Walnut Creek, Concord, and Lafayette, CA
Dentists and Sleep Breathing Disorders
Why should dentists even be discussing the airway? The answer comes from even a simple look at the anatomy of the human airway. The whole jaw and mouth structure fits into the corner of the airway, and how we treat the jaw and mouth structure can profoundly affect the function of the airway. Also, the way our faces and jaws grow is the largest factor in how healthy our airway will form.
Dentists and Sleep Apnea Appliances – I disagree
Dentists have been sold on the idea that making appliances for patients with sleep apnea will be the new “profit center” of their dental practice. Many appliances are made by dentists to treat sleep apnea without fully realizing the consequences of these appliances. This concerns us, because we see long-term consequences of these appliances which are scary. Our approach goes beyond making one-size-fits-all appliances, and draws upon experience with orthodontics, orthotropics (facial growth guidance), airway orthodontics, and airway prosthodontics. The options we have for you are meant to address the causes of the problems, and they are sometimes a bit “outside-the-box” and unique.
Obstructive Sleep Apnea (OSA)
When the jaws fail to grow forward enough, the airway behind the tongue is compromised. For some people, the airway closes off during sleep due to the weight of the tongue, palate, and lower jaw. The result is a temporary stoppage of breathing (an “apnea”), and it’s called Obstructive Sleep Apnea (OSA), the most common of the Sleep Breathing Disorders. The brain, sensing the problem, puts the body into a “fight or flight” red alert, and breathing resumes. But here’s the bad part: the sleep gets fragmented, and the constant “fight or flight” red alerts during the night take a toll on the body.
Sleep fragmentation doesn’t mean that you wake up. It means that your stage of sleep gets disrupted and you may not even be aware. It’s is bad because sleep is important. All the stages of sleep are important. Sleep is when we re-charge, but it’s also when our brain files away our experiences from the awake time. When we don’t get the sleep we need, our memory, intelligence, moods, and other cognitive factors are affected. Daytime sleepiness and drowsiness can also result. Workplace and other accidents are strongly associated with sleep fragmentation due to OSA.
“Fight or flight” red alerts are bad especially because of the effects they have on the cardiovascular system. Untreated sleep apnea is associated with increases in blood pressure, cardiovascular diseases, heart attacks, and strokes. Other problems also associated with OSA are: diabetes, GERD, sexual dysfunction, depression, obesity, insomnia, and even cancer.
The AHI Index Measures OSA Severity The severity of OSA is measured most commonly by how many times breathing stops per hour. Also important are the temporary drops in blood oxygen which result. These are called “hypopneas.” Adding the apneas (stopping breathing) to the hypopneas (lowered oxygen) per hour give us the Apnea Hypopnea Index (AHI).
For adults, the consensus is that it’s normal if we have an apnea or hypopnea up to five times an hour during sleep. Mild OSA is defined by 6-15, moderate OSA is 16-30, and severe OSA means stopping breathing over 30 times an hour on average. It can get as high as 80 to 100 or more!
For children, it’s a different standard. Normal for children is an AHI of less than 1. This means it’s not normal for a child even to have an average of one apnea per hour during sleep. For children “snoring is not normal, and should never occur.” (Gozal) While snoring is a definite warning for children, it’s important to note that children with OSA often do NOT snore or exhibit daytime sleepiness. On the contrary, children with sleep breathing disorders are often hyperactive during the day, leading to a misdiagnosis of ADHD. See the symptoms to look for in children here.
The bottom line is: untreated sleep apnea shortens life expectancy 20%. Warning signs should be taken seriously, and a positive diagnosis should be treated aggressively and conscientiously.
How is Sleep Apnea Treated?
The three general ways OSA is treated are:
- Push harder on the air going in.
- Open the airway temporarily
- Open the airway permanently
Push Harder on the Air – PAP Therapy
This is the so-called “gold standard” of the medical profession, and it consists of connecting a pump to a mask that is worn during sleep over the mouth or the nose or both. It’s called PAP therapy, for “Positive Air Pressure.” Form many patients, PAP therapy has the advantages that it can be very effective at treating OSA when it’s used, the insurance may pay for it, no additional treatment may be required, and it’s simple and available. The disadvantages are big, however. So big that, after six months, up to 70% of people will give up on using their PAP machine. The disadvantages include claustrophobic feelings and discomfort from the mask, air leaks, dry mouth, disruption of bed partner’s sleep, and the biggest drawback: it not only does not solve the underlying structural problem, but it might make it worse over time due to permanent facial-flattening changes caused by the pressure of the mask.
Open the Airway Temporarily – Oral Appliance Therapy
Wearing a dental appliance which holds the lower jaw forward or pushes the tongue down will open the airway temporarily during sleep. Studies show this approach is most effective for sleep apnea that is mild to moderate. Recommendations have even gone so far as to recommend an oral appliance as the fist line of treatment in these cases. It can help when the OSA is severe, but not as predictably, and not as effectively, and would only be tried in these cases when PAP therapy has failed.
Advantages of Oral Appliance Therapy: It’s comparatively inexpensive, it avoids the hassles of PAP therapy, travel with appliances is easy, and it’s a quick and generally effective solution for mild to moderate OSA.
Disadvantages of Oral Appliance Therapy: The biggest disadvantage is that it risks permanent bite changes which might even result in compounding the original problem (both jaws being too far back), it may not be adequately effective, the appliances are often not adjusted correctly, and the appliances can sometimes be uncomfortable.
Open the Airway Permanently
The airway can be opened more permanently by orthotropics, by orthodontics, and by surgery. (Myofunctional Therapy can also help, but it’s not considered a first line of treatment.)
Orthotropics means “facial growth guidance,” and it describes a postural orthodontic treatment for children between 5 and 9. It’s not as effective for older ages, and generally not indicated past the age of 11 or 12. Orthotropics aims to redirect vertical growth of the jaws to become horizontal growth. By learning to change the mouth rest posture, a child can cause changes in facial growth that will improve the size of the airway.
Orthodontics can be done in very specific cases to increase the tongue space, and thereby improve the airway. This is not recommended or performed in the vast majority of orthodontic practices, and is truly cutting edge thinking in the management of breathing disorders.
Surgery to more ideally reposition the upper an lower jaws can bring about the most definitive improvement in the airway. This fixes the original problem, and eliminates the need for either PAP therapy or dental appliances.