Sleep Apnea and Dentistry:
A Breathing Disorder that Impacts Sleep and our Overall Health
As an oral-systemic practice, one of the heath conditions that we look for and help patients with is something that’s commonly referred to as “Sleep Apnea”. Sleep Apnea is not a sleep disorder as much as it is a breathing disorder that interferes with your ability to get deep sleep and rest. If we have a breathing issue and oxygen can’t get from the lungs and supply our organs with oxygen, that’s quite serious. When that occurs, it impacts our health and can range from mild to moderate and even severe and therefore, life threatening. The goal for our team in our oral-systemic dental practice is to help educate patients with what’s going on with this condition, help screen them and move them towards getting a diagnosis from a licensed medical professional and then, treatment.
Definition: Apnea = “Want of Breath”
We refer to Sleep Apnea as asphyxia, the inability to get oxygen in and out of the lungs and body as needed. In fact the greek word, “apnea” relates to ‘want of breath’, which is the heart of the matter. Asphyxia during sleep can ranch from depressed breathing while we’re sleeping to Obstructive Sleep Apnea (OSA) during the nighttime which is caused by an obstruction and that’s usually soft tissue in the back of the upper airway, either a soft palate or the tongue which is usually is the issue that closes off the trachea in the back of the throat that inhibits a smooth, rhythmic airflow that enters our lungs and then goes on to oxygenate our blood.
Two other types of sleep apnea are Central Sleep Apnea and Mixed Sleep Apnea. These are much less common than Obstructive Sleep Apnea (OSA), and aren’t the focus for dentists. What we’re really talking about here is OSA that involves some sort of obstruction that inhibits breathing at night and interrupts our sleep.
Normal Breathing During Sleep versus Obstructive Sleep Apnea
The image to the left illustrates the position of he tongue, uvula and soft palate during sleep compared to Obstructive Sleep Apnea. To breathe normally during sleep, the tounge and soft tissue would stay in place and air would enter our nose and mouth with a smooth transition and air flow down into the lungs and oxygenating of the blood. With Obstructive Sleep Apnea the soft tissues, usually the soft palate or the tounge, flops back causing the airway to close. And as you can see the inhibited breathing caused by OSA would cause a lack of oxygen in the blood and the organs would suffer.
Sleep Disruption Cycle (Pathoshysiology of Sleep Apnea)
The sleep disruption cycle of OSA starts with falling asleep, then there is an airway closure due to the soft tissue flopping back causing a blockage of the airway. By definition, apnea means that we end up with reduced oxygenation in our body. Next, our brain senses that reduced oxygenation in the blood which triggers ventilation which in turn triggers a struggle to wake us up so that we start breathing again. We experience a varying degree of waking up by gasping and struggling to breath, that typically opens the airway and then we end up breathing again at an excelerated rate along with an excellerated heart rate to try to get the blood values back to normal. Once that happens we go back to sleep and the cycle can go on endlessly at night from a few times to many.
Obstructive Sleep Apnea: Signs and Symptoms
As an integrative health dentist, we aim to educate and screen our patients for sleep apnea. Snoring is one of the most obvious sign and symptom that someone may have OSA. Its usually a bed partner that recognizes the snoring and that has driven patients to me to start the conversation and the screening process. Snoring is a significant sign that something quite significant is going that needs to be addressed.
Although snoring and the subsequent sound can be alarming, it’s not really the issue, it’s the harmful impacts on the entire body, and it’s systems and organs that is concerning. Another significant screening factor is daytime sleepiness or daytime drowsiness. The Epsworth Sleepiness Scale, which can be administered at our office is a valuable tool in screening for OSA. Another component of this that we see is high blood pressure. If your heart is having to work triple overtime at night to awaken you in order to pump blood and to get your oxygen back to appropriate levels, we know that your heart is going to suffer from that and that you’re going to end up with high blood pressure. This is very common. Acid reflux and diabetes are a big deal that most patients don’t realize the significance of when they are being regularly awakened throughout the night, often times violently to try to breathe again. The violent awakening/arousal can tend to push gastric juices back up into the esophageal area; that’s where the reflux comes from.
If you’re sleeping normally and breathing perfectly, there’s no need for dramatic awakening/arousal, then you don’t end up with acid reflux. Although patients aren’t generally not aware of the impact on Acid Reflux and Diabetes, but when we mention it to them and it comes out in the screening, they put two-and-two together.
As dentists, we are first responders and see various symptoms and help in screening for Obstructive Sleep Apnea. We see heavy wear on teeth, we can see a scalloped tongue and other things like an inflamed uvula and soft tissue. Contributing factors include obesity; we look at BMI (body mass index). Large neck circumferences are a concerning factor; and we taking age, breathing history and family history into consideration. Through questionnaires and screening we discover valuable information; we then can conduct a clinical exam, and review the possible contributing factors in order to get a comprehensive picture and get an idea whether the patient should be screened or be referred to a Obstructive Sleep Apnea physician specializing in Sleep Apnea diagnosis.
Obstructive Sleep Apnea: Prevalence Among Medical Conditions
Sleep apnea is not just a snoring issue. Nor is it a ‘struggling to sleep at night’ or drowsiness issue. The real affects are far-reaching and systemic. Medical issues that are directly related to sleep apnea include:
- Hypertension
- Drug resistant hypertension
- Chronic heart failure
- Congestive heart failure
- Atrial fibrillation
- Ischemic heart disease
- Stroke
- Medically refractory epilepsy
- Metabolic syndrome
- Type II diabetes
- Obese diabetics
- Morbid obesity
- GERD
Pediatric Obstructive Sleep Apnea: Signs and Symptoms
One component that parents need to know is that we’re seeing increasing concentration issues, ADHD, and behavioral issues among children today. It seems that we hear reports daily from parents and their kids. One important area that is seemingly ignored is Obstructive Sleep Apnea in kids. If they are testing positive for OSA, they are mouth breathers and they really have difficulty breathing during the day and they’re having more difficulty breathing at night. Again, this leads to lower oxygenation levels for the brain, We see issues like among children with OSA:
- Snoring
- Mouth breathing
- Difficulty with concentration
- Behavioral issues
- Bed wetting
- ?Alteration of facial growth
- Alteration of jaw development
- Enlarged tonsils and adenoids
Parents: Keep in mind that if your child is displaying any of these (signs and symptoms) listed above, you may want to look at the apnea component in your child.
Screening for Sleep Apnea
That’s basically why we as dentists want to look at this, why its important to educate our patients and make them aware of what may be going on; help them get going in a direction of being screened and diagnosed. The way that we do that is screening. Fortunately we have more patients that do not have sleep apnea than do, but in any case, its important that as a dentist, as a frontline responder, to help screen and diagnose for this. In the next video we will show how we do that.