Sleep Problems May Complicate Many Illnesses
Dr. Strauss is absolutely passionate about what he does. After devouring a textbook on dental occlusion; something that would have put most people to sleep, he decided he wanted to learn more, which led him to study with Dr. Charles Stewart, known as the 'father of gnathology' (the study of the masticatory system, relating to the movement of your jaw).
He also studied with Stan Tillman, who wrote textbooks on crowns and bridges used in dental school, and his interest in prevention led him to join the Academy of Preventive Dentistry.
His journey to becoming an expert on sleep apnea began in 1988, when he took a class with Tom Meade, the inventor of an anti-snoring appliance called the Snore Guard.
What is Sleep Apnea?
Apnea is a Greek word that means "breathe." Sleep apnea is the inability to breathe properly, or the limitation of breath or breathing, during sleep.
There are three general types of apnea described in the literature:
- Central apnea, which typically relates to your diaphragm and chest wall and an inability to properly pull air in
- Obstructive apnea, which relates to an obstruction of your airway that begins in your nose and ends in your lungs
- Mixed apnea is a combination of both
Obstructive sleep apnea consists of the frequent collapse of the airway during sleep, making it difficult for victims to breathe for periods lasting as long as 10 seconds. Those with a severe form of the disorder have at least 30 disruptions per hour. Not only do these breathing disruptions interfere with sleep, leaving you unusually tired the next day, it also reduces the amount of oxygen in your blood, which can impair the function of internal organs and/or exacerbate other health conditions you may have.
Dr. Strauss estimates that as many as 30-50 percent of the population are affected with some form of sleep apnea.
"When we look at evolution… our mouths are getting smaller… Dr. Weston Price showed the relationship of diet and how it affects mouths of people.
When you look at the percentage of people in civilized societies seeing orthodontists, and then when you add to it the lack of breastfeeding, which generally is a positive way of expanding the size of the palate, moving the jaw further forward and having a larger mouth to hold the teeth, it's not surprising [that so many have sleep apnea] in civilized society," Dr. Strauss says.
He goes on to explain that if your palate is broad, there's more room for breathing. It actually improves your entire nasal and sinus area. As Dr. Strauss mentions, your diet is a major factor that will influence the development of your entire mouth—not just your teeth—and that includes breast feeding when you're young.
Not Sleeping Well? Check Your Breathing…
The conventional treatment for sleep apnea today is a machine called CPAP, which is an acronym for "continuous positive airway pressure" and creates a forceful pressure that mechanically opens up your airway. But that does not address the cause of the problem, although it may provide some symptom relief.
It's important to understand that your body is constantly working to keep you alive—it's in constant CPR mode, if you will. So at night, your body is constantly shifting and compensating to keep you breathing.
One sign that you're having trouble breathing is when your body compensates with increased forward head posture when sleeping. The worse your apnea gets, the more pronounced this forward posture becomes, because pulling your head forward helps compensate for the lack of room behind the back of your tongue.
Another common compensation that can indicate sleep apnea is frequent tossing and turning at night. This is because when you're laying on your back, gravity will pull your jaw and tongue backward, further into your throat, which can obstruct breathing. Hence, tossing and turning may be your body's way of keeping you breathing.
Snoring can also be an indication that you may have sleep apnea.
A simple test you can perform to check whether or not you're breathing properly is to stand with your back against a wall, with your heels, buttocks, shoulder blades and head touching the wall. Say "Hello," swallow, and then breathe. If you can speak, swallow, and breathe easily and comfortably in this position, then your mouth and throat are clear. If you can't perform those three functions, your breathing is probably obstructed, which may be exacerbated when lying down to sleep.
Selecting a Qualified Sleep Specialist
If you suspect you may be suffering from sleep apnea, your next step would be to identify a sleep specialist. Dr. Strauss recommends doing your homework first, and to make sure the sleep specialist you select isn't just a "one-trick pony" with nothing to offer except a CPAP machine. You want to make sure they have the knowledge and resources to help you address your sleep apnea at the foundational level.
Diagnostic testing, such as a sleep study, is just one part of the process. A qualified sleep specialist will also discuss your sleep habits, and look at potential contributing factors, such as your weight, for example, prior to doing the sleep study. This is an important step that should not be overlooked.
After the study is done, the sleep physician should also explain the results of the sleep study with you; its implications and the proposed treatment. The oral appliance approach has been recognized as part of the standard of care since about 1995. Since 2001, oral appliances are recommended as the first line treatment for mild to moderate sleep apnea.
For severe sleep apnea, a CPAP should be considered first. If the CPAP is unsuccessful, surgery or an oral appliance may be considered.
"This is important to hear," Dr. Strauss says. "If the patient is either unable or unwilling to use a nasal CPAP, then an oral appliance should be considered. That's how it's written. How third-party providers relate to this may vary depending on the third party provider. I would call them the insurance companies who are dealing with the money at the payment aspect of it."
You Don't have to Be Obese to Suffer from Sleep Apnea
Years ago, sleep apnea tended to be associated with morbid obesity, which clearly can be a significant contributing factor. However, in Dr. Strauss' experience, many patients with sleep apnea today do not have a weight problem. Rather the primary issue is the tongue.
In those cases, a specialty trained dentist, such as Dr. Strauss, can recommend and design an oral appliance to address this issue. There are over 100 different appliances. Some are mandibular repositioning devices, designed to shift your jaw forward, while others help hold your tongue forward without moving your jaw.
"There is one out that depresses the tongue also, which I haven't worked with, but I have concerns about its impact on the body just because of how I feel it would impact the autonomic nervous system holding the tongue in a depressed state," Dr. Strauss says.
"What we originally developed in treatment was called trial procedures. I would have a patient take home a generic type of tongue retaining device and spend some nights with that, and then I have another patient take home a generic very basic type of mandibular repositioning device and have them go home with that and come back.
We have sleep blogs and other questionnaires to determine how [the device] is working for them. How effective is it, how ineffective is it. What are the positives and negatives? Are these positives and negatives things that can be worked out with one of these particular long term appliances?
That's how we would come to a conclusion as to what the best appliance is for that person."
At this time, this is not generally practiced. There is a point in the protocol that says the dentist will determine the appropriate appliance for the patient. What happens is the patient comes in, and usually in one visit the dentist examines them, takes moulds of the teeth and comes up with the appliance by looking at the patient.
In my prejudiced mind that's not very scientific in nature, and it's not very thorough, because there are many factors that make appliances different from one another."
It's unfortunate, but most dentists will not let you try out different appliances to see which one works best for you. So, take care when selecting a dentist for your appliance. You'll want to make sure they have experience with a multitude of appliances, and, ideally, will let you try a few out before settling on one—although that's not standard care practice.
Getting used to your appliance may require some patience. In Dr. Strauss' experience, three months is a good trial period to evaluate whether a specific appliance is successfully resolving your sleep apnea.
Dr. Strauss also shares many other fine details to consider when trying to identify an ideal oral appliance, so for more information, please listen to the entire interview, or read through the transcript.
Home Testing Technologies
Although you need proper testing and diagnosis by a sleep specialist in order to treat sleep apnea, there are technologies available that can help you determine whether or not you may have a problem that may require seeing a specialist.
These home technologies can also be used to evaluate how well an oral appliance is working.
For example, there are iPhone apps that can measure snoring, and you can record the sounds of you sleeping using Audacity, a free software program available online.
"You can have your laptop hooked up… with the microphone and the camera next to you bed, or you could have a digital recorder next to your bed and record during the night," Dr. Strauss says. "You can record the sound and visually see those eight hours. You can see whether it's a one solid line, which would be silence, or whenever there is noise you can see the noise and when it is. The patient can do this every single night.
This allows the patient to have their health in their own hands…"
You can also purchase an oximeter, which measures blood oxygen levels. According to Dr. Strauss you can find them for less than $150.
"Very often when you have sleep apnea you're going have a drop in blood oxygen," he explains. "When it drops to a certain level it indicates there is a problem. If that's the case – it isn't in all apnea people, but generally it is, then that's another aid that a patient can use to objectively measure it…"
Hopefully, once you've been evaluated and diagnosed by a sleep specialist, he or she will be able to refer you to a qualified dentist if you need an oral appliance. However, you can also check out the Academy of Dental Sleep Medicine, originally co-founded to represent dentists with an interest in this field.
Dr. Strauss still practices in Falls Church, Virginia. You can find more information about his practice on his website, www.AMStraussDDS.com. He also writes monthly articles relating to sleep apnea.