OBSTRUCTIVE SLEEP APNEA, WOMEN SNORE AND HAVE SLEEP APNEA OFTEN IN CONJUNCTION WITH TMJ DISORDERS

Jacque: I am a 51 year old woman and have snored most of my life. Sleep study said Chronic Obstructive blahblah and the doc told me I had the WORST sleep patterns he had ever seen. Tried CPAP...NO WAY...couldn't stand it. Had shots in the back of my throat...didn't work. Tried a mouth appliance about 5 years ago and it flared up my TMJ terrrrrribly. So I was just wondering what my options are or if you mouth devices don't flare up the jaw?

DR SHAPIRA RESPONSE: Sleep Apnea and TMJ disorders have the same underlying causes, functions and problems. Usually we treat patients with TMJ disorders with an appliance that is worn 24 hours/day 7 days a week. This is done to stabilize the jaw joints (Temporomandibular Joints, TMJ), relax the muscles and control facial pain, TM Joint pain, headasches, migraines, sinus pain, ear pain, stuffiness in the ears, tinnitus, and other numerous symptoms.

For sleep apnea patients we usually use an appliance that is only worn at night and give the patient exercises that return the jaw to its original pathologic position. The original position is pathologic because it does no perform the single most important function of maintaining a patent airway. This works well for the majority of patients without problems. Patients with TMJ disorders may need their appliances adjusted with design changes or alterations based on symptoms.

Long Term research has shown bite changes but not negative changes to the TM Joints. Most symptoms of TMD from oral appliances to treat sleep apnea will be only during initial treatment. Long term problems are rare.

The best treatment would be combining TMJD and Sleep Apnea treatment.

This is accomplished with a small comfortable diagnostic neuromuscular orthotic during the day and a MAD sleep apnea appliance at night. Most TMJ problems are caused by the jaw healing at night but the muscles resist going back to your original pathologic position in the morning. This combination treatment allows the jaw joints and muscles to heal at night and supports this healthier position during the day. It no longer requires the patient to return to their original pathologic position.

An interesting fact is the changes in bite seen with oral appliances is actually healing.

Dr Shapira Response:

"Life is not about waiting for the storms to pass - it is learning to dance in the rain!"

ORAL APPLIANCES ARE A CONSERVATIVE METHOD OF TREATMENT ACCORDING TO THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE.

THE FOLLOWING PAGE FROM THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE OF THE NIH IS REPRINTED FROM http://www.ninds.nih.gov/disorders/sleep_apnea/sleep_apnea.htm

IN ADDITION TO THE WELL KNOWN SYMPTOM OF EXCESSIVE DAYTIME SLEEPINESS IT ALSO RECOGNIZES "morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression AS ASSOCIATED DISORDER.

WHILE MANY IN THE MEDICAL SLEEP COMMUNITY ALWAYS LOOK AT CPAP AS THE FIRST LINE TREATMENT THE NINDS RECOGNIZES ORAL APPLIANCES AS A CONSERVATIVE TREATMENT OF SLEEP APNEA. THE FIRST LINE THERAPY FOR SLEEP APNEA ARE CONSERVATIVE METHODS "Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep." AND CPAP IS COSIDERED A LESS CONSERVATIVE APPROACH ALONG WITH SURGERY. THE ARTICLE STATES "If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway.

THE SLEEP COMMUNTIY OFTEN MAKES CPAP THE FIRST AND SOMETIMES ONLY TREATMENT OF CHOICE. THE MORE RATIONAL APPROACH OF THE THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE OF THE NIH IS A FRESH APPROACH.

WHY CONSIDR CPAP A FIRST LINE TREATMENT WHEN MOST PATIENTS DO NOT TOLERATE CPAP.

CONSIDERING SLEEP POSITION, WEIGHT LOSS AND ORAL APPLIANCES AS CONSEVATIVE APPROACHES RECOGNIZE NOT JUST THE EFFECTIVENESS OF THESE TREATMENTS BUT ALSO THE CONSERVATIVE NATURE OF THESE TREATMENTS.

THE FOLLOWING IS INFORMATION FROM THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SITE.

What is Sleep Apnea?
Sleep apnea is a common sleep disorder characterized by brief interruptions of breathing during sleep. These episodes usually last 10 seconds or more and occur repeatedly throughout the night. People with sleep apnea will partially awaken as they struggle to breathe, but in the morning they will not be aware of the disturbances in their sleep. The most common type of sleep apnea is obstructive sleep apnea (OSA), caused by relaxation of soft tissue in the back of the throat that blocks the passage of air. Central sleep apnea (CSA) is caused by irregularities in the brain’s normal signals to breathe. Most people with sleep apnea will have a combination of both types. The hallmark symptom of the disorder is excessive daytime sleepiness. Additional symptoms of sleep apnea include restless sleep, loud snoring (with periods of silence followed by gasps), falling asleep during the day, morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression. Not everyone who has these symptoms will have sleep apnea, but it is recommended that people who are experiencing even a few of these symptoms visit their doctor for evaluation. Sleep apnea is more likely to occur in men than women, and in people who are overweight or obese.

Is there any treatment?

There are a variety of treatments for sleep apnea, depending on an individual’s medical history and the severity of the disorder. Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep. If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway. Some individuals may need a combination of therapies to successfully treat their sleep apnea.
What is the prognosis?

Untreated, sleep apnea can be life threatening. Excessive daytime sleepiness can cause people to fall asleep at inappropriate times, such as while driving. Sleep apnea also appears to put individuals at risk for stroke and transient ischemic attacks (TIAs, also known as “mini-strokes”), and is associated with coronary heart disease, heart failure, irregular heartbeat, heart attack, and high blood pressure. Although there is no cure for sleep apnea, recent studies show that successful treatment can reduce the risk of heart and blood pressure problems.
What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research related to sleep apnea in laboratories at the NIH, and also support additional research through grants to major medical institutions across the country. Much of this research focuses on finding better ways to prevent, treat, and ultimately cure sleep disorders, such as sleep apnea.

SLEEP APNEA AND ANXIETY: A PUBMED SEARCH ON THOSE TERMS YIELDS 243 RESULTS.

THERE ARE MANY STUDIES THAT SUGGEST NEGATIVE HEALTH EFFECTS FROM POOR SLEEP. AN ARTICLE IN Behav Sleep Med. 2010 Jul;8(3):157-71. TITLED Sleepiness and health in midlife women: results of the National Sleep Foundation's 2007 Sleep in America poll CONCLDES THAT " sleep disruptions and daytime sleepiness negatively affect the daily life of midlife women."

ANOTHER ARTICLE IN J Adolesc Health. 2010 Feb;46(2):124-32. Epub 2009 Aug 3.
Sleep patterns and predictors of disturbed sleep in a large population of college students CONCLUDES THAT "insufficient sleep and irregular sleep-wake patterns, which have been extensively documented in younger adolescents, are also present at alarming levels in the college student population. Given the close relationships between sleep quality and physical and mental health, intervention programs for sleep disturbance in this population should be considered."

A THIRD ARTICLE IN Acta Otorrinolaringol Esp. 2009 Sep-Oct;60(5):325-31. Epub 2009 Aug 13.
[Neurocognitive and behavioural abnormalities in paediatric sleep-related breathing disorders] CONCLUDES THAT " A high prevalence of behavioural and neurocognitive abnormalities was observed in children with sleep-related breathing disorders compared to a control group of healthy children. The use of objective assessment such as psychological tests revealed more abnormalities than were expressed by parents in response to clinical interviews."

IT APPEARS THAT RGARDLESS OF AGE AND/OR HEALTH STATUS SLEEP DISORDERS WREAK HAVOC ON BOTH PHYSICAL AND EMOTIONAL WELL BEING.


Behav Sleep Med. 2010 Jul;8(3):157-71.
Sleepiness and health in midlife women: results of the National Sleep Foundation's 2007 Sleep in America poll.
Chasens ER, Twerski SR, Yang K, Umlauf MG.

School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15261, USA. chasense@pitt.edu
Abstract
The 2007 Sleep in America poll, a random-sample telephone survey, provided data for this study of sleep in community-dwelling women aged 40 to 60 years. The majority of the respondents were post- or perimenopausal, overweight, married or living with someone, and reported good health. A subsample (20%) reported sleepiness that consistently interfered with daily life; the sleepy subsample reported more symptoms of insomnia, restless legs syndrome, obstructive sleep apnea, depression and anxiety, as well as more problems with health-promoting behaviors, drowsy driving, job performance, household duties, and personal relationships. Hierarchical regression showed that sleepiness along with depressive symptoms, medical comorbidities, obesity, and lower education were associated with poor self-rated health, whereas menopause status (pre-, peri- or post-) was not. These results suggest that sleep disruptions and daytime sleepiness negatively affect the daily life of midlife women.

PMID: 20582759 [PubMed - in process]

J Adolesc Health. 2010 Feb;46(2):124-32. Epub 2009 Aug 3.
Sleep patterns and predictors of disturbed sleep in a large population of college students.
Lund HG, Reider BD, Whiting AB, Prichard JR.

Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA.
Abstract
PURPOSE: To characterize sleep patterns and predictors of poor sleep quality in a large population of college students. This study extends the 2006 National Sleep Foundation examination of sleep in early adolescence by examining sleep in older adolescents.

METHOD: One thousand one hundred twenty-five students aged 17 to 24 years from an urban Midwestern university completed a cross-sectional online survey about sleep habits that included the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale, the Horne-Ostberg Morningness-Eveningness Scale, the Profile of Mood States, the Subjective Units of Distress Scale, and questions about academic performance, physical health, and psychoactive drug use.

RESULTS: Students reported disturbed sleep; over 60% were categorized as poor-quality sleepers by the PSQI, bedtimes and risetimes were delayed during weekends, and students reported frequently taking prescription, over the counter, and recreational psychoactive drugs to alter sleep/wakefulness. Students classified as poor-quality sleepers reported significantly more problems with physical and psychological health than did good-quality sleepers. Students overwhelmingly stated that emotional and academic stress negatively impacted sleep. Multiple regression analyses revealed that tension and stress accounted for 24% of the variance in the PSQI score, whereas exercise, alcohol and caffeine consumption, and consistency of sleep schedule were not significant predictors of sleep quality.

CONCLUSIONS: These results demonstrate that insufficient sleep and irregular sleep-wake patterns, which have been extensively documented in younger adolescents, are also present at alarming levels in the college student population. Given the close relationships between sleep quality and physical and mental health, intervention programs for sleep disturbance in this population should be considered.

PMID: 20113918 [PubMed - indexed for MEDLINE]

Acta Otorrinolaringol Esp. 2009 Sep-Oct;60(5):325-31. Epub 2009 Aug 13.
[Neurocognitive and behavioural abnormalities in paediatric sleep-related breathing disorders]
[Article in Spanish]

Esteller Moré E, Barceló Mongil M, Segarra Isern F, Piñeiro Aguín Z, Pujol Olmo A, Soler EM, Ademà Alcover JM.

Servicio de Otorrinolaringología, Hospital General de Catalunya, San Cugat del Vallès, Barcelona, España. esteller@abaforum.es
Abstract
INTRODUCTION: Behavioural and neurocognitive abnormalities in children may be a consequence of sleep-related breathing disorders. The effectiveness of assessments based on questioning parents is dubious and objective assessment tools are therefore required.

AIM: To ascertain the impact of these abnormalities in children with sleep-related breathing disorders and compare the reliability of questioning parents in relation to validated psychological tests.

METHOD: A prospective study was performed on 20 children with sleep-related breathing disorders and 20 healthy control children between 3 and 12 years of age. Both groups were subjected to a battery of validated psychological tests. The results of both groups were compared with each other and with the response to clinical questionnaires given to parents in the problem group.

RESULTS: More than 75% of the cases in the problem group presented abnormalities with regard to attention, anxiety, memory and spatial structuring. The percentage involvement in all concepts was higher in the problem group. Comparisons of attention (40% of children affected in the control group and 80% in the problem group), memory (50% and 84.2%), and spatial structuring (45% and 75%) were statistically significant. More abnormality was observed in the parameters assessed with psychological tests than the equivalent concept obtained from interviewing the parents. Comparison of abnormal concentration assessed from the questionnaires (40% of children affected) with attention during the psychological test (80%), memory (15% and 84.21%), and delayed language development (10%) compared to spatial structuring (75%) was statistically significant.

CONCLUSIONS: A high prevalence of behavioural and neurocognitive abnormalities was observed in children with sleep-related breathing disorders compared to a control group of healthy children. The use of objective assessment such as psychological tests revealed more abnormalities than were expressed by parents in response to clinical interviews.

PMID: 19814984 [PubMed - indexed for MEDLINE]Free Article