Sleep and Dentistry

***Oregon Sleep Associates does not make oral appliances for sleep apnea in our office. We work with several dental clinics in the area and can refer patients to any one of them.***

SLEEP AND DENTISTRY - Dental Treatments for Sleep Disordered Breathing

For over twenty years positive airway pressure (PAP) therapy has been the gold standard treatment for obstructive sleep apnea. Although modern PAP machines are comfortable, quiet, and compact, not everyone can tolerate them.

What is the solution for those who cannot or will not use PAP?

“Oral appliances are not recommended for severe sleep apnea.”

One of the most common PAP alternatives for sleep-disordered breathing is called a mandibular re-positioning appliance [MRA), or oral appliance. These devices resemble orthodontic retainers and work by re-positioning the lower jaw forward during sleep, anchoring obstructive tissue out of the airway and preventing apneas. The devices usually have some sort of adjustment screw or tensioner that allows for minute advancements. A health professional performs these advancements over time until the breathing is corrected. The devices have been shown effective in treating some forms of sleep disordered breathing such as snoring and mild to moderate sleep apnea. Patients with severe sleep apnea might see a reduction in severity, but the problem is likely to remain. For this reason, oral appliances are not recommended for severe sleep apnea.

As Seen on TV

You may have seen the commercials on television for so-coiled "boil and bite" mouth guards that help to treat snoring. These devices are generally not beneficial. To be truly effective, oral appliance therapy must be custom fit to each patient and a qualified dentist must supervise the advancement of the device. Advancing the jaw too far forward too quickly, can lead to complications including temporomandibular joint (TMJ) pain.

It is important that there be an objective measurement of the treatment's efficacy after initiation. Patients may subjectively feel some relief after using an oral appliance, yet they can still have significant sleep disruptions. An overnight sleep study should be performed to confirm or refute the efficacy of the oral device. 

When correctly fit and titrated, oral appliances provide a convenient way of treating mild sleep disordered breathing. Alternatively, they may be used in conjunction with PAP therapy to allow for reduced pressures. Oregon Sleep Associates has longstanding relationships with several dental providers in the area who specialize in oral appliance therapy. If you are interested in an alternative to CPAP or are seeking treatment for the first time, contact our sleep specialists for more information at 503-288-5201.

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SLEEP DISORDERED BREATHING AND TMD

Obstructive sleep apnea (0SA) has been linked to multiple conditions including hypertension, cardiovascular disease, and type II diabetes. New evidence shows a correlation between OSA and temporomandibular disorder. 

The temporomandibular joint is the "hinge" that connects the lower jaw to the temporal bone of the skull. This joint is flexible, allowing for yawning, chewing, and talking. Temporomandibular disorder (TMD) is a painful condition characterized by tenderness in the face, jaw, neck and shoulders. The pain is often present in or around the ears when chewing, speaking, or opening the mouth. The condition afflicts between 5-12% of the population and may become debilitating enough to warrant surgical intervention in some cases.

Researchers from multiple universities recently conducted a study using the 5-year Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) cohort study of over 2600 adults ages 18-44 with temporomandibular disorder. The researchers identified participants as having a high likelihood for OSA if they reported a history of sleep apnea or had at least two of the following hallmarks of sleep apnea: loud snoring, daytime sleepiness, witnessed apneas, and hypertension.

The results suggest a strong correlation between sleep disordered breathing and TMD. "Men and women with two or more signs/symptoms of 0SA had a 73% greater incidence of first-onset TMD, in relative terms, than those with fewer signs/symptoms, independent of age, gender, race/ethnicity, obesity. smoking history, and autonomic parameters," the study authors explained. "The prospective cohort findings imply that OSA contributes to the onset of painful TMD symptoms."

If you experience jaw pain on a regular basis or have been diagnosed with TMD or TMJ problems, you may be at higher risk for having undiagnosed sleep apnea. Contact Oregon Sleep Associates at 503-288-5201 to schedule a consultation and get screened for the sleep disorders.

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BRUXISM MAY BE RELATED TO COMMON SLEEP DISORDER

The dentist has been telling you for years. Maybe you even use a night guard to protect your pearly whites. But new research indicates that teeth grinding, or bruxism, may be a sign of something more dangerous to your health.

Bruxism occurs in approximately 8% of the US population and is not considered a life threatening condition. It can cause excessive wear on the enamel surfaces of the teeth and is usually diagnosed by dentists. Many times a simple nighttime retainer or oral appliance is all that is needed to correct the problem. But researchers recently uncovered a connection between bruxism and obstructive sleep apnea. They found that nearly 25% of people with sleep apnea also grind their teeth at night. The connection may come from the frequent nocturnal arousals associated with sleep apnea. "The ending of on apneic event may be accompanied by a number of mouth phenomena, such as snoring, gasps, mumbles, and teeth grinding," said Dr. Shyom Subramanian of Baylor College of Medicine. The researchers also found that teeth grinding is most prevalent in Caucasian males and may also be related to anxiety and heavy caffeine use.

While having bruxism doesn’t guarantee you have obstructive sleep apnea. It may be prudent to watch for signs of the condition. Overly sensitive teeth, painful jaws, and inflammation in the mouth are all symptoms of bruxism. At your next dental visit, ask your dentist to check for signs of teeth grinding. They can tell you if there is damage to the enamel of your teeth and the best method to prevent it. Then, visit a sleep specialist to make sure you don't have an underlying sleep disorder such as sleep apnea.

For more information on Sleep Apnea or to contact a sleep specialist, visit our website at www.OregonSleepAssociates.com

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Sleep and Metabolism

SLEEP AND METABOLIC SYNDROME - How Sleep Disorders Increase Weight and Health Risks

In recent years, physicians and researchers have observed a growing percentage of the population afflicted with “Metabolic Syndrome”. The condition, which currently affects roughly 25% of the US adult population, refers to a group of risk factors that occur together and increase chances of coronary artery disease, stroke, type 2 diabetes, kidney disease, and early mortality. As more attention is given to ailment, its connections to sleep disorders are now being examined.

One of the greatest health risks to today’s population is obesity. Roughly one third of Americans are considered obese (Body Mass Index > 30) and that percentage is predicted to double by 2030. Obesity is the primary cause for development of metabolic syndrome and is also a primary risk factor for some sleep disorders. Sleep quality and quantity can greatly impact the elements that make up metabolic syndrome. Multiple studies have shown that obstructive sleep apnea, a condition in which a sleeping person’s airway collapses repeatedly and causes disrupted slumber, leads to increased insulin resistance, stroke, heart attacks, and may contribute to weight gain.

Chronically shortened sleep duration may also wreck havoc with metabolism. Adults who sleep less than 6 hours per night have a 45% higher chance of having metabolic syndrome and for each hour less of sleep there is a .35 increase in BMI. Those with shortened sleep also have increased levels of the hormone ghrelin, which stimulates appetite. Coupled with daytime fatigue and a sedentary lifestyle, these influences can lead to obesity and increase the possibility of developing metabolic syndrome.

Fortunately, reversing metabolic syndrome is possible through lifestyle changes and medical intervention. Weight loss and exercise can help curb its effects and medications can be used to control blood sugar levels and heart disease. Properly treating sleep disorders can have dramatic effects on health in general and correcting the sleep disruptions caused by OSA may help to lessen the risks that become categorized as metabolic syndrome. If you are overweight, you may be at risk for this disorder. Talk to your doctor to learn more about how to address the problem through a process of lifestyle changes and medical treatment. Contact Oregon Sleep Associates to get screened for sleep disorders as part of this process.

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LONG-TERM CPAP USE IMPROVES NEUROCOGNITIVE FUNCTION AND SLEEPINESS

Obstructive sleep apnea has been shown to affect both physical and mental functions in the body. OSA can cause excessive fatigue, memory loss, and hinder cognition. CPAP therapy, the most commonly used treatment for OSA, may reverse some of these problems.

CPAP works by providing the user with a constant flow of room air delivered via a facial mask. The air splints open the wearer’s airway using positive pressure, thereby eliminating nighttime airflow restrictions. In a recent 6-month long multicenter study, over 1500 participants were randomly given either real or sham CPAP to gauge the device’s effectiveness in reducing neurocognitive problems caused by sleep apnea. 

The participants in the study were tested using a variety of methods to assess three areas of cognition: attention and psychomotor function, learning and memory, and executive and frontal-lobe function. The results of the study showed “improvement in the most sensitive measures of executive and frontal-lobe function for those with severe disease, which suggests the existence of a complex OSA-neurocognitive relationship” The research also indicates that CPAP users benefit from “a significantly greater ability to remain awake whether measured subjectively or objectively” than non-CPAP users who suffer from sleep apnea. 

If you or a loved one has untreated sleep apnea, it could be affecting your memory, reasoning and daytime energy levels. Seeking treatment using CPAP therapy could greatly improve the way you think and feel. To get tested for sleep disorders, contact the sleep specialists at Oregon Sleep Associates at 503-288-5201 or visit www.oregonsleepassociates.com.

Sleep and Depression

Depression and sleep

You feel like there’s no reason to get out of bed anymore. What’s the point of all this? You can’t get out of this dark cloud. Why is this happening? Will it ever end?

Everyone has felt sad or unmotivated at times in their lives. But while feeling down occasionally is normal, long term depression is not. In the past few decades, depression has become one of the most commonly diagnosed conditions in the world. Approximately 16% of Americans will suffer from depression in their lifetimes. Its symptoms can vary from feeling sad and unmotivated to irritability, anxiety, and insomnia. It is not something people can simply “snap out of” or will away on their own.

There can be many causes for depression including chemical imbalances in the brain, traumatic experiences, or physical and psychological diseases. Treatments exist for all these conditions, but there is one area that of health that is often overlooked when addressing the root causes of depression: sleep disorders.

There are several sleep disorders which may cause depression-like symptoms. Trouble falling or staying asleep, called insomnia, is very common for people suffering from clinical depression. In fact, a study conducted in 2005 by the University of North Texas found that people who suffer from insomnia have a ten-fold risk of developing depression compared to those who sleep well. (SLEEP, Nov 2005) Like the proverbial chicken and the egg, it’s hard to pin down which came first. Does the insomnia result from the depression, or is the depression coming from the lack of sleep? When people are deprived of sleep they often exhibit symptoms such as irritability, hopelessness and sadness, confusion, and loss of libido and energy. These symptoms are also classically associated with depression. So if you are experiencing chronic insomnia, know that you are at high risk for developing depression as well. Moreover, if you are being treated for depression, talk to a sleep specialist about getting screened for a sleep disorder.

Another common sleep disorder which may lead to depression is obstructive sleep apnea. Sleep apnea is a condition that occurs when the muscles and tissue in a person’s airway collapse during sleep, causing sleep disruptions. These sleep disruptions may occur hundreds of times per night and result in similar symptoms as depression. Stanford University researchers found that people who suffer from depression are five times more likely to have sleep apnea than those without. A large scale study conducted by the Centers for Disease Control also recently found that “frequent snorting or stopping breathing was associated with probable major depression”. (SLEEP, April 2012) 

Fortunately, there is relief from depressive symptoms that doesn’t involve medications. The most effective treatment option for sleep apnea, continuous positive airway pressure (CPAP), was found to decrease depression symptoms by 94% after only 1 year of use. (AASM)

If you are feeling any of the symptoms of depression previously mentioned, tell your doctor. Make sure to bring up any sleep issues you may have and request a referral to a sleep specialist such as those at Oregon Sleep Associates. They can conduct simple tests to determine if your symptoms are indicative of a sleep disorder. Treatment of these disorders may actually help solve your depressive feelings and break out of the darkness.

Are sleeping pills deadly?

Hypnotics such as Ambien, Sonata, and Lunesta are among the most prescribed medications in the country. It was estimated that in 2010 alone, prescription drug companies made $5 billion selling these types of medications. Hypnotics are widely used to treat insomnia but a new study calls attention to the possible detrimental effects of these medications.

The study was carried out by researchers from the Scripps Clinic Viterbi Family Sleep Center and the Jackson Hole Center for Preventive Medicine and published in the peer-reviewed medical journal BMJ Open. The research consisted of a large cohort study comparing death and cancer rates between two groups of patients: hypnotics users and people who had never taken the medications.

Despite how it was commonly reported by mainstream media outlets, the results do imply that sleeping pills directly cause death or cancer. Rather they suggest there could be a correlation between the medication and increased risks. The basic results of the study suggest that patients prescribed any hypnotic had increased risk of dying compared with patients who had never been prescribed hypnotics. The risk of dying increased in line with the amount of hypnotics they were prescribed:

• Patients who were prescribed 1-18 pills of any hypnotic per year were 3.6 times more likely to die than matched patients not using the drugs.

• Patients who were prescribed 18-132 pills a year were almost 4.5 times more likely to die.

• Patients who were prescribed more than 132 pills a year were 5.3 times more likely to die.

It is important to stress this is only one study and is not indicative of a causal relationship between hypnotics and mortality. The results do support the idea that sleeping pills should be used only as temporary measure to address symptoms of insomnia, not as a long-term treatment. The medications are still a viable option when prescribed properly and used in conjunction with a comprehensive approach to treating sleep concerns. The sleep specialists at Oregon Sleep Associates use this approach to addressing your sleep issues. If you are having trouble sleeping, contact them today at 503-288-5201.

Rem behavior disorder diagnoses delayed

Screaming, running, fighting, kicking, dancing and driving. These are things we normally wouldn’t associate with sleep. But for some members of the population, activities such as these take place every night, all while asleep. They suffer from REM behavior disorder, a mysterious affliction that despite dramatic symptoms, tends to be under-diagnosed.

REM behavioral disorder, or RBD, is a sleep disorder in which a person physically acts out their dreams while in REM sleep. REM is rapid eye movement sleep, the stage in which the skeletal muscles of the body essentially shut down and the brain becomes very active. It is thought that most dreaming occurs during REM sleep and muscles may be deactivated to prevent these dreams from being acted out. But in some people, the system that “paralyzes” these muscles doesn’t always function correctly. In these cases, bizarre and sometimes dangerous behavior may occur. Some patients simply wander around completing tasks they would normally do while awake. Others however may experience more intense dreams and can be seen violently fighting off invisible foes, shouting, and even jumping out windows.

There are effective methods of treating RBD, but according to a recent study reported in the Journal of Clinical Sleep Medicine, many people do not seek treatment for the condition. In fact, patients wait on average nine years before seeking treatment. Reasons vary for the delay, with most people (59%) not thinking the symptoms were serious enough, some (56%) citing the behavior as infrequent, and others (47%) hoped the symptoms would go away or were not aware of the disease. Concerned or fed up bed partners were often responsible for spurring the decision to seek treatment.

Some may question why RBD patients should seek treatment if the behavior is infrequent or not of concern to the patient. However, RBD can become quite serious when the actions take on dangerous or violent aspects. Driving while sleeping can put many people’s lives at risk and patients have been known to be seriously injured or killed by acting out dreams. Early identification of the condition is also important because studies have shown that RBD may be a precursor to Parkinson’s Disease. A research project conducted through the University of Minnesota found that 38% of patients diagnosed as having RBD developed Parkinson’s or similar neurological disorders within 5 years of the study. Seven years later, the researchers looked at the same group and found that 65% had developed Parkinson’s Disease. (SLEEP 25,8)

Having RBD does not necessarily mean you will develop Parkinson’s. It is also important to note that sleepwalking and sleeptalking are not considered related to RBD. These instances are more common in the general population and usually occur during deep sleep stages, not REM. However, if you or anyone you know show symptoms of RBD such as acting out dreams on a regular basis, contact your doctor.

Dangers on the road for tired truck drivers

The backbone of our economic infrastructure is based on open access to readily available goods. To keep this system working properly, we rely upon an extensive network of freight transportation, including the trucking industry. In fact, trucking accounts for 70% of all freight transported annually in the U.S.,  $671 billion worth of manufactured and retail goods. Truckers work hard to stay on schedule, sometimes to the detriment of their health.

Drowsy driving is a constant danger for truck drivers. The long hours and monotonous routes lend themselves to fatigue. Coupled with a lack of exercise and unhealthy truck stop dining, the risk for both obesity and sleep related health risks is high. 

Truck drivers are not the best judges at diagnosing their own sleep apnea, a new study reports. Research showed that self-diagnosis and symptom reports fell far short of determining sleep apnea when compared to home testing. Only 4% of 517 commercial vehicle drivers in Australia reported an earlier diagnosis of sleep apnea. The study found another 41 percent when drivers were tested with home monitors.

Obstructive sleep apnea (OSA) has been associated with a higher risk of motor vehicle crashes. In December, the Federal Motor Carrier Safety Administration (FMCSA) announced new rules for the maximum hours of work per shift and mandatory rest periods for truck drivers. The FMCSA reduced by 12 hours the maximum number of hours a truck driver. Truck drivers also were mandated a break of at least 30 minutes after every eight hours worked.

The truckers in the Australian study worked an average of 65 hours a week. When surveyed, 40% of the drivers said they had trouble staying awake while driving in the last month. Of the commercial operators diagnosed with sleep apnea, less than half used continuous positive airway pressure (CPAP) therapy. CPAP is the first-line treatment for sleep apnea. The study appears in the April edition of the journal SLEEP.

Sleep Disordered Breathing

1 IN 4 PEOPLE AT HIGH RISK FOR SLEEP APNEA

A recent study conducted by the National Sleep Foundation concluded that 26% of the adult population has a high risk of having obstructive sleep apnea. 

This is significant because, at current adult population estimates of the United States, almost 60 million Americans are in this risk group. Also alarming is that only 10% of this number have been diagnosed with sleep apnea. Previously it had been accepted that only around 12 million Americans are affected. Other findings from the study suggest men have a higher risk for apnea, 31%, than women, 21%. 

Tired? It may be sleep apnea. New evidence shows it is more common than originally believed.

Obstructive sleep apnea (OSA) is a common medical condition which has been linked to an increased risk of hypertension, coronary vascular disease, congestive heart failure, cerebrovascular disease, glucose intolerance, impotence, and increased cardiovascular mortality. OSA occurs when the tissue at the back of a person’s throat relaxes and closes their airway during sleep. This leads to lowered blood oxygen levels and multiple awakenings. 

The study, which was published in the medical journal CHEST in June 2006, utilized the Berlin Sleep Questionnaire to predict the number of people surveyed who fell into the high risk category for sleep apnea. The Berlin questionnaire is a tool that estimates the likelihood of obstructive sleep apnea based on answers to specific questions. For more information on the Berlin questionnaire, please refer to page 2 of this publication. For more information about sleep disorders and what you can do if you think you have sleep apnea, visit our website at www.oregonsleepassociates.com.

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SLEEP APNEA DOUBLES RISK OF CAR CRASHES

Having sleep apnea significantly increases your chances of being involved in a car crash, Canadian researchers recently announced. As reported in May 2007 by Forbes.com, the University of British Columbia conducted a comparison over three years of 1600 people, half with sleep apnea, half without. Those with apnea had 250 crashes in that time frame while those without had only 123. Apnea patients also were three to five times more likely to be involved in serious crashes with personal injuries. "We were surprised not only about how many of the sleep apnea patients' crashes involved personal injury, but that some patients had fairly mild sleep apnea and were still having serious crashes," said study author Dr. Alan Mulgrew, of the University of British Columbia Sleep Disorders Program. 

If you feel tired at all when driving, pull over and take a rest. You could be saving your life and someone else’s. For more information and tips on staying awake, visit www.drowsydriving.org.

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PARENTS OUT OF TOUCH WITH KIDS’ SLEEP PATTERNS

According to the National Sleep Foundation’s 2006 Sleep in America poll of adolescents and parents, most parents in this country don’t know their children aren’t getting enough sleep. Adolescents from 6th through 12th grade participated in the study, and the results were surprising. On average, only 20% of children and teens get the amount of sleep they need on school nights. An estimated 45% of adolescents get an insufficient amount of sleep (7.5 hrs) and 31% are borderline (8 to less than 9 hrs). The recommended time is at least 9 hours.

Children and teens need at least 9 hours of sleep every night.

When researchers polled parents, they found 90% of them believed their children get
enough sleep on school nights. The disparity between the numbers shows that in general,
most parents are in the dark about their children’s sleep.

“Only 20% of children and teens get the recommended amount of sleep on school nights.”

There are many possible reasons for the lack of sufficient sleep in adolescents. Researchers point increased school workload, earlier wakeup times and commutes, and more access to electronics devices such as TV, cell phones, and computers. Sleep researchers also believe as children get older they continue to need plenty of sleep but often their circadian rhythm, or “biological clock,” shifts forward. Teenagers can often feel like they’re dragging in the morning but become increasingly energized as the day progresses. Unfortunately, this cycle can collide with school schedules. This means teens tend to get less sleep than younger children. The majority of them (58%) consider themselves night owls, forced into a system structured in a way that prevents them from getting enough rest time.

Some ways of helping kids get enough sleep include setting a definite bedtime, avoiding caffeine or stimulating activities like videogames or computer use close to bedtime, and not oversleeping too much on weekends which can further disrupt sleep cycles.

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WHAT IS THE BERLIN SLEEP QUESTIONNAIRE? 

The Berlin sleep questionnaire is a explorative tool medical professionals use to determine the likelihood patients will have a sleep disorder. The questionnaire was developed in 1996 and consists of three categories containing questions addressing common symptoms of obstructive sleep apnea. These include the frequency and intensity of snoring, risk factors such as high blood pressure and BMI, and excessive daytimes sleepiness. Each multiple choice answer is given a numerical value and the end total is calculated to determine whether the patient exhibits evidence of a possible sleep disorder.

When the healthcare worker reviews the results, they can decide whether there is sufficient cause to bring the patient for a sleep evaluation. While it doesn’t take the place of an overnight sleep study, the questionnaire has been found to be a valuable tool for predicting sleep apnea. If you would like to test yourself or someone else, you can get a copy of the Berlin sleep questionnaire and have your questions about sleep apnea answered by contacting Oregon Sleep Associates at [email protected].

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TIPS FOR A BETTER NIGHT'S SLEEP

Your sleep environment should be dark, quiet , comfortable, and cool.

Approximately 70 million people in the United States are affected by a sleep problem. About 40 million Americans suffer from chronic sleep disorders, and an additional 20 - 30 million are affected by intermittent sleep-related problems. However, an overwhelming majority of sleep disorders remain undiagnosed and untreated.

Sleep deprivation and sleep disorders are estimated to cost Americans over $100 billion annually in lost productivity, medical expenses, sick leave, and property and environmental damage.

According to NSF’s 2005 Sleep in America poll, while the majority of America’s adults do not use any type of sleep aid, 11 % said they used alcohol, beer or wine at least a few nights a month; 9% said they use over the counter remedies, and 7% use a prescription medication at least a few nights a month. However, there are ways that you can naturally change your behavior in order to get more sleep and to wake up feeling refreshed. If you are having problems sleeping, try to follow these healthy tips for better Sseep:

• Maintain a regular bed and wake time schedule including weekends.

• Establish a regular, relaxing bedtime routine such as soaking in a hot bath or hot tub and then reading a book or listening to soothing music.

• Create a sleep-conducive environment that is dark, quiet, comfortable and cool and sleep on a comfortable mattress and pillows.

• Use your bedroom only for sleep and sex. It is best to take work materials, computers and televisions out of the sleeping environment.

• Finish eating at least two to three hours before your regular bedtime and avoid caffeine, nicotine, and alcohol close to bedtime.

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MAJOR LINK FOUND BETWEEN APNEA AND HEART ATTACKS

Depending on its severity, sleep apnea can increase your risk of heart attack or death by 20-90% over 5 years.

Getting treated for obstructive sleep apnea may save your life. A recent study from Yale University demonstrated a strong link between obstructive sleep apnea (OSA) and cardiac events. The study compared two groups of subjects, those with sleep apnea and those without. After following the subjects for 5 years the researchers examined the rates of cardiac events including heart attacks, coronary angiography, bypass surgery, and death. The results are shocking, the average patient with sleep apnea has a 40% higher risk of a myocardial infarction or death than those without OSA.

The risk increases substantially with the severity of the apnea. Patients with only mild sleep apnea, defined by apnea-hypopnea index (AHI) of 5-14 breathing events per hour, have a 20% higher risk. Those with moderate apnea (AHI 15-30) have a 50% increase. Perhaps most startling, severe apnea (AHI >30) leads to a 90% increased risk for heart attack or death over 5 years.

The presenting doctor, Neomi A Shah MD, emphasized that the risk with OSA “is the same level as having had a heart attack in the past.” Based on these findings, it is very important that anyone who might have sleep apnea be treated as soon as possible to reduce their risk. For treatment options go to www.oregonsleepassociates.com.