Sleep Disordered Breathing

Did you know you spend one-third of your life asleep? Yes, it's true, which means the quality of your sleep has a very real impact on the quality of your life.

Sleep Disordered Breathing (SDB) comprises two key areas:

1. Snoring
2. Obstructive Sleep Apnea

SDB affects more than 40 percent of the population, with that percentage increasing for people over the age of 50. Fortunately, Sleep Disordered Breathing can be treated with a variety of dentist-prescribed anti-snoring/apnea appliances.

Quality of sleep and sleep medicine are two relatively new areas within medicine, with growing awareness of the serious health consequences associated with snoring. With the ability to now diagnose and treat sleep-related conditions, many people are experiencing a greatly enhanced quality of life.

Dentists and physicians will meet many people with SDB. These patients could have chronic medical conditions, which are in part related to sleep disorders. Therefore, each patient should be screened and issued practical advice for the treatment of their individual sleep disorder.

Apnea is Greek for "without breath," where the tongue is completely sucked against the back of the throat and blocks breathing.

Snoring is caused by a narrowing of the upper airway during sleep. This can be due to large tonsils, a long uvula (the small piece of soft tissue that dangles from the soft palate over the back of the tongue) or excessive flabby tissue in the throat. All of these areas relax during sleep.

In other cases, nasal congestion from allergies or deformities of the cartilage between the two sides of the nose can contribute to narrowing of the airway.

However, the most common cause of narrowing of the upper airway is a tongue muscle that becomes too relaxed during sleep. When relaxed, the muscle is sucked into the back of the throat with each breath taken.

Snoring occurs when air travels faster through a narrow tube than through a broad one. This rapidly moving air causes the relaxed soft tissues of the throat to vibrate. It is this vibration that creates the sound of snoring.

By keeping the airway open, air travels more slowly, reducing throat vibrations and thus reducing or stopping snoring. One of the most effective ways to keep the airway open during sleep is by holding the tongue forward.

Snoring can progress into a condition known as Obstructive Sleep Apnea (OSA). Airway obstruction causes the heart rate to fall below normal, with decreases in blood oxygen levels. The obstruction will not clear until oxygen levels to the brain fall low enough to partly wake the sleeper with a release of adrenaline. This is an automatic body reaction and is intended to prevent suffocation. The airway obstruction is usually broken with one or several gasps to take in fresh air.

This event may happen hundreds of times a night for someone who suffers from OSA, which means the sleeper does not get a deep, restorative sleep. Such a condition greatly affects body chemistry and poses many serious health risks.

• Supine body position (lying face up)
• Large tonsils, long uvula, excessive flabby tissue in the throat
• A tongue that becomes too relaxed during sleep
• Being overweight: A recent study showed that a 10 percent weight gain is associated with a six-fold increase in the odds of developing OSA.⁵
• Nasal congestion from colds, allergies or deformities of cartilage within the nose
• Menopause: Postmenopausal women were shown to have more than twice the risk for SDB and three times the risk for severe SDB.
• Consumption of alcohol, medication or tobacco
• Hypothyroidism: Due to lack of thyroid hormone, sufferers tend to have a larger tongue, as well as increased fat deposition in the tissues of the upper airway.

Sleep apnea occurs when the tongue falls back into the throat and obstructs the airway. Apnea episodes, in which the snorer gasps for breath, can happen hundreds of times per night.

Snoring and sleep apnea reduce deep, restorative sleep. This results in extreme tiredness through the following day, which can negatively affect personal, intellectual and physical performance and quality of life.

Obstruction of the airway causes the heart rate to fall below normal, with decreases in blood oxygen levels. The obstruction will not clear until blood oxygen levels fall low enough to trigger the brain to send a signal for a release of adrenaline to prevent suffocation. The airway obstruction is usually (but tragically not always) broken with a gasp for air and, due to the adrenaline release, an increased heart rate.

Reduced blood oxygen levels during the night also cause the brain to send signals through the nervous system to protect vital organs, the heart and the brain. To compensate for the low blood oxygen levels, blood vessels are instructed to tighten up to increase blood flow, to ensure the heart and brain get the required amount of oxygen.

This tightening of the blood vessels causes hypertension and high blood pressure. Night-induced blood pressure continues into the day, even with normal breathing.

Reduced blood oxygen levels can also stimulate the production of red blood cells. This thickens the blood and slows circulation, worsening the overall situation.

Apnea episodes cause disrupted sleep, leading to excessive tiredness and sleepiness during the day, thus increasing the risk of car accidents.^7,8

A study released in November 2006 and published in the Journal of the American Academy of Physician Assistants linked OSA, and therefore snoring, to cognitive dysfunction and vascular dementia. Due to cyclical oxygen desaturation from recurring asphyxia, stopped-breathing episodes during sleep reduce oxygen to local brain tissue, causing an infarct and tissue damage with permanent neuropsychological dysfunction.

OSA is directly linked to:

1. Hypertension/high blood pressure: 30 to 80 percent of patients with hypertension have sleep apnea.^9,10,11
2. Strokes
3. Cardiovascular disorders^12,13,14
4. Diabetes
5. Obesity-altered body chemistry/glucose levels affect the body's metabolism.¹⁷
6. Dementia/memory problems due to starved oxygen to the brain
7. Depression¹⁶
8. Reflux/heartburn/GERD: 85 percent of sufferers have SDB; in many cases, treating SDB also treats reflux/heartburn.¹⁵
9. Nocturia
10. Insomnia
11. Nocturnal asthma/COPD
12. Impotence

• Snoring is No. 3 on the list of reasons for divorce in married couples. Only infidelity and finances are blamed before snoring.⁴
• Snoring can be very distressing for sleep partners, with banishment from the bedroom for the snorer.
• Sleep disturbance/deprivation to sleep partners is very real, with a negative impact on well-being and quality of life.
• Snoring can be the cause of embarrassment/humiliation when traveling with others.
• Snorers experience tiredness, morning headaches, dry mouth, relationship difficulties, lower blood oxygen levels and other associated consequences.
• New research has shown that loud snoring poses health risks similar to OSA.⁶

1. Snoring
2. Gasping, choking, stopped or irregular breathing during sleep
3. Frequent nocturnal urination
4. Hypertension/high blood pressure
5. Reflux/heartburn/GERD
6. Morning headaches
7. Extreme daytime sleepiness
8. Memory deficit
9. Depression

1. Six out of 10 of all adults (59 percent) say they snore. More than one-half (57 percent) of those who snore say their snoring bothers others. National Sleep Foundation, 2005 Sleep in America Poll.
2. Kryger MH, Roth T, Dement WC. Principles and practice of sleep medicine, 2nd Edition. Philadelphia, Pennsylvania: W.B. Saunders Company, 1994. Goblin, AZ, The World of Children's Sleep, Parents' Guide to Understanding Children & Their Sleep Problems. Michaelis Medical Publishing Corp., 1994.
3. Lefcourt LA, Rodis JF. Obstructive Sleep Apnea in pregnancy. Obstet Gynecol Surv 1996;51:503-6.
4. The causes of snoring: A nemesis in many a bedroom. Dr. David W. Sparks.
5. Peppard PE, Young T, Palta M, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000;284:3015-3021.
6. Punjabi NM. The epidemiology of adult obstructive sleep apnea, Pro Am Thorac, 2008;5:136-143.
7. Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents, for The Cooperative Group Burgos-Santander.
8. Risk factors for traffic accidents in patients with obstructive sleep apnea syndrome Akiko Yoshino, 1,2 Maki Higcuhi, 1,2 Fusae Kawana, 1,2 Mitsue Kato 1,2 Minae Kamata, 1,2 Shigemoto Nakanishi, 1 Takatoshi Kasai 3 and Koji Narui 2 1 Department of Clinical Physiology and 2 Sleep Center, Toranomon Hospital, and 3 Department of Cardiology, Juntendo University, School of Medicine, Tokyo, Japan.
9. Schaefer, et al. Obstructive sleep apnea as a risk marker in coronary artery disease. Cardiology 1999;92(2)79-84.
10. Thirty-80 percent of patients with hypertension have Sleep Disordered Breathing (Logan et al. J Hypertension 2001;19:2271-2277).
11. Fifty-90 percent of Obstructive Sleep Apnoea patients have hypertension (Peppard 2000, Lavie 2000).
12. Milleron, et al. Benefits of Obstructive Sleep Apnea treatment in coronary artery disease: a long-term follow-up study. European Heart Journal 2004;25:728-734.
13. Somers, et al. Sleep-Disordered Breathing and cardiovascular disease. Circulation 2003;108(1):9-12.
14. Schaefer, et al. Obstructive Sleep Apnea as a risk marker in coronary artery disease. Cardiology 1999;92(2)79-84.
15. Payne R, Kost K, Frenkiel S, et al. Laryngeal inflammation assessed using the reflux finding score in Obstructive Sleep Apnea Otolaryngology - Head and Neck Surgery.
16. Psychiatr News November 4, 2005;40(21)20.
17. Gami AS, Caples SM, Somers VK. Obesity and obstructive sleep apnea. Endocrinol Metab Clin North Am. 2003;32(4):869-94.