Snoring and Sleep Apnea

Snoring and Sleep Apnea in Chesapeake, VA

Sleep is important for health while contributing to physical and psychological rest and long-term emotional well being.  There is no normal amount of sleep because it is the quality and not the quantity of sleep that matters.  However, for adults, sleeping between six and eight hours a night has been found to be optimal for good long-term health.  There are many conditions that can interfere with restful restorative sleep.  One of the leading reasons and highest contributing factors to inadequate sleep is disordered nighttime breathing, which encompasses snoring and obstructive sleep apnea (OSA).

What is Obstructive Sleep Apnea?

Chesapeake Snoring and Sleep ApneaOSA occurs when the muscles at the back of the throat, which support the tongue and other soft tissues, relax excessively and limit or prevent airflow.  Simple snoring will result if the airway is only partially closed.  However, if the airway completely collapses and breathing stops for at least 10 seconds, then OSA exists.  Not everyone who snores has OSA.  But the more loudly one snores and if the snoring is interrupted with gasps and choking, then most likely OSA is present.

When breathing stops, the body and brain are deprived of oxygen.  The brain will then arouse (not awaken) the individual with a gasp to open the airway.  Each occurrence will arouse the individual from restful sleep without him or her having any awareness of what is happening.  This can occur over a hundred times during the night.

The resulting impact on one's health is enormous.  The sudden drop in blood oxygen levels due to OSA places a big strain on the cardiovascular system, which increases one's risk for hypertension, congestive heart failure, irregular heart beat, stroke, and sudden cardiac death.  Also the lack of restorative sleep leads to daytime sleepiness, can affect work productivity and performance, and increases one's risk for injury or illness.  OSA individuals have an increased rate of motor vehicle accidents and are seven times more likely to have multiple accidents.  Although people with OSA are completely unaware of their nighttime snoring and choking, heir bed partners are aroused from deep sleep (by the loud snoring and choking) and suffer from sleep deprivation and daytime sleepiness.  This places a strain on personal relationships.  Frequently, it is a sleep-deprived bed partner who convinces the apnea patient to seek treatment.

How to Treat Your Sleep Apnea

The National Institutes of Health estimates that 12 million American adults suffer from OSA. More men than women have OSA, but the incidence in women increases after menopause.  At least one in 10 people over 65 has sleep apnea and it worsens with age.  Children can also suffer from OSA.  Other risk factors include being overweight, having high blood pressure, having a narrow throat or enlarged tonsils and adenoids, smoking, having chronic nasal congestion, using substances that cause relaxation of throat muscles, i.e., alcohol. sedatives, and tranquilizers, and having a family history of apnea.

In cases of milder sleep apnea, changes in lifestyle can correct the OSA.  Losing weight, smoking cessation, or elimination of alcohol, sedatives, and tranquilizers at bedtime are examples of changes that may be helpful.  When not effective or in cases of more severe OSA, other treatment options are available to open a blocked airway.

The gold standard for treating OSA is continuous positive airway pressure (CPAP).  While you sleep, an air pump (CPAP) is used blow air into your throat through a mask worn over your nose and mouth.  The positive pressure keeps the upper airway open so that oxygen reaches the lungs.  It allows an individual to get a good night's rest and eliminates the strain on the cardiovascular system.  But adjusting to CPAP is difficult, and compliance is only 40-50%.

Another treatment modality for OSA involves wearing an oral appliance while you sleep.  There are currently two basic types of appliances for treating OSA, and they are available from dentists:  mandibular repositioning appliances (MRAs) and tongue-retaining (TR) appliances.  MRAs are most frequently recommended, and they work by moving the lower jaw forward and thereby opening the airway.  This works very well for individuals with simple snoring and/or with mild to moderate sleep apnea.  The present generation MRAs are smaller, more comfortable, less visible, custom fitted, and incrementally adjustable.  The TR devices open the airway by holding the tongue in a forward position  While effective, they are not as comfortable as MRAs.  But if the apneic individual has loose teeth, only a few teeth, or no teeth, then TRs are the only oral appliance that can be utilized.

If all else fails then sometimes surgery will resolve the apnea.  The most common procedure is uvulopalatopharyngoplasty, in which the tonsils and other tissue from the back of the throat and roof of the mouth are removed to prevent airway obstruction during sleep.  Facial and nasal surgical procedures can also be performed on people with facial abnormalities or nasal obstruction, which can contribute to sleep apnea.

If one suffers from daytime fatigue, headaches, forgetfulness, sexual dysfunction, chronic sore throat, snoring, and sudden awakening during sleep, then obstructive sleep apnea may be the cause.  Inform your doctor of these symptoms and he can refer you to a sleep specialist.  The specialist will conduct an overnight sleep study in a sleep lab and determine if apnea is present and to what degree.  At this time,  a discussion can take place concerning the best mode of treatment to correct the disturbed sleep.

The best treatment is CPAP, but compliance is poor.  The American Academy of Sleep Medicine recommends an oral appliance to treat simple snoring and mild to moderate OSA and for anyone with severe apnea who cannot tolerate a CPAP. A dentist knowledgeable in sleep medicine can fabricate the appropriate appliance.  If the above-mentioned treatments are not helpful, then surgery many be the only recourse.

Airway Obstruction - A Link to ADHD, Sleep Apnea, and Bed Wetting

A complete dental exam should always include a survey of the back of the mouth and the throat.  The size and shape of the jaws, the throat, the tonsils, the adenoids, and the tongue can have an enormous influence on one's health and quality of life - especially for children.  A size discrepancy in any of the above that cause complete or partial upper airway obstruction can result in a surprising number of health issues such as ADHD, bed wetting, sleep apnea, poor growth and development and poor academics.  Abnormal findings discovered at an early age can lead to beneficial life altering outcomes.

A normal, healthy airway will allow air to proceed easily and quietly from the nose to the lungs (nasal breathing).  As the air passes through the nose it is warmed, humidified and filtered.  Nitric oxide (NO), from the adjoining sinuses, is continuously excreted into the nasal passages.  NO is a potent gas and a key component for human health.  With nasal breathing, NO is carried from the nose to the lungs.  It is well known to relax blood vessel walls, to prevent clotting, to increase blood oxygen levels, to kill bacteria and viruses and is a strong brain transmitter (The discovery of the effect of nitric oxide on cardiovascular function won a Nobel Prize in 1998).  Because of these factors, nasal breathing is presently acknowledged to be vital to good health.  Any obstruction along this airway will result in a complete or partial absence of nasal breathing and cause one to breathe through the mouth (mouth breathing).  But mouth-inhaled air does not benefit the lungs and the body as does nasally inhaled air.  Therefore, one's health can be severely compromised.

What Causes Airway Obstruction?

There are many causes for partial or complete airway obstruction i.e., mouth breathing.  The most common conditions that lead to mouth breathing are allergic rhinitis (hay fever), swollen tonsils and/or adenoids, deviated nasal septum and large inferior turbinates - i.e. small nasal air passages.

Chesapeake Woman with Hay FeverAllergic rhinitis, swelling of the soft tissues in the nose, is the primary contributor to airway blockage.  The allergens may be inhaled and/or they may be consumed in foods.  Allergies to house allergens (house dust, animal dander, etc.) will cause year round symptoms, whereas allergies to pollens will cause seasonal nasal obstruction.  The more chronic the condition leading to mouth breathing, the greater will be the impact on one's health.

In children, enlarged tonsils and/or adenoids are also important causes for airway obstruction.  Enlarged adenoids block the back of the nose which can result in nasal speech, post nasal discharge, coughing, vomiting, bad breath and chronic mouth breathing.  The opening into the Eustacian tubes (leading to the ears), which are adjacent to the adenoids, can also get blocked causing ear aches, fullness in the ears and middle ear infections.  Tonsils are located at the base of the tongue and their enlargement will also cause a physical obstruction of the airway.  Large tonsils also force the tongue down and forward (in order to mouth breathe) which leads to malocclusion (bad bite), narrow upper and lower jaws and a postural change.

The nasal septum, (the wall that separates your nose down the middle) is composed of bone and cartilage.  It usually separates the nose into two symmetrical nostrils.  A deviated septum is one that deflects from side to side creating a large and a small nostril.  Since nasal breathing cycles from one nostril to the other every 1 to 4 hours, only one nostril is open for maximum airflow at any one time.  When it becomes time to breathe through the smaller nostril, partial nasal obstruction occurs.  When a septum deviates from side to side and front to back, chronic nasal obstruction occurs.

Turbinates are delicate scroll shaped bones projecting into the nose from the right and left sides.  There are 3 levels of turbinates and all are covered with mucosal soft tissue.  The purpose of the turbinates is to clean, warm and humidify the air.  If the bone or the overlying tissue is too thick, then nasal obstruction will occur.

Any obstruction that results in chronic mouth breathing can have a multitude of ill consequences for an individual.   In addition to experiencing dry mouth and bad breath, the air that is inhaled through the mouth bypasses the warming, humidifying and filtering functions of nasally inhaled air.  Therefore tissues are cooler, drier, and more easily infected.  Also, the beneficial and protective effects of nitric oxide (NO) are absent.  Blood gas studies indicate a 20% drop in oxygen levels and a 20% rise in carbon dioxide levels in mouth breathers.  Therefore, mouth breathers are more easily fatigued and exhausted.  This long term reduction in oxygen saturation can also lead to hypertension, a malfunctioning of the lungs and an enlargement of the right ventricle of the heart.  Furthermore, snoring and sleep apnea are very prevalent in individuals who mouth breath.  This disruption in sleep can result in bedwetting.  This breathing pattern will also influence an individual's physical appearance.  Chronic mouth breathers will exhibit postural changes (head tilted backwards), develop crooked teeth, incur deformities of the jaws and skull that lead to the "long face syndrome".  These individuals are often "well below their peers in height and weight.

The signs and symptoms of enlarged tonsils and adenoids in young children can present a very confusing scenario and lead to misdiagnoses.  Adenoids grow from 6 months to 2 - 3 years old and occupy about 50% of the throat area behind the nose.  Swollen tonsils cause the tongue to move down and forward, and the head to tilt back in an effort to breathe.  Enlarged adenoids and tonsils are the primary reason for snoring and sleep apnea in children.  Research at the University of Michigan has indicated that a child who snores regularly is four times more likely to exhibit symptoms of ADHD.  An obstructed airway at night will reduce the amount of oxygen that gets to the brain.  The consequences may be disturbed sleep (moving violently), problems waking up, being easily fatigues, getting morning headaches, and exhibiting daytime behavior problems that might include irritability, hyperactivity and being easily distracted.  One study even found that a child who snored was more likely to exhibit poor academic performance in middle school.  These children are often misdiagnosed with ADHD and placed on stimulant drugs such as Adderal or Ritalin.

An obstructed airway also can lead to bedwetting.  If a child has been toilet trained and suddenly begins bedwetting again then it may be due to an  obstructed airway.  When a child with breathing problems finally falls asleep, the sleep is so deep that they lose bladder control.

How to Correct Airway Obstruction

All of these health problems can usually be eliminated by correcting the airway obstruction and establishing good nasal breathing.  Removal of tonsils and adenoids will almost, 90% of the time, cure sleep apnea and therefore eliminate all the related health issues and behavioral problems.  75% of all tonsillectomies and adenoidectomies are performed to correct airway obstruction.

Where the airway obstruction is caused by allergies then referral to an allergist should be made.  If the above are not found to be responsible for the mouth breathing, then referral to an ENT is necessary to evaluate the nasal septum and turbinates.

When the obstruction to nasal breathing is corrected by medication (for allergies) or surgery (other physical obstructions), the individual may still continue to mouth breathe.  In order to breathe nasally, the tongue must be positioned in the roof of the mouth.  But, in cases of chronic obstruction, the individuals wind up with narrow and small jaws.  If the upper jaw is too narrow, the tongue will not have enough room to rest in the roof of the mouth and mouth breathing will continue.  Functional orthodontics is then required to expand the jaws and create a resting place for the tongue.  When the tongue is positioned in the palate then mouth breathing cannot occur.  In some cases, myofunctional therapy is also necessary to retrain the tongue (once there is adequate room) to rest in the palate so that nasal breathing can easily occur 24/7.  After all, nasal breathing is the main goal and is an absolute necessity for achieving good health and a long productive life.

Interested in learning more about our Snoring and Sleep Apnea Treatment? Call our Chesapeake, VA office today at (757) 436-0026 to learn how we can help you!

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