Snoring vs. Sleep Apnea

Hi, this is Dr. Michelle with Jax Beaches family dentistry. I practice dentistry in Neptune beach with my partner, Dr. Elizabeth Alfuente. We have an amazing practice that focuses on complete health. We also do most dental services under one roof, including same-day emergencies, which is really helpful for our patients. Today, we're talking about snoring versus sleep apnea. I had already decided last year in 2019 to do a webinar a month, and I decided that the sleep apnea and snoring webinar was still very timely considering that we're in this pandemic because it focuses on decreasing inflammation in your mouth.

So welcome to our class on snoring versus sleep apnea and we're going to talk about, I can figure out how to push these buttons, and I'm not pushing the button. I'm pushing the button, but nothing's happening. So my technical person's going to help me.

This topic is going to become a passion for me because people are impacted by it and often it's not addressed. So I went to a class recently about sleep apnea and they talked about how even just simple snoring is an issue because simple snoring is usually negatively impacting your health issue. And I'm just going to read a statement that I found online from a sleep doctor that talked about how normal breathing and our bodies produce nitric oxide. So when you're breathing through your nose, you produce nitric oxide and when you're snoring, you don't produce nitric oxide. And the problem with that is that nitric oxide is an antioxidant and that antioxidant is critical to cardiovascular health. The minute you start to snore your nitric oxide stops. And the problem with that is that is what increases the clotting and the breakdown of your cardiovascular system.

Snoring also triggers your sympathetic response and that sympathetic response is what causes your fight or flight, and that can increase your high blood pressure. And as people know the problem with that when you have apnea is that apnea already increases your blood pressure. So if you snore or somebody that you know snores, you're going to appreciate this information that's coming up.

Sleep apnea is a common condition and the reason that that matters and the reason that interrupted sleep is a problem is that sleep is really important for your health. And what sleep apnea does is either your tongue or your palate, depending on what your issues are actually closed off your airway, and that is a problem because interrupted sleep is bad for your health.

So there are several risk factors when it comes to sleep apnea. The Harvard school of medicine identifies a bunch of the biggest risk factors. So they are, we'll just read them, obesity. Also when you're a post-menopausal woman. The thing I say to my patients is there are very few things that are more predominant in men than women and sleep apnea is one of those. But when you're a post-menopausal woman, of course, then you also are at risk. It's also very hereditary. So if someone in your family has sleep apnea, then you're likely to have it. Like if your father has a C-PAP machine or doesn't sleep very well, you definitely want to have on your radar that possibly you're going to also inherit that. Alcohol consumption at bedtime also sometimes causes apnea. So some people have almost no apnea if they don't drink, but then if they have a few drinks right before bed, they are APNIC. So please don't sedate yourself. That's not a good idea. Some people say, Oh my gosh, I can't sleep. So what I do is have a couple of bourbons before bed. That's not a good idea because it makes it worse. Sometimes just having a small, lower jaw or inheriting a bigger neck than other people can cause apnea and then low thyroid is an issue too and about half of the people who have sleep apnea also have high blood pressure. Sleep apnea is also linked to smoking diabetes and risk factors like stroke and heart attack. So most people that have apnea or have sleep issues already know that it's really bad for them and they've generally a lot of times talk to a physician. But it is important to keep those things in mind.

Now part of what we're going to talk about is why just sleep itself is important. I have always struggled with that because I've always felt like, Oh, well, if I get less sleep and I'm, you know, focused on working hard, it doesn't really matter. But the reality is that sleep is just as important as food, water and other things. So I've been anybody that knows me, knows that I get up at four o'clock in the morning and I've always prided myself in getting up, working out. That's when I do a lot of my work. But once I was exposed to this information and exposed to lots of different studies about how important sleep is, I have a tendency now to keep track of the number of hours of sleep that I get and work really hard to make sure that I do. One thing I wanted to mention in regard to that is I'm going to be talking a lot about different sources and different pieces of information. And then at the end of this webinar, my email address will be up so if any of the information is interesting to you or you feel like it's confusing or you think maybe I'm contradicting something, please feel free to shoot me an email and I can send you some of the sources.

Now, this map was given to me and shown to me by one of my amazing mentors, Dr. Chip Whitney. And I think it's really good and important for people to take a look at it. So when you look at this map, you can see that we all have two different paths; path A and path B that we wander down. And a lot of times things like snoring, sleep apnea going on a blood pressure medication, we think of it as no big deal. But what we want to always keep in mind is that in life we're heading down either path A or path B, and you slowly over time, if you have healthy relationships, healthy sleep, good oral health, what you're doing is going down path A where you're headed towards a healthy brain and an active lifestyle as you age. When you slowly go down this other path, path B, things like sleep apnea, your gums being inflamed certain hereditary issues, and again, inflammation because inflammation is huge, right? We're learning that more and more now in the news, will start to lead you towards dementia and potentially being in a nursing home or immobility, which is not where we want to be heading.

Oh, these are my sweet girls. That's my reason for wanting to stay healthy. So why does sleep matter? Sleep matters because of all the different issues, you know, with your health, you can't be completely healthy without having enough sleep, and sleep apnea is one of those things that interfere with sleep. So there's the number of hours of sleep and then there's the potential, you know, to have sleep apnea. And sleep apnea is when you're sleeping and you have like a loud snort and you, your sleep is interrupted by your airway shutting off. But obviously, that airway shutting off is creating those sleep issues. It's a chronic condition and it's something that is really, like we were talking about earlier, either from your palette, which is the tissue that hangs down in the back of your throat. Either that has become floppy. Unfortunately, that's the cause of collagen, as we get older, right? collagen interferes with a lot of things that cause, you know, wrinkles but when your palette gets sloppy, cause the college and is aging, then that's can shut off your airway. And then sometimes it's from, you know, your tongue blocking your airway. So those things are a problem and that causes a brief awakening. What I notice with patients is a lot of times they'll say to me, well, I wake up because I have to go to the bathroom. But the reality is a lot of times you're waking up because your airway has shut off. And really you're not waking up because you have to go to the bathroom. We were waking up because your airway has been blocked. You have no idea why you woke up but now that you're awake, then you go to the bathroom.

So Harvard women's health watch put out some of the top health issues that are associated with sleep apnea and that's low weight gain. I'm just going to read them high blood pressure. And here's the big one, right? For us now decrease in the immune system's power to fight other health challenges. So a lot of what's going on in the news right now with the pandemic is, you know, we're trying to figure out who is more prone to something like this virus or other pandemic issues and really who's prone are people with predisposing conditions. And sometimes those predisposing conditions are things like sleep apnea and snoring that aren't even really on someone's medical history because they haven't been identified as an issue for them. Because a lot of times sleep apnea really isn't diagnosed or hasn't even been discussed with the patient.

The other thing is that stroke, heart disease, dementia, diabetes, acid reflux, and that's another kind of blind spot for people. A lot of people take a daily reflux medication and they don't really associate it with their sleep or their lack of sleep or their interrupted sleep. So if you find yourself taking reflux medication, I encourage you to at least think about how your sleep is because they're often related to each other. And then we have Ed. And that's primarily when I took this advanced sleep class associated with that decrease in nitric oxide. And that really can impact men and then severe untreated sleep apnea even increases your risk of death. So, you know, we often hear about that. There was an athlete recently who died in his sleep and they associated that with him not being compliant with his C-PAP machine.

The NIH believes that sleep is so important that they're putting a lot of research, dollars, into a sleep which they would not do if they didn't feel like it was important. So feeling tired is only one consequence of poor sleep. Researchers covered links between poor sleep and health issues ranging from obesity to cardiovascular disease and even mental health disorders. In fact, 70% of high school students feel sleep-deprived. You know, we hear a lot, unfortunately, about high school students committing suicide and having mental health issues. And a lot of times it's really just, they're not sleeping, you know, they stay up until two in the morning staring at their screens and they don't get enough sleep and it can really affect their already difficult moods, which we are all aware of, any of us that interact with teenagers.

And the other unfortunate news, and I see it all the time in my practice because we do a really comprehensive medical history is most people don't really know they have sleep apnea up to 80% of sleep apnea is completely undiagnosed And one of those 20% that have been diagnosed and know they have it. A lot of those people are getting no treatment at all. They have a C-PAP machine, they can't wear it and it's sitting in their closet. So I encourage you to get that C-PAP machine out of your closet.

It also affects how your body processes, insulin, which can lead to diabetes and also lead to weight challenges. The problem with that, which we're going to talk about later is that an increase in weight or obesity or a certain level of BMI also makes apnea worse. So it's a slippery slope or, you know, a big circle.

So how much sleep do we need? Well, that's a big debate because I can tell you that I would always use to say, Oh, I only need six hours of sleep. I'm good. And it's really not true. And anybody out there that knows that I don't sleep well is laughing right now because I've always been up at four in the morning and Oh, I'm fine If I don't sleep enough kind of person. Again, because I'm busy and I have kids and at four in the morning, I can get a lot of stuff done. So what they say is if you go to sleep and you're not disturbed, you sleep on average eight to eight and a half hours. But the amount of sleep that you need as a human really there isn't, it varies mostly on your age. You know, newborn sleep forever, right? 14 to 17 hours, three to five-year-olds go down to about 10 to 13, teenagers need 9 to 11. And as adults, we need seven to nine hours. And if you fall lower than that on a scale, I encourage you to take a look at that and try to figure out different ways. I talk to my patients all the time, try to figure out different ways to increase that number of hours Cause it really is important. And it's important for a couple of different reasons. We alluded a little bit to the whole weight thing. And like I said, sleep and weight gain are important because as you increase in weight, as your weight gets higher, then that also increases your apnea.

So if you sleep less than five hours or you sleep more than nine hours, it appears to increase the likelihood that you're going to gain weight, and there's multiple reasons for that. In men, it tends to be that it increases their desire to eat high calorie foods. So that's interesting, right? With less sleep you have the bigger max you eat apparently. And then in women, if they sleep less than six hours or more than nine, they have a tendency to have trouble with their hormone balance and that causes them to feel hungrier. So it's really just triggering something that causes you to feel like you're hungry, even if you aren't. And then the other obvious thing, right, is when you're tired, you know, especially I used to work out at night after work and most the time I would just be too tired. I'm like too tired to work out and I would just go home instead. So if you're not getting enough sleep and you have daytime sleepiness, obviously you're less likely to be active. And then like I said before, the difficulty about that is as you gain weight, then you have a tendency to be more APNIC, which is a problem.

So sleep quality is really important too. It's characterized by quantity. Like we talked about, you have to have a certain number of hours, but then you also need to have high quality sleep. The cool thing for me now in terms of that, because I've been thinking a lot about sleep, is that on your, if you have a Fit bit or if you have, I think even an iWatch or there's some other watches like that show you all kinds of interesting stuff about your health, but you can see what stages of sleep you're in on most of those devices. And you want to get into those deeper levels of sleep. You know, sleep is divided into REM and non REM sleep. And when you're in those really deep levels of non REM sleep, that's when you have the restorative, you know, health inducing components of the sleep. And that's super important, you know, for all different reasons. And most of us already know about that. As we get older, we have a tendency to have less of that deep sleep, which means we have less of that restorative stuff and that's not good. And then as we were talking about earlier, if you're apneic and your airway shuts off, you just end up getting bursted out of or busted out of whatever level of sleep you happen to be in at that moment. And that's a real problem in terms of your, you know, restorative part of sleeping.

So there's six reasons to get enough sleep. I mean, we already talked about a bunch of them, but learning and memory is a problem. You know, if you're tired, you just can't recall things. Your metabolism and weight, which we already kind of beat that dead horse. And also safety, which is really important. You know, if you're falling asleep at the wheel or you're operating machinery and you're tired, that's a problem. And then mood, you know, you just have a tendency to be right, more stressed out, more irritable if you're tired and also your cardiovascular health which we talked about. And that, you know, is really important to think about and really important to make sure that I'm driving that home. That nitric oxide production is critical to your cardiovascular health and if you are snoring, you are not producing any of that all night. Super, super important.

And then the last one is just disease. And the reason I want to drive this point home too is that when you are APNIC or when you are snoring, your T killer cells, which are really important in your immunity, just don't function properly. And right now super important to have as high of an immunity as we can. This is really funny to me. The suggestion is you keep a sleep diary with a pen, pencil, and paper and a book. So highly unlikely any of us are really going to do that, but you could. I think the awesome thing to me with technology and anybody that knows me knows I'm not like a techno person, but I love my Fit bit. I love just going to sleep, waking up, being able to look at how I did it gives me like a little score. And then what you can do in terms of it diary though, is on those individual days, when you can see that the number of hours or the quality of your sleep wasn't poor, you could keep track of how you felt, whether you worked out or not And all of those things. And what we're trying to sort out with our daytime sleepiness, diaries or scores is that, you know, do those things correlate? On the days when I didn't sleep well, you know, how did I function?

We're going to talk a little bit about what sleep apnea is. Of course we already mentioned it. It's when your airway closes. And one thing I find that's really interesting in my practice is that people are hesitant to talk about sleep. They're hesitant to talk about this topic and a lot of it is because they've heard of sleep apnea and when they've heard of sleep apnea and they've heard of a C-PAP machine. And everybody knows for sure that even if they're tired, even if they're having trouble functioning, they don't want to wear a C-PAP machine. So a lot of times they don't want to get a sleep test And I actually don't even want to talk about their sleep because they're afraid that as a healthcare provider, that's what I'm going to be talking to them about or that I'm going to be insisting that that's what their diagnosis is. And that's not necessarily true. There are all kinds of sleep disorders that cause pretty severe daytime sleepiness, including something which I have, which is upper airway resistance. Very common in thin fit, active, you know, sort of go getting women. I'm not saying I'm a go getter, but it is something that is often not diagnosed when you have a sleep test, especially if you have a sleep test in a sleep lab, it's often missed completely. And the problem too is your AHI, which is your score comes back completely normal. So it looks like you're completely normal and yet you're exhausted all the time and you often will have interrupted sleep.

So that's the important thing to know. When we're talking to you about being tired and we're talking to you about having a sleep disorder, you know, it's not necessarily that your diagnosis is going to be apnea. There's all different levels of airway restrictions. And it's just important to have that knowledge with a sleep test about what it is that you have.

So the next thing is how do we know that we have apnea? Chronic snoring is one of the most common signs of apnea. So if you are a snore, it is important in my opinion, not just because of the nitric, which we already know just with snoring is not good for you, but also because we want to know, you know, if you're a snorer or do you have apnea? Some of the other symptoms that would go along with snoring are daytime drowsiness, waking up with a dry mouth, having a sore throat and having morning headaches are a big indicator. And if you have any of these symptoms, you definitely want to bring them up with your physician but you also want to mention them to your dentist and, you know, on our health history, that's something that you would be checking off.

So the other thing that is interesting to me about sleep apnea is a lot of times people have this airway restriction, they even have sleep apnea and their symptoms are really subtle. So what you're going to want to ask yourself is, do you have trouble sleeping? Do you sleep differently when you are off of work than you do during your workdays? How long does it take you to fall asleep? How often do you wake up at night? And how long does it take you to fall back asleep? Do you snore loudly or wake up gasping? Now that’s what a lot of people get sort of stuck on. They feel like unless they're gasping or unless their airway is completely shut off, they don't have apnea. Because I'll have people say to me, well, I used to have apnea, which means their spouse told them that their airway was shutting off. And now I don't because I lost 20 pounds. And the reality of that is probably somewhere in between the two. Yes your apnea is probably better. And it's always better when you lose those 20 pounds but that doesn't mean that you don't still have an airway restriction that would be improved right. By having some sort of treatment. So that's a very important defining thing that I helped my patients understand.

And then the other questions to ask is if you feel refreshed in the morning. So it's great. A lot of people will say to me too, Oh, I'm such a sound sleeper, which is me too. I mean a fire drill doesn't wake me up. But that doesn't mean that when I wake up in the morning, I feel refreshed like, woo I'm ready for my day. So that's really important. And then how tired do you feel during the day do you doze off? And again, with the safety thing, especially during driving. We do not want that. And then the other signs and symptoms would be some of what we already mentioned, dry mouth snoring, sore throat, morning headache, daytime drowsiness. And these symptoms can be very subtle. I've done sleep tests on people and found out they had severe apnea and they had almost no symptoms at all.

Another sort of first symptoms. So one of the first symptoms, even in somebody like in their twenties is snoring, even slight snoring. And then the other symptom that we can pick up on on the dental side. It was funny. I was talking to somebody last night and they said to me, you're talking about sleep apnea, but you're not really a doctor, you know, which cracks me up. Right? But I was explaining to them that there are things that show up in the mouth that allow us to have a conversation with people about their airway. And one of them is tooth grinding. So the reason that you grind your teeth when you have an airway issue is because when you move your jaw around and you grind, it helps to open up your airway. So it's really just your body's natural function to move your jaw around. And that causes you to grind and that opens up your airway so that you can breathe and it's nice to breathe in your sleep. And one thing I can warn people about that if you are a grinder, is that if you put a traditional appliance in and this is important for everyone to know, if you just put a traditional appliance in, which is something that we did for decades, a lot of times that appliance can actually block your airway. So now what we do in our practice is we have people get a sleep test prior to giving them any kind of appliance. We care about their teeth. We don't want them to grind their teeth. We don't want them to break their teeth. We don't want them to get decay or gum disease or recession from the grinding. However, we also don't want to block their airway. So that's super important for people to know about.

The other thing that's super interesting to me about sleep apnea is that it pairs with gum disease a little bit like it pairs with obesity and an increase in weight. So if you have gum disease, you're 60% more likely to have an airway restriction. And if you have an airway restriction and your gums are inflamed, it makes that whole situation worse. So it's again, a little bit like a snowball. And when you have apnea increases your risk of gum disease, and if you have gum disease that increases your risk of apnea. And we also know, since both of those things are an inflammatory disease that during this pandemic, it's really important to reduce the inflammation, to help with your overall health.

Okay. So what do we do about all this? So there are, I am definitely not a physician so I don't want anybody to think that I'm trying to be a physician. But as a dentist, we have a lot of opportunities to help people with their airway restrictions and help people with their apnea. The most important thing, like I said before, is getting information. And that information comes from a sleep test. So the sleep test gives us information about the severity of the sleep restriction and airway restriction. And that allows us to then give our patients information. If a patient comes back and their airway obstruction is very severe, the first line of defense is always going to be a C-PAP machine, even if we're just using that C-PAP machine temporarily until they can lose some weight, until we can do things, to treat their palate, it is definitely the gold standard and very important, especially if people are having severe health issues and symptoms.

The other thing that we can do, which we mentioned a little bit before is using an appliance. That appliance pulls your jaw forward and get your tongue off of your airway. There are a lot of surgical options. Used to be very common for people to get their pallet cut away. That surgery isn't done very much anymore. It's not very successful. It creates a choking hazard and so it's pretty limited. Now I think in, you know, severe cases where people can't wear a C-PAP machine, it certainly is still on the table.

We also do laser treatment on the pallet. Like I think I mentioned a little bit before that tightens up the college and, and keeps the pallet from moving. And then the other things that people can do are sort of things that they can do on their own. Sometimes people's apnea is very severe when they're sleeping on their back, but when they're on their side, they have almost no apnea. So you can use something that I call positional therapy. So you really can just order online sleep positioners and those positioners keep you from getting on your back and have you sleep on your side. The only problem with that, I have a lot of friends that are chiropractors that holler at me about this, but because sleeping on your side from a chiropractic spine point of view is not particularly healthy. Those are the debates that we get into. I can debate those things with the chiropractor. We can start with positional therapy, if that's what the person needs to do for whatever reason. And then coordinate, I love coordinating care with other healthcare practitioners. So we can talk about, you know, the risks versus benefits of different therapies. And then I also partner with people like acupuncturists and other holistic medicine people, because we're going to be managing people's diet. We're going to be managing all kinds of different things. And acupuncture is a great modality too.

So like we said before appliances are really helpful for a lot of people. There's a bunch of different appliances on the market. Many of them are FDA approved and they really simply, purely and simply, take the structures that are blocking your airway and, and move them off of the airway. And these are mostly used for people with mild to moderate apnea. The other really cool thing that we can do with appliances and the laser treatment is make that airway and blockage less. So even if you're using a C-PAP machine, the C-PAP machine does not have to force point as much air, you know, down your airway. So then that makes the CPAP therapy more comfortable. That's called hybrid therapy where you're using both modalities to help keep that airway open. And research shows that both modalities are good. I feel really strongly that, you know, if you have severe, we really need to you know, take a look at the C-PAP machine and do all that we can a comfortable nose piece to get people on that from the beginning. I have a lot of people that are motivated to not wear a C-PAP machine. So we sometimes will put them in appliance, get really, you know, down and dirty with weight loss and lifestyle issues including, you know, alcohol consumption and detoxing and things like that so that they don't have to wear a C-PAP machine. And these are things that obviously as a dentist, we're going to be coordinating with a medical doctor. I do not want to play a medical doctor. I don't want to play one on TV. I don't want to get involved in that at all, but I'm really blessed in that. I have lots of people that I coordinate care with.

And then, you know, the topic of this webinar was snoring versus apnea and I know we sort of got sidetracked and we're focused on apnea treatment, but the one thing for everyone to know is that snoring is also treated by appliances and the laser treatment on the pallet and what position you're sleeping in in bed And all of those things. A couple of things that I learned about that at our advanced class is that you can use nasal dilators to help us snoring, so everybody knows about the read-write strips, but there are things called mutes, which you actually put into your upper airway to dilate your nasal passages to help you do more. The really important thing in terms of snoring, not just because snoring is annoying, but to get that nitric oxide is your nasal breathing. So there's two things you can do. You can dilate your nasal passages and then you can also do mouth taping. I know that sounds crazy, but we really need to breathe through our nose. So there are several products online to where you can tape your mouth and then dilate your nasals and focus on breathing through your nose. And I'm also super blessed in that I work with a great ENT. And so when we talk to people and it's really obvious that they have an upper airway issue and their main problem is snoring, I refer them to the ENT and he does an upper airway evaluation and then helps me facilitate the C-PAP machine which is awesome.

Let’s see. So fatigue and all those things we've already talked about. It's really is a lifesaver for people without having to get on the C-PAP machine. However, like I said, there are many other things that we can do to help manage that. And pretty much sums it up. So I think we're done for today. I really loved talking about this. It's a super important topic to me. I'm very passionate about it. I am also very accessible. I love sharing about it. So one of the things that we do at our office is we do a free consultation for anybody that has sleep issues. So please feel free to call our office if you're in my area. Even if you're not in my area, I would love to chat with you about it, consult with you about it. So you can email me at the email address that is on the slide. And anything I can do to help, I love also coordinating care with other healthcare practitioners. I love talking to dentists about this. So if you're a dentist and you want to hear more about complete health, you want to hear more about sleep apnea, snoring and how it relates to your practice. I would love to talk to you about that too. So feel free to email me, feel free to ask me any questions that you would like and have an awesome Memorial Day weekend.

And I don't really know how to stop. So I'm going to keep talking until we end.

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