Archives for posts with tag: Sleep Apnea
“I’ve tried so many diets and none of them work”  How many times have you heard that? Have you said that?  NOW YOU MAY HAVE A SOLUTION.
Lack of sleep is causally connected to many physical problems. We know that from numerous reliable studies.
 Obstructive Sleep Apnea (OSA) is a major cause of sleep loss and one of the common symptoms of (OSA) is being overweight. Sleeping less than six hours, or more than nine hours a night appears to increase the likelihood of weight gain. So then, how does OSA effect weight gain?
There are three hormones that factor in the equation of lack of sleep contributing to weight gain.

1. Ghrelin: the Hunger Hormone

Lack of sleep increases ghrelin, and decreases leptin, both effects influencing increased hunger and obesity. Ghrelin is produced in the gastrointestinal tract and functions as neurotransmitter. When the circadian rhythm is interrupted by exposure to light at night, gherlin is released.

 2.  Leptin: the Anti-hunger Hormone.

Leptin is the satiety hormone that has opposite effects from ghrelin.  The receptor for leptin is found on the same cells in the brain as the receptor for ghrelin.

3. Melatonin

Melatonin maintains the body’s circadian rhythm by regulating the other hormones. The circadian rhythm is an internal 24-hour “clock” that plays a critical role in when we fall asleep and when we wake up. When it is dark, your body produces more melatonin. When it is light, the production of melatonin drops. Being exposed to bright lights in the evening, or too little light during the day, can disrupt the body’s normal melatonin cycles. For example, jet lag, shift work, and poor vision can disrupt melatonin cycles.
Melatonin supplements can be helpful for those who are sleep disadvantaged but adherence to directions is recommended.

melatonin 5-6-15

The Process

An inverse relationship between the hours of sleep and blood concentrations of ghrelin exists: as the hours of sleep increase, ghrelin levels trend lower and obesity is less likely.  Short sleep duration is associated with high levels of ghrelin and obesity.

When the stomach is empty, ghrelin is secreted. When we eat something the stomach is stretched and ghrelin secretion stops. Ghrelin acts to increase hunger and to increase gastric acid secretion and gastrointestinal motility to prepare the body for food intake.

What else does Ghrelin do to effect weight gain?

Beyond regulating hunger, ghrelin also plays a significant role in other systemic functions. Ghrelin influences body composition, it stimulates the release of growth hormone and regulates the distribution and rate of use of energy.

Conclusion

This is just another convincing reason to get adequate healthy sleep…. at the right time. 

Light is the circadian rhythm disrupter. Avoid light disturbances during sleep: have no lights in the bed room, pull the shades down to block any outside light, turn off the TV and computer. Blue light at the end of the spectrum is the most disruptive. When you are ready for sleep, wear an eye mask.

https://adental.files.wordpress.com/2015/06/counting-sheep-a.jpg

Abfractions- Common in patients with Obstructive Sleep Apnea.
Nocturnal bruxism, which is indicative of OSA, plays a major role. The effective solution requires treatment of the causes- OSA with occlusal imbalance.
 
Abfractions are non-carious cervical lesions (NCCL) caused by flexural forces; the enamel, especially at the cemento-enamel junction (CEJ), undergoes this pattern of destruction by separating the enamel rods.  Studies show that within the same patient, teeth with abfractions presented more gingival attachment loss than those without abfractions.  
 
 

 

An abfraction occurs on the lower part of the crown of a tooth, near the gum line.

            The enamel covering the crown tapers down to its thinnest there.  Uneven pressures on the biting surfaces of teeth cause a torque on the tooth which produces a slight bend at the center where the crown meets the root. As the tooth keeps bending, the thin enamel at the bottom of the crown, near the gum line, chips away.

 

The sensitive “dentin” surface inside the enamel is now exposed. Vigorous, improper teeth brushing will then wear away the unprotected dentin and the notches will grow deeper and larger.  The dentin also becomes vulnerable to acid erosion from foods such as citrus.

 

 

1. Mallampati Airway Exam  

2. Scalloped tongue

 

 

During an apnic event the tongue will force itself forward to remove itself as an air-blocking barrier.  Repeated compressions like this, pushing against the teeth, will leave impressions in the lateral edges of the tongue. The patient subconsciously  tries to force the tongue to move forward from the air tract and forces it against the teeth.This sign is readily detectable. This is also called Crenulated Tongue.

 
This indicator is nearly infallible; it must be differentiated from a similar condition (sign) in  a thyroid disorder.
 
 
We are in an excellent position to screen for sleep apnea and to help identify our undiagnosed (and therefore, untreated) OSA patients.
How can you miss these clinical signs?
You…..
• have direct observational access to the physiological structures of your patients’ upper airways
• are already screening chair side for other health conditions that can be easily spotted during a dental visit
• may see these patients more frequently than primary care physicians will, and are nearly one quarter more likely to see a dentist than a physician over any given time period.

Your field of operations is right next to the opening of the airway.

                  MALLAMPATI EXAM

The Mallampati Scale is a simple but effective test to assess your patient’s (or your own) airway .

The subject should be sitting or standing with their head on a 90 degree axis to the floor.
They protrude their tongue (not necessary to say “ahh”) and with a direct light into the  mouth, look in and/ or take a picture.
 
Class III or IV conditions are certain candidates for further testing and possible therapy.
The tongue is the most common factor in Obstructive Sleep Apnea.

Now that you learned this you will probably be heading for a mirror. How did you rate?                                     

                                  MALLAMPATI EXAM

The Mallampati Scale is a simple but effective test to assess your patient’s (or your own) airway .

The subject should be sitting or standing with their head on a 90 degree axis to the floor. They protrude their tongue (not necessary to say “ahh”) and with a direct light into the  mouth, look in and/ or take a picture.
 
Class III or IV conditions are certain candidates for further testing and possible therapy.
The tongue is the most common factor in Obstructive Sleep Apnea.
Now that you learned this you will probably be heading for a mirror. How did you rate?   

WHY WOMEN ARE LESS LIKELY TO BE DIAGNOSED FOR SLEEP APNEA

By Charles Kravitz, DDS in Women’s Health
Swedish scientist Dr. Karl Franklin and his team set out to find out how prevalent sleep apnea is among women and how often symptoms occur. Out of a population-based random sample of 10,000 women between the ages of 20 and 70 years, they gathered data on 400 of them. The test group were given questionnaires which included several questions regarding their sleeping habits and sleep quality. They also underwent overnight polysomnography.

WOMEN ARE LESS LIKELY TO BE DIAGNOSED FOR SLEEP APNEA

Women with sleep apnea are less likely to be diagnosed compared to men. In studies of patients registering for evaluation for sleep apnea, the ratio of men to women has sometimes been extremely lopsided, with 8 or 9 men diagnosed with obstructive sleep apnea (OSA) for each woman found to have OSA. However, we know from studies in the general population that the actual ratio is likely to be closer to 2 or 3 men with OSA for each woman who has the condition.  Women make up about 45 percent of sleep study referrals and most sleep studies are still done to screen for sleep apnea.

WHY ARE WOMEN LESS LIKELY TO BE DIAGNOSED FOR SLEEP APNEA?

 First, there is an unfortunate predefined notion of the make-up of a sleep apnea patient. The stereotype is a middle-age, overweight or obese male. Physicians may not be thinking of this OSA diagnosis when the patient is female. Second, women may present with slightly different symptoms than the “classic” symptoms of snoring, witnessed breathing pauses at night and excessive sleepiness during the day.

Instead, women may present with fatigue, insomnia, disrupted sleep, chronic fatigue and depression morning headaches, mood disturbances or other symptoms that may suggest reasons other than OSA for their symptoms. Because these symptoms are not specific for OSA, women may be misdiagnosed and are less likely to be referred to a sleep study for further evaluation. Another problem is that women with sleep apnea have more subtle breathing disturbances and are more likely to have REM-related apneas, so they may be tougher to diagnose.

COMMON SLEEP APNEA MISDIAGNOSES
Women are often diagnosed in error with one of the following conditions, rather than sleep apnea.
  • Anemia
  • Cardiac or pulmonary illnesses
  • Depression
  • Diabetes
  • Fatigue from overwork
  • Fibromyalgia
  • Hypertension
  • Hypochondria
  • Hypothyroidism
  • Insomnia
  • Menopausal changes
  • Obesity

Sources

Dr. Karl Franklin, European Respiratory Journal

Grace W. Pien MD, MS, assistant professor of medicine, divisions of Sleep Medicine and Pulmonary and Critical Care at the University of Pennsylvania School of Medicine.

Nancy A. Collop , MD, medical director at Johns Hopkins Hospital Sleep Disorders Center and associate professor of medicine atHopkins’ Division of Pulmonary and Critical Care Medicine in Baltimore, Md .

Fiona C. Baker, PhD, sleep physiologist, Center for Health Sciences, SRI International, in Menlo Park, Calif.

Anita L. Blosser, MD, with Duke Primary Care at the Henderson Family Medicine Clinic in Henderson, N.C.

We know that men are more at risk of developing obstructive sleep apnea. But for women who suffer from OSA the risk of developing cancer is more than your male counterparts, says a recent research published in the European Respiratory Journal. During the study the scientists collected data of 20,000 patients with OSA. It was found that a large per cent of these patients were later diagnosed with cancer.

Researchers analysed data based on age, gender, alcohol consumption, body mass index and smoking. Again, there was a strong association between sleep apnea and higher cancer prevalence. Additionally, the link was stronger in women than men.

How Sleep Apnea Influences Cancer

The studies show that people suffering from sleep-disordered breathing have an increased risk of developing cancer and are up to five times more likely to die from the disease.
Once again the culprit is HYPOXIA. The lack of oxygen (hypoxia) caused by untreated Obstructive Sleep Apnea (OSA) can be a catalyst for a process called neovascularization (the creation of new blood vessels), giving a blood supply that can encourage tumor growth.

Sleep apnea leads to neurochemical imbalances. When poor sleep is the result of any untreated sleep disorder, the neurochemical balance that a whole-body process like sleep requires is disrupted.

 Two of the key hormones that fall out of balance—cortisol and melatonin—are critical for maintaining a healthy immune system (cortisol) and for regulating the body’s circadian system (melatonin). In addition, this neurochemical balance can lead to body-wide (systemic) inflammation.

 

How does this relate to cancer?

  • Without a healthy immune system, the body can struggle to fight off the aggressive cellular behaviors that can lead to tumors.
  • With an imbalance in circadian rhythms as the result of decreased melatonin, the body produces higher amounts of other substances that are risk factors for cancer (for women, higher estrogen can lead to breast cancer, and for men, higher estrogen can lead to prostate, bowel, lung, and bladder cancer).
  • Systemic inflammation causes oxidative stress to the organs. Oxidation is a breakdown of tissues that is the consequence of long-term inflammation; oxidative stress refers to the damage that results from unchecked systemic inflammation, which makes it easier for cancer—an opportunistic disease—to establish itself wherever the body is most vulnerable.

Cancer cells thrive in a low oxygen environment. Hospitals will put a patient on oxygen if their O2 levels drop below 92. Untreated OSA can cause oxygen levels to drop anywhere from the 90’s, 80’s and even in the 50’s.

Sleep apnea causes sustained low blood oxygen. 

One of the biggest problems with sleep apnea is the way in which it deprives the body of necessary oxygen. Frequent apneas (pauses in breathing that last at least 10 seconds, but often last much longer) lead to nocturnal intermittent hypoxia. 

Conclusion

Detecting OSA and leading the way for treatment can add YEARS to a  patient’s lifespan while significantly improving quality of life. Both cancer and OSA have symptoms that can be easily recognized in the chair during a regular checkup. While checking the mouth for masses and swelling, you can also check on the Mallampati score  and be alert to possible concerns you may have. 

                  MALLAMPATI EXAM

 

 More case studies

A 2012 study identified a link between sleep and aggressive breast cancers.  Ref: American Cancer Society 

In 2013, Spanish researchers reported that people with severe sleep apnea had a 65 percent increased risk for cancer. They suggested the risk is associated with increased hypoxia, a condition where the body is deprived of oxygen.

Another study from the University of Wisconsin found people with sleep-disordered breathing are five times more likely to die from cancer than people without sleep apnea. Researchers from the American study admit the study is limited in that there are no studies to compare it with that look at cancer survival in people with sleep apnea.

One recent study reported in the Journal of Sleep Medicine shows moderate and severe cases of sleep apnea are associated with increased cancer risk. That study also showed an increased risk for all “all-cause mortality” and cancer mortality due to cancer. The 20-year study showed that people with moderate to severe cases of sleep apnea are two and a half times more likely to develop cancer and three times more likely to die from cancer. The authors noted these findings confirmed previous research conducted by American and Spanish researchers. 

Animal studies have also confirmed previous findings. One 2014 study  reported in the journal Cancer Research linked sleep apnea with aggressive cancer growth in mouse models. Mice with tumors were placed in low oxygen environments that mimic the effects of sleep apnea and tumor growth in the mice progressed rapidly.

  

Researchers have also suggested a correlation between sleep apnea and increased cancer risk of any kind.   Risk of some cancers may increase. One Cancer study of 1,240 participants who underwent colonoscopies found that those who slept fewer than six hours a night had a 50 percent spike in risk of colorectal adenomas, which can turn malignant over time.
 
Sources: 

American Sleep Apnea Association
Centers for Disease Control
Mayo Clinic
National Institutes of Health
National Sleep Foundation
The New York Times
Wisconsin Cohort Study
World Health Organization

CANCER IS AN INCREASED RISK FOR WOMEN IF THEY HAVE SLEEP APNEA

We know that men are more at risk of developing sleep apnea. But if you are a woman and you suffer from obstructive sleep apnea (OSA) your risk of developing cancer is more than your male counterparts, says a recent research published in the European Respiratory Journal. During the study the scientists collected data of 20,000 patients with OSA. It was found that around 2 per cent of these patients were later diagnosed with cancer.

Researchers analysed data based on age, gender, body mass index and smoking. Again, there was a strong association between sleep apnea and higher cancer prevalence. Additionally, the link was stronger in women than men.

A 2012 study identified a link between sleep and aggressive breast cancers. Ref: American Cancer Society

ADDITIONAL CASE STUDIES

In 2013, Spanish researchers reported that people with severe sleep apnea had a 65 percent increased risk for cancer. The risk is associated with increased hypoxia.

Another study from the Univ. of Wisconsin found people with sleep-disordered breathing are five times more likely to die from cancer than people without sleep apnea. 

One recent study reported in the Journal of Sleep Medicine shows moderate and severe cases of sleep apnea are associated with increased cancer risk. That study also showed an increased risk for all “all-cause mortality” and cancer mortality due to cancer. The 20-year study showed that people with moderate to severe cases of sleep apnea are two and a half times more likely to develop cancer and three times more likely to die from cancer. The authors noted these findings confirmed previous research conducted by American and Spanish researchers.

 With a convincing condemnation of Sleep Apnea as a cause of cancer we need to be more serious about screening patients for cancer and OSA.

HOW SLEEP APNEA INFLUENCES SYSTEMIC DISORDERS AND HOW YOU CORRECT THEM
The article on women with sleep apnea raised so much interest that I am offering a follow-up with some explanations you asked for.
So, you are a woman in dentistry, caring and dedicated. You want to give your obstructive sleep apnea (OSA) afflicted patient a simple layman explanation on the importance of healthy sleep.

Try this:

1.  The key is oxygen.

Can you imagine holding your breath for 10 seconds and even up to a minute, 20 times per hour on average, when you thought you were sleeping? That’s Moderate (not Severe) sleep apnea. That’s 160 apnea events X 10 seconds  = 1600 seconds (27 minutes during an 8 hour “sleep” session. And it could be much higher.
How much oxygen would pass to your lungs and consequently to all your organs during that time? Every system in your body will suffer and break down. And that would lead to strokes among other repercussions.
2.  Why high blood pressure and acid reflux (GERD) are common co-morbidities of OSA
During the cessations of breathing the body will increase its efforts to take in air.
Abdominal contractions are exaggerated and increase until breathing resumes.  The contractions squeeze the stomach and force acid through the LES and up the esophagus.
The efforts to breathe also increase a negative pressure in the esophagus which also pull up acid and elevate blood pressure. Aha! The mystery is resolved!
3. The solution.
 Correct the sleep breathing disorder (Oral Appliance Therapy ((OAT) is effective, economical and convenient), and you will observe the symptoms of OSA diminish and in many cases disappear. Isn’t hat a lot better than popping pills every day.?

Are you ready to cut those strings that have tied you to the dental chair for all those years? You have had a long productive career of interacting with people in need and improving their quality of life. Now, after years of intense dedication to detail you are looking for alternatives. You want to hang up the loupes but are wondering what to do first and what will you do when you start to miss the patient interaction.   Here’s what one astute dentist did:

Dr. Sidney Shaw was an old-fashioned type dentist. She had a conservative treatment approach to the practice of dentistry, She exuded an obvious passion for helping her patients, and everyone loved her. She had an admired and successful general dental practice.  At the ripe young age of 66 she was diagnosed with atrial fibrillation and her doctor told her she had to slow down. That’s when she made the painful decision to put her practice up for sale and reap the rewards from the 38 years of hard work invested into building her practice. She felt she could retire comfortably on her proceeds from the sale.

She contacted a dental transition broker who conducted a very comprehensive practice valuation. To Sidney’s dismay the valuation reported a market value of 310,000. This was more than disappointing to Sidney; it was devastating. It was not enough to comfortably support her and her mounting medical bills.

“Disappointment is a temporary obstacle on the road to success.”

Sidney contacted me and we came up with a solution for her.  We implemented a new program that added another three hundred thousand dollars in value to her sale price.

Within two months of making her decision she was treating two patients, on average, each day for sleep apnea. Her average fee for each case was $3500. This amounted to $21,000 a week for three easy, relaxed, rewarding half days a week. This projected to revenues of an incredible $1,050,000 for a 50 week year. This may sound like “pie in the sky” but when you check around you will find examples like this being quietly conducted all throughout the nation.

The happy ending:

Sidney sold her practice for 2.5 times more than that original market value and she stayed on 3 half days a week as a ” sleep specialist” for the new owner. How is that for a ROI of two months’ training?