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Confessions of a Snorer
Could snoring (yours or someone else's) be affecting your life? My snoring was affecting mine - much worse, and for a longer time, than I realized. Most people think of snoring as nothing more than a nuisance to those who have to listen to it, but I learned from experience and my studies that it can have more severe consequences than that.
If you sleep in earshot of someone who snores, studies show that you lose an average of one hour of sleep per night. If you are the one snoring, the consequences could be worse than sleep deprivation. Over time, it could seriously affect your health.
About ten years ago, my husband informed me that I was snoring. By the time a couple of years had passed, my snoring had become so frequent that he had resorted to sleeping on the sofa. Not too long after that, I became aware of being more tired, more often. The sleepiness progressed to the point that, on weekends, I usually needed a nap in the middle of the day in order to function, even though I felt fine while I was working. There were a few mornings when I almost fell asleep while driving! I also had bouts of insomnia, which was new for me. I would lie awake for hours in the middle of the night. I figured I must be worried about something, but I didn't know what that was. Over time, the insomnia and tiredness became "normal" to me.
Luckily, I attended a meeting of the American Academy of Craniofacial Pain, a few years ago. I started learning about the negative health effects of what's called "sleep-disordered breathing," which includes snoring and obstructive sleep apnea . I attended lectures by experts and took courses by one of them, Dr. Jonathan Parker, in Minneapolis. I completed his advanced course in treating snoring and sleep apnea in November, 2011. I've been talking to patients (and sometimes, patients' spouses) about snoring. I have encountered a few myths about snoring in these discussions, which I will dispel. It also surprises me that there is a stigma about snoring - a lot of people are embarrassed by it, to the point of adamantly denying it when their sleep partners inform them that they snore.
Snoring occurs because the muscles that hold our airways open while we're awake, relax. The snoring sound happens when the soft palate vibrates as the air tries to get through too-small of a space. If the airway closes completely, the snoring will stop for a few seconds, and then the person will make a loud, snorting, sound and start snoring again. The bed partner enduring the snoring may be relieved by the silence, but the silence means the snorer has STOPPED BREATHING. This is called obstructive sleep apnea.
A surprising number of patients and spouses have told me that the snoring is worse when the snorer is "very tired." Actually, the amount of tiredness has nothing to do with snoring, but the level of sedation does. Anything that sedates us (alcohol, medications that cause drowsiness, etc.) will relax the airway muscles more than usual and cause an increase in the potential for sleep-disordered breathing. Nasal allergy symptoms can also make snoring worse, but unfortunately, adhesive nasal strips don't treat snoring because snoring mostly occurs in the throat. (I heard a funny story at a meeting by one of the experts, who went with four other men on a hunting trip. The four hunters boasted that they had stopped snoring since they had started using their nasal strips. The expert said, however, that the amount of snoring in the tent that night was enough to scare away any wild animals in the area!)
With testing, I found out that what I thought was only snoring was actually sleep apnea. It was a frightening thought, that there were many periods during the night during which I stopped breathing. No wonder I was so tired! I learned from my studies that an estimated 17-20% of Americans have sleep apnea (a huge number), but only 10-15% of people with sleep apnea have been diagnosed - that's a bigger number than the number of undiagnosed diabetics - talk about a health care crisis!
I also learned that excessive daytime sleepiness is only one of many negative consequences of sleep apnea. These include high blood pressure and an increased risk for: heart disease, stroke, diabetes, metabolic syndrome, dementia, depression, difficulty in losing weight, acid reflux during sleeping (heartburn), pain, and motor vehicle accidents. Studies have shown that high blood pressure improves when sleep apnea is treated.
The health issues with sleep-disordered breathing appear to be due to a decrease in oxygen levels and an increase in adrenaline in the blood. Imagine that someone suddenly holds something over your face, to prevent you from breathing. Your immediate "fight or flight" central-nervous-system response kicks in because of an instantaneous release of adrenaline into your bloodstream. The adrenaline sets off a series of events in your body that help you to cope with a stressful situation such as this. Our bodies are designed to be able to deal with only short-term stresses (such as our ancient ancestors' need to be on alert while hunting food, or running to keep from being the food!). The body releases a smaller amount of adrenaline when we're not breathing well during sleeping, but it occurs throughout the night. After years of this excess adrenaline, the blood vessels and heart are negatively affected.
The adrenaline increase can make us "on edge," anxious; it was the cause of my insomnia. It tightens muscles, causing muscle tension and leading to pain. Experts are noticing that there appears to be a relationship between airway difficulties and pain, and increased pain actually causes increased negative cardiovascular consequences (National Heart-Lung-Blood Institute). Pain disrupts sleep, and disturbed sleep in turn aggravates pain. Not breathing well during sleeping also changes normal blood chemicals' secretions (one of these effects is to cause your bladder to fill up during the night, causing you to wake up to go to the restroom, sometimes more than once - believe me, I know about this one).
Excessive body weight is associated with greater risk for sleep apnea, and losing weight often helps decrease snoring and improve sleep apnea. However, there are many thin people who have sleep apnea. Anatomic imperfections can make breathing more difficult while sleeping. For example, if the dental arches are narrow, the tongue doesn?t have enough room in the mouth, so it pulls back into the throat. A large tongue or long soft palate can also increase the potential for sleep apnea. Sometimes, the airway space is simply smaller than normal. Simple snoring tends to progress, over time, into sleep apnea. Not only do most people gain weight as they age, but the soft palate tends to lengthen and get flabbier, with snoring, which makes it easier for the airway to close.
The number of patients we see with evidence of "grinding" their teeth at night (called, "bruxism") is incredibly high, but many patients don?t believe it because they're unconscious when it happens. Obstructive sleep apnea is the most common risk factor reported for sleep-related bruxism (Chest 2001, 119:53-61). Common sense seems to tell you that snoring and bruxism don't go together - after all, the teeth are together during bruxism, but the mouth is open during snoring. Sleep studies have confirmed that when you snore and the body becomes more distressed from the changes in oxygen and carbon dioxide in the blood, a slight "arousal" occurs, in which the body "wakes you up" just enough to start breathing better (but almost never enough that you become aware of it). Bruxism occurs during this stage of arousal. Then you fall into deeper sleep, and the cycle starts again. Clenching the teeth stimulates muscles whose increased activity help increase airway space by moving the tongue temporarily out of the airway.
We look for signs in all our young patients for signs of obstructed airway because of its huge negative effects on growth and development. Plus, it's our belief that if children aren't treated for airway issues now, they'll be our future sleep apnea patients. ANY snoring in a child (without a short-term upper respiratory virus, etc.) is abnormal. Believe it or not, bedwetting in children past the age of potty training is often due to breathing difficulties during sleeping.
Because sleep-disordered breathing is a medical issue, we don't do treatment for it without a medical diagnosis. We refer to a physician who orders a "sleep study" to determine whether snoring or sleep apnea is occurring, and also if there are any other sleep disorders involved.
The treatment that physicians typically use is a positive air pressure machine (such as CPAP), in which a mask or other device is used to gently blow air into the airway, thus holding it open during sleeping. These devices definitely treat sleep apnea well, but many patients have trouble tolerating them, for various reasons. Studies have shown that in cases of snoring and mild to moderate sleep apnea, custom oral appliances treat sleep-disordered breathing just as well. Plus, they are easy to travel with and seem to have a greater compliance rate. Most possible side effects of the appliances (such as mild tooth soreness) are short-term and manageable with adjustments to the appliance. We spend quite a bit of time doing measurements and discussing the patient's lifestyle compared to the types of appliances available. The different appliances have the same basic outcome (holding the lower jaw forward slightly, which keeps the airway open), but they have some different features. With the patient, we decide which appliance will most likely increase the patient's chance of success. The length of service of appliances is typically 2-5 years, depending on the appliance's design and the amount of force created by the patient during bruxing.
I've been wearing my snoring appliance for a couple of years, with much success. My husband is happier because he isn't exiled to the sofa anymore. After a short time wearing my appliance whenever sleeping, my daytime sleepiness ended. Now, I sleep through the night, without insomnia or getting up to use the restroom like before. I?ve even had a great improvement in my TMJ symptoms. I feel like my appliance is saving my life.
Please call our office at (504) 347-6000 if you have any questions about snoring or sleep apnea. We'd love to talk to you about it.
Dr. Wendy Maes
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