“Oral health is more than healthy teeth.” – US Surgeon General Dr. Richard Carmona(1).
3D CT imaging of oral airway volume: Example 1: White-Blue: Airway is normal or near-normal: Green-Yellow: Airway is hazardous to health
Pain, fatigue, and insomnia drive patients to doctors, and heart disease and cancer head the list of America’s leading killers (2). Lots of advice on diet, exercise, and stress is given, but little attention is paid to a root cause: oxygen deficiency from airway blockage during sleep.
A Holistic Mouth is structurally sound to support deep sleep. An Impaired Mouth features a tongue driven into the throat like a 6 foot tiger in a 3 foot cage.
Example 2: a marginally adequate airway
Example 3: hazardous airway — enough to conceivably contribute to cancer.
Deep overbite, narrow jaws, and/or retruded (opposite of protruded) jaws reduce oral volume for the tongue. With the tongue as an airway blocker, Obstructive Sleep Apnea (OSA) follows in due course, with escalating medical and dental complications.
Daytime sleepiness is a cardinal feature of undiagnosed sleep apnea (3). So is teeth grinding and jaw clenching, in my experience. Other signs and symptoms of OSA can include (4):
- Disruptive Snoring
- Witnesses apnea or snorts during sleep
- Gasping or choking during sleep
- Excessive daytime sleepiness
- Difficulty with concentration
- Short-term memory loss
- Excessive bladder urgency during sleep
- Difficulty staying asleep
- Decreased libido
- Morning headaches
- Weight gain despite diet and exercise (in Dr. Liao’s experience)
In a nutshell, OSA means oxygen deprivation during sleep with the tongue blocking airway. So OSA patients suffer a dry form of “water boarding” and life-death crises every time they sleep.
Example 4: hazardous airway — may contribute to head-neck-shoulder-back pain and teeth grinding.
Example 5: dangerous airway — this patient had a heart attack.
“95% of the Americans with sleep apnea do not know they have sleep apnea and consequently face cardiovascular complications and sudden death.” (5). “The severity of sleep-disordered breathing was associated with the magnitude of medical costs.” (6)
The medical cost is about 2X for patients with undiagnosed sleep apnea compared to age and sex matched individuals (6). Obstructive Sleep Apnea (OSA) is a medical diagnosis that is established only by a sleep test. Sleep Breathing Disorder (SBD) is defined as AHI > 5 from sleep test.
Snoring may be an early siren:
- “Snoring and daytime sleepiness can progress into sleep apnea if not treated: AHI 4 rose from 13 in 10 years. (7)
- Habitual snorers are more likely to have more severe Sleep Breathing Disorders.” (3)
- “Loud Snorers and OSA subjects are 1.4 and 1.8 times more likely to report teeth grinding, respectively” (8)
Cone Beam CT imaging can reveal sleep apnea propensity early on.
- “Snorers have smaller pharyngeal cross-sectional areas than non-snorers.” (9)
- “Snorers with sleep apnea have a further decrease (in pharyngeal cross-sectional area) as lung volume falls.” (9)
- Structural defects have been linked to boney and soft tissue abnormalities in OSA patients (10).
- “Malocclusion (bad bite) influences the occurrence of sleep apnea” (11).
A dentist familiar with oral-facial-dental signs related to OSA can help screen for OSA, refer for sleep test as needed, and treat the oral factors contributing to OSA.
Which one of these airways would you rather have?
Example 6: off-the scale dangerous airway in a 31 year old man who has started oral appliance therapy.
Rule Out OSA Early because there are serious consequences:
- Cancer patients with severe OSA patients (AHI >30) have 4.8 X greater death rate than patients with the same cancer but without sleep apnea, and 2X for those with moderate OSA (AHI =15-30) (12).
- OSA is behind 50% of high blood pressure, 30% of heart attacks, and 60% of strokes (13).
- 35.3 % of patients who had been treated for Acute Coronary Syndrome (ACS – chest pain, jaw pain, arm numbness and other symptoms stemming from blocked coronary artery) have OSA. (14)
- Patient with history of ACS treatment with OSA are 7 X more likely to die from second heart attack compared to those without OSA (14).
- “Treatment of OSA completely reverses its cardiovascular consequences…OSA should be approached as an important modifiable cardiovascular risk factor.” (15).
- Woman over age 30 with OSA may be more vulnerable to breast cancer, concludes a new study from Taiwan (16). This study found: (a) Breast cancer rate was 1.89 X higher in women with OSA; (b) Breast cancer women with OSA have 2.09 X death rate compared to non-OSA breast cancer women during the five-year follow-up.
Impaired Mouth-Sleep Apnea Links:
Tongue position relative to uvula with the mouth open and patient in seated position is related to OSA severity (19)
- Teeth grinding is associated with snoring and sleep apnea. (7, 10, 9, 17)
- Tooth prints on the side of the tongue is associated with obstruction in sleep apnea (18).
- Tongue position predicts severity of Obstructive Sleep Apnea (19)
Dr. Liao’s Points:
- Don’t wait even if you only have just a few of the symptoms in the Holistic Mouth Score sheet (see Appendix), or it will be much costlier later.
- Impaired Mouth should be considered the start of a domino effect leading to OSA, and thus it should be recognized and treated as early as possible.
- Symptom Checklist and 3D Cone Beam imaging can be a proactive way to screen for OSA tendency early on.
Here are few examples:
Tooth prints on the sides of the tongue (crenation) is associated with lower sleep efficiency and oxygen drop of 4% or more — an OSA criteria (18)
Example 1: this patient has fought Lyme disease for 10+ years with an airway in the red zone. She is nearly bankrupt and still does not feel well.
Example 2: an almost adequate airway, which is rare among my patients, nearly all of them have well-maintained teeth and great oral hygiene.
Example 3: this patient in his mid-40’s has a history of testicular cancer and he found out about his airway only after chemotherapy.
Example 4: this 45 year old woman with teeth grinding, alternating constipation and diarrhea, pain in head-neck-shoulder pain.
Example 5: this 43 year old father of a new daughter bikes to work everyday and had a heart attack one morning. He found out his airway issue later.
Example 6: this 31 year old IT manager with off-the-scale dangerous airway. He has started oral appliance therapy as proactive and preventive care.
The Good News: “complete eradication of teeth grinding is observed with CPAP”, says an Israeli study (17). Dr. Liao’s clinical experience is the same with oral appliances, based on patient feedback.
According American Academy of Dental Sleep Medicine, Oral appliances are “a front-line treatment for patients with mild to moderate Obstructive Sleep Apnea (OSA) who prefer OAs to continuous positive airway pressure (CPAP), or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep position change.” (19)
Which one of these airways would you rather have? Is Your Sleep Partner At Risk For A Heart Attack?
Take Action: Complete this 1 minute Epworth Sleepiness Scale, and start a conversation with your doctor or dentist. It can save you medical and dental troubles, money, and even your life.
Do Whole Health: Go for foundational corrections of the causes instead of just managing symptoms. Do not count on oral appliance therapy alone to fix your airway. Your body is much more complex, and all its parts are inter-connected. So adopt the Whole Health approach: eat smart, live sensibly, improve sleep hygiene, stay positive, and do plus corrective exercises to rebuild breathing muscles that have slacked off for so long.
Teeth grinding as sleep issue is Dr. Liao’s own conclusion, and not listed in Dr. Dement’s original article (5).
References:
1. A National Call to Action to Promote Oral Health: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, and the National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03- 5303, May 2003.
2. Leading Causes of Death: US Center for Disease Control and Prevention
3. Young T, and others, The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults, N Engl J Med 1993; 328:1230-1235April 29, 1993.
4. Park JG, and others, Updates on Definition, Consequences, and Management of Obstructive Sleep Apnea, Mayo Clin Proc. Jun 2011; 86(6): 549–555.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104914/
5. Dement W, Mitler M, It’s Time to Wake Up to the Importance of Sleep Disorders, JAMA. 1993;269(12):1548-1550. doi:10.1001/jama.1993.03500120086032
6. Kapur V, and others, The Medical Cost of Undiagnosed Sleep Apnea, SLEEP, Vol. 22, No. 6, 1999, p. 749-55.
7. Lindberg E, et al, Evolution of Sleep Apnea Syndrome in Sleepy Snorers: A Population-based Prospective Study. American Journal of Respiratory and Critical Care Medicine, 1999, Vol.159: 2024-2027.
8. Ohayon MM, and others, Risk factors for sleep bruxism in the general population. Chest. 2001 Jan;119(1):53-61.
9. Bradley DT, et. al, N Engl J Med 1986; 315:1327–31.
10. Isono S, et. al, The role of malocclusion in non-obese patients with obstructive sleep apnea syndrome. Journal of Applied Physiology April 1, 1997 vol. 82 no. 4 1319-1326.
11. Miyao E, and others, Intern Med. 2008;47(18):1573-8.
12. Nieto J, and others, Sleep disordered breathing and cancer mortality: results from the Wisconsin Sleep Cohort Study, Am J Respir Crit Care Med. 2012 Jul 15;186(2):190-4. doi: 10.1164/rccm.201201-0130OC. Epub 2012 May 20.
13. Lattimore JDL, et al, Obstructive Sleep Apnea and Cardiovascular Disease. J Am Coll Cardiol. 2003;41(9):1429-1437.
14. Loo G, et al., Prognostic implication of obstructive sleep apnea diagnosed by post-discharge sleep study in patients presenting with acute coronary syndrome. Sleep Journal, published online 14 April 2014. doi:10.1016/j.sleep.2014.02.009.
15. Devulapally K, et al, OSA: the new cardiovascular disease: Part II: overview of cardiovascular diseases associated with obstructive sleep apnea. Heart Fail Rev. 2009 September; 14(3): 155–164. doi: 10.1007/s10741-008-9101-2.
16. Chang WP, and others, Sleep apnea and the subsequent risk of breast cancer in women: a nationwide population-based cohort study. doi:10.1016/j.sleep.2014.05.026.
17. Oksenberg A, Arons E, Sleep bruxism related to obstructive sleep apnea: the effect of continuous positive airway pressure. Sleep Med. 2002 Nov;3(6):513-5.
18. Weiss et al, Archives of Otolaryngology, Head & Neck Surgery 2005:133(6)966-71.
19. Barcelo X, and others, Oropharyngeal Examination to Predict Sleep Apnea Severity. Arch Otolaryngol Head Neck Surg. 2011;137(10):990-996.
20. Oral appliances: American Academy of Dental Sleep Medicine.
