Slumber Gaps

May 1, 2000
Are you tired? Look around. Is someone next to you yawning? Or the ultimate - ever had a patient who fell asleep while you were cleaning their teeth? If you have not already noticed, there are many weary people in our country, just barely dragging through the day. They`re sleepless in Seattle ... and Spokane ... and San Diego. Many people have no idea why they`re so tired, and they`re too tired to figure out why! Science tells us we spend one-third of our lives sleeping, so why are we all so exh

The search for deep sleep nears dreamland when you assess if a patient suffers from sleep apnea.

Cathleen Terhune Alty, RDH

Are you tired? Look around. Is someone next to you yawning? Or the ultimate - ever had a patient who fell asleep while you were cleaning their teeth? If you have not already noticed, there are many weary people in our country, just barely dragging through the day. They`re sleepless in Seattle ... and Spokane ... and San Diego. Many people have no idea why they`re so tired, and they`re too tired to figure out why! Science tells us we spend one-third of our lives sleeping, so why are we all so exhausted?

According to the FDA, an estimated 18 million Americans suffer from a condition known as sleep apnea, but less than 1 million are actually aware of it. As with so many health problems, dental professionals likely are the first to see symptoms and signs of the problem in our patients.

Sleep apnea is a sleeping disorder where a person stops breathing anywhere from a few seconds up to two minutes repeatedly during sleep. There are three forms of sleep apnea, but obstructive sleep apnea (OSA) is the most common form. Tissues at the back of the throat collapse at intervals during sleep and block the airway. Apnea decreases the amount of oxygen in the blood which triggers the lungs to suck in air. Most people are unaware that they may be gasping or snorting for air hundreds of times a night, interrupting their sleep patterns. Children can be affected as well as adults.

With 18 million Americans snorting and gasping all night long, it`s amazing any of us get a good night`s rest! According to Mike Middleton, a polysomnographer at the Crittenton Hospital Sleep Clinic in Rochester, Mich., sleep apnea is just one of 82 known sleep disorders. Sleep apnea is often combined with other sleep disorders and is often treated in combination with other problems.

While it`s true that sleep needs vary greatly with each individual, on average an adult needs seven to eight hours of sleep every night. Although the actual benefits of sleep are not completely understood, studies have shown that sleep normally progresses through several stages which repeat several times each night. An interruption in any of these night stages seems to cause many daytime impairments.

The FDA reports that sleep apnea is "among the most common and most dangerous types of sleep disorder." The dangers are varied, ranging from increased accidents, irritability, and mental confusion to more serious medical problems. A 1997 study concluded that as many as 100,000 automobile accidents are caused each year by daytime sleepiness. A 1995 poll found that 33 percent of those questioned admitted to falling asleep while driving. Studies done in 1997 and 1998 found that people with sleep apnea have two to three times more car accidents and five to seven times the risk for multiple accidents. Another study in Australia reported that 17 hours of sleep deprivation was comparable to people with a blood alcohol level of 0.10 percent - a level that defines intoxication in many states in America.

Although many studies have attempted to establish a link, it has not yet been firmly established that sleep apnea directly causes serious diseases such as high blood pressure, heart attack, stroke, heart failure, and kidney failure. However, many serious diseases can be triggered by the lack of oxygen and higher carbon dioxide levels that occur in people suffering from sleep apnea, especially over a long term. It has also been noted that patients with sleep apnea heal slower from tissue trauma.

Obesity is reported to be a major risk factor for sleep apnea, although obesity can be the cause as well as the effect of the problem. Fatty deposits can invade throat and other oral tissues, which can cause airway obstruction and sleep apnea. On the other hand, studies have shown that animals deprived of REM sleep tend to eat more. Also, tired people may find it harder to exercise and therefore put on weight.

In the past, a misconception was that all people with sleep apnea also snore. But studies have proven that people can have apnea and not snore. Studies also show that snoring vibrations may cause the soft palate to lengthen over time, which can trigger some cases of sleep apnea.

Middleton singles out the dental office as the best place for initial diagnosis of sleep apnea. "I believe that people who work in the dental field may be able to pick up the signs of airway occlusion before a physician would simply because patients are reclined and on their back," he said.

Middleton says that a normal airway is about 11 mm, but 30 to 70 percent of a person`s airway may be obstructed when lying down. He adds that a serious medical emergency can occur if the patient is relaxed and the airway becomes obstructed by the soft palate or tongue while under sedation. If faced with this situation, he suggests simply turning the patient`s head to the left or right to increase air flow.

But such medical emergencies do not have to be a surprise, particularly when there are many indicators of sleep apnea to look for (many of them are quite obvious). Signs arising from health histories and medical conditions can include high blood pressure or blood pressure fluctuations, trouble breathing, a family history of apnea, snoring, severe heartburn, chronic headaches, impaired emotional or intellectual functioning, some forms of dementia in the elderly, depression, reporting being accident-prone or clumsy, daytime sleepiness or tiredness, and insomnia.

Some extraoral examination signs of possible airway obstruction may include a wide or large neck, upper body obesity, an elongated face, a narrow upper jaw, and/or a receding chin (retrognathic). Smokers tend to be a higher risk for having sleep apnea, and heavy smokers (more than two packs per day) have a 40 times greater risk of having the problem than nonsmokers.

The intraoral clues include an enlarged uvula and/or tonsils, a fatty tongue, and a crowded or abnormal airway.

What do you do if you see signs of sleep apnea in a patient? Middleton suggests you refer the patient to a sleep center program or to a physician. At most sleep centers, patients are offered full sleep studies, receiving an in-depth analysis of their sleeping patterns and problems. Overnight polysomnography uses various monitoring instruments (including electroencephalogram, electrocardiogram, electromyogram, and electrooculogram) to track patients as they pass (or fail to pass) through the various stages of sleep.

"Sleep centers can monitor the patient in a controlled environment," he said. "We can make sure the patient is properly wired and adjustments can be made if necessary during observation."

Home monitoring devices are not as reliable, Middleton claims, as a sleep center. "You can get improper wiring, inadequate recordings, interference from other power sources, and their accuracy in general is questionable."

When making a referral, Middleton suggests making sure the physician is a board certified sleep specialist, and the polysomnographer is a registered technologist. "Just like I like to know that the person working in my mouth is certified and licensed, make sure the clinic you refer to has the proper credentials," he said.

Treatment for sleep apnea depends on the severity of the problem. Treatment can be as simple as having patients sleep on their sides instead of their backs. If rolling onto their back is a problem, experts suggest sewing a pocket into the back of the pajamas and placing a tennis ball in it. Neck support pillows can help as can over-the-counter nasal strips, although they are reported to be better for stopping snoring than sleep apnea. If the patient smokes, here`s another good reason to quit. Experts do not recommend sleeping pills or tranquilizers. More severe cases can require the use of a device called a continuous positive airflow pressure (CPAP) machine, which supplies a pressurized stream of air into a plastic mask to keep tissues from collapsing.

Dental devices similar to a sports mouthguard also are available. They hold the tongue in position to keep the airway open. Another oral device forces the mandible forward to keep the airway open. Orthodontic treatment and orthognathic surgery can also be helpful.

Few drugs have been found to be effective with sleep apnea treatment. Some patients are purchasing the hormone melatonin at health food stores to help them sleep. Melatonin is naturally manufactured in the hypothalmus from tryptophan and it causes a drop in body temperature and sleepiness. The FDA says that products containing melatonin have not been tested or proven for safety or helpfulness in treating insomnia.

Sometimes surgery is indicated to increase the size of the airway. A procedure called uvulopalatopharyngoplasty removes soft tissue from the back of the throat and palate, but is recommended for only severe cases.

Unfortunately, even though sleep apnea is considered a serious problem and many treatment options are available, studies show that long-term compliance is low among patients because of the cumbersome masks or appliances. New methods of treatment are always being researched so that everyone in America can catch those needed ZZZZZZ?s.

Cathleen Terhune Alty, RDH, is a frequent contributor to RDH who is based in Clarkston, Michigan.

If counting sheep doesn`t work...

Sleep specialists provide these tips to help you reach dreamland:

- Avoid caffeine (including caffeine-containing drugs), nicotine, and alcohol for four to six hours before bedtime. The first two are stimulants that can make it difficult to sleep. And while alcohol may have a sedative effect at first, it tends to disturb sleep after several hours.

- Don`t exercise within four to six hours of bedtime. Working out earlier in the day not only doesn`t hinder sleep, it can actually improve it.

- Perform relaxing rituals before bed, such as taking a warm bath, listening to relaxing music, or eating a light snack.

- Before going to bed, strive to put your worries out of your mind and plan to address them at another time.

- Reserve your bed for sleeping. To preserve the association between bed and slumber, don`t watch TV or do work in bed.

- Go to bed only when sleepy. If you can`t fall asleep within 15 to 20 minutes, get out of bed and read a book or do another relaxing activity for awhile rather than trying harder to fall asleep.

- Make sure your bed is comfortable and the bedroom is conducive to restful sleep (quiet and at a comfortable temperature, for example).

- Wake up at the same time every day, even on weekends, to normalize the sleep-wake schedule.

- Don`t take naps, or nap during the mid-afternoon for no more than 20 minutes.

- From the Food and Drug Administration, "Tossing and Turning No More," July-August 1998 features/1998/498-sleep.html

A dental solutions to sleep apnea

Tymon Totte, DDS, who practices in Grosse Pointe Farms, Mich., fabricates appliances for his patients with snoring and/or sleep apnea symptoms. A specialist in rehab and prosthetic dentistry, he started researching the problem when diagnosed with sleep apnea several years ago. His snoring problem sent him to an ENT and a local sleep clinic, where he was tested and diagnosed with sleep apnea. When his research found that surgery and pressurized breathing apparatuses were not always effective in treating the problem because of patient compliance, he and a colleague set out to create an appliance that patients would find acceptable and be effective.

The appliance was a success. "We have found a 99 percent success rate for stopping snoring," Dr. Totte said. "We have a 90-95 percent effective rate for mild apnea, 80-85 percent success rate for moderate apnea and for severe apnea, well, it`s all over the place. Sometimes it makes it better and sometimes it makes it worse."

Dr. Totte has incorporated a "night time breathing" questionnaire in his office`s health history forms to help diagnose any problems in his patients. Using an scale, "never," "occasionally," "frequently," or "always," the form asks 30 questions such as:

- "Do you have difficulty breathing through your nose?"

- "Does your nose run when you don`t have a cold?"

- "Do you experience a dry mouth?"

- "Do you most often wake up feeling refreshed?"

Once the history is scored, if the patient has a high number they are a candidate for a polysonograph at a sleep laboratory.

Additional resources

American Sleep Disorders Association

1610 14th Street NW, Suite 300

Rochester, MN 55901

National Center On Sleep Disorders Research

NIH National Heart, Lung And Blood Institute

Two Rockledge Centre, Suite 7024

6701 Rockledge Drive (MSC7920)

Bethesda, MD 20892

(301) 435-0199

American Sleep Apnea Association

2025 Pennsylvania Ave NW

Washington, DC 20006

(202) 293-3650

The Well Connected

Nidus Information Services Inc.

41 East 11th St, 11th Floor

New York, NY 10003

The Food And Drug Administration

"Tossing and Turning No More" July-August 1998

FDA Consumer