Ask the Expert:
The Importance of Breathing Through Your Nose
by Tamra L. Neaugebauer, DDS

 

The Connection Between Good Oral Hygiene and Sleep

Noses are for breathing, mouths are for eating.  When I ask most of my patients whether they breathe through their nose I often get a resounding “Of course!”  When I investigate a little further into the patient’s oral health I find that many, if not most, are not breathing through their nose; rather, they are breathing through their mouth because of nasal obstruction.

As a dentist, I am fortunate to be in the position to help people improve and maintain their overall health by treating the root cause of health issues that I can identify by routine oral examinations.  When patients are evaluated with poor dental health it’s usually indicative of other underlying health issues rather than poor dental hygiene.  When I see decay, malocclusion (crooked teeth), gum recession, scalloped or coated tongue my first thought isn’t how often or long the patient brushes her teeth, but whether she is able to fall asleep, stay asleep, and wakes feeling refreshed.

The connection between good oral hygiene and sleep-related breathing disorders (SRBD) is one that is often underdiagnosed because until recently sleep evaluations tended to stay in the medical realm and physicians would not think to include the patient’s dentist in the treatment plan unless the physician wrote an order for the dentist to make an oral appliance to treat sleep apnea.  As the field of dentistry progressed over the last several decades, the dentist is now recognized as an integral part of coordinating treatment for SRBDs with medical physicians.

In 2017, the American Dental Association recognized the importance of the dentist’s role in identifying and treating SRBDs stating:

“The dentist’s role in the treatment of SRBD includes the following:

  • Dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, choking, snoring, or witnessed apneas and evaluation for risk factors such as obesity, retrognathia, or hypertension. If the risk for SRBD is determined, these patients should be referred, as needed, to the appropriate physicians for proper diagnosis.
  • In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development or other risk factors that may lead to airway issues. If the risk for SRBD is determined, intervention through medical/dental referral or evidenced-based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.
  • Oral appliance therapy is an appropriate treatment for mild and moderate sleep apnea, and for severe sleep apnea when a CPAP is not tolerated by the patient. When oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient with obstructive sleep apnea, a dentist should evaluate the patient for the appropriateness of fabricating a suitable oral appliance. If deemed appropriate, a dentist should fabricate an oral appliance.
  • Dentists treating SRBD should continually update their knowledge and training of dental sleep medicine with related continuing education. Dentists should maintain regular communications with the patient’s referring physician and other healthcare providers to the patient’s treatment progress and any recommended follow-up treatment. Follow-up sleep testing by a physician should be conducted to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities.”

 

Sleep apnea and Snoring

 Sleep apnea is a potentially serious sleep disorder in which a person’s breathing can start and stop repeatedly throughout the night.  Imagine trying to breathe with a bag over your head.  Sleep apnea can also cause decreased oxygen levels, similar to what happens to your body when you are at extremely high altitudes.  So not only are you trying to breathe with a bag over your head, but you are also trying to climb Mount Everest.  All of this happens during the period your body has designed to rest and heal itself.  It’s easy to see why the combination of stopping breathing and lowered oxygen can lead to hypertension, heart disease, and mood and memory problems.

There are two main types of sleep apnea:

  • Obstructive sleep apnea – blocked airflow during sleep usually occurring when the soft tissue at the back of the throat collapses blocking the airway. Health conditions such as obesity can be a contributing factor as well as diet, exercise, alcohol consumption, etc.
  • Central sleep apnea – this occurs when there is a problem with how the brain sends signals to the breathing muscles. The airway is not blocked; however, the brain fails to tell the appropriate muscles to breathe.

More than 18 million American adults are afflicted with sleep apnea.  Although sleep apnea can occur in men and women alike, there are several factors that increase the likelihood of sleep apnea:

  • Adults over 40 years old,
  • Being overweight,
  • Large tonsils, large tongue, small jaw,
  • Family history of sleep apnea; and
  • Any kind of nasal obstruction due to a deviated septum, allergies, or sinus problems.

If left untreated, sleep apnea can lead to high blood pressure, obesity, irregular heartbeat, strokes, heart attacks, depression, diabetes, and worsening of ADHD.

Sleep apnea is also common in children, with an estimated 10 to 20 of all children who snore.  It has been found that an estimated 70% of children who are diagnosed with ADHD have an SRBD.  Common signs that children have an SRBD include:

  • Trouble falling asleep
  • Trouble staying asleep
  • Trouble waking up in the morning
  • Waking up screaming or in a panic
  • Waking up coughing
  • Labored breathing or pauses in breathing during sleep
  • Strange noises during sleep
  • Irritability
  • Falling asleep in class
  • Distractibility and difficulty paying attention

 

The Connection Between OSA, Sleep Bruxism, and TMD

 Bruxism is a condition in which you grind, clench, or gnash your teeth.  There are two types of bruxism, awake bruxism and sleep bruxism.  Sleep bruxism is a reflex that occurs at night in response to a person’s airway collapsing.  The natural reflex of any mammal is to protect its airway and if there is a collapse of the airway during the night the reflexive nature will initiate clenching and grinding to produce an increase in airway.  Clenching of the jaw at night is many times more powerful than during the day because humans are unaware of the pressure exerted on the jaw joint (imagine biting down on a grain of sand – your brain will automatically stop you from biting with more pressure because it can sense the grain of sand, but when asleep you don’t have the same sensory perceptions).

This parafunctional (nighttime) activity is greater at night and will start to wear down the jaw joint (TMJ) as well as the muscles and structures attached to it.  This nocturnal activity will create structural changes to the skull, muscles, and nerves and will commonly lead to facial pain, headaches, migraines, and can lead to pain in other structures in the body.

Over time, evidence of sleep bruxism can be seen as abfractions, wearing of the teeth, gum recession, etc.  I often see a patient in my dental chair who has great dental hygiene but is continually breaking teeth or the gum line has started to recede.  It seems counterintuitive for the gums to recede as a result of the constant pressure exerted on the jaw throughout the night, and for a long time, it was thought that gum recession was due to excessive or hard brushing.  We now know that teeth will act similar to a post in the ground – when constant pressure is applied to the post it will create erosion at the base of the post where it is inserted into the ground.  This is an indicator to me that the patient’s airway is collapsing at night.

The patient is now on a “pain cycle” and will often feel pain in the morning and it will increase throughout the day.  When the patient tries to go to sleep at night, the pain is so stimulating she can either not fall asleep, or will wake up due to the pain stimulation.  This disrupts the patient’s sleep and her body does not receive the benefits of restful sleep (e.g. healing, memory retention, etc.).  In addition, when the human body does not go through the natural cycle of sleep it will produce cortisol, a hormone that increases weight gain and makes it difficult to lose weight.

Excessive clenching can affect the jaw joint (TMJ) in several ways.  The direct force that clenching applies to the TMJ can create structural changes and wear down the TMJ condyles and the articulator disc which is designed to absorb the impact of the TMJ.  When these structures are worn down it is painful for the patient to clench or grind, even swallowing can exacerbate the pain.  The articulator disc can become displaced causing the TMJ to be misaligned; this is commonly noted by patients as clicking or popping in the jaw as well being locked open or closed.  This is a critical point for rehabilitating the patients TMJ because once the patient becomes locked open or closed the efficacy of treatment is greatly reduced.

The long-held standard of practice for treating sleep bruxism was a single arch nightguard to protect the patient’s teeth from clenching and grinding at night.  Studies have shown that this single arch night guard approach actually increases apneic events in the apneic patient by up to 50% – 50% of the time.  In other words, using an oral device that is only one arch will increase the symptoms you are seeking to prevent.  This increase in apneic events pushes the moderate apneic into the severe apneic range and potentially places their lives at risk.

The answer is to use a two-component night guard that fits over the top and bottom arches which offers mandibular advancement to treat the collapsing airway.

Well Beyond Dental is the best Reno dentist for Sleep Disorder Therapy and TMJ Disorder Treatment. Contact us today to find out more!