CSA may emerge as a result of untreated (severe) obstructive sleep apnea that has damaged the heart or nervous system. CSA can also emerge or persist while treating OSA with CPAP (continuous positive airway pressure) and lead to complex sleep apnea. High altitudes may cause a temporary CSA to emerge in some because of low levels of oxygen in the air; however, returning to a lower elevation will eliminate this kind of CSA.
CSA is considered neurological in origin and in general difficult to treat as a result. Some types of CSA may respond to oxygen therapy, nasal CPAP, or bilevel positive airway pressure (BiPAP). If CSA is due to an underlying condition, such as heart failure – that condition should be treated first. Otherwise anything that irritates or has the potential to irritate the nervous system should be eliminated. Correcting forward head posture, TMJ and/or subluxations of the spine/posture may be critical in some patients as any of these can impinge neuromuscularly (muscular nerve impingement) on spinal nerves. Elimination of biomechanical stressors may allow the CNS to heal; self regulate and restore function to the system.
Mixed sleep apnea is a combination of obstructive and central sleep apnea, as it has elements of both types of apneas. The individual exhibits a blockage or collapse of the airway due to soft tissue interference as well as the inability to maintain normal breathing effort because of the brain’s failure to send the right signal to breathe. A patient who has had OSA for a long time can develop CSA as well. If the patient has OSA and active cardiovascular disease the CSA may be concomitant result of the heart disease.
However, it can also be a direct result of treating OSA with CPAP that is titrated to high – as too much air pressure is applied, which depresses the sleep center responsible for breathing and therefore no effort is made to breathe. This is known as complex sleep apnea as obstructive events are converted to all or predominant central apneas when treated with CPAP therapy. Changing to BiPAP (bilevel positive airway pressure) instead of CPAP may be a solution for some.
Treatment of mixed sleep apnea should be oriented to treating any underlying obstruction and eliminating any noxious stimuli to the nervous system – such as correcting postural alignment throughout the body and/or eliminating any food or beverages that over stimulate the body. Treatment can involve CPAP or BiPAP therapy, a mandibular advancing device or splint, the Full Breathe Solution, enlarging the jaws with the DNA appliance or a combination thereof.
Gene regulation and the environment:
Epigenesis is gene-regulating activity that does not alter the genetic structure of the underlying gene. In other words, it is any change in gene-regulation
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(expression) affecting an organism that is due to outside influences rather than to genetically determined ones. The genes we have are inherited from both parents and these combined genes regulate the development of the jaws in an individual. However, gene-environment interactions can co-regulate or contribute to jaw development and outcome of size and functionality. Some individuals, for instance, will not develop fully sized jaws because of environmental conditions that are noxious to growth – somehow outside and/or inside influences have derailed what was programmed into the genes. The gene structure remains the same, yet the expression of the gene has been altered, so that what could have been is not realized. A surgery or accident, for instance, can stunt the growth of a limb, the potential for growth is still there, however it has been inhibited by the surgery or accident. In the same way, the foods we eat, environmental pollutants, allergies, poor dentistry, poor oral habits and disease influence jaw size.
Epigenetically, we can influence the development of the jaws, especially in a growing child, and to a certain degree in adults. The reason for this is the natural plasticity (flexibility) of the jawbones. The jawbones are plastic in the sense that they easily adapt and continuously change to what is occurring to the teeth and oral cavity. Bone is continually regulated and assaulted by osteoblasts and osteoclasts. Osteoblasts are cells responsible for building bone and osteoclasts are cells responsible for assimilating or absorbing bone. Osteoblasts and osteoclasts are responsible for bone regeneration, which occurs continuously throughout our lives. That is how the body regenerates bone for growth or mends a broken bone. However, growth and repair are not the same and should be seen as divergent processes, as repair leads to scar tissue formation whereas growth does not.
This is a nonstop process that keeps bone alive, growing and healthy. It is also the reason that growth can be initiated in the jawbone by an outside influence. The teeth can be positively arranged by dentists using braces to move the teeth into better alignment with each other. The teeth move gradually as new bone is born and the old bone eliminated in a process of absorption. However, straightening teeth for purely esthetic reasons is not a good enough reason to move them around, as how the teeth and jaws function together are more important than how the teeth look. A pretty smile is important, yet a functional smile is so much more important than the illusion of health. Teeth can be moved when there is sufficient space in the jaws for them to be moved, and no tooth should be removed to artificially provide enough space for them to be straightened.
The jaws can be potentially influenced to grow, especially in children, (also in adults to a lesser degree, yet enough to provide breathing space), by the use of functional appliances that apply a force sufficient to accelerate osteoblast and osteoclast activity. These appliances use an epigenetic force that instigates further growth of the jawbones. When the jaws are large enough the teeth will naturally fill-in and a natural process of straightening will occur, if better
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 15 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy alignment is desired functional braces can be used to align the teeth and jaws so that they function as a harmonious unit.
Bone cells respond to mechanical stimuli like movement and pressure. Think about Chinese foot binding, it was the custom of binding the feet of young girls (mostly upper-class) to prevent further growth of the feet beyond a certain size. The binding inhibited the bones in the feet from growing because of the constant inward pressure. Functional dental appliances are made so that there is a steady pressure in the desired direction of growth. A jaw that is too narrow and small would require directional pressure forward and to the sides, so that the jaw grows in length and in width. And as a result all associated structures and structural spaces will grow or develop with it, i.e. – tooth space, tongue space and airway space for instance.
The appliance, in essence, will act as a gene-regulating device – providing environmental stimuli that influence gene-expression by exploiting the process of bone regeneration, which has as its essence the potential for bone growth regardless of age or gender.
LONG FACE SYNRDOME:
Example of Long Face – Shelley Duvall – narrow face & large central incisors & open pursed lips
The mandible has huge potential plasticity (capable of being molded) – it’s shape and size is directly influenced by the posture in which it is customarily held, (since childhood) and can shrink and enlarge in different directions. Correct craniofacial growth is dependant on nasal breathing and correct soft tissue positioning. The jaws normally grow forward and are guided by the force exerted by the lips, tongue and cheeks. Craniofacial and dental defects are not necessarily genetically determined; rather they are more often than not due to functional misuse of the tongue, lips and muscles of the face (epigenesis). Facial growth patterns are functional in nature and respond to weak forces derived from oral facial posturing.
Switching from nasal breathing to mouth breathing forces the body to adapt functionally and leads to alterations in genetically determined craniofacial growth patterns. And which, in general, leads to the development of a long and narrow face, especially of the lower anterior face, and reducing or flattening the middle third of the face. This vertical growth pattern results in long face syndrome and often to hypoplasia (flattening) of the upper jaw. The lower jaw is often small and weak looking and/or sometimes can be large and protruding, depending on individual adaptability. The chin is almost always retruded with open lips that are
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 16 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy unable to seal. The nose will often be large or at least appear large, even though the nostrils are often very narrow and not highly functional. Forward head posture will often accompany, as compensation to open the airway. Even though the face appears larger than a normal face, the jaws are actually smaller as they have not grown to the full potential in the horizontal, away from the base of the skull. The teeth will therefore not fit the mouth and will often look large and crooked.
According to Yosh Jefferson DMD in an article for General Dentistry titled: Mouth breathing: Adverse effects on facial growth, health, academics, and behavior. He states: “However, many health care professionals (as well as the public) feel that individual facial features are the result of genetics and therefore cannot be altered or changed–in other words, the genotype ultimately controls the phenotype. However, more and more studies are showing that environmental factors may play a significant role in facial and dental development and may alter the phenotype.” Dr Jefferson cited studies using young rhesus monkeys that had their nasal openings blocked with latex plugs. In other words they were forced to change from nasal breathing to mouth breathing. The monkeys developed either (1) an open bite with long faces, (2) bucked teeth with a smaller shorter lower jaw or (3) a flat mid-face with a larger longer lower jaw that did not fit the upper jaw. According to Dr Jefferson the changes occurred due to how the monkeys adapted to oral breathing and in what muscular jaw positions they used in order to mouth breathe.
Long face syndrome can also be the result of poorly thought-out orthodontic care, where teeth are extracted and the remaining teeth are straightened to accommodate small jaws. If teeth appear large to the face – it is a possible tell that the jaws have not fully developed due to an epigenetic-regulating event. If this is the case the orthodontist should develop the jaws so that they grow wider and longer (forward). The child should also receive Myofunctional Therapy at the same time. This is a series of neuromuscular exercises meant to re-pattern, re- educate and optimize the functions of the oral cavity by targeting the muscles involved in chewing and swallowing. Behavioral modification is used to eliminate poor muscular habits contributing to or creating negative growth patterns in and around the oral cavity. Strengthening and correctly coordinating these muscles also help to keep the airway open, especially during sleep.
Biological Clock & Sleep:
Humans have biological patterns known today as circadian rhythms. They are genetic in nature and are patterned on a daily time scale of approximately 25 hours. They help to regulate body temperature, appetite, alertness, hormonal secretions and sleep. Adult humans are genetically programmed to be awake from 15 to 16 hours a day and to sleep 7 to 9 hours a night. These biological rhythms are internal, however, environmental cues are necessary to maintain the accuracy of the biological clock, such as sunrise, sunset and daily routines. Of
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 17 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy course it will be influenced by sleep/wake homeostasis, in which the amount of hours awake will begin to influence the amount of time needed for sleep.
Of course each individual is unique, however, there will be a level of sleep deprivation that the individual cannot surpass, if they want to function and have a healthy life. Working or studying at night, shifting sleep to the daytime, however, can disrupt the biological clock temporarily, yet the necessity for sleep will still be enormously present. It is probably better to sleep at night, as we are biologically set-up to do so, yet we can still get the required hours of sleep during the daytime with a slight alteration of the biological clock. The danger is that many never get the sleep they need and build-up a large sleep debt, where payment is sleep itself, or excess sleepiness and biological consequences occur.
Sleep Debt:
Sleep debt is the difference between the amount of sleep you should be getting and the amount you actually get, and most adults need between seven and nine hours of sleep each night for optimum performance, health and safety. It's a deficit that grows minutes and hours at a time until it becomes chronic and widespread. Studies show that short-term sleep deprivation leads to a foggy brain, worsened vision, impaired driving, and trouble remembering – imagine what long-term deprivation will do to cognitive functioning. Long-term effects will also affect the body – obesity, insulin resistance, and heart disease. All lost sleep accumulates progressively as a larger and larger sleep debt and the only way to reduce this indebtedness is by obtaining extra sleep over and above the daily requirements of the individual – until the sleep debt is paid off.
Sleep deprivation has plenty of other harmful sequelae, like disruption of carbohydrate metabolism and endocrine function that lead to many other diseases. Plus it can lead to heart disease, diabetes, fluctuations in weight, colds and flues and hallucinations. It can worsen any mental health problem and vice versa. Sleepiness and illegal drug use, especially in the young, can be a recipe for disaster, either as pedestrians or drivers of a motor vehicle. Parents should monitor their children for excessive sleepiness, especially if they drive a motorcycle or car to school.
Determining how sleepy you are? Measuring Sleepiness Subjectively:
Questionnaires such as the Stanford Sleepiness Scale or the Epworth Sleepiness Scale exist to help measure self-rated symptoms of sleepiness that can be done at home or in the office. These scales measure subjective feelings of sleepiness or the chance of dozing off during an activity.
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Stanford Sleepiness Scale:
This is a quick test developed by William C. Dement while at Stanford University. The test takes into account that there are two daily peak times of alertness both occurring around 9 (a.m. and p.m.) and a waning of alertness at around 3 p.m. with a subsequent buildup of it. Alertness is rated at different times of the day. This test is done for 7days – any score higher than 3 may be an indication that you have a serious sleep debt and require more sleep.
Degree of Sleepiness Scale Rating
Feeling active, vital, alert, or wide awake 1 Functioning at high levels, but not at peak; able to concentrate 2 Awake, but relaxed; responsive but not fully alert 3 Somewhat foggy, let down 4 Foggy; losing interest in remaining awake; slowed down 5 Sleepy, woozy, fighting sleep; prefer to lie down 6 Cannot stay awake, sleep onset soon; having dream-like thoughts 7 Asleep X
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12am
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Epworth Sleepiness Scale:
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
It is important that you answer each question as best you can.
Situation Chance of Dozing (0-3)
Sitting and reading ______
Watching TV ______
Sitting, inactive in a public place (e.g. a theatre or a meeting) ______
As a passenger in a car for an hour without a break ______
Lying down to rest in the afternoon when circumstances permit ______
Sitting and talking to someone ______
Sitting quietly after a lunch without alcohol ______
In a car, while stopped for a few minutes in the traffic ______
OSA questionnaire: Score the questions below with a yes or no:
1. Do you snore loudly or have been told that you snore? 2. Do you ever awaken with a sensation of gasping or choking? 3. Has anyone ever noticed that you stop breathing during your sleep? 4. Do you often wake up with a dry mouth? 5. Do you find your sleep to be non-refreshing? 6. Do you often feel tired, fatigued, or sleepy during daytime?
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7. Do you ever fall asleep or nod off in situations where you did not intend to? 8. Do you have (or are being treated for) high blood pressure and or diabetes?
If you have more than one of these symptoms you are at a higher risk for OSA. The risk increases if you are overweight or obese, have a large neck size, have hypertension and/or cardiovascular disease.
The influence of sleep on creativity, efficiency, productivity, memory and learning:
Sleep is essential for the growing body as chemical growth factors are released during deep sleep; however, it is also a key ingredient in learning and productivity, which is important for the child at school and for the adult in the workspace. Learning and performance greatly deteriorates with chronic sleep deprivation. In the adult this will lead to hypersomnolence (sleepiness) and in the young child paradoxically to hyperactivity and an inability to learn. And in some children a failure to thrive, which is the pronounced lack of growth due to inadequate absorption of nutrients.
Professionals in their fields would greatly benefit from good sleep. This is essential in those who run heavy machinery, including automobiles. The Exxon Valdez oil spill disaster that occurred in 1989 was in reality due to sleep deprivation of a junior officer and not alcohol consumption of the captain who was not on the bridge during the accident. Three Mile Island Nuclear Meltdown (1979), Bhopal Pesticide Release Disaster (1984) Space Shuttle Disaster (1986) and Chernobyl Nuclear Power Plant Explosion (1986) have all been implicated as disasters due to hypersomnolence or excessive sleepiness. How many other unknown disasters, personal or public have been due to the accumulation of sleep debt, sleep deprivation and uncontrolled excessive sleepiness.
Most teens today are sleep deprived. How many parents nowadays allow their teen-age children to drive heavy-vehicles, such as cars or motorcycles without getting enough sleep? How many parents have lost teen-aged children to motor- vehicle accidents? Sleep deprived teens – drugs – and motor vehicles don’t mix. Even taking an over-the-counter allergy medication, which can cause drowsiness, when excessively sleepy can by extremely dangerous when driving. These are important questions to consider and it is vital that they not be ignored. Many lives are at stake and many lives can be saved if we do the right thing.
Sleep deprivation affects all known professionals, including surgeons, lawyers, market traders, pilots, truck drivers, taxi drivers, limousine drivers, ship captains, train engineers and engineers in general. These professions all affect the lives of others, including their own lives and livelihood. Imagine being under the knife of a surgeon who is extremely sleep deprived – or being flown by a pilot who is
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 21 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy excessively sleepy. Yet this is what occurs day in and day out all across America and throughout the world.
Business executives are notorious for traveling abroad to a different time zone thinking it wise to make deals while they are sleep deprived. It’s true that the early bird catches the worm. Yet only if they have had adequate rest and sleep the night before. Concentration and memory are directly influenced by the quality and quantity of sleep one gets. It is essential for adults to get between 7 to 9 hours of good continuous sleep and without any chronic sleep debt. Sleep debt is the accumulated number of hours of missing sleep that builds up from not sleeping the required number of hours for the individual.
The numbers of sleep hours required would be unique to the individual, however, for most individuals it will be between 7 to 9 hours of uninterrupted sleep. However, a significant portion of that sleep must be in slow-wave sleep or deep sleep for it to be restful and refreshing. Sleeping 7 to 9 hours regularly in light sleep with very little time spent in slow-wave sleep – is not refreshing to the individual and leads to chronic sleep deprivation and harmful consequences to the immune and nervous system. OSA deprives the individual of deep sleep, as obstructive events steal the individual away from deep restorative sleep and back to light sleep, which is shallow and a non-restorative type of sleep or awakens them completely.
Misdiagnosing depression, fatigue & cardiac related illnesses:
According to William C. Dement in his seminal work “The Promise of Sleep” – “between 95 and 99 percent of all sleep disorder sufferers in 1991, and 1998, remain undiagnosed and untreated or misdiagnosed and mistreated. That is millions and millions of people. We have solidly confirmed this conclusion in our continuing on-site studies of primary care medical practice…There are several key reasons why primary care and other doctors lack the inclination or time to deal with sleep problems. First and foremost…is lack of education. Second, physicians often believe that sleep disorders are not serious or life-threatening. “Sleep apnea is not a fatal disorder,” they may claim. While it is true that few people actually die during a nighttime apnea attack, the disorder leads directly to many fatal events such as heart attacks, strokes and accidents…Typically doctors spend between four and five minutes with patients – long enough only to deal with the specific problem for which the appointment was made. It is certainly not enough time to evaluate a patient’s sleep patterns and problems.”
If you believe that in 15 years the whole sleep disordered breathing issue has been overhauled in medical practices – you would be dead wrong. Doctors, especially those in HMOs are pushed to spend the minimal amount of time with their patients, as they are getting paid so little by insurance companies these days. Also sleep medicine is considered a specialty, and doctors have to spend
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 22 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy many thousands and thousands of dollars for this training. Dentists especially are loathed to spend so much money on post doctorate training. It is only those with a true interest who will go the distance and complete their education and training. Since OSA has symptoms that share or resemble other conditions, it is often overlooked and frequently misdiagnosed as fatigue or depression. Most medical doctors and dentists are truly unfamiliar with OSA and sleep disordered breathing, as these conditions do not fall under medical or dental training and are not taught in either medical or dental schools. Sleep medicine is considered post-graduate specialty training only. In fact, sleep medicine has only been recognized as a medical specialty since 2005. Most medical doctors and dentists do not know what to look for and/or the sequelae involved in sleep disordered breathing. A sequelae is a disorder or disease that is caused by a preceding disorder or disease. For instance, high blood pressure and cardiac disease can result from untreated obstructed sleep apnea. OSA is a correlated cause of these disorders.
Many doctors today are treating fatigue, where in many cases they should be treating OSA and sleep disordered breathing instead. Fatigue is often mistaken for hypersomnolence (excessive sleepiness), as they share similar indications, however, they are not the same and should be treated distinctly and differently. Fatigue is extreme tiredness or weariness. Sleepiness is feeling drowsy and wanting to sleep. You can be fatigued but not sleepy or you can be sleepy and not fatigued; you can also be sleepy and fatigued and vice versa. Fatigue implies bodily weakness, whereas sleepiness does not. Daytime sleepiness is not fatigue; it is the result of accumulated sleep debt that can be worked off if the individual dedicates some time to catching up on much needed sleep. Disorders, such as chronic fatigue, do not lessen or abate with sleep. They have nothing to do with the amount of sleep one gets. Make sure your doctor has not misdiagnosed you, especially if your condition is not getting any better.
Depression is another oft-misdiagnosed condition, as OSA and sleep disordered breathing can lead to altered behavior and cognitive sluggishness, which can be interpreted as apathy or indifference and normally considered indicative of depression. Sleepiness can make us feel less vital, less motivated, and slothful – feelings of lacking energy and drive are common to both chronic sleepiness and depression. Both depression and chronic sleepiness affect sexual drive and both greatly influence psychogenic (originating in the mind/emotions) impotency.
OSA can also physically influence erectile dysfunction as it is the parasympathetic system that controls erections – OSA lowers and inhibits the parasympathetic system by making the sympathetic system dominant. This can suppress erections from occurring; as the body is in fight or flight mode, and the necessary amount of blood for engorgement of the penis is diverted away. This fight or flight response is a stress response. Erections are only possible in relaxation, (which the parasympathetic system rules). It is difficult for a man or woman to get aroused when they are in chronic fight or flight mode, as the
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 23 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy sympathetic system diverts the blood away from non-survival areas like the groin to the heart, brain and the muscles needed during the stress response. The stress response is an involuntary physiological reaction set up to survive imminent danger. However it can also be triggered by chronic obstructive apnea or sleep disordered breathing.
Depression and chronic sleepiness can both lead to diminished performance, lack of concentration, lack of interest, diminished cognitive power, forgetfulness and a general inability to integrate social and cognitive abilities cohesively. Sleep disturbance is a common feature in depression. In fact sleep disturbance can be correlated to depression and attention-deficit hyper-activity in children and adults.
Hypersomnolence is directly influenced by the amount of sleep debt you owe yourself. Sleep debt is the difference between the quantity/quality of sleep one ought to be getting and the amount one actually gets. If your body requires 8 hours of sleep a night to feel refreshed and awake and you consistently only get 6 hours of sleep a night – you then weekly have accumulated 14 hours of sleep debt. Meaning that your body, mind and emotions will begin to progressively become more and more sleepy. If you do this for a month you owe yourself 56 hours of sleep, which is pretty difficult or impossible to make up if you have a busy schedule. Luckily catching up on the missing hours of sleep can pay off the sleep debt. Yet for the sleep apneic this is not so easily done as said. For no matter how many hours of sleep the untreated sleep apneic gets – the quality of his sleep remains disturbed by a factor of one to four hours a night. The sleep apneic is accumulating a large sleep debt that will be difficult to pay off, since OSA is usually not acute and for most sufferers is a decades-long condition.
With a large sleep debt it is easy to be misdiagnosed as the symptoms of sleepiness can easily be confused with other disorders. I would consider it preferable to err on the side of a sleep disturbed disorder, which is treatable, rather than trying to treat something like chronic fatigue, depression or ADHD (attention-deficit hyperactivity syndrome), which are implicitly more complicated to treat and very difficult to resolve with or without medications. If you are misdiagnosed with any of these, treatment will be ineffectual anyway, as the underlying source is missed and suppression of symptoms will only make OSA and/or sleep disturbed breathing (SDB) worse and not better. The misdiagnosed medications will also contribute to a worsening of OSA and SDB.
Patients with hypertension, stroke or history of cardiac disease ought to be evaluated for sleep disordered breathing, especially OSA, as OSA might be contributing to or be the underlying cause of these disorders. Treating theses disorders without treating OSA null and voids any benefits that one might receive from therapy; as the underlying stressor has not be eliminated. And sleep with dozens to hundreds of fits and starts can and does unleash a cascade of chemical and hormonal stressors that damages the body.
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Anatomical structures to consider in OSA & sleep disordered breathing:
The Nose:
The nasal cavity is one of the best places to start, especially in a child, since obstructions of the nose are directly responsible for the occurrence of mouth breathing in children and which consequently leads to anatomical changes in facial features. Specifically one should look at the nasal structures for any potential obstructions due to septal deviation, hypertrophied turbinates, and nasal polyps or enlarged adenoids. A large nose does not mean better breathing or a larger breathing apparatus – as it may be a compensation for poor breathing or the nose may appear large because of a small lower jaw and chin and/or flattening of the mid-face or both.
Right behind the nose are the sinuses, the organs of smell and the beginning of the respiratory tract. The nose is intricate with many functions, including filtration, humidifying and controlling the temperature of the air we breathe in before it enters the lower airways and the lungs. The nose is also integral to the sense of smell and acts as an early warning system as it easily reacts to aerosolized irritants. Anything obstructing the nose, especially in the child, ought to be looked at and treated immediately, as obstruction can lead to open-mouth breathing and worsening of the breathing apparatus of the nose and sinuses. This includes tending to any obvious allergies or chronic infection affecting the nose, ears and sinuses. For some medications will be enough. Medications include homeopathy or natural cures, if they work for you. If not, over-the-counter or doctor prescribed medications are in order. For others surgery will be required to open-up the upper airway. These tend to be non-invasive and simple enough to be done in a doctors’ office with local anesthesia and with no significant loss of tissue and with minimal side effects. For some patients this will eliminate a significant source of obstruction, allowing them to sleep and breathe easily enough.
Deviated Septum:
The nasal septum is the bone and cartilage in the nose that separates the nasal cavity into the two nostrils. A deviated septum is an abnormal condition in which
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 25 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy this thin wall between the nostrils is displaced to one side, causing obstruction of the affected nasal passage. The condition can result in poor drainage of the sinuses, as one nasal passage is smaller than the other. When it is severe, it can block one side of the nose and reduce airflow, causing difficult breathing, nosebleeds and other symptoms. Part of the septum is slow growing and continues to grow upwards of 30-years, a deviation can occur anywhere in these 3 decades.
Hypertrophied Turbinates:
The turbinates are small spongy bony structures that are located on the sides of the inner nose and they help to clean, warm and regulate airflow while protecting the inner nose. Their main function is controlling airflow, but they also clean, moisten and filter the air, while protecting the sinuses and the smell receptors. Hypertrophied turbinates are swollen and enlarged and they can congest or block the nose. They can be caused by allergies, chronic sinus inflammation, and environmental irritants and can be exacerbated by a deviated septum. They are often associated with difficulty breathing at night and snoring, chronic nosebleeds and chronic sinus infections. A concha bullosa is an air pocket in the middle turbinate and is considered a common anatomical variation and is further associated with deviated septum on the opposite side; a hypertrophied turbinate with an air pocket will without a doubt prevent the sinuses from draining properly.
Nasal Polyps:
According to the Mayo Clinic, “Nasal polyps are soft, painless, noncancerous growths on the lining of your nasal passages or sinuses. They hang down like teardrops or grapes. They result from chronic inflammation due to asthma, recurring infection, allergies, drug sensitivity or certain immune disorders.” Nasal polyps are masses derived from the mucosa that can block the nose, reduce the sense of smell and lead to frequent infections.
Enlarged Adenoids:
The adenoids are tonsil-like lymphatic tissue situated between the nose and the back of the pharynx. If they become significantly enlarged due to infection (hypertrophied) they can completely block the upper airway. The degree of obstruction to nasal airflow depends on the size of the pharynx and the size of the enlarged tissue involved. They can remain enlarged due to chronic inflammation. This frequently leads to mouth breathing in a child and must be eliminated as soon as possible. If this is a consistent and chronic condition with many
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 26 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy flare-ups consider having them surgically reduced or removed. Even though they are considered lymphatic tissue that helps to fight infection – at this point they are causing excessive damage to your child’s health. Including damaging the natural morphology of your child’s face and jaws, as mouth breathing forces the face to develop differently, as it is an accommodation to a dysfunction.
Sinuses:
Paranasal Sinuses are the hollow openings filled with air and leading into the nasal passages located within the cranium (head and facial bones). The word sinus is Latin for cavity. There are four sets in the head – the ethmoid, sphenoid, frontal and maxillary. The sinuses are lined with soft, pink tissue called mucosa. Normally, the sinuses are empty except for a thin layer of mucus. There are many possible functions of the sinuses, including helping to lighten the weight of the skull, increase the resonance of the voice, filter, heat and humidify the air that is inhaled, aid in the sense of smell, and most importantly an immunological defense.
One of the key functions of the cavities is the production and drainage of mucus, which normally flows into the nose. Mucus, which is constantly produced, is used to trap harmful substances that could potentially penetrate the body. The sinuses facilitate the trapping, collection and drainage of mucus so that it cannot accumulate and greatly reduces the chances of an infection from forming by ensnaring dust, dirt, viruses, bacteria, and allergens from entering the body.
When this drainage pathway is blocked or obstructed, the sinus tissue becomes irritated, which leads to swelling and infection. You may ask, how do these pathways become blocked? Many conditions, such as colds, allergies and even polyps may lead to sinus blockage. Polyps are small sacs of swollen tissue, which swell and can grow to block passages. Typically, mucus can be very beneficial in providing moisture and irrigation to the nasal membrane, thus filtering out foreign matter and attacking infection. Ultimately, however, when these secretions become thick and heavy, their cleaning mechanics become clogged and may block their very function. This may lead to a decrease in circulation, headaches and infection.
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Post nasal drip:
Normally, you don't notice the mucus from your nose because it mixes with saliva and drips harmlessly down the back of your throat to be swallowed gradually and continuously throughout the day. It is a constant unabated process. Only when your body produces more mucus than usual or the mucus is thicker than normal does it become more noticeable. Excess mucus can come out the front of your nose in the form of a runny nose. When excess mucus accumulates or runs down the back of the nose to the throat, it's called postnasal drip.
This is associated with constant, thick and excessive mucosal secretions that accumulates in the throat or the back of the nose and is often linked to colds, allergies, infections, structural malformations, and sometimes with swallowing disorders.
Disorders of swallowing occur when the mouth, throat, and esophageal passage are not working and interacting properly. As a result, mucosal secretions can leak into the larynx and inhibit breathing. Treatments for postnasal drip and sinus issues include prescription drugs, such as antibiotics, antihistamine, decongestants and diet changes. Unfortunately, these treatments may only temporarily bring relief in certain situations and are not a cure.
The Mouth:
The oral cavity contains many structures that can be implicated with OSA, the teeth, tongue, vulva, tonsils, palate, arches and the jaws. As with the nose, check for inflammation or infections of lymphatic tissue that can block the size of the airway.
Teeth:
Strangely enough the size and height of the teeth directly influences the size of the oral cavity, as small or short teeth directly reduces the amount of airway space, tongue space and arch size. Complete endentulism (complete loss of teeth) alters the oral cavity’s anatomy and depending by how much it is reduced, it may impair upper airway size and function including that of the tongue. Missing teeth may have the same affect, as jaw size directly correlates with the amount of
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 28 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy teeth in the oral cavity. Crowded teeth indicate possible small jaws. Those with very short eroded teeth may consider increasing the height of the teeth with neuromuscular dentistry, as the crowns and veneers used will increase the oral space – hence the airway. Furthermore it will prevent further erosion and breakage of the teeth and also correct for a poor bite – that can lead to TMJ issues. If the jaws are small it is preferable to expand the arches first using a functional device like the DNA appliance and then treat the teeth neuromuscularly.
Tongue:
Macroglossia or an unusually large tongue can easily block the airway, as the large size already partially obstructs the back of the mouth. This is further exacerbated when sleeping as the tongue may fall back due to muscle relaxation. The tongue ought to fit the size of the jaws and not exceed the space provided by them. Increasing the vertical dimension of the teeth (height) alone may provide sufficient space (neuromuscular dentistry). However, if the jaws were small expanding them with a functional device (DNA appliance, orthotropic appliance) would provide adequate space for the tongue. Surgery to reduce the tongue ought not to be considered unless the size of the teeth or jaws is not an issue. There are also devices like the Full Breath Solution that can control the tongue from blocking the airway.
Uvula:
The uvula is the small fleshy v-shaped extension hanging off the soft palate directly above the tongue at the opening of the pharynx. It is considered an organ of speech, especially in those languages using guttural sounds. There is no standard size. However, in some cases it can swell three to five times its normal size. It can swell due to dehydration, chronic snoring, smoking, infection or a cold. Palliative treatment should be enough to reduce it if it’s hypertrophic. Reductive surgery is permanent and does not guarantee that it will work.
Soft Palate:
The soft palate is the roof of the mouth that separates the oral cavity from the nasal cavity. The soft palate is movable, unlike the hard palate, which contains bone, and consists of muscles sheaved in mucous membrane. It protects and closes off the adjacent nasal passages during the act of swallowing and sneezing. An elongated soft palate is considered redundant and is the area responsible for snoring. An oral appliance should be able to help control this area. Again, reductive surgery is permanent and does not guarantee that it will work.
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Arches:
A high palatal vault (the upper arch) with narrow arches creates a v-shaped arch, which reduces the amount of space for the teeth and for the tongue, again reducing the size of the airway space. Tongue thrusting, improper swallow, bottled fed babies and thumb sucking contributes to narrow arches and overjet, where the upper teeth are bucked and projecting away from the lower teeth. Expanding the upper arch with a functional device (DNA appliance) ought to drop the palate significantly. Providing more room for the teeth and especially the tongue. The lower jaw, in most cases will adjust itself accordingly to the development of the maxilla. In some cases a lower DNA appliance will be necessary to further develop the lower jaw and arch.
The Lower Pharynx (laryngopharynx):
The lower pharynx can be affected by its narrowness, by the base of the tongue and the position and size of the lower jaw.
Base of the Tongue:
The base of the tongue is important for swallowing and speech – it provides the main force for movement of food from the oropharynx (mid-throat) into the laryngopharynx (lower-throat). The base of the tongue, when we sleep supine (on our backs), can drop to the back of the throat and block the lower airway. If the tongue is large and the lower jaw is either small or receding – the base, which is the bulk of the tongue will greatly reduce the airway at the mid-throat and lower-throat. Treatment can consist of a dental device that pulls the lower jaw forward and away from the throat – reducing the chances for obstruction; or a functional appliance that further develops the size of the mandible, while preventing the tongue from obstruction.
The Mandible:
If the lower jaw is small and/or retruded (thrust backwards) it will reduce the overall airway space of the throat, as it can drive the tongue back into the throat and block off the airway. It can also thrust the tongue upwards, (if there is not enough lower jaw-space for it), so that it elevates the soft palate against the upper airway, again blocking off the airway and preventing the Eustachian tubes from clearing. Treatment can consist of a dental device that pulls the lower jaw forward and away from the throat – reducing the chances for obstruction; or a functional appliance that enlarges and further develops the size of the mandible permanently.
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Hyoid Bone:
The hyoid is a small movable U-shaped bone in the upper neck region that the muscles of the base of the tongue and pharynx are attached to. And is the only bone in the body not connected to any other bone.
Larynx:
The larynx is the cartilaginous box-shaped part of the throat between the root of the tongue and the top of the trachea.
Hypoplasia of the Jaws:
Hypoplasia (failure of body part to develop fully) of the jaws are common in certain conditions: such as, Down’s syndrome, Crouzon’s syndrome, Apert’s syndrome and Cornelia De Lange syndrome, etc. However, they can also occur in the normal population especially hypoplasia of the lower jaw. Common craniofacial differences of the lower jaw, such as, retrognathia and micrognathia are widespread. These can be considered congenital, developmental and acquired conditions. The congenital (present at birth) group is associated with the above-mentioned syndromes.
However, hypoplasia of the upper jaw is easily as widespread, although it is generally not as recognized as hypoplasia of the mandible. Those with Down’s syndrome have an obvious flattening of the mid-face and are subgroup that invariably suffers from obstructed sleep apnea, (especially as they age and as a result have a short life expectancy). Flattening of the mid-face if often seen in those with long faces, as the face has developed downwardly and not outwardly, as it should have. It gives the middle of the face a sunken appearance and makes the lower jaw protrude or appear as if it were popping out, even though it may be of normal size. Acquired hypoplasia of the maxilla (upper jaw) can be gotten by poorly planned dental extractions, as the maxilla may fail to develop without certain critical teeth to guide the growth pattern of the jaw.
Small jaws (hypoplasia) in general can lead to difficulty in breathing, chewing and swallowing, which can then lead to sleep apnea and/or sleep disordered breathing. In young children it can lead to weight loss and failure to thrive. Retrognathia can be considered a condition in which either or both jaws recede with respect to the frontal plane of the forehead, meaning that they are posterior to or behind this and other facial structures. Micrognathia refers to the smallness of either or both jaws regardless of their position in relation to other facial structures.
There are plenty of individuals in the general population with small and receding jaws that are able to function to a high degree without any frank breathing disturbances in the day-time, as their bodies are able to compensate for this
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 31 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy while they are awake. However, during sleep these anatomically poorly sized and poorly positioned facial differences can interfere with nighttime breathing, especially as they age. These are conditions that are easier to treat in the young and become progressively more difficult to treat as we age (although they do not remain impossible to treat).
The jaws (especially in the young) can be guided to grow (develop), as the underlying genetic code has not been disturbed – it has been merely derailed, usually by environmental factors that are both inside and outside the body. Myofunctional therapy (neuromuscular exercises that are meant to re-pattern, re- educate and optimize the functions of the face, head, neck and oral cavity) in combination with oral devices can initiate growth in both children and adults. Of course sleep apnea and other sleep disordered breathing can be treated without altering or initiating the growth of the jaws, however, treatment will remain palliative (alleviating the symptoms only) at best; as the underlying cause, in this case the size and positioning of the jaws, remains the same.
To treat palliatively, especially in children, is incongruous and a disservice to you and your child. Parents have to keep this in mind before straightening their child’s teeth, as the teeth often are not the issue but the size of their jaws, which can be further developed before tooth straightening. This is especially true if your dentist requires that teeth be extracted in order for the teeth to remain straightened and aligned, as this is done solely because the jaws are too small for the size of the teeth. Once those teeth are extracted the jaws will never (by themselves) further grow or develop, as the practitioner has arrested the growth and development of the jaw or jaws.
These are two adorable twins – yet you can begin to see how their faces are developing differently from one another – the girl has a round-square face, very pretty & very healthy, whereas the boy is developing a long narrow face that does not appear to be as healthy & probably has problems breathing thoroughly through the nose
If your child has allergies and/or daytime and nighttime breathing issues and permanent teeth are extracted for esthetic reasons (straightening) alone, the result is often paradoxical, as the teeth may appear somewhat esthetic but the face will slowly and gradually become less attractive. For many, (not all), the mid-face will appear sunken and the overall length of the face will lengthen in compensation for the missing teeth and breathing dysfunction. Individuals will acquire forward head posture, (the head is dangling forward and away from the center of gravity, which is the middle of the spine) in order to breathe better. I have seen pretty children
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 32 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy become unattractive adolescents with conventional orthodontic treatments. If you want to see Internet evidence of this please go to orthotropics.com and you will see plenty of pictures of acquired long-face-syndrome and acquired hypoplasia of the jaws. Orthotropics is one way of functionally treating malocclusions (misalignment of the bite), hypoplasia of the jaws and esthetic considerations. However, there are many more ways of treating functionally, so that growth is properly initiated in both the child and adult. Orthotropics is pretty much only for young children and does not work so well with late adolescents and adults – as the appliance is intrusive and painful, (furthermore, it is an English phenomena with very few American practitioners).
OSA, Forward Head Posture and Temporomandibular Dysfunction:
The classic symptoms of TMJ dysfunction are:
Clicking, grating, popping of the jaws Pain in the jaw and joint Teeth pain Clenching and/or grinding Difficulty closing the mouth Difficulty opening the mouth Facial pain of unknown origin Ringing in the ears Inability to chew comfortably Fatigue of the facial muscles while chewing or talking Headaches Ear pain Locking of the jaw in either the open or closed position Unexplained pain in neck, shoulders & back even with therapy Sinus pain and stuffiness Lower jaw that deviates to the left or right while opening or closing
Temporomandibular Dysfunction (TMD) is often mislabeled or misnamed as TMJ, all TMJ stands for is temporomandibular joint – it is not a disorder or condition, however, most people know TMD as TMJ. I will be using TMJ – so as not to confuse those who use TMJ as TMD. TMJ (TMD) is a dysfunction of the temporomandibular joints. These are bilateral (both sides of the face) joints and are the only joints of the body that have lateral and horizontal movements of its kind. Most joints of the body are hinged joints, the TM joints can move side-to- side, slide forward and backwards and to a degree up and down. We use these joints more than any other joint in the body, in excess of 5000 times a day, as we talk, eat, drink and swallow (saliva incessantly) all day long. There are many dysfunctions of these joints, however, we will only be considering it a general dysfunction affecting OSA and sleep disturbed breathing.
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TMJ and forward head posture can occur independently of each other, however, many who have TMJ invariably have forward head posture as a consequence and vice versa. (Although forward head posture is manifested while standing or sitting, it can also be produced when lying on the back with too many and/or high pillows that push the head and neck forward and away from the body while supine.) Forward head posture is not only a poor use of postural alignment; it can for some function as a way to open up the airway, as a protruding jaw unlocks the pharynx by pulling the tongue forward and away from the throat.
Many who have open mouth breathing develop forward head posture, elevated shoulders, increase curvature of the spine and tilting of the pelvis; all in an attempt to keep the airway open. In other words, open mouth breathing can lead to exaggerated changes in posture of the back, neck and head. These are adaptive changes that if acute pose no threat to the individual person. However, if not corrected can lead to permanent changes in bodily posture. A misaligned body will lead to changes in head and neck positioning and will affect alignment of the jaws. Breathing is one of the most important functions of the body and the body in its infinite wisdom will sacrifice body parts in order to receive enough oxygen to keep the body alive. It will sacrifice the temporomandibular joints and the correct curvature of the spine in order to do so.
TMJ dysfunction is generally an acquired condition, it can stem from myofunctional misuse, open mouth breathing, subluxations of the spine, malocclusion (improper bite), dental treatment and/or dental trauma or accident. Grinding, clenching and gnashing of the teeth are principally myofunctional (muscular) in origin, as something in the individual, whether organic or not, causes them to muscularly abuse the teeth, jaws and TM joints. The result for many is the flattening and fracturing of teeth to the point where the joints invariably can no longer compensate and become dysfunctional themselves. Once the joints become unhealthy, the entire oral cavity is impacted because of the non-serviceability of the joints. Unhealthy TM joints leads to more myofunctional (muscular) misuse, which can lead to more grinding, clenching and gnashing of teeth. With malocclusions and short misaligned teeth – forward head posture invariably follows.
Malocclusion can occur from myofunctional misuse, poor dental treatments, extractions, broken or fractured teeth, congenitally missing teeth, orthodontics, root canals, too much dentistry, disordered daytime breathing, retrognathia, micrognathia and/or trauma or accidents. Malocclusion occurs when the bite is off and not very functional. If the teeth are short in the back of the mouth – it will be quite difficult to chew properly. If the teeth are short throughout – airway space is greatly reduced and the tongue may not fit the jaws.
TMJ and OSA are considered unrelated conditions, yet they can be concomitant (existing with or at the same time) and they may affect and worsen the symptoms of the other condition. Both may have a myofunctional origin or aspect that are
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 34 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy shared, such as mouth breathing or thumb sucking. An open bite may result (the front upper and lower teeth do not meet or touch), leading to an exacerbation of TMJ and/or OSA. An open bite will possibly worsen the TM joints, as the teeth do not occlude properly as the teeth are ill-fitting one to the other and the jaws may be narrow with a high palate. Narrow jaws and a high palate are of course indicative of a large tongue and a small airway. If the TMJ worsens and the individual begins to grind their teeth away or fractures them – the oral space or size of the oral cavity shrinks proportionally to the reduction in teeth size. With the lessening of the oral space the tongue will not be able to rest correctly in the jaws, especially if they are small and narrow. The grinding will both worsen the TMJ and the OSA by similar differences. The reduction of tooth size will reduce the TM joint capsule space and reduce the airway space of the oral cavity. It must be remembered that if the teeth are healthy and intact, they increase the size of the oral cavity by about 15mm in a healthy individual. If they are greatly worn away (vertically) – then that shrinks significantly to 8 or 7mms or less.
Furthermore, the possible pain derived from TMJ may interfere with staying asleep, especially in deep sleep. It may also inhibit transitioning from individual sleep stages (light to deep) so that the individual remains in shallow light sleep. The combination of pain from TMJ and soft tissue obstruction can awaken the individual before achieving slow-wave sleep (deep sleep), which is necessary for growth, healing and regeneration. Chronic pain syndrome is a developing set of correlated dysfunctions that persist longer than 6 months resulting in mood alteration (i.e., depression), narcotic dependence and atrophy of a body part or parts leading to a loss of strength and functioning throughout the affected body parts and sometimes affecting the entire body. Injury to susceptible tissue can lead to hyperalgesia – that is an increased sensitivity to pain, which may be caused by damaged to nociceptors or peripheral nerves. Involving central nervous system hyper-excitability leading to long-term changes in the nervous system. Hyperalgesia can also result from long-term opiate use – so that pain no longer responds to drug intervention or may lead to an increase and dependency of narcotics.
Craniofacial deep tissue persistent pain and disrupted sleep are frequently associated, as they share a clear cause-and-effect relationship of a fragmented sleep cycle that worsens the pain response. Long-term narcotic use can cause or exacerbates sleep-disordered breathing. In general, chronic pain sufferers of any kind often have impaired sleep due to the arousal of increasing pain that inhibits the start of sleep and its continuity. Chronic pain sufferers often display alpha intrusion, when this occurs the brain frequency of light sleep (alpha) intrudes into slow wave (deep) sleep (SWS) delta wave frequency. This is commonly referred to as alpha delta sleep – and is considered a dysfunctional sleep pattern.
However, it is interesting to me that both TMJ & OSA can share similar anatomical coincidences: such as receding of one or both jaws, projecting lower jaw with crossbite, overbite (bucked) of the upper front teeth with narrow arches,
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 35 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy small mouth with large tongue, mouth breathing, forward head posture, long face syndrome, receding chin, facial asymmetry and countless other variations. In a 2009 landmark study, Cunali, Almeida et al, concluded that 75% of TMD/oral- facial pain patients have OSA and that 52% of patients with OSA also have TMJ (TMD). According to Steven Park M.D. (ENT) sleep apnea is a craniofacial problem due to constricted facial structures. Furthermore, open mouth breathing can lead to both TMJ and OSA together or independently of each other.
The Stages of Sleep:
Sleep can be considered an active local process, as the whole brain is not asleep – and whose timing and length are controlled and determined by the individual nervous system. There are four stages of sleep in the classic system, which are considered non-REM sleep, (REM sleep is rapid eye movement and in which almost all dreaming occurs). None or very little dreaming occurs in the other stages of sleep. Non-REM sleep is characterized by parasympathetic dominance in which the body is in a state of rest.
Each stage of sleep depends on the depth of slumber achieved. Techniques that record the electrical activity of the nervous system categorize the depth or stage of sleep in humans. Categorizing sleep depth uses the frequency, amplitude and pattern of brainwave activity, eye movements, and muscle tone. Stages 1 and 2 are considered light sleep and stages 3 and 4 are considered deep or slow wave sleep. These are considered the classic sleep stages, however, a new updated stage definition has just come out (Stage 1 = N1, stage 2 = N2, stage 3 & 4 = N3 and REM is now = R). We will use the updated version, as it is close enough to the classic version.
N1 is the stage between sleep and wakefulness; brainwave activity is in the beta and alpha stage transitioning to the theta. Beta waves are high-frequency waves that are associated with wakefulness and normal everyday consciousness. Alpha waves are slower and can also be achieved during relaxed wakefulness, (meditation, prayer, relaxation and biofeedback). During alpha the mind and body are relaxed and in a peaceful mode of being. Emotionally it is a state of well- being, pleasure and tranquility. Alpha may be the bridge from the conscious to the unconscious. The alpha state may lower cortisol levels, boosts the immune system and increase DHEA and melatonin levels.
N2 is still considered light sleep, however, the brain is now in the theta frequency, which is slower than alpha and is considered true sleep. This stage is of sleeping with reduced consciousness. Theta can also be reached during deep meditation. Recent studies have also shown that increased theta activity improves memory recall, creativity and a lasting ability to learn. Perhaps the elderly do not get enough theta activity during sleep and as a result suffer from different forms of memory loss (dementias)?
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N3 represents deep sleep and the brain is in delta wave, which is the slowest of wave frequencies. HGH (human growth hormone) is released during N3. HGH is responsible for growth and repair in the body. Deep sleep increases the secretion of prolactin and decreases stress hormones, such as cortisol. The delta wave of deep sleep is very refreshing and very rapidly reduces sleep need. Deep sleep is when the body repairs itself and builds energy for the day ahead. It may also play a major role in clearing the brain for new learning the next day.
R (REM) is a stage of sleep that reoccurs several times a night and is marked by dreaming, rapid eye movement (hence the abbreviation REM), elevated pulse rate, intense sympathetic activation, and brain activity during its most active phase. Yet because of the intensity of the active phase – the body is unable to move – preventing the dreamer from actually hurting himself or someone else by acting out the dream. It can account for upwards of 25% of sleep in healthy subjects. Many researchers consider it crucial for learning and memory consolidation.
R sleep occupies most of the sleep in newborns and gradually decreases as we age and may be vital in training central neural networks related to repeated and instinctive behavior. Successful learning during wakefulness results in increased R sleep. Without it the recollection of newly learned and complex material is impaired. Dreaming may be a form of brain stimulation and may also be a way to resolve daytime problems and conflicts.
Patients with OSA have respiratory induced arousals which causes sleep fragmentation, depletion in stages of deep sleep (N3) and of R (rapid eye movement) sleep; resulting in hypersomnolence and fatigue. Deep sleep is vulnerable to stress, sleep disruption, ageing and drugs. Higher blood levels of inflammatory proteins have been associated with people who do not get enough sleep. Inflammation is directly linked to cardiovascular disease, stroke, arthritis, diabetes and premature aging. The process of sporadic hypoxia (lack of oxygen) with an attempt at re-oxygenation at the tissue level is believed to activate several inflammatory pathways in the body.
With a reduction in critical deep sleep (N3) and rapid eye movement sleep (R) the body, mind and brain may become vulnerable to disease, as the process of consolidation, resting and regeneration has been halted by the need for oxygen. The body has chosen one physiological need over many others in order to survive. This acute survival mechanism preempts the need for deep and rewarding sleep. The body of course can get by on light sleep – for a while anyhow. However, eventually the body, mind and brain will no longer be able to compensate for the lack or oxygen and non-refreshing shallow sleep. The stages of sleep are not exactly of chronological order – yet, in a healthy individual they do form a pattern of light sleep into deep sleep and then into R sleep. If an individual is cycling mostly between N1 and N2 because of respiratory induced arousals the healing aspects of N3 and R are not being realized.
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Combined this with hypoxia and low blood oxygenation saturation and we have a recipe for disaster. It is only be restoring proper oxygen levels to deep tissue and allowing the body, mind and brain to cycle in deep N3 sleep and dreaming related R sleep that the body will naturally heal.
TREATMENTS:
CPAP (continuous positive airway pressure) machines:
Until recently, treatment options for sleep apneics were limited to mechanisms that mechanically kept the airway open and/or forced air down the airway. CPAP or continuous positive airway pressure is an apparatus used to force air down the pharyngeal airway. CPAP is approximately the size of a shoebox and weights about five pounds. The apparatus allows air to be sent through the airway passage via a six-foot flexible tube, connecting the CPAP machine to a mask worn around the face. When in use, specific air pressure strength is prescribed to hold the airway open. The constant airflow holds the airway open to ensure uninterrupted breathing during sleep.
CPAP is considered the gold standard in treating OSA, but it has many disadvantages including causing sore throat, nasal dryness, sinus congestion, dry eyes, rash around the nose and forehead, dry mouth, upper respiratory infections, heart arrhythmias, high blood pressure, ear pressure, headache, nose bleeds, claustrophobia, sleep disturbances from the mask, nightmares, and lack of intimacy. And as a result long-term compliance with CPAP is very, very low, as many find CPAP cumbersome, uncomfortable, and interferes with their personal and intimate life. Furthermore, treatment does not eliminate the structural causes of OSA.
However, for those with severe sleep apnea (30 or more episodes per hour) – it is a must. Especially in early treatment – for it will reduce any of the negative sequelae for which it is known to produce, such as stroke or hypertension. Once OSA is more or less controlled then a program can be built around reducing some or many of the risk factors – reducing neck and body circumference for instance. However, CPAP or BiPAP (bilevel positive airway pressure) machines
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 38 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy can be used in combination with other therapies in the meanwhile – thus augmenting the benefits of therapy and receiving some recuperative sleep.
These machines can be life changing and life saving for some patients, allowing them to sleep and breathe for the first time in years. CPAP and BiPAP are not sexy and can even be considered esthetically offensive yet they can play an essential role in treating OSA. Benefits accrue even if CPAP is used for only a couple of hours a night for those who do not tolerate it well. CPAP and BiPAP are prescribed to those with moderate to severe OSA. Moderate OSA is considered 15 to 30 apnea/hypopnea events per hour and severe is minimally 30 and above. In my office I have seen a prominent personality with an apnea–hypopnea index (AHI) of 144 events per hour, every hour – without treatment she was in danger of an imminent heart attack or stroke. She was immediately prescribed a CPAP machine to significantly lower the amount of OSA episodes she was experiencing during sleep thus greatly reducing the risk of a cardiovascular event from occurring. A few weeks later she was fitted with a functional dental device (DNA appliance) to widen her upper arch and jaw in order to gradually remodel and widen the airway and so eventually reducing the occurrence of soft tissue obstruction.
Oral Appliance Therapy:
Dental devices, which have been available for sleep apnea, include MAS (mandibular advancement splint), which captures the lower jaw and positions it forward and down. The device mechanically opens the airway by drawing the mandible away from the airspace providing more space in the throat by indirectly moving the soft tissue away from obstructing airspace, as the collapse of the soft tissue is what causes the obstruction. By bringing the mandible forward the tongue that is attached is also brought forward and away from the throat, temporarily preventing the base of the tongue from blocking the back of the throat.
Another type of dental device is a tongue-retaining appliance that repositions and captures the tongue towards the anterior. They do this by securing the tongue with negative pressure in a soft plastic bulb or plastic depressor that directly contacts the back of the tongue, where it meets the mid-pharynx.
However these treatments do not eliminate the causes of OSA as discussed, rather they provide a palliative solution at best. In addition, these devices can have negative side effects for the individual. The University of Maryland Medical
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Center posts this on there website: “Nighttime pain, dry lips, tooth discomfort, and excessive salivation. In general, these side effects are mild, although over the long term they cause nearly half of patients to stop using dental devices. Devices made of softer materials may produce fewer side effects. Permanent changes in the position of the teeth or jaw have occurred in some cases of long- term use. Patients should have regular visits with a health professional to check the devices and make adjustments. In a small percentage of patients, the treatment may worsen apnea.”
The majorities of dental devices are mandibular repositioning appliances and are either a one-piece or two-piece designs that are custom made for the patient. These devices rigidly fix the lower jaw forward and away from the throat and are achieved by clasping, screwing or hooking the upper and lower jaws together to minimize movement. These transmit forces towards the lips against the lower front teeth and upper front teeth, which may change the inclination and position of the teeth, placement of the lower jaw and negatively increase the loading forces of the temporomandibular joints. The lower jaw is held in a forward and vertically opened position throughout the night. These appliances generate orthodontic-like forces and should not be used in children or teens. Oral appliance therapy is generally recommended to patients that do not tolerate CPAP or refuse surgery. It is not recommended as stand alone therapy for those with severe sleep apnea. In general these are bulky devices that are difficult for some patients to tolerate as they have two parts an upper and lower appliance that are interlocked and fixed into positioned. Nevertheless MAS devices have been successful in treating those with mild to moderate obstructive sleep apnea (mild 5 to 15 events per hour – moderate 15 to 30). Oral appliance therapy can be used in combination with CPAP or BiPAP therapy.
Full Breath Solution:
The Full Breath Solution is a novel and effective approach in oral appliance therapy used in managing OSA. The device is fitted only to the lower teeth, as there is no opposing appliance, and as a result does not pull the lower jaw forward. Consequently the appliance is small and comfortable when compared to bulky traditional devices, which have upper and lower appliances that lock together. Instead the Full Breath appliance is a single orthotic-like device that slightly increases the vertical dimension (height) of the teeth. Thereby increasing the size of the oral cavity (by separating the teeth) by approximately 3mm, which translates to 3mm more of airway space available. It is also fitted with a tongue- depressor-like tail that inhibits the tongue from moving upward and backward and consequently blocking the airway space during sleep. The length of the tail or tongue depressor is custom fitted to each individual depending on his or her
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 40 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy individual anatomy. The device does not cause or worsen TMJ, as the lower jaw is not pulled out of alignment as with MAS appliances. Instead the device is aligned to the upper teeth and jaw.
However the appliance is palliative and does not alter the anatomy of obstruction. It will not permanently increase the airway space. However, it is the best appliance I have found to temporarily treat OSA and snoring. It is a quick fix solution for someone on the run or with a busy schedule. I prefer this device above any mandibular advancing appliance, as it does the job without altering the bite. It has a high compliance rate amongst patients and can also be used with CPAP or BiPAP as a combination therapy.
The DNA Appliance - expanding the jaws via genetic potential:
DNA appliance therapy is a unique and powerful way of treating OSA and other sleep disordered breathing problems. As its main function is in helping the body to realign the mid-facial and lower-facial parts of the face wherein the jaws reside. The upper jaw or maxilla forms part of the mid-face, where the mid-pharynx or oropharynx lie. Development of the maxilla can increase the size of the airway and also may help in eliminating upper airway breathing issues, as the maxilla forms part of the cranium. And as the maxilla develops so does the cranium, which houses the sinuses and other important upper airway structures. Development of the lower jaw will increase the size of the airway space at and around the mid-face. Yet it will also influence the airway space at the lower-pharynx or laryngopharynx, where the base and bulk of the tongue is located. A larger lower jaw or mandible will provide ample space for the tongue and it will also help develop the lower part of the face, including all the soft tissue and muscles of the area. Those with small chins and small lower jaws are known to have trouble with malocclusion (poor bite), OSA and other sleep disordered breathing.
The DNA appliance uses the body’s underlying code for growth as it main tool. Epigenesis is the regulation of the expression of gene activity without altering the genetic structure of the gene. This device initiates growth in the jaws by a gentle intermittent force that activates the underlying growth mechanism in gene- regulation. In 2008, Dr Dave Singh developed this revolutionary device. As the name suggest, the appliance gives reference to our DNA as well as an acronym for Daytime-Nighttime appliance™. The appliance works with the body by allowing for physiological change by developing the facial bones via genetic
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 41 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy potential. The directionality of the force, and not the strength of it create the potential for growth by activating chemical factors involved in growth.
The appliance is worn only at night, allowing for rest and regeneration of the tissue involved. This is crucial, as development is not dependent on a constant unchanging force, as most other devices are, yet on the regenerative power of rest, allowing anabolic (tissue building) processes to take over. Moreover, the DNA appliance does not damage the underlying bone by excessive force – which is common to most other dental devices that expand the jaws. Bone damage that is due to the excessive expanding forces of a dental device initiates a process of wound healing (an immune response to trauma) and not one of growth. Bone damage sets off a repair process that can be seen in x-rays, because the resultant bone is different from the original bone – it is scarification of bone tissue. Bone repair occurs in stages: inflammation stage, soft callus formation stage, hard callus formation stage and bone remodeling stage. Instead growth is an anabolic process where tissue building occurs as a consequence of chemical factors that signal gene-regulation and cannot be seen in x-rays because there is no reparative scar tissue involved in the process. The DNA appliance captures this growth process by changing the environmental cues involved in metabolic growth.
Rather, growth of the jaws and mid-face regions can be initiated by gentle force that is directional in nature. This directional force instructs the body, allowing it to respond deeply by activating the growth process via messaging. This technology is unique, causing the patient’s mid-facial region to expand laterally and also anteriorly (forward), enlarging the mid-face and creating spatial definition to functional spaces which lay above (sinuses) and behind the upper jaw (mid & upper pharynx). As the appliance slowly expands the maxilla, arches that are narrow and vaulted will gradually drop and flatten, providing additional space for the upper airway including the nasal cavity,
The DNA appliance can also be designed with a wire loop extension that is approximately 7mm long (the actual length is determined by the patient’s anatomy). The loop is curved at a 45-degree angle from the end of the palate towards the throat to control the tongue during sleep and prevent blockage of the airway space. This feature helps to control soft tissue collapse during sleep.
DNA appliance therapy is a non-invasive option for those who cannot comply with CPAP, and/or refuse surgery as too radical and risky. The appliance, unlike other dental devices, is designed to engage and/or initiate growth in the jaws. Why is this important? By changing the size of the jaws, the size of the airway is directly increased. Oxygen depletion stresses all the tissues and organs of the body. A broader face has more airway space behind it. A person who is suffering from OSA is chronically oxygen starved. It is critical to restore unperturbed restful sleep owing to the impact of oxygen on cellular and tissue growth and regeneration. Oxygen depletion stresses all the tissues and organs of the body.
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Healthy oxygen levels are essential for overall wellbeing. The appliance is designed to manage OSA temporarily, while at the same time permanently altering the underlying anatomy responsible for a reduced and narrow airway that can cause obstructive events to occur.
While it is important to receive some form of treatment, enlarging the jaws through the use of an appliance makes the most sense, especially in a child or teen, as the benefits are permanent with little to no side effects. Additionally the changes are esthetically pleasing to the eye, as the shape of the face becomes more proportional and balanced. And as stated before a broader face has more airway space behind it. Yet it has become traditional in modern dentistry to remove the third molars (wisdom teeth) because modern humans do not have the jaw size and capacity that they did 90 years ago. It is well accepted that jaw size in humans have been shrinking during the modern era of fast and processed foods. Environmental pollutants and stress have also taken a toll on developing craniofacial shape and size, which directly impacts jaw size and shape. The DNA appliance can also be used in a preemptive manner. Even if a child or teen does not have OSA or sleep disordered breathing, small or underdeveloped jaws, greatly increases the likelihood of developing these later in life. By developing the jaws and mid-face we not only enhance the airway space yet also facial harmony and beauty. For those with moderate to severe OSA the appliance can be used effectively with CPAP and BiPAP therapy, while the airway of the mid-face and jaws are gradually enlarged.
Myofunctional (Myofascial) Therapy
Digit Sucking: should be discouraged in young children, as the consequences can be severe
What are Myofunctional disorders and how can they lead to obstructive sleep apnea (OSA) and sleep disordered breathing (SDB)? These are disorders involving the muscles of the face, mouth, lips, jaws and neck and are caused by a variety of parafunctional (disordered function – dysfunctional) muscular habits that lead to misuse of these muscle groups. Thumb sucking is probably one of the best-known parafunctional habits that lead to misuse of muscle groups that contribute heavily to malocclusion (crooked teeth), high and narrow upper arch, lack of lip seal and mouth breathing, (which all contribute to OSA and SDB). The lack of lip-seal is considered parafunctional in itself, as the individual is unable to swallow correctly and mostly likely unable to breathe correctly through the nose. Lack of lip seal is an excessive separation of the lips at rest.
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Parafunctional habits include:
Bruxism Clenching Mouth breathing Tongue thrusting Thumb or finger sucking Forward head posture Tongue resting in mandible only Lip and fingernail biting Chewing only on one-side of mouth Resting chin or part of the face on the hands
Upper airway obstruction (nose & sinuses), lack of breast feeding, chronic thumb sucking, extended pacifier and bottle use, allergies, enlarged tonsils and pollution can cause Myofunctional disorders to develop. The sequelae of Myofunctional disorders can begin with babies that are not breast-fed, as breast-feeding helps to properly form the size, shape and function of the oral cavity. Breast-feeding, furthermore, improves the muscular coordination of the mouth, lips, tongue and jaws and therefore functional use of the muscles of the face, head and neck. It also encourages nasal breathing, proper positioning of the tongue, correct swallowing patterns, saliva flow and palate development. Oral motor skills are highly improved in breast-fed individuals, and are the foundation for eating solid foods, drinking, speaking and optimal range of motion. These motor skills include strength, coordination, range of motion, and sensitivity. Babies that are not breast-fed often have oral-muscular weakness. If the baby develops allergies and excessively sucks their thumb, mouth breathing will be an expected outcome.
Breast-feeding promotes an optimal relationship between the upper and lower jaw, which is the foundation for a good stable bite (occlusion). Having a good stable bite is essential to all aspects of health. If a child is unable to fully close their mouth with a good relaxed lip seal – it may lead to occlusal dysfunction or may indicate that it is already present. Ideally the tongue should rest in the upper jaw, the tip against the hard palate and slightly behind the upper front teeth, as this will epigenetically develop it, as the tongue is a powerful muscle. If this muscle rests in the lower jaw, it will lead to a narrow upper arch and a high vaulted palate. The lower jaw takes it cues from the upper jaw and will develop accordingly, so if the upper jaw is narrow – it too will be narrow or it may grow wider or longer than the maxilla. A crossbite develops when the upper jaw, which should be wider than the lower, is narrower than the lower – this is often times due to dysfunctional misuse of the tongue and mouth breathing. Furthermore, a low tongue rest position may indicate a dysfunctional swallow. A correct swallow is absolutely necessary in the functional formation of the upper and lower jaws, without it the palate does not descend correctly and the jaws do not lengthen or widen sufficiently to fit 32 teeth in the adult.
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Orthodontic failure or relapse is often due to a low forward tongue, as the tongue if not properly trained to rest correctly in the mouth, will by the force of its musculature, undo the straightening of the teeth. The tongue helps to protect the airway and naturally expands the palate and arches by dropping the palate downwards if used properly.
Myofunctional (Myofascial) Therapy – is a series of neuromuscular exercises that are meant to re-pattern, re-educate and optimize the functions of the face, head, neck and oral cavity by targeting the muscles involved in chewing and swallowing. Behavioral modification is used to eliminate any poor muscular habits that contribute or help create negative growth patterns in and around the oral cavity. Strengthening and correctly coordinating these muscles, also help to keep the airway open, especially during sleep. If these muscles are weak and do not exhibit-coordinated action, they may disrupt the flow of air and snoring may ensue, if the pharynx collapses then an obstructive event may occur. If the tongue is hypotonic (low or diminished muscle tone) then it may fall back into the throat and block the airspace. Myofunctional therapy can be used to improve breathing during the day, and especially during the night, when awareness of breathing is not present. It is epigenetic in nature and therefore can be used to properly guide and develop the oral cavity and jaws to their full genetic potential.
Surgery:
Treatment is principally aimed at surgically enlarging the airway and lessening the possibility of airway collapsibility at key sites, such as the soft palate, uvula and back of the tongue. Interventions are mostly designed to alter the soft-tissue where obstructions are known to occur – i.e., direct ablative soft tissue surgery of the pharynx, tongue, uvula, palate, etc., or surgical manipulation of the skeleton that aims at soft tissue repositioning by surgically enlarging the jaws. For those suffering from severe OSA, surgery is often considered necessary by ear, nose and throat specialists (ENT), especially in removing any obvious and frank obstructions – particularly if CPAP and oral appliance therapy has demonstratively failed them. However, it should be stated that many of these surgeries are permanent and irreversible and many have severe and painful side effects.
If a patient opts for surgery it must be kept in mind that the surgical outcome, for the most part, cannot be undone – and it is possible that the patient will have to live with an altered anatomy for the rest of their lives. Surgery should only be considered as a last resort and should not be the first consideration when tackling obstructive sleep apnea or snoring. Only those with severe OSA should consider surgery and/or those with life threatening conditions that cannot tolerate CPAP therapy.
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[Commonsense surgery for nasal obstructions (such as a deviated septum, turbinate reduction or nasal valve collapse) that contribute to OSA and sleep disordered breathing should be promptly taken care of to eliminate any possible obstruction to the nasal airway that leads to mouth breathing. Same thing goes for adenoids and/or tonsils that are chronically infected and inflamed (enlarged) that block the throat. These surgeries are crucial in reducing and ruling out upper airway obstructions of the nose or lymphatic tissue as a significant source of blockage before attempting these more severe and serious surgeries.]
Uvulopalatopharyngoplasty (UPPP):
UPPP removes what is considered excessive soft tissue at the back of the mouth and throat. This can include all or part of the uvula, parts of the soft palate and pharynx in and around the mid-throat (oropharynx) area. If the tonsils and adenoids are still present they too will be surgically removed regardless if they are inflamed or not. Remember these are lymphatic tissue meant to fight illness and infection. These should only be removed if they are chronically infected. It is assumed that UPPP surgery will increase the width of the airway in areas known to occlude the throat during sleep. The procedure may also inhibit excessive muscular relaxation and improve the movement and closure of the soft palate.
UPPP however, is a very painful treatment and requires several weeks for recovery. It can only be done with general anesthesia. Furthermore, there is a large failure rate of around 50% – and in my mind these are not good odds. Complications include infection and impairment of the soft palate and muscles of the throat, known as velopharyngeal insufficiency. UPPP can result in difficulty keeping liquids out of the upper airway and nose, changes in the voice, problems swallowing, loss of smell and sleep apnea. There is also an increase probability of mouth leakage during CPAP treatment.
Laser-Assisted Uvulopalatoplasty (LAUP):
This is UPPP surgery done with laser technology and can be done in a doctor’s office using local anesthesia. It is considered less invasive as less tissue is surgically removed – only a small portion of the uvula and soft palate is removed. It is believed that with time and scarring the palate stiffens and elevates – inhibiting snoring and obstruction. Complications include sore and dry throats, narrowing and scarring of the throat and mouth tissue. Success rates are considered modest at best.
Pillar Palatal Implant:
Is considered a noninvasive surgical treatment for snoring and mild to moderate sleep apnea and can be done in a doctor’s office using local anesthesia. The procedure involves inserting three to four small Teflon strips into the soft palate to keep it from vibrating or closing off the upper airway when you sleep. It is not
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 46 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy recommended for patients that are significantly overweight or obese. Complications include infection, sore throat, uncomfortable feeling in the soft palate, swelling and difficulty swallowing. Most insurance companies will not pay for it – so it is an out of pocket expense for most patients and runs about $2000.00 for the procedure. There are no long-term studies available for this procedure as is hasn’t been around for that long.
Tracheotomy:
Many years ago tracheotomy was considered the only known successful treatment for OSA. Today it is used only if the OSA is severe and life threatening and associated with other deadly co-morbidities (diseases or conditions). It is by medical standards considered 100% successful. But it requires surgically cutting an opening into the neck below the larynx into the windpipe and inserting a tube. A valve keeps the opening of the tube closed during the day, allowing the patient to speak and breathe normally. At night the valve is opened so that air bypasses the throat and enters directly into the tube and into the lower airway. Tracheotomy bypasses all obstructions, but it is cosmetically unacceptable to most everyone. This operation should only be considered when other options do not exist, have failed, are refused, or when deemed necessary by clinical urgency. There are many complications; including scarring of tissue at the opening, bleeding and infection in and around the opening, difficulty speaking, an increased in lung infections and issues with self-image and depression and possible tube failure.
Radiofrequency Ablation (RFA):
Thermal destruction of soft tissue using radiofrequency is used to reduce the uvula, tongue, palate and other soft tissue using surgical radio waves. RFA can be done in a doctor’s office using local anesthesia. Besides removing what is considered redundant or excessive tissue it is believed to improve the texture of the remaining tissue so that is becomes more dynamically stable. Complications can involve pain, swelling and mucosal ulceration and repeated treatments may be needed to achieve satisfactory results.
Maxillomandibular Advancement (MMA):
Maxillomandibular advancement is a complex upper airway surgery that is considered somewhat successful. Both the upper and lower jaws are cut and then reconfigured to a more desirable location. It is believed that by moving the jaws forward the entire airway is enlarged and provides more room for the tongue, palate and other soft tissue. Both upper and lower teeth are moved to maintain adequate occlusion (bite) during this procedure. MMA enlarges the airway by moving the skeletal framework forward and tensioning key musculature. Even though this procedure is considered surgically invasive – the success rate is rather high, around 75%. However, complications can involve
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 47 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy bleeding, swelling, infection, pain, permanent numbness and malocclusion (poor bite). Malocclusion by itself can further lead to chronic TMJ symptoms and more pain. This surgery is done under full anesthesia and in a hospital setting. The surgery can take 3 to 4 hours to perform and requires hospitalization (2 to 3 days). The patient can return to normal activities within a 4-week period. Chewing needs to be avoided for about 4 weeks.
Hyoid Advancement:
The hyoid is a small movable U-shaped bone in the upper neck region that the muscles of the base of the tongue and pharynx are attached to. And is the only bone in the body not connected to any other bone. It is thought that many patients with OSA have a large tongue base and that this tongue base falls back during sleep and makes contact with the back of the pharynx blocking it. The bone is surgically repositioned forward, pulling the tongue muscle along with it by a suture that suspends it to the front of the lower jawbone. Depending on the doctor surgery can be done either with local or general anesthesia. Complications can involve pain and difficulty swallowing for 7 to 10 days. It is often a combined surgery that is done with tongue advancement surgery.
Genioglossus (tongue) Advancement:
This surgical procedure involves moving one of the main tongue muscles forward (the Genioglossus muscle), in order to inhibit the tongue from falling backwards while sleeping. An opening is made where the tongue joins or attaches to the jawbone and a part of the bone (with muscle attached) are cut and pulled forward and is re-attached to the jawbone with a titanium plate. The procedure is done with general anesthesia and if often done with other procedures to maximize the airway. Complications can involve pain, difficulty swallowing and speaking for 7 to 10 days.
Examining the physical:
Size of jaws Look at nostrils Mallampati score Scalloped tongue Large or infected tonsils Large of infected adenoids High narrow palate & arch Tongue piercing may restrict movement Frenum restriction (tongue tied)
Examination of patients should target physical abnormalities associated with OSA. These should include BMI (body mass index – measure of body fat), blood
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 48 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy pressure, and thorough examination of the nose, ears, mouth and throat for any abnormalities, smallness and obstructions. Crooked teeth, a large neck and a small chin are possible indicative signs. For men a neck size larger then 17” and 16” in women are suggestive of OSA, yet these are only guidelines and not diagnostic of it – as there must be other parameters involved. Medically only a sleep test (polysomnography) will verify if a patient has obstructive sleep apnea (OSA) or other sleep disordered breathing (SDB).
However, there are key physical elements that are suggestive of OSA or SDB. These are an increased BMI (body mass index), nasal obstruction, mouth breathing, high arched palate, small or retruded chin, large neck size, crooked teeth, large tongue, tongue scalloping and increased Mallampati score (back of the throat is visually obscured by surrounding soft tissue), etc. The nostrils play a very important part in upper airway breathing. They should be approximately of the same size, configuration and open. If they are narrow, especially in a child – it may point to a poorly functioning nose and possible mouth breathing. The size of the mandible (lower jaw) is also a very important consideration for it can determine the anatomical size of other structures. If it is small it is suggestive of small and compromised airway.
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Figure 2. Modified Mallampati Score: Same classification as above
The Mallampati score is an independent predictor of both the presence and possible severity of OSA. On average, for every 1-point increase in score the odds of having OSA increases 2-fold. The Mallampati scoring system was developed as an oral airway classification system. Patients are instructed to open their mouths and stick out their tongues as far as possible to allow for direct visualization of the back of the mouth and throat. Classification are grouped as Class I, Class II, Class III and IV– based on how many of the four normally visualized anatomical structures seen, (soft palate, hard palate, uvula and tonsils). It allows for quick assessment of how much airway space an individual has around anatomical structures and possible crowding of these. The modified Mallampati has the patient open their mouths as wide as possible without the tongue sticking out of the mouth. This is valuable as the size of the tongue can be visualized inside the mouth, determining if it is obstructive to the mid-pharynx. If the tongue is scalloped it will help clarify if it is too large for the jaws, especially the mandible.
Scalloped tongue grading 0 no scalloping visible 1 barely visible 2 partial scalloping 3 complete tongue scalloping
MAJOR LIFE CHANGES THAT CAN TRIGGER SLEEP APNEA:
Sleep apnea can occur on its own; yet it can also be triggered by major events or life changes, which your body may not have been used to before.
- A new baby brings joy and excitement, yet it is followed by sleepless nights, chaotic sleep patterns, changes in eating habits and possible weight gain – ALL of these can contribute to the development of sleep apnea.
- New college students get their first taste of independence in their first year of school, and that independence is usually correlated with the term “Freshman 15”. This rapid weight gain and late night meals cause acid and other materials from
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 50 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy your stomach to go to the throat, which leads to constant arousals and lack of sleep.
- An injury not only causes medical and physical damage to a person, but it also forces the person to change their daily habits and routines. Sleeping on their back for example, instead of the usual side can cause tongue collapse, arousals and infrequent sleeping patterns.
- Hormonal changes in both men and women cause the protective impacts on the upper airway to diminish, particularly for women, who endure menopause. During this time for women, the loss pf progesterone causes the tongue to relax which means bad sleep throughout the night!
- Obese children and adults are more likely to suffer obstructive sleep apnea, which creates a barrier between the brain and the oxygen trying to get in. This can bring about sleep deprivation, mood changes and behavioral inadequacy, which are all correlated with lack of good performance on tests.
CORRELATION BETWEEN SEIZURES AND SLEEP APNEA:
- Studies show that there is a link between inflammation and seizures as well as a link between seizures and obstructive sleep apnea. Other studies show that obstructive sleep apnea causes inflammation in the brain.
HAVING A BIG MIDSECTION CAN UP YOUR RISK OF DYING SUDDENLY AND HAVING OBSTRUCTIVE SLEEP APNEA:
- Being over weight increases your chances of having sleep apnea because the more obese you are, the more you are prone to upper airway collapsibility during sleep. Untreated obstructive sleep apnea is linked to sudden cardiac death.
THINGS TO AVOID:
- Don’t eat or snack close to bedtime. You are making yourself prone to frequent arousals and breathing obstructions during sleep.
- Don’t drink alcohol before bedtime! It causes your throat muscles to relax which makes you stop breathing more often.
- Don’t sleep on your back – the side is the preferred way for someone who suffers from snoring or sleep apnea!
- Don’t bottle feed an infant! It is shown that bottle-feeding changes the bite and structures of the mouth, which is linked to developing sleep apnea later on in life.
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- Don’t undergo jaw surgery! See if this truly the only thing you can do? Many of these surgeries are invasive, irreversible and not as successful as many think and believe. Try as many options before deciding.
- Not treating your sleep apnea, especially, in the early stages, can have serious effects on your body later in life.
SLEEP HYGIENE:
Have a consistent bedtime and awakening time: make an effort to go to bed at the same time each night. You will eventually get used to falling asleep at the same time every night. The same goes with waking in the morning. Having a schedule will allow for better time management. Avoid napping during the day if it can be helped: this may be a gradual process, as you begin to sleep better. However, if you are exhausted napping may be essential to keeping you healthy. Napping disturbs the normal pattern of sleep and wakefulness, yet if you have severe OSA it may be necessary until it is under control. Exercise on a regular basis: avoid exercising right before bedtime. Strenuous exercise before bedtime can decrease your body’s ability to relax and fall asleep. However, relaxing gentle exercise like tai chi, Hatha Yoga can be done before to help relax you and initiate restful sleep. Vigorous exercise should be done in the morning or afternoon, where it has the most health benefits. Over-weight and obese patients with OSA will benefit greatly from exercise and losing weight. Avoid drinking caffeinated drinks (coffee, non-herbal teas, sodas, chocolate, energy drinks, etc…) before going to bed: give yourself 4-6 hours of leeway time to make sure they don’t affect your sleep. These are also diuretics that cause an increase flow of urine and may wake you because of a frequent urge to urinate. Avoid drinking excessive alcohol before going to bed: it is considered healthy and acceptable for men to drink 2 glasses of wine and women 1 glass of wine daily. This can be done during the evening meal, which should be no later than 8:PM if your schedule permits (the earlier the better). Give yourself at least two hours if you do consume alcoholic beverages before going to bed. Alcohol does have an immediate sleep-inducing affect, but it has the opposite effect a few hours afterwards. Drinking worsens snoring and OSA – and can be devastating to someone with severe OSA. Avoid heavy, large, spicy or sugary foods during the evening meal: foods can be disruptive right before bedtime. Breakfast and lunch should be the foods that fuel your day – dinner should be on the light side, only enough to squelch your appetite, so you don’t wake from hunger. Avoid eating gassy foods, especially if you have acid-reflux or heartburn, as these will keep you awake at night or interfere with deep-sleep.
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Make sure you have adequate exposure to natural light as this helps to set the circadian clock and sleep-wake cycle: Take time to be outdoors during daylight or bathe in daylight if you have a patio, or a window that gets lots of light exposure during the day.
Sleep Environment:
Your bedroom should be a bedroom only: not a TV room, a computer room, a reading room or music media room. Associate your bed with sleeping and sex only and not with excessive nocturnal activity. Your room should be dark and quiet as this promotes sleep. Make sure that your bed is sufficiently big and comfortable enough to promote rest, especially if there are two of you. Your room should not be too cool or too warm. Refrain from working in your room. Don’t fight or argue in your room, especially right before going to bed. Block out any distracting lights from the streets: strong light can interfere with the sleep cycle and alter it. Same thing goes with street noise, especially in a big city. Consider buying sound absorbing drapery if room is exposed to a busy street. The bed and bedding should be comfortable: the mattress ought to be cozy for both of you and not just for one partner. Natural materials absorb moisture better and breathe better; they are also more comfortable against the skin. Keep the room well ventilated and do not sleep with electronics near the head. Make sure that there are adequate blankets or comforter in case one of you gets cold and the other doesn’t. Pillows ought to be the right size for the sleeper. There are many in the market that promotes side sleeping for those who snore or have OSA. The bedroom environment including the color and design of the room should be pleasant and relaxing. If possible teenagers should have their own room: yet all computers and computer work should be in the family or work space and not in their bedrooms.
PHYSICAL DEFORMITIES AND THE WORK OF DR WESTIN PRICE:
Genetic coding suggests that our face and body structure should maintain a particular structure in our traditional environment. However, when these bony structures do not develop the way we anticipate, we notice distortion in the genetic pattern.
Dr Weston Price was a dentist in the 1920’s, from Cleveland Ohio. His curiosity in the field of genetic development led to his extensive research in the field of nutrition. Dr Price traveled around the world, when it was still possible to study the craniofacial development of various indigenous people and/or people living in one locale for hundreds of years and before the advent of modernization took a stronghold in these cultures. Some of the communities he studied included;
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Eskimos, North America Indians, South Sea Islanders, African Tribes, South America Indians, Isolated Mountain people of Switzerland, etc…
Those on the left have nice round faces with a full complement of teeth; whereas those on the right have narrow faces, missing teeth & decay throughout
Dr Price noticed, that the individuals possessing the best health, immunity, teeth, craniofacial structure and body all had one thing in common – they all maintained a healthy diet, typical of the area, and typical of their ancestors – the food was local, natural and had been eaten by many generations. For the Eskimos it was an all meat diet with lots of fat. For the mountain Swiss it was homemade breads with cheese or butter and raw milk. For the South Sea Islanders it was fish with lots of local vegetables. The key was that it was local, natural (organic) and had been eaten by these people for hundreds if not thousands of years. It was a diet that was genetically suitable for these individual groups. These groups of individuals all had beautiful teeth free of caries, large broad faces, large jaws that could fit the full complement of 32 teeth and no facial or bodily deformities.
However, individuals or communities in these indigenous groups that ate western food – sugar, white flour, white rice, pasteurized milk and non-natural, non- organic foods all within one generation had significant changes to their teeth, jaw size and craniofacial shape. Dental caries became rampant, jaw size shrank, long narrow faces developed, allergies and malocclusions developed and distortions of the craniofacial shape. These changes were also somewhat passed down to their children and definitely so if they ate the same western style diet. What Dr Price noticed was that not only were these not natural whole foods – they were also not locally grown or harvested foods. It was not the kind of food
YYoouurrr SSmmiiillleee YYoouurrr HHeeeaalllttthh 54 CCoorrttteesss AAddvvaanncceedd DDeenntttiiissstttrryy that was important – yet it had to be local whole foods that were eaten for generations by the same people. Eskimos at the time were virtually not eating any vegetables yet they were very healthy. Their diet, however, was appropriate to them alone, as their digestive systems had acclimated to the all meat diet provided by their frozen environment.
Dental and facial changes occurred with the introduction of non-local, non- organic foods. It clearly shows that the western style food, which was processed, packaged and shipped, acted environmentally on gene-expression.
Berlin Questionnaire (for sleep apnea):
The questionnaire consists of 3 categories related to the risk of having sleep apnea.
Patients can be classified into High Risk or Low Risk based on their responses to the individual items and their overall scores in the symptom categories.
Categories and scoring: Category 1: items 1, 2, 3, 4, 5. Item 1: if ‘Yes’, assign 1 point Item 2: if ‘c’ or ‘d’ is the response, assign 1 point Item 3: if ‘a’ or ‘b’ is the response, assign 1 point Item 4: if ‘a’ is the response, assign 1 point Item 5: if ‘a’ or ‘b’ is the response, assign 2 points
Add points. Category 1 is positive if the total score is 2 or more points Category 2: items 6, 7, 8 (item 9 should be noted separately). Item 6: if ‘a’ or ‘b’ is the response, assign 1 point Item 7: if ‘a’ or ‘b’ is the response, assign 1 point Item 8: if ‘a’ is the response, assign 1 point
Add points. Category 2 is positive if the total score is 2 or more points Category 3 is positive if the answer to item 10 is ‘Yes’ OR if the BMI of the patient is greater than 30kg/m2. (BMI must be calculated. BMI is defined as weight (kg) divided by height (m) squared, i.e., kg/m2).
High Risk: if there are 2 or more Categories where the score is positive Low Risk: if there is only 1 or no Categories where the score is positive
Additional question: item 9 should be noted separately.
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BERLIN QUESTIONNAIRE:
Height (m) ______Weight (kg)______Age______Male / Female Please choose the correct response to each question.
CATEGORY 1 1. Do you snore? _ a. Yes _ b. No _ c. Don’t know
If you snore: 2. Your snoring is: _ a. Slightly louder than breathing _ b. As loud as talking _ c. Louder than talking _ d. Very loud – can be heard in adjacent rooms
3. How often do you snore _ a. Nearly every day _ b. 3-4 times a week _ c. 1-2 times a week _ d. 1-2 times a month _ e. Never or nearly never
4. Has your snoring ever bothered other people? _ a. Yes _ b. No _ c. Don’t Know 5. Has anyone noticed that you quit breathing during your sleep?
_ a. Nearly every day _ b. 3-4 times a week _ c. 1-2 times a week _ d. 1-2 times a month _ e. Never or nearly never
CATEGORY 2 6. How often do you feel tired or fatigued after your sleep? _ a. Nearly every day _ b. 3-4 times a week _ c. 1-2 times a week
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_ d. 1-2 times a month _ e. Never or nearly never
7. During your waking time, do you feel tired, fatigued or not up to par? _ a. Nearly every day _ b. 3-4 times a week _ c. 1-2 times a week _ d. 1-2 times a month _ e. Never or nearly never
8. Have you ever nodded off or fallen asleep while driving a vehicle? _ a. Yes _ b. No
If yes: 9. How often does this occur? _ a. Nearly every day _ b. 3-4 times a week _ c. 1-2 times a week _ d. 1-2 times a month _ e. Never or nearly never
CATEGORY 3 10. Do you have high blood pressure? _ Yes _ No _ Don’t know
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