What is Obstructive Sleep Apnea(OSA)?
"Obstructive sleep apnea is a common and serious sleep disorder that causes you to stop breathing during sleep. The airway repeatedly becomes blocked, limiting the amount of air that reaches your lungs. When this happens, you may snore loudly or making choking noises as you try to breathe. Your brain and body becomes oxygen deprived and you may wake up. This may happen a few times a night, or in more severe cases, several hundred times a night.
In many cases, an apnea, or temporary pause in breathing, is caused by the tissue in the back of the throat collapsing. The muscles of the upper airway relax when you fall asleep. If you sleep on your back, gravity can cause the tongue to fall back. This narrows the airway, which reduces the amount of air that can reach your lungs. The narrowed airway causes snoring by making the tissue in back of the throat vibrate as you breathe.
Sleep apnea can make you wake up in the morning feeling tired or unrefreshed even though you have had a full night of sleep. During the day, you may feel fatigued, have difficulty concentrating or you may even unintentionally fall asleep. This is because your body is waking up numerous times throughout the night, even though you might not be conscious of each awakening.
The lack of oxygen your body receives can have negative long-term consequences for your health. This includes:
- High blood pressure
- Heart disease
- Pre-diabetes and diabetes
Obstructive sleep apnea in adults is considered a sleep-related breathing disorder. Causes and symptoms differ for obstructive sleep apnea in children and central sleep apnea." -American Academy of Sleep Medicine
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The tongue and other muscles in the throat collapse in REM sleep causing the airway to the lungs to close. Breathing stops repeatedly for 10 seconds or more. This decreases the oxygen in the blood to dangerous levels causing the following problems to the heart and brain. 1 in 5 people have mild Obstructive Sleep Apnea. It is as common as Diabetes. About 80-90% of people with Obstructive Sleep Apnea DO NOT KNOW IT ! Snoring is a partial obstruction of the airway causing the tissue in the throat to vibrate. 20% of snorers have Obstructive Sleep Apnea.
OSA is related to:
- Ischemic heart disease, heart attack-OSA increases chance by 23.3%(more than obesity-7.1%; hypertension-7.8%; smoking-11.1%)
- Congestive heart failure
- Abnormal heart rhythms(atrial fibrillation)
- Hypertension (may be able to lower high blood pressure medication when sleep apnea is resolved)
- Daytime sleepiness(unintentionally falling asleep during the day)
- 7 times greater chance of car accidents
- Sudden death during sleep
- Decreased productivity
- Impaired concentration
- Memory loss
- Morning headaches
- Unrefreshed sleep
- Waking from sleep with a choking sound or gasping for breath
- Loud snoring
- Night time grinding of teeth (bruxism)
- Acid Reflux(Melatonin and treating OSA will help-ask Dr. Sheffield for more information)
- decreases Leptin, the hormone that suppresses appetite. It is difficult to lose weight until OSA is treated.
If you have some of the following symptoms, you should be checked by your physician:(1)heard to stop breathing in your sleep; (2)wake up with headaches; (3)overweight. Colorado is thinnest state with 15-19% obesity; (4)male; (5)over 50 years old; (6)neck circumference over 17 inches in a man, 16 inches in a woman; (7)high blood pressure; (8)wanting to fall asleep during the day or while driving. Teens,16-24 years old, are 80% more likely to have a drowsy driving accident than an adult over 40 because teens often do not get enough sleep. If you are falling asleep while driving, pull over, take a nap, then walk around to wake up. The radio or open window is not enough.
Screening signs For OSA:
- STOP and BANG and Mallampati Score
- Observed to stop breathing
- Pressure(OSA increases blood pressure)
- BMI greater than 30(overweight)
- Age greater than 50
- Neck circumference(17 inches or more in men)
- Gender(males more likely to have OSA)
Being conscientious about OSA may extend your life by 20 years and make every day of your life healthier and happier with more energy.
All dentists are doctors of the mouth. If you have any concerns with anything in your mouth, see Dr. Sheffield . Dentists who are members of the American Academy of Dental Sleep Medicine, like Dr. Sheffield, go one step further into the throat to look for Obstructive Sleep Apnea. You want to wake up refreshed so you can have the best quality of life possible. A sleep partner snoring or you having untreated Obstructive Sleep Apnea will rob you of that quality of life. Dr. Sheffield can make an oral appliance that is comfortable, quiet, portable, and easy to care for. Medical insurance often pays for most or all of sleep apnea appliances. Medical and dental insurances do not pay for snoring appliances. Often the sleep study will pick up sleep apnea in snoring patients and the medical insurance pays. The oral appliances brings the lower jaw forward which brings the tongue forward to open the airway during sleep. They cover all the teeth, allow you to breath normally, never make you gag, and allow you to move your jaw. The oral appliances are custom made for you and are adjustable for maximum effectiveness. Store bought appliances are not effective and can cause damage. In snoring, mild or moderate sleep apnea, the oral appliance is more comfortable than CPAP(see next section). Your physician will give you a choice of an oral appliance or CPAP in mild or moderate sleep apnea. If the sleep test determines you have severe sleep apnea, medical insurance wants you to try CPAP; only if you can not tolerate the CPAP would you have an oral appliance made. The oral appliances are more comfortable than CPAP. They work 90% of the time for snoring and 70% of the time for mild or moderate sleep apnea. The % is lower for severe sleep apnea. Your physician and Dr. Sheffield will work together. All dentistry will be done by your dentist if Dr. Sheffield is not your dentist.
Non-surgical Treatments of Obstructive Sleep Apnea:
- Sleep on side (If a heart or digestive problem is present, sleeping on the right side is preferable. Dr. Sheffield has devices to keep you sleeping on side)
- 10% weight loss = 25% decrease in AHI (Apnea Hypopnea Index)
- Weight loss through exercise and healthy diet(lots of vegetables, minimize carbohydrates, have some fats, small portions,3 meals/day).
- Do not eat a big meal, consume large quantities of alcohol or take sedatives in evening before going to bed.
- Reduce light and noise in bedroom (have bedroom dark, shades closed. Especially avoid blue light at night) Blue light from a TV, computer, or alarm clock will reduce N3 sleep when Growth Hormone is secreted. Growth Hormone is needed for children to grow and for adults to repair muscles used from the previous day.
- Avoid reading or watching TV in bed
- Physical and mental relaxation before bed(do not exercise immediately before bed)
- Use support hose on feet during day if you have swelling of the ankles from poor circulation. This will decrease obstructive sleep apnea at night.
- Do not nap during the day- you would not be able to sleep at night
- Avoid caffeine- it will effect your circadian rhythm (daily natural body clock). Caffeine interferes with Adenosine which builds up during the day and makes you sleepy.
- Exercise will decrease obstructive sleep apnea even if you do not lose weight. Avoid exercising immediately before bed-wakes you up by increasing your cortisol level.
- A forward head posture will close the airway to increase apnea index. If you sleep on your back, do not use a thick pillow
- Sometimes nose pieces will decrease sleep apnea-ask Dr. Sheffield if appropriate for you
- Adults should have 7 hours sleep +/- an hour; pre-school children average 14 hours sleep; teenagers average 9 hours sleep
- nicotine leads to insomnia
- sleeping on side can reduce snoring and OSA. Dr. Sheffield can recommend side sleeping devices.
- Nasal steroid sprays if nasal airway obstruction; RDI (Respiratory Disturbance Index) - can decrease from 20-11
- Thyroid replacement therapy if have hypothyroidism
- Treating sinusitis and nasal congestion if a problem
- 70% effective for mild to moderate sleep apnea
- 90% effective for snoring
- more comfortable than the PAPs below
- easy to clean
- easy to travel
- no electricity needed
- Mandibular Advancement Device-moves lower jaw forward during the night(tongue moves forward with it and opens airway.
- another dental device retains the tongue forward. Not as comfortable as Mandibular Advancement Device but can be used with few teeth.
CPAP (Continuous Positive Airway Pressure)
- Most successful treatment if worn (50% of patients can not tolerate CPAP; an oral appliance would be made)
- A dental appliance may be able to replace the CPAP or lower the air pressure of the CPAP
- It should be adjusted by a professional before determining intolerance
- 50-60% of CPAP users are non-compliant
BiPAP (Bi-Level Positive Airway Pressure)
- Delivers a higher pressure during inspiration and a lower pressure during expiration
- Can be more tolerable than CPAP
- Insurance usually only pays if CPAP cannot be tolerated
- A dental appliance with a low pressure CPAP can sometimes be better than a BiPAP. Sometimes the low pressure during exhalation will not be high enough to keep the airway open.
- Adjusts air pressure at different stages of sleep and positions depending on need.
Surgery for Obstructive Sleep Apnea
It is not cute for children to snore; it is a serious condition. Sleep apnea is usually present and should be treated immediately by removing the tonsils and adenoids. This surgery will open the airway. Many children with ADHD who are on medication no longer need the medication after the sleep apnea is treated. Oral appliances are not appropriate for children. Children with obstructive sleep apnea have morning headaches, slow growth rate, excessive daytime sleepiness, poor school performance, have hyperactivity and aggressive behavior.
Stages of Sleep:
- N1-light sleep( can be in N1 sleep if dosing during day)
- N2-a deeper sleep than N1
- N3- a deep sleep where it is difficult to wake a person. N3 sleep is needed for Growth Hormone secretion and is reduced while sleeping with blue light in the room. This would effect growth in a child and muscle repair in adults.
REM(Rapid Eye Movement) - This should be 25% of sleep. Usually starts 90 minutes after falling asleep and lasts 10-60 minutes. REM lasts longer with each passing sleep cycle so the longest REM sleep is before you wake up in the morning. It is reduced with OSA. This is when you dream. The brain is very active assimilating the previous day's thoughts so you are ready for tomorrow. This is when you determine what to remember and forget from the previous day. REM is necessary to wake up refreshed.
OSA effects Circadian Rhythm, your natural body clock by disturbing your sleep. Cortisol secreted from the Adrenal Gland and Melatonin secreted from the GI Tract and Pineal Gland in the brain modulate Circadian Rhythm by making us alert or sleepy. The following is a healthy Circadian Rhythm:
- 6:45AM - sharpest rise in blood pressure
- 7:30AM - Melatonin (hormone that makes you sleepy) secretion stops
- 10:00AM - highest alertness
- 2:30PM - best coordination
- 3:30PM - fastest reaction time
- 5:00PM - greatest cardio vascular efficiency and muscle strength
- 6:30PM - highest blood pressure
- 7:00PM - highest body temperature
- 9:00PM - melatonin secretion starts( melatonin comes from Pineal gland in brain)
- 2:00AM - deepest sleep
- Interesting note - An evening person can become a morning person and vice versa.