Sleep Like Your Life Depends on it!

                                                         Weary with toil, I haste me to my bed.
     
 Even Shakespeare seems to have had trouble sleeping, if his sonnet is any indication.  Why am I again writing about sleep?  What's that got to do with dental health and dental hygiene?  Lots and lots!  Your dental hygienist can be your hero!!  He or she is looking out for you. They can see signs of  possible sleep apnea in your mouth that may well indicate trouble brewing.

As a dental hygienist, my job is to look over your mouth-  your teeth and gums, yes, but also your tissues, throat, oral muscles, and tonsils.  I evaluate your breathing and airway and, after looking over your health history, your over-all general health.  Obstructive sleep apnea (OSA) signs are subtle and often missed.  I have written about all this before but some new sleep medicine studies and my own journey down this path have caused me to revisit this important issue and share these new findings with you.

My Sleep Journey

As I headed into menopause, sleep, or the lack there of, was a constant problem.  I started taking Diphenhydramine (a.k.a. Benadryl), at night to keep me sleeping all night.  I took it on the recommendation of my doctor, always had it on my medical history, and never tried to hide it.  Had my physician even vaguely recommended I see a sleep doctor, I most certainly would have.  I had thus just assumed (and you know what happens when you assume) my sleep issues were due to hormone changes and would eventually pass.
Alas, I didn't know two very important things:
         
              #1. This was the beginning of my sleep apnea.

(More on my sleep apnea journey in a moment.)

              #2. Long-term Diphenhydramine use may be linked to IRREVERSIBLE memory loss

This study came out last year in the JAMA Internal Medicine.  Anticholinergic drugs have a strong link to dementia.

          Anticholinergics decrease acetylcholine activity to balance out the production of dopamine and                   acetylcholine.  They are used to treat incontinence, depression and sleep disorders. Medications with strong anticholinergic effects, such as antihistamines that cause drowsiness, are well known for causing acute cognitive impairment in individuals with dementia.  


I did stop taking Benadryl a few years ago, before I learned about this very scary consequence.  (Now though, every time I forget where my glasses or keys are, I'm nervous this is the beginning of dementia.)  So, please, please read the research, stop taking any over the counter sleep aids or supplements, and instead, see a sleep medicine doctor.  These sleep aids, while "over the counter," are not safe on a constant basis.  They are still medicine, and all medicine does have risks and side effects.  Sleep issues like I've listed below are not normal and need the help of a specialist to sleuth out a cause, and then a resolution.  (Take the STOP-BANG quiz to help screen and learn more about your own risk level.)

Some sleep questions for you:

            #1. Do you wake up with a headache?
     
            #2. Do you clench or grind your teeth at night?

            #3. Do you wake up with tired jaws- possibly from "bracing" your muscles?

            #4. Do you snore? or make other noises?

            #5. Is your neck circumference greater than 16 inches (40.6 cm)  in women?
                  17 inches (43 cm) in men?

            #6 Do you wake up to urinate more than once per night?

            #7. Do you wake up more than once per night?

            #8. Are you wide awake in the middle of the night?

            #9. Does your tongue look like someone took pinking shears to the sides?
   

If you answered YES!! to any of these questions you may have sleep issues and would benefit from further information and a visit to your doctor.  I've listed these signs here because I've chatted with too many people who thought these symptoms were not related to OSA.  There are many more signs and symptoms of OSA.  Check out my post The Silent Killer - for adults and Sleep like a (cranky, fussy) Baby  for children for more information.  Now, let's review the sleep questions above:

#1, #2 and #3: Waking up with a headache  may be an indication you're holding your breath at night and building up Carbon Dioxide. Some CO2 is okay, a build up of too much can cause morning headaches.  (I had no idea that's why I had morning headaches- I just thought I was stressed and clenching my teeth together.  I may well have been clenching, but stress was not the cause.)
Clenching, grinding, and bracing are now considered primarily a "sleep-related movement disorder".  Sorry, not related to stress.  Instead, (and this is BIG!!)  It is the *new red flag* of sleep apnea!  New research has made this connection.  And, for those of you wearing a night guard or other dental appliance- be aware!  The appliance may well be holding your jaw in such a position that it may actually be making your sleep apnea and breathing (or lack there of) worse.  Ouch!  I know you've spent a lot of money on that dental appliance.  Time to take thee and it to a sleep doctor and evaluate your airway...

#4. As we age all our body parts sag and bag both outside and inside, and the mouth/throat/palate are no exception.  Thus, as we sleep, the tongue and other oral muscles relax.  Pretty soon, our airway is blocked.   And then we snore or make other noises.  Just for the record, we should sleep as quietly as we breathe while awake, and it should be in and out through the nose.  (More on mouth breathing shortly.)  Just like when your car makes those noises, noisy breathing is a sign of trouble.

#5. Men, you know your neck size.  Ladies, get a tape measure and find out.  A thick neck can increase your risk of obstructive sleep apnea.

#6. Waking up for that nightly trip down the hall to the bathroom - more than once a night?  Really, unless you're glugging a lot of water right before bed, you should be able to go (or not go, as the case may be) all night (those with prostrate issues notwithstanding).  Really!  Sleep deprivation increases urine output at night.

#7. and #8.  That middle of the night waking and staying awake is called "Sleep Maintenance Insomnia."  It has a name! and there is a connection to OSA.  Read Dr. Steven Park's website for more information.  Thirty nine to 58% of folks with insomnia also have OSA.

tongue pressing against teeth

#9. Take a look at your tongue- does it look like someone put little indents along the edges?  If your tongue's scalloped, there's an 89% chance you have OSA.  Your tongue's size is normal, unfortunately, your jaw's too small, especially if you've had teeth removed or worn headgear.  Click here for more.

More Recent Science 

Hot off the press- just out this month- a group of researchers have published a study in mice demonstrating a connection between a lack of oxygen flow and worse cancer outcomes.  Hypoxia 

(a deficiency in oxygen reaching the tissues) promotes blood vessel formation within tumors which in turn gives the tumors nutrients.  Feeds them just like plant food feeds our gardens.  It always comes back to oxygen, doesn't it!?   While this study was done using mice, it should give us pause.  Brain tumors and other cancers grow in a lack of oxygen.  Now we may know how and why.  

Diabetes

Another research study published in a 2013 Family Medicine article discussed the connection between type two diabetes and obstructive sleep apnea- nearly half of all diabetic people may be at risk for OSA.  If you have type two diabetes- get tested.  Diabetes can worsen in conjunction with OSA, causing high blood pressure, heart disease and stroke.  

Sleeping for Two 

Something that's not gotten a lot of press and research but should is obstructive sleep apnea during pregnancy.   A study published in the journal Sleep released in 2014 from University of South Florida researchers found that  pregnant women/new moms with OSA were five times more likely to die in the hospital.  In addition to that, researchers also found a higher level of eclampsia, preeclampsia, restricted growth of the fetus, preterm delivery, cesarean sections,and gestational diabetes in women with apnea even controlling for obesity.  Newborns of mom's with apnea were admitted to the NICU at a higher frequency and many had breathing problems, which may be due to to the higher rate of c-sections for this group. 

Another study done in  rats found that those mother rats deprived of oxygen while pregnant had pups that could not tolerate glucose well, leading to diabetes and obesity when these pups reached adulthood.  This is only the tip of the iceberg on fetal problems connected to lack of oxygen.  Why aren't all pregnant women screened for sleep apnea?  

Back to my Sleep Journey

I needed to take my own advice.  I had many of the signs of OSA.  My mandibular advancement appliance (which moved my jaw forward during the night) was no longer working.  I was snoring (not sexy!), still waking up at night with occasional sleep maintenance insomnia, and really looked forward to that jolt from my morning cuppa coffee.  I knew better, so I finally went in and chatted with my new sleep doctor, Dr. Matt Lee.  I'm so very glad I did.  I was able to easily do a home sleep study and it told me what I suspected.   While my c-pap machine and I aren't best friends yet, we're working on that.  Actually, and much to my surprise, it's been easier than I had anticipated.  I now sleep all night, don't get up to make that nightly trip down the hall, and while I still enjoy my cuppa Joe- I'm not desperate to have it, like before.  My teeth are no longer touching at night- my tongue is staying in its "spot", and  I feel great in the morning.  You don't realize how tired you are until you experience how being truly rested feels.  If you're "not a morning person" (or live with said person) maybe it's time to explore why that is and finally fix it! 

Nasal pillows 

There's a definite learning curve to using the c-pap mask.  I did a lot of fussing the first few weeks, then I got a bad cold and couldn't breath through the congestion.  It takes time to even decide you want to be tethered to this machine.  It's not sexy, but then neither is snoring, or the dire results of OSA.  What I have found - if your mask isn't comfortable, take the entire thing in to see your doctor.  My nasal pillows were the wrong size, and I was leaking air like a tire going flat.  It was very frustrating until Dr. Lee fixed it.  So if you're fussing and it's uncomfortable, your mask may not be the right size.  You may need an entirely new mask.  I'm sure many of you have helpful hints we could add to this-- leave your comments below!  

Orofacial Myofunctional Therapy does help to tighten the muscles in the mouth.  I've started doing these exercises in addition to my c-pap machine use.  Research shows that it reduces apnea-hypopnia (the rate you stop breathing and have shallow breathing) incidents by 50% in adults and 62% in children that complete the therapies.  Think of it as a gym workout for your mouth! 

Mouth Breathing

 full mask pulls the lower jaw backward

A big concern for me as a dental hygienist is the full face mask.  I discussed this with Dr Lee.  From a dental perspective, mouth breathing is connected to high rates of dental decay and also periodontal disease.  Even thought the c-pap has a humidifier, I still know there's dry mouth happening with all that forced air and mouth breathing.  From Dr. Lee's perspective, he sees the mask and chin strap as pulling the lower jaw backward, closing off the airway!  That defeats the purpose of the c-pap!
He would like all his c-pap-using patients to breathe only through their nose, with a nasal mask or pillow, as I do.  Nasal breathing is vitally important for so many reasons.  Click here for even more information.  Breathing through the nose is absolutely vital to a healthy body for children of all ages.  I get that you have a deviated septum and "can't breathe" through your nose.  It's time to get that fixed!  The more you mouth breathe, the more clogged your sinuses get, and the more it affects other parts of your body.  Mouth breathing is not healthy breathing.

OSA is bad news for just about everyone! 

Oh sleep, oh gentle sleep 

Sleep apnea is not just in overweight old men.  One in four Americans would benefit from an evaluation by a sleep medicine doctor for OSA. With all this bad news about sleep apnea, how about a screening for everyone every ten years, just like we recommend colonoscopy or mammogram screenings?   With the new take home sleep study tests, it's easy and very informative.

Sleep should be restorative, not a struggle.  It should refresh, it helps guard against major health ailments such as diabetes, high blood pressure, acid reflux, heart attack, stroke, and obesity.  You'll have less pain, less injury, be in a better mood, have clearer thinking, more energy, weight control, and a better immune system.  Don't accept poor quality sleep.
Ask your dental health providers to look beyond your teeth and help you to be the healthiest you can be!  If you have symptoms, get a sleep study and know where you stand.  A c-pap machine is not the end of the world, it may well be the beginning of a whole new life!


Sleep like your life depends on it!

Be well my friends!  and of course, keep smiling!

Barbara Tritz
Registered Dental Hygienist
Orofacial Myofunctional Therapist

To links of my references, click on the highlighted pink words!

Questions, comments, anything? let me know!