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Obstructive sleep apnea affects around 20 million Americans and can lead to hypertension, heart attack, stroke, depression, muscle pain, fibromyalgia, morning headaches, and excessive daytime sleepiness.

Tuesday, November 30, 2010

Women and Sleep Apnea

Although men are more likely to suffer from sleep apnea, women can also suffer from this deadly condition. In fact, sleep apnea is likely underdiagnosed in women. While some sleep centers report seeing 8 or 9 men for every one woman, the actual proportion of sleep apnea sufferers who are women is more likely 33-45%. One reason why women may be underdiagnosed with sleep apnea is that men are more sound sleepers and may not notice disturbances in their partner's sleep. Also, because some physicians think of sleep apnea as a man's disease, women who report common sleep apnea symptoms (fatigue, daytime sleepiness, mood changes, waking with headaches), are often misdiagnosed with:

  • Anemia
  • Depression
  • Overwork or overstress
  • Fibromyalgia
  • Insomnia
  • Hypothyroidism
  • Menopausal changes or other hormonal conditions

Or they may be told they are hypochondriacs with nothing wrong. Overall, the main symptoms of sleep apnea were the same for men and women, but women were more likely to report morning headaches, while men were more likely to report dry mouth in the morning. Women with sleep apnea are more likely to have depression than men.

However, because sleep apnea is misdiagnosed or underdiagnosed in women, there is not enough data about the condition's different effects on men and women. However, what data there is suggests that the mortality rate for women for the dangers of sleep-apnea may actually be higher.

If you are a woman suffering from depression, daytime sleepiness, fatigue, or other conditions, you should consider the possibility that you have sleep apnea. To learn more, please contact a local sleep dentist today.

posted by Dr. Candelaria at 8:04 AM

Friday, November 26, 2010

Chronic Cough? Sleep apnea evaluation is probably indicated according to new article in Journal Cough.

A new article in the Journal Cough suggests that patients with chronic cough should be evaluated for obstructive sleep apnea (OSA). The article "Chronic cough and obstructive sleep apnea in a community-based pulmonary practice." details evaluation of 75 chronic cough patients. 38 of these patients were evaluated for OSA and 33 were positve for OSA. That translates into 44% of all patients had OSA. That also translates into over 86% of patients with a chronic cough were positive for sleep apnea. The authors also reported "93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough" which is an incredible relief. This is especially true since CPAP causes cough in some patients. The patients who did not get relief from CPAP should be evaluated on an oral appliance. Oral Appliances are better tolerated than CPAP by the majority of patients with obstructive sleep apnea.

The article Quantifying chronic cough: objective versus subjective measurements." from Respirology. 2010 Nov 5 discusses counting coughs and this approach could be used in patients to see if there is a circadian pattern to the coughs in apnea vs non-apnea patients. The authors stated "Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity" .

A major fault of the authors, Sundar KM, Daly SE, Pearce MJ, Alward WT was that they did not go back and evaluate the other 37 patients for sleep apnea. I assume that the other patients were not "typical" sleep apnea patients but many patients with sleep apnea do not fit the typical pattern of obese, thick neck and older male patient. If the 86% OSA figure was consistent throughout the Chronic cough population than perhaps chronic cough would be an absolute indication for sleep apnea testing.

Another interesting correlation would be to GERD (gastroesophageal reflux) and OSA which is a known risk factor for GERD. GERD accounted for 37% of cough population as a single etiology but GERD was also involved in multiple etiologies cough in 31 of the 75 patients. Multiple etiologies for the chronic cough included: GERD-upper airway cough syndrome (UACS), 31%, GERD-cough variant asthma (CVA), 5%, and GERD-UACS-CVA 3%

There is a commonality between cough, breathing, TMJ disorders and oral and pharyngeal reflexes. These reflexes that control breathing and pharyngeal structures are well described by A J Miller in "ORAL AND PHARYNGEAL REFLEXES IN THE MAMMALIAN NERVOUS SYSTEM: THEIR DIVERSE RANGE IN COMPLEXITY AND THE PIVOTAL ROLE OF THE TONGUE"

I have frequent references to his work in the www.ihateheadaches.org site and the www.ihatecpap.com site. These reflexes have direct effects on swallowing and breathing two essential functions of the jaws, tongue and oral cavity. Chronic misuse of these structures leads to repetitive strain injuries to the muscles and joints. These are frequently lumped into a junk diagnosis of TMJ, TMD, MPD, myofascial pain, Myofacial pain and are associated with sleep disorders, chronic pain, fibromyalgia and other central sensitization disorders involving the trigeminal nerve.

Cough. 2010 Apr 15;6(1):2.
Chronic cough and obstructive sleep apnea in a community-based pulmonary practice.
Sundar KM, Daly SE, Pearce MJ, Alward WT.

Intermountain Utah Valley Pulmonary Clinic, 1055N, 300W, Provo, UT 84604, USA. krishna.sundar@imail.org
Abstract
BACKGROUND: Recent reports suggest an association between unexplained chronic cough and obstructive sleep apnea (OSA). Current guidelines provide an empiric integrative approach to the management of chronic cough, particularly for etiologies of gastroesophageal reflux (GERD), upper airway cough syndrome (UACS) and cough variant asthma (CVA) but do not provide any recommendations regarding testing for OSA. This study was done to evaluate the prevalence of OSA in patients referred for chronic cough and examine the impact of treating OSA in resolution of chronic cough.

METHODS: A retrospective review of chronic cough patients seen over a four-year period in a community-based pulmonary practice was done. Patients with abnormal chest radiographs, abnormal pulmonary function tests, history of known parenchymal lung disease, and inadequate followup were excluded. Clinical data, treatments provided and degree of resolution of cough was evaluated based on chart review. Specifically, diagnostic testing for OSA and impact of management of OSA on chronic cough was assessed.

RESULTS: 75 patients with isolated chronic cough were identified. 44/75 had single etiologies for cough (GERD 37%, UACS 12%, CVA 8%). 31/75 had multiple etiologies for their chronic cough (GERD-UACS 31%, GERD-CVA 5%, UACS-CVA 3%, GERD-UACS-CVA 3%). 31% patients underwent further diagnostic testing to evaluate for UACS, GERD and CVA. Specific testing for OSA was carried out in 38/75 (51%) patients and 33/75 (44%) were found to have obstructive sleep apnea. 93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough.

CONCLUSIONS: OSA is a common finding in patients with chronic cough, even when another cause of cough has been identified. CPAP therapy in combination with other specific therapy for cough leads to a reduction in cough severity. Sleep apnea evaluation and therapy needs to considered early during the management of chronic cough and as a part of the diagnostic workup for chronic cough.

PMID: 20398333 [PubMed]PMCID: PMC2861010Free PMC Article

Respirology. 2010 Nov 5. doi: 10.1111/j.1440-1843.2010.01893.x. [Epub ahead of print]
Quantifying chronic cough: objective versus subjective measurements.
Faruqi S, Thompson R, Wright C, Sheedy W, Morice AH.

Division of Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, United Kingdom. HU16 5JQ.
Abstract
Background and objective: The assessment of chronic cough has been improved by the development of objective ambulatory cough monitoring systems and subjective quality of life questionnaires. Experimental induction of cough is a useful tool in the assessment of the cough reflex. We wanted to assess the reproducibility of and association between these measurements. Methods: This was a prospective observational study in patients with chronic cough of greater than six months duration. All patients had an initial 24 hour cough recording. They also completed a Leicester Cough Questionnaire, a Symptom Assessment Score, a Visual Analogue Score for cough and had a capsaicin cough challenge performed. They were reviewed at 8 weeks when all assessments were repeated. Results: The study included 25 patients (15 females) with a mean age of 54 years. The median cough count at the second visit (302) was significantly lower compared to the first visit (381, p<0.01). However the cough counts at both the visits correlated well (r=0.9. p<0.01).All the other forms of assessment were found to be highly reproducible at 8 weeks (r= 0.6-0.9, p<0.01). Cough counts correlated well with the other forms of assessment (r= 0.4-0.6, p<0.01). There was good correlation between each of the subjective forms of assessment (r= 0.6, p<0.01). Conclusions: The various forms of assessment of cough are reproducible. Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity. It appears to lie between these latter two assessments of cough and may represent the best global objective synthesis of cough.

© 2010 The Authors. Respirology © 2010 Asian Pacific Society of Respirology.
PMID: 21054670 [PubMed - as supplied by publisher]

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posted by Dr Shapira at 12:37 PM

Thursday, November 25, 2010

WHAT IS THE GOLD STANDARD OF TREATMENT FOR SLEEP APNEA?

THE QUESTION OF WHAT IS THE BEST SLEEP APNEA TREATMENT IS ACTUALLY A VERY POOR QUESTION. THE CORRECT QUESTION IS WHAT IS THE BEST SLEEP APNEA TREATMENT FOR A SPECIFIC PATIENT. Most patients prefer oral appliances to CPAP.

CPAP or Continuous Positive Air Pressure has long been considered the "Gold Standard" for treating sleep apnea. It is extremely effective when patients use it but patient compliance has always been a major problem It is interesting that the NHLBI lists oral appliances before CPAP. (See website info below) but also says that oral appliances are for mild apnea and snoring while it has now been shown that when properly titrated Oral Appliances are equally effective to CPAP for treating mild to moderate sleep apnea. Oral Appliances are also considered to be an alternative to CPAP when it is not tolerated.

The NHLBI website states
"The goals of treating sleep apnea are to:
Restore regular breathing during sleep
Relieve symptoms such as loud snoring and daytime sleepiness
Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes."

Approximately one in four CPAP users actually meet those goals. Those patients generally adapt easily to CPAP and rarely go without using it. 60% of patients abandon CPAP entirely and 15% struggle with it and use it in less that effective manner. It is the 75% that are not adequately treated with CPAP that usually utilize oral appliances or surgery. Oral Appliances are also not tolerated by everyone and patients need significant numbers of teeth or implants to use many types of appliances. While most patients prefer oral appliances to CPAP there are some patients who do not tolerate appliances and must seek alternative treatments.

This Goal statement is a very interesting statement. Is use of CPAP a restoration of "Normal Breathing" or "Regular Breathing" ? I would propose that an effectively titrated oral appliance actually restores both regular and normal breathing. CPAP breathing is not "normal" trhough it may be regular. BiPAP breathing is probably closer to "normal" breathing.

Secondly treatment should relieve snoring and daytime sleepiness. Daytime sleepiness is an interesting aspect as it can be measured subjectively (patient opinion) or objectively by MSLT (multiple sleep latency test) or MWT (Maintenance of Wakefulness Test)

Patients utilizing oral appliances frequently report being more rested with an oral appliance than when treated with CPAP even when the CPAP machine gave more complete resolution of AHI. This may be a difference between regular and normal breathing.

The statement "Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes" is extremely important. Treatment of sleep apnea has numerous health benefits. These benefits are achieved with CPAP, Surgery and Oral Appliances.

The NHLBI site also discusses that some patients may benefit from surgery. It is important to note that the surgery must meet the goals stated. Soft palate surgery does not restore regular breathing and should be cosidered adjunctive surgery not curative surgery.


THE FOLLOWING INFORMATION IS TAKEN FROM THE NATIONAL HEART LUNG AND BLOOD INSTITUTE WEBSITE http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html

How Is Sleep Apnea Treated?

Lifestyle changes, mouthpieces, breathing devices, and surgery are used to treat sleep apnea. Medicines typically aren't used to treat the condition.

The goals of treating sleep apnea are to:

Restore regular breathing during sleep
Relieve symptoms such as loud snoring and daytime sleepiness
Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes.

If you have sleep apnea, talk with your doctor or sleep specialist about the treatment options that will work best for you.

Lifestyle changes and/or mouthpieces may be enough to relieve mild sleep apnea. People who have moderate or severe sleep apnea may need breathing devices or surgery.

If you continue to have daytime sleepiness despite treatment, your doctor may ask whether you're getting enough sleep. (Adults should get at least 7 to 8 hours of sleep; children and adolescents need more.)

If treatment and enough sleep don't relieve your daytime sleepiness, your doctor will consider other treatment options.

Lifestyle Changes

If you have mild sleep apnea, some changes in daily activities or habits may be all the treatment you need.

Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep.
Lose weight if you're overweight or obese. Even a little weight loss can improve your symptoms.
Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
Keep your nasal passages open at night with nasal sprays or allergy medicines, if needed. Talk with your doctor about whether these treatments might help you.
If you smoke, quit. Talk with your doctor about programs and products that can help you quit smoking.
Mouthpieces

A mouthpiece, sometimes called an oral appliance, may help some people who have mild sleep apnea. Your doctor also may recommend a mouthpiece if you snore loudly but don't have sleep apnea.

A dentist or orthodontist can make a custom-fit plastic mouthpiece for treating sleep apnea. (An orthodontist specializes in correcting teeth or jaw problems.) The mouthpiece will adjust your lower jaw and your tongue to help keep your airways open while you sleep.

If you use a mouthpiece, tell your doctor if you have discomfort or pain while using the device. You may need periodic office visits so your doctor can adjust your mouthpiece to fit better.

Breathing Devices

CPAP (continuous positive airway pressure) is the most common treatment for moderate to severe sleep apnea in adults. A CPAP machine uses a mask that fits over your mouth and nose, or just over your nose. The machine gently blows air into your throat.

The air presses on the wall of your airway. The air pressure is adjusted so that it's just enough to stop the airways from becoming narrowed or blocked during sleep.

Treating sleep apnea may help you stop snoring. But not snoring doesn't mean that you no longer have sleep apnea or can stop using CPAP. Sleep apnea will return if CPAP is stopped or not used correctly.

Usually, a technician will come to your home to bring the CPAP equipment. The technician will set up the CPAP machine and adjust it based on your doctor's prescription. After the initial setup, you may need to have the CPAP adjusted on occasion for the best results.

CPAP treatment may cause side effects in some people. These side effects include a dry or stuffy nose, irritated skin on your face, dry mouth, and headaches. If your CPAP isn't adjusted properly, you may get stomach bloating and discomfort while wearing the mask.

If you're having trouble with CPAP side effects, work with your sleep specialist, his or her nursing staff, and the CPAP technician. Together, you can take steps to reduce these side effects. These steps include adjusting the CPAP settings or the size/fit of the mask, or adding moisture to the air as it flows through the mask. A nasal spray may relieve a dry, stuffy, or runny nose.

There are many types of CPAP machines and masks. Tell your doctor if you're not happy with the type you're using. He or she may suggest switching to a different type that may work better for you.

People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP.

Surgery

Some people who have sleep apnea may benefit from surgery. The type of surgery and how well it works depend on the cause of the sleep apnea.

Surgery is done to widen breathing passages. It usually involves shrinking, stiffening, or removing excess tissue in the mouth and throat or resetting the lower jaw.

Surgery to shrink or stiffen excess tissue in the mouth or throat is done in a doctor's office or a hospital. Shrinking tissue may involve small shots or other treatments to the tissue. A series of such treatments may be needed to shrink the excess tissue. To stiffen excess tissue, the doctor makes a small cut in the tissue and inserts a small piece of stiff plastic.

Surgery to remove excess tissue is done in a hospital. You're given medicine that makes you sleep during the surgery. After surgery, you may have throat pain that lasts for 1 to 2 weeks.

Surgery to remove the tonsils, if they're blocking the airway, may be very helpful for some children. Your child's doctor may suggest waiting some time to see whether these tissues shrink on their own. This is common as small children grow.

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posted by Dr Shapira at 2:51 AM

Somnomed Appliance Caused Patient To Develop "TMJ"

JEFF: I have an oral device (sonomed) for sleep apnea. It gave me TMJ. I haven't been able to tolerate cpap.


Dr Shapira: YOU STATE THAT YOU HAVE A SOMNOMED TO TREAT SLEEP APNEA BECAUSE YOU CANNOT TOLERATE CPAP.
It is excellent that you have chosen to treat the sleep apnea which can cause heart attacks, strokes, memory loss and excessive daytime sleepiness.

YOU THEN STATE THAT YOU DEVELOPED TMJ BUT GAVE NO SPECIFICS AS TO SYMPTOMS. TMJ STANDS FOR TEMPOROMANDIBULAR JOINT, NOT A DISEASE. It is important to understand the SPECIFIC problems so they can be addressed. Patients wearing oral appliances for sleep apnea may experience bite changes or tooth movement but damage should not occur to the joints. It is essential to work with a dentist who has training in treating sleep apnea and TMJ disorders.

ACCORDING TO THE NHLBI SLEEP APNEA IS A TMJ DISORDER. SEE http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf You have actually developed a new symptom from the same disorder but because you didn't specify symptoms I can not specify what to do next.

The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances should be well trained in treating TMJ disorders.

IF YOU CAN GIVE ME SPECIFIC INFORMATION I MAY BE OF MORE HELP. Please review www.ihateheadaches.org to learn about Neuromuscular Treatment of TMJ Disorders, headaches and migraines.

The following is the result of a web form submission from:
comments: I have an oral device (sonomed) for sleep apnea. It gave me TMJ
I haven't been able to tolerate cpap

THIS IS A RECENT NEW POST; I also got tmj from sonomed sleep appliance / it was pulling my jaw forward too much. It clicks when i chew and my ear feels like watery.

DR SHAPIRA RESPONSE: THESE PROBLEMS ARE USUALLLY EASY TO PREVENT OR CORRECT BUT YOU MUST BE PROCACTIVE FROM THE START OF APPLIANCE USE

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posted by Dr Shapira at 1:27 AM

Monday, November 22, 2010

CPAP Machines Cause Facial Changes

According to research published in the October Issue of the journal Chest, wearing a CPAP mask can change the shape of your face. Researchers in Japan and Canada x-rayed 46 patients (41 men and 5 women, average age56) who were using CPAP machines for treatment of sleep apnea. X-rays were taken before patients started using the machine and after they had used the machine for at least two years (on average 35 months). Although previous research had shown that these changes occurred in children, this is the first time evidence of changes in facial physiognomy have been linked to CPAP use.

According to researchers, the people who used the CPAP machine experienced significant changes in the shape of their dental arches, as well as changes in the relationship between their upper and lower jaws. Several variables contributed to the overall shift of the jaw backward. Although the patients did not self-report the changes in their face shape, the researchers expressed concern at the trend in the changes.

The concern is that by pushing the jaw backward, CPAP may worsen obstructive sleep apnea in the long term. A recessed jaw reduces space for the tongue and may make the tissues of the airway more likely to collapse.

An alternative to CPAP is oral appliance therapy, which works by moving the jaw forward to help keep the airway open. Oral appliances have not been shown to alter the shape of the face or dental arches.

To learn more about sleep apnea treatment options, please talk to a local sleep dentist today.

posted by Dr. Candelaria at 3:20 PM

Saturday, November 20, 2010

Oral APPLIANCES AND NASAL CPAP ARE EQUAL IN EFFECTIVENESS ACCORDING TO NEW ARTICLE IN RESPIRATION.

A recent article " Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial" in Respiration compared oral appliance therapy and nasal CPAP therapy in treating mild to moderate sleep apnea. The article looked at carefully controlled studies in which both the CPAP and the oral appliances were carefully titrated. The article concluded that "There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively."

It is important to note that the article clearly states that treatment is equal when there is objective titration of the oral appliances. I have strongly been recommending titration on all oral appliance therapy for over ten years. This is trtuly a landmark study because while CPAP has always been considered "the gold standard for treatment of sleep apnea" that statement is no longer true for mild to moderate sleep apnea.

This study did not cover severe sleep apnea therefore CPAP is still considered the gold standard of treatment for severe sleep apnea and oral appliances are an alternative for patients who do not tolerate CPAP.

The major problem with CPAP has always been low compliance. A recent study showed 60% of patients do not tolerate CPAP treatment. If compliance is factored in then it is clear that oral appliances are now the "Gold Standard" of treatment for mild to moderate sleep apnea.



PubMed abstract:
Respiration. 2010 Oct 20. [Epub ahead of print]ral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial.
Aarab G, Lobbezoo F, Hamburger HL, Naeije M.

Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, Research Institute MOVE, University of Amsterdam and VU University Amsterdam, The Netherlands.
Abstract
Background: Previous randomized controlled trials have addressed the efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA). Their common control condition, nasal continuous positive airway pressure (nCPAP), was frequently found to be superior to MAD therapy. However, in most of these studies, only nCPAP was titrated objectively but not MAD. To enable an unbiased comparison between both treatment modalities, the MAD should be titrated objectively as well. Objective: The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device. Methods: Sixty-four mild/moderate patients with obstructive sleep apnea (OSA; 52.0 ± 9.6 years) were randomly assigned to three parallel groups: MAD, nCPAP and placebo device. From all patients, two polysomnographic recordings were obtained at the hospital: one before treatment and one after approximately 6 months of treatment. Results: The change in the apnea-hypopnea index (ΔAHI) between baseline and therapy evaluation differed significantly between the three therapy groups (ANCOVA; p = 0.000). No differences in the ΔAHI were found between the MAD and nCPAP therapy (p = 0.092), whereas the changes in AHI in these groups were significantly larger than those in the placebo group (p = 0.000 and 0.002, respectively). Conclusion: There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.

Copyright © 2010 S. Karger AG, Basel.
PMID: 20962502 [PubMed - as supplied by publisher]

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posted by Dr Shapira at 8:11 AM

Friday, November 19, 2010

Did Sleep Apnea Cause the Death of State Representative Donatucci?


 

In the debate about whether CPAP or oral appliances are a better treatment for sleep apnea, sometimes there comes along an opportunity that is too good to miss. Consider, for example, the recent story of the Pennsylvania state representative who died of sleep apnea because the CPAP mask was too uncomfortable to wear.

Or did he? According to reputable sources, the actual cause of Rep. Donatucci's death is currently unknown, but because of its association with sleep apnea and CPAP, the forces of oral appliances have taken up the cause to promote his death as evidence that sleep apnea, and by extension ineffective treatments like CPAP, kills. However, it is unclear that this is the story at all.

Rep. Robert C. Donatucci was a Philadelphia democrat who was overweight and, it seems, had been positively diagnosed with sleep apnea the week before his death. He had been encouraged to try sleep apnea treatment with CPAP, but found the mask too uncomfortable. Instead, he planned to lose weight and try other lifestyle changes to treat his condition. Unfortunately, he died before he was able to lose his weight.

This leads us to two questions: Does sleep apnea kill? And Did sleep apnea kill Rep. Donatucci?

The answer to the first question is yes, although not acutely. Sleep apnea causes physical and psychological problems that increase your risk of all-cause mortality sixfold, according to at least one study. Death could be caused by heart attack, stroke, or other cardiovascular damage related to sleep apnea. Or it could be caused by a car crash, whose risks are increased by the daytime sleepiness that sleep apnea causes.

The answer to the second question is a little harder to come by. We do not have access to the full amount of information we need to answer it. However, it is likely that sleep apnea contributed to the representative's death.

If a person dies only one week after being diagnosed with sleep apnea, it is unlikely that any treatment method could save his or her life. This stresses again the need to undergo a sleep study if you have any of the known risk factors for sleep apnea, including being overweight, snoring, or having daytime sleepiness.

To learn more about sleep apnea diagnosis, please contact a local sleep dentist and head off the dangers before they become irreversible.

posted by Dr. Candelaria at 2:53 PM

Friday, November 12, 2010

Specific Areas of Brain Damage Associated with Sleep Apnea

Italian researchers have identified several regions in the brain that suffer damage as a result of obstructive sleep apnea. They also found that these regions responded to treatment with significant structural recovery.

The researchers matched 17 sleep apnea sufferers with 15 age-matched healthy individuals. All subjects underwent a sleep study, took cognitive tests, and underwent magnetic resonance imaging. Then the sleep apnea sufferers began treatment. Three months later, the tests were repeated.

Initially, the sleep apnea sufferers showed impairment in most cognitive areas, as well as their mood. Many reported sleepiness. They also showed focal reductions in brain matter in the enthorhinal cortex, the left posterior parietal cortex, and the right superior frontal gyrus. The Enthorhinal cortex plays an important role in memory, especially biographical memory. The posterior parietal cortex controls voluntary movements. The superior frontal gyrus has been shown to be involved in self-awareness, mood, laughter, spatial cognition, and working memory. Identifying these damaged regions provides important insight into the mechanisms of sleep apnea's dangers. It shows, too, that there are other potential risks that cannot objectively be measured. With sleep apnea, you may be at risk for losing important parts of your identity and self-awareness.

Fortunately, the researchers also found that treatment of sleep apnea could reverse the damage suffered in these specific regions of the brain. Although the researchers used CPAP as the treatment method, it is likely that other adequate treatment methods like oral appliance therapy could lead to similar reverses.

If you are a sleep apnea sufferer, don't put your life and your personality at risk, get treatment today. To learn more about sleep apnea treatment options, please contact a local sleep dentist today.

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posted by Dr. Candelaria at 2:30 PM

Monday, November 8, 2010

Did use of headgear cause sleep apnea problem?

Robert: As a kid, I had to wear head gear to pull my lower jaw back to help correct a slight under bite. Could this adjustment of my mouth/jaw be a factor in my sleep apena.

Dr Shapira response: It is quite possible that the headgear made you more likely to have sleep apnea. What is probably more important was the opportunity to increase your airway during ortho tx.

Orthodontics can ce a complete of partial sleep apnea cure or a major complicating factor.

When orthodontic widening is done at a young age it widens the palate and the floor of the nose. It is recommended that pediatric patients with sleep apnea should have obstructive tonsils and adenoids removed. It is also recommended that a followup sleep study always be done to evaluate residual disease. The majority of patients may benefit from maxillary widening as well.

Some top researchers are recommending that orthodontic widening precede T & A removal to lessen surgical complications and risks.

Treatment of sleep apnea with an oral appliance advances the mandible at night but those changes can become permenant. CPAP tend to act like a Headgear causing backward movement of the maxilla and upper teeth.

All parents contemplating orthodontics for their children should work with growth and development orthodontists who understandf airway and sleep apnea. The outmoded practice of removing permenant bicuspid can produce an orthopedic position more prone to sleep apnea.

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posted by Dr Shapira at 6:43 PM

Sunday, November 7, 2010

Can Carbon Dioxide help treat central and mixed sleep apnea? Should CO2 be added to CPAP Flow to Treat Central Sleep Apnea & Cheyne-Stokes Breathing?

Patients with central and mixed sleep apnea are different than obstructive sleep apnea patients. There has been work done with increased dead space in CPAP units and addition or carbon dioxide to treat central sleep apnea and Cheye-Stokes breathing. It is actually a build-up in CO2 that cause awakening and breathing in all apnea patients.

If Carbon Dioxide can be judiciously supplied to these patients it could solve the problems of central sleep apnea and emerging central apnea in patients treated with CPAP or Oral Appliances.

It may also explain why appliances like the TAP that limit opening seem more effective in some patients than Herbsts, Suad,, or Somnomed appliances. Appliances that allow easier oral opening and breating are more likely to have decreased CO2 levels.

Remember, it is the rise in CO2 (carbon dioxide) that turns on the drive to breathe.

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posted by Dr Shapira at 1:05 PM

Sleep Apnea Treatment in Children improves Performance and Behavior. Treacher-Collins syndrome is discussed in Cleft Palate Journal

I recently came across an older article on sleep apnea and Treacher-Collins syndrome. The article describes improvements in Behavior and performance after correction of micrognathia. What is startling is that the article was published almost 30 years ago long before most physicians worried about pediatric sleep apnea. We now know that 80% of ADD and ADHD children have sleep apnea. Scalloped tongues are indicative (80% predictive) of sleep apnea.

We now know that all snoring and even the mildest sleep apnea can never be ignored in children. It is a shame how many years were wasted with children waiting to outgrow tonsils or adenoids. If you read the story of my son on the main website I had to fight to have his airway corrected. Even seeking a sleep study was considered for Billy was considered crazy. Now it appears the literature supported treating airway obstructions in children several years prior to my experiences.

I have to wonder what other advances are being ignored or just unknown despite published literature.

I know that headache and pain treatment is currently grossly undertreated by neuromuscular dentistry despite the research and case studies. See http://www.ihateheadaches.org


Cleft Palate J. 1981 Jan;18(1):39-44.
Obstructive sleep apnea in Treacher-Collins syndrome.
Johnston C, Taussig LM, Koopmann C, Smith P, Bjelland J.

Abstract
Studies of the Treacher-Collins syndrome have emphasized hearing and surgical considerations. Although craniofacial anomalies have been associated with respiratory disorders in infancy, the presence of such problems in older children has not been emphasized. An eight-year-old with Treacher-Collins syndrome presented a history of recent behavioral problems at home, poor attention span and performance in school, daytime somnolence, and sleep apnea with relatively long periods of chest movement but no airflow. He also had abnormal sleep behavior consisting of rocking to and fro on his hands and knees, often to such an extent that his nose became abraded. ICU monitoring with observation and recording of sleep patterns and sounds, and fluoroscopy of his upper airway utilizing cineradiography while asleep confirmed the diagnosis of obstructive sleep apnea. The patient subsequently underwent an orthognathic surgery consisting of insertion of rib bone grafts after anterior advancement of his mandible. This procedure resulted in disappearance of the obstructive sleep apnea and associated symptoms. Because of micrognathia, patients with Treacher-Collins syndrome are at high risk for developing obstructive sleep apnea. Surgical correction of their deformities can result in improvement in cosmetic appearance as well as in resolution of the obstructive episodes with improvement in performance and behavior.

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posted by Dr Shapira at 12:49 PM

Saturday, November 6, 2010

CPAP USE CAUSES SIGNIFICANT CHANGES IN POSITION OF BONES OF FACE AND TEETH. THESE CHANGES MAY CAUSE TMJ DISORDERS OR SMASHED FACES.

A new study in Chest shows significant changes in bone and teeth positio secondary to CPAP use. The changes are retropositioning of the upper maxillary teeth and the bones of the face. Smashed Face Syndrome resulting from long term CPAP use could have negative consequences of a cosmetic and physiologic nature.

It is important to note that treatment of sleep apnea is essential and that CPAP and Oral Appliances the only First Line treatments can cause changes. These changes should not be considered a reason to discontinue life-saving treatment with either modality.

The changes that occur with Oral Appliance treatment are not the same as changes that occur with CPAP use. There are ominous problems that could be associated with the CPAP specific changes. These changes could cause worsening of Sleep Apnea if CPAP use is discontinued and even lead to an addiction to CPAP. I have discussed problems with "CPAP Addiction" with Dr Alex Golbin a prominent sleep physician and pioneer of the field of Sleep Medicine.

The change that occured with use of CPAP include "Significant retrusion of the anterior maxilla, a decrease in maxillary-mandibular discrepancy, a setback of the supramentale and chin positions, a retroclination of maxillary incisors, and a decrease of convexity" These findings were visible on cephalometric radiographs but were not reported by patients. All of these changes have the potential to cause TMJ problems, tension headaches and migraines. The changes CPAP cause will lead to retropositioning of the mandible. The changes caused by oral appliances are anterior positioning of the mandible. Studies have shown that these changes do not adversly affect the TM Joints (TMJ). In fact these are the same changes that take place when treating TMJ disorders with a neuromuscular orthotic. Part of the effect of neuromuscular treatment of headaches and migraines (see www.ihateheadaches.org) is thought to be do to improvements in airway and quality of sleep.

Dentists routinely explain to their patients that oral appliances can change bites and move teeth as part of their informed consent for treatment.

The responsibility for informing patients of negative orthopedic changes from CPAP falls on the prescribing physicians and on CPAP manufacturers. The FDA should make device manufcturers include information on this subject in their materials.

Chest. 2010 Oct;138(4):870-4. Epub 2010 Jul 8.
Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea.
Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA.

Department of Oral Health Sciences, The University of British Columbia, Vancouver, BC, Canada. htsuda@dent.kyushu-u.ac.jp
Abstract
BACKGROUND: Many patients with obstructive sleep apnea (OSA) use nasal continuous positive airway pressure (nCPAP) as a first-line therapy. Previous studies have reported midfacial hypoplasia in children using nCPAP. The aim of this study is to assess the craniofacial changes in adult subjects with OSA after nCPAP use.

METHODS: Forty-six Japanese subjects who used nCPAP for a minimum of 2 years had both a baseline and a follow-up cephalometric radiograph taken. These two radiographs were analyzed, and changes in craniofacial structures were assessed. The cephalometric measurements evaluated were related to face height, interarch relationship, and tooth position.

RESULTS: Most of the patients with OSA were men (89.1%), and the mean baseline values for age, BMI, and apnea-hypopnea index (AHI) were 56.3 ± 13.4 years, 26.8 ± 5.6 kg/m(2), and 42.0 ± 18.6/h. The average duration of nCPAP use was 35.0 ± 6.7 months. After nCPAP use, cephalometric variables demonstrated a significant retrusion of the anterior maxilla, a decrease in maxillary-mandibular discrepancy, a setback of the supramentale and chin positions, a retroclination of maxillary incisors, and a decrease of convexity. However, significant correlations between the craniofacial changes, demographic variables, or the duration of nCPAP use could not be identified. None of the patients self-reported any permanent change of occlusion or facial profile.

CONCLUSION: The use of an nCPAP machine for > 2 years may change craniofacial form by reducing maxillary and mandibular prominence and/or by altering the relationship between the dental arches.

PMID: 20616213 [PubMed - indexed for MEDLINE]

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posted by Dr Shapira at 6:11 AM

Friday, November 5, 2010

Sleep Apnea Elevated in Veterans with PTSD

We know that sleep apnea is commonly correlated with mental health disorders, but until now it was unknown just how strongly the disorder was correlated with post-traumatic stress disorder (PTSD). However, a recent study, conducted by researchers at the Walter Reed Army Medical Center, shows just how close the connection is.

According to the study, 54% of PTSD patients had obstructive sleep apnea, far above the normal population rate of approximately 20%. Furthermore, although the patients were on average slightly overweight (28.91 average BMI), the difference between PTSD patients and the general population was still statistically significant. Also statistically significant was the relative youth of the population compared to the typical age of sleep apnea sufferers. Sleep apnea has been known to be associated with traumatic brain injury, but surprisingly in this population the OSA sufferers were less likely to have traumatic brain injury than the non-sufferers.

One contributing factor was the use of painkillers and sedatives among the veterans with PTSD. But this was not statistically significant.

The study authors noted that one challenge for treating sleep apnea in this group was that compliance with CPAP therapy was potentially even lower than in the general population.

If you are suffering from mild to moderate sleep apnea, there is a more comfortable and easier treatment option. Oral appliance therapy is a treatment option for many obstructive sleep apnea patients. To learn more about sleep apnea and its treatment option, contact a local sleep dentist today.

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posted by Dr. Candelaria at 3:33 PM

Thursday, November 4, 2010

Inland Empire Sleep Solutions offers alternatives to CPAP for Patients in Washington State and Idaho. Live a Better Life Through Sleep!

Reprinted information from 24/7 Press Release
Inland Empire Sleep Solutions: The Best Sleep Apnea Treatment: CPAP vs. Oral Appliances. A Question of Compliance and Effectiveness. Oral Appliances Win the Compliance Award. Snoring Can Be Cured!

CPAP is considered the gold standard for sleep apnea treatment but poor compliance issues with CPAP often make oral appliances the best sleep apnea treatment. For the morbidly obese patient, CPAP is the best first line treatment.

What is the best sleep apnea treatment? It is not CPAP, according to a recent study that showed 60% of patients abandon CPAP use. At least it is not the best treatment for the 60% of patients who abandoned it. This does not mean CPAP is not the most effective treatment, what it means is no matter how effective a treatment may be, it is a poor treatment if it is not used. Oral appliances are an extremely effective treatment for mild to moderate sleep apnea but less effective for morbidly obese patients and those with severe sleep apnea.

Oral appliances are the "Best Sleep Apnea Treatment" because patients actually use them. Compliance issues have always been the biggest problem with CPAP. Studies have shown most patients quit CPAP completely but even patients who use CPAP average only 4-5 hours/ night 4-5 nights a week. That is not the best treatment but it is better than no treatment. The best site for information on oral appliance therapy and dental sleep medicine is http://www.ihatecpap.com.

Dr Ira L Shapira is a Diplomate of the American Board of Dental Sleep Medicine. He is the president of I HATE CPAP LLC. He is proud to announce a new resource for Washington State and Idaho to help patients with sleep apnea and snoring find solutions. Inland Empire Sleep Solutions http://www.inlandempiresleepsolutions.com/ is bringing the best information on Sleep Apnea Treatment to the Inland Empire region.

Medicare recognized how poor CPAP compliance was and now has minimum usage schedules for CPAP that will save Medicare millions of dollars because such a small percentage of patients actually utilize their machines on a regular basis. Inland Sleep Solutions will feature dental offices where there has been training in Dental Sleep Medicine.

CPAP is the "best treatment" for the 25% of patients who love their CPAP, and use it all night, every night.

Oral appliances may be less effective across a range of all patients at eliminating sleep apnea but they are much more effective at achieving patient compliance. A treatment that is used will always be superior to a treatment that is not used.

Oral appliance success can be greatly improved by titration of appliances in the sleep lab. When an appliance eliminates sleep apnea based on a sleep study it is effectively equivalent to CPAP. The issue of compliance almost always favors oral appliances but objective monitors for oral appliance use are not yet available. They probably will be available in the very near future making oral appliances a leading choice of sleep medicine physicians who care about patients desires.

The best treatment is one that works and is used. For most patients with mild to moderate sleep apnea the best treatment is an oral appliance due to much higher compliance. If compliance is equal and CPAP or appliances are equally effective than both would qualify as the best treatment. The patient can chose their desired treatment. Studies have shown the majority of patients offered a choice prefer a comfortable oral appliance over CPAP.

Some severe sleep apnea patients refuse CPAP, for those patients an oral appliance is superior to "no treatment".

CPAP is almost always the best treatment for the morbidly obese patients but an oral appliance is still better than no treatment if CPAP is refused.

There are patients who are severe and/or morbidly obese and the "best treatment" is actually combination treatment of an oral appliance and CPAP combined. A mask retained by the teeth instead of straps may be considerably more comfortable for many patients and lower pressure from combined use makes CPAP easier to tolerate.

The best treatment may be CPAP but with a custom made nasal mask that is made from an impression of the patients face similar to how dentures are made. Custom masks combined with oral appliances are a new entry in the field coming from airway management.

Cleanliness is of major importance with both CPAP and oral appliance treatments. Dirty masks and hoses can lead to sinus infections, bronchitis and pneumonia while poor oral hygiene with an oral appliance can lead to periodontal disease. Dr Shapira advise all patients to keep their masks and hoses scrupulously clean. It is vital to be just as thorough in cleaning oral appliances and in maintaining oral hygiene care when wearing an oral appliance. They are not well suited for patients who do not regularly brush their teeth.

What is the best CPAP mask for patients who utilize CPAP? Studies have shown that different masks and machines usually do not increase patient compliance but they do increase comfort for patients who actually use CPAP. Other studies have shown that patients' usage of CPAP initially predicts long term compliance with CPAP. Patients who reject CPAP initially rarely embrace CPAP use in the long term. What is the best CPAP mask? A mask the patient actually uses. This will be very patient specific.

What is the best type of CPAP machine? There is standard CPAP machines that come in many styles and shapes. The industry has done a good job of making CPAP machines quieter and smaller. BiPAP machines have lower pressure during expiration that reduces claustrophobic feelings in some patients and often eliminates the sensation of drowning on air. Ramping is a gradual increase in pressure allowing patients to fall asleep prior to pressure increasing. Humidification and heated hoses are also increasing patient comfort. Unfortunately all of these advances have not been shown to increase overall patient compliance.

Servo-ventilation machines are more efficient and effective in treating central sleep apnea, which is a neurological condition where the brain "forgets" to breathe.

The best sleep apnea treatment is always patient specific. The 60% of patients who do not tolerate CPAP will likely find comfortable oral appliances are the best treatment.

A small minority of patients do not tolerate CPAP or oral appliances. The best treatment for these patients may be surgery.

What is the best sleep apnea surgery? The morbidly obese and extremely severe sleep apneics may find that a tracheotomy is the best treatment. Patients breathe through their throat bypassing the pharyngeal blockages. Most patients do not want a trach.

Soft palate surgery is almost never the best sleep apnea treatment. UP3 or Uvulopalatopharyngealplasty is painful and has very high morbidity but more importantly rarely eliminates sleep apnea and patients still require CPAP or oral appliance therapy. Pillars, somnoplasty, LAUP or laser-assisted uvuloplasty are less painful but still ineffective in treating most apnea patients completely.

Maxilo mandibular advancement is extremely effective but is major surgery where the upper jaw (maxilla) is cut loose from the skull and often split in pieces, the lower jaw (mandible) is sectioned into 3 pieces and the hyoid bone is sectioned in pieces and then the patient is wired shut for six weeks. This surgery is often very successful. A geniohyoid surgery is less invasive only splitting the lower jaw in pieces and advancing the chin and tongue. While it is effective in patients with severely recessed lower jaws (weak chin) in most patients it is the "Jay Leno" surgery creating his unique profile.

For severely obese patients with severe sleep apnea bariatric surgery may be the best sleep apnea treatment.

It is also possible to do several tongue reduction surgeries that vary in effectiveness. Dr Shapira suggests that patients attempt CPAP and/or Oral Appliances before considering surgery. Patients with blocked nasal airways frequently improve with partial turbinectomies and correction of deviated septums but while helpful this will usually not eliminate sleep apnea.

Dr Shapira reminds patients of the famous quote: "There is no disease or disorder known to man that can't be made worse by sticking a knife in it." This does not mean to avoid surgery cautions Dr Shapira but rather to approach any surgery with caution and consider the possible problems associated with surgery.

Information on the dangers of sleep apnea, sleep apnea treatment and comfortable oral appliances is available at http://www.ihatecpap.com.

We are currently looking for Dentists with training in Dental sleep Medicine in the following communities. Dentist wishing to become part of the program can contact Meg at meg@hamiltonsaunderson.com

Washington State
Clarkston
Colfax
Ellensburg
Ephrata
Kennewick
Moses Lake
Pasco
Pullman
Richland
Ritzville
Spokane
Spokane Valley
Walla Walla
Washougal
Wenatchee
Yakima
Idaho
Coeur d'Alene
Lewiston
Moscow
Priest Lake

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posted by Dr Shapira at 7:57 AM