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Airway & Sleep Apnea Care

Dentists and Sleep Breathing Disorders

Why should dentists even be discussing the airway? The answer comes from even a simple look at the anatomy of the human airway. The whole jaw and mouth structure fits into the corner of the airway, and how we treat the jaw and mouth structure can profoundly affect the function of the airway. Also, the way our faces and jaws grow is the largest factor in how healthy our airway will form.

Dentists and Sleep Apnea Appliances – I disagree

Dentists have been sold on the idea that making appliances for patients with sleep apnea will be the new “profit center” of their dental practice. Many appliances are made by dentists to treat sleep apnea without fully realizing the consequences of these appliances. This concerns us, because we see long-term consequences of these appliances which are scary. Our approach goes beyond making one-size-fits-all appliances, and draws upon experience with orthodontics, orthotropics (facial growth guidance), airway orthodontics, and airway prosthodontics. The options we have for you are meant to address the causes of the problems, and they are sometimes a bit “outside-the-box” and unique.

Obstructive Sleep Apnea (OSA)

When the jaws fail to grow forward enough, the airway behind the tongue is compromised. For some people, the airway closes off during sleep due to the weight of the tongue, palate, and lower jaw. The result is a temporary stoppage of breathing (an “apnea”), and it’s called Obstructive Sleep Apnea (OSA), the most common of the Sleep Breathing Disorders. The brain, sensing the problem, puts the body into a “fight or flight” red alert, and breathing resumes. But here’s the bad part: the sleep gets fragmented, and the constant “fight or flight” red alerts during the night take a toll on the body.

Sleep fragmentation doesn’t mean that you wake up. It means that your stage of sleep gets disrupted and you may not even be aware. It’s is bad because sleep is important. All the stages of sleep are important. Sleep is when we re-charge, but it’s also when our brain files away our experiences from the awake time. When we don’t get the sleep we need, our memory, intelligence, moods, and other cognitive factors are affected. Daytime sleepiness and drowsiness can also result. Workplace and other accidents are strongly associated with sleep fragmentation due to OSA.

“Fight or flight” red alerts are bad especially because of the effects they have on the cardiovascular system. Untreated sleep apnea is associated with increases in blood pressure, cardiovascular diseases, heart attacks, and strokes. Other problems also associated with OSA are: diabetes, GERD, sexual dysfunction, depression, obesity, insomnia, and even cancer.

The AHI Index Measures OSA Severity The severity of OSA is measured most commonly by how many times breathing stops per hour. Also important are the temporary drops in blood oxygen which result. These are called “hypopneas.” Adding the apneas (stopping breathing) to the hypopneas (lowered oxygen) per hour give us the Apnea Hypopnea Index (AHI).

Adults

For adults, the consensus is that it’s normal if we have an apnea or hypopnea up to five times an hour during sleep. Mild OSA is defined by 6-15, moderate OSA is 16-30, and severe OSA means stopping breathing over 30 times an hour on average. It can get as high as 80 to 100 or more!

Children

For children, it’s a different standard. Normal for children is an AHI of less than 1. This means it’s not normal for a child even to have an average of one apnea per hour during sleep. For children “snoring is not normal, and should never occur.” (Gozal) While snoring is a definite warning for children, it’s important to note that children with OSA often do NOT snore or exhibit daytime sleepiness. On the contrary, children with sleep breathing disorders are often hyperactive during the day, leading to a misdiagnosis of ADHD. See the symptoms to look for in children here.

The bottom line is: untreated sleep apnea shortens life expectancy 20%. Warning signs should be taken seriously, and a positive diagnosis should be treated aggressively and conscientiously.

How is Sleep Apnea Treated?

The three general ways OSA is treated are:

1. Push harder on the air going in.

2. Open the airway temporarily.

3. Open the airway permanently

Push Harder on the Air – PAP Therapy

This is the so-called “gold standard” of the medical profession, and it consists of connecting a pump to a mask that is worn during sleep over the mouth or the nose or both. It’s called PAP therapy, for “Positive Air Pressure.” Form many patients, PAP therapy has the advantages that it can be very effective at treating OSA when it’s used, the insurance may pay for it, no additional treatment may be required, and it’s simple and available. The disadvantages are big, however. So big that, after six months, up to 70% of people will give up on using their PAP machine. The disadvantages include claustrophobic feelings and discomfort from the mask, air leaks, dry mouth, disruption of bed partner’s sleep, and the biggest drawback: it not only does not solve the underlying structural problem, but it might make it worse over time due to permanent facial-flattening changes caused by the pressure of the mask.

Open the Airway Temporarily – Oral Appliance Therapy

Wearing a dental appliance which holds the lower jaw forward or pushes the tongue down will open the airway temporarily during sleep. Studies show this approach is most effective for sleep apnea that is mild to moderate. Recommendations have even gone so far as to recommend an oral appliance as the first line of treatment in these cases. It can help when the OSA is severe, but not as predictably, and not as effectively, and would only be tried in these cases when PAP therapy has failed.

Advantages of Oral Appliance Therapy: It’s comparatively inexpensive, it avoids the hassles of PAP therapy, travel with appliances is easy, and it’s a quick and generally effective solution for mild to moderate OSA.

Disadvantages of Oral Appliance Therapy: The biggest disadvantage is that it risks permanent bite changes which might even result in compounding the original problem (both jaws being too far back), it may not be adequately effective, the appliances are often not adjusted correctly, and the appliances can sometimes be uncomfortable.

Dentists and Sleep Breathing Disorders

The airway can be opened more permanently by orthotropics, by orthodontics, and by surgery. (Myofunctional Therapy can also help, but it’s not considered a first line of treatment.)

Orthotropics means “facial growth guidance,” and it describes a postural orthodontic treatment for children between 5 and 9. It’s not as effective for older ages, and generally not indicated past the age of 11 or 12. Orthotropics aims to redirect vertical growth of the jaws to become horizontal growth. By learning to change the mouth rest posture, a child can cause changes in facial growth that will improve the size of the airway.

Orthodontics can be done in very specific cases to increase the tongue space, and thereby improve the airway. This is not recommended or performed in the vast majority of orthodontic practices, and is truly cutting-edge thinking in the management of breathing disorders.

Surgery to more ideally reposition the upper and lower jaws can bring about the most definitive improvement in the airway. This fixes the original problem, and eliminates the need for either PAP therapy or dental appliances.

If you are interested in receiving airway and sleep apnea treatments, contact our office at (925) 934-3434 to schedule your initial consultation with our dentists.

Dr. Brian J. Hockel and our team at Life Dental & Orthodontics are pleased to provide alternative treatments for Obstructive Sleep Apnea to patients from Walnut Creek, Clayton, and Concord, California, as well as those from the greater San Francisco East Bay area and beyond.

Early Intervention

Many orthodontic, orthotropic, airway, or sleep apnea treatments are appropriate for children, even though they may not have any or all of their permanent teeth. Reasons to consider early treatment evaluation for a child are:

1. Crowding – not enough room for the permanent teeth. When baby teeth have no gaps between them, they are crowded.

2. Bite problems: deep bite, cross bite, overjet, overbite, underbite, or “buck teeth.”

3. Mouth-breathing, low tongue posture, thumb-sucking, difficulty breastfeeding.

4. Facial growth, recognized or not, that is not optimal: recessed chin, gummy smile, long face, flat cheeks, asymmetries, dark circles under eyes.

5. Snoring, teeth grinding, daytime hyperactivity, bed-wetting, ADD-like symptoms – all of which have been associated with airway problems related to facial growth. Early treatment can help!

6. Cosmetic issues about which the child is self-conscious.

“Why not just wait and do all orthodontics in one phase in high school?”

Isn’t treatment at a young age a waste?

Sometimes we are asked a very logical question: why spend potentially more time and money on two phases of orthodontics, a first phase now and then a braces phase to align teeth later? Many times we have seen patients who have had “Phase I Orthodontics” in another office, and we have asked the same question. It looked like the patient had wasted time and money because they were left with problems large enough that, in the end, no real time or effort or cost was saved. We do not recommend this!

If orthodontic treatment is undertaken when some or all of the primary (baby) teeth are present, there had better be a good reason. There must be attainable objectives, producing important enough benefits to outweigh the cost, time and hassle of the treatment.

Is Orthodontics Just Straightening Teeth?

The reasons for doing any orthodontic treatment can vary. Most of the time, simply straightening teeth becomes the number one goal. We have learned, however, that there are larger issues at stake – some of them even affecting how long a child might live! This is not an exaggeration. When the growth of the jaws, and the formation of the airway are not optimal, serious health consequences can result: irreversible cardiovascular damage, ADD or ADHD, delayed language and phonological skills, altered social development, lower IQ, etc. We take all these seriously.

The Role of Mouth Posture

Ideal rest oral posture is: lips together, teeth lightly together, and tongue to the roof of the mouth. If the rest posture of the mouth is not optimal, then facial and airway growth are a concern – and they will remain a concern throughout life. Correcting muscle function and tone is much easier at younger ages, and when the tongue-space is corrected with expansion or arch development, the muscles adapt to the surrounding structures. They won’t do this as readily with expansion at a later age.

Structural Changes

Early treatment focuses on structural and/or postural correction: the size of the jaws, the direction of jaw growth, etc. It’s like getting a space ship pointed toward the moon soon after it leaves earth; waiting until later will often mean a larger and more difficult correction. Children also cooperate with and tolerate simpler treatment at a younger age – much better than teenagers do. Early treatment can make the teenage treatment, when it is necessary, shorter, simpler, and more comfortable.

Arch Development

When more space is made for the erupting teeth, the likelihood of needing extractions or jaw surgery is decreased. The permanent teeth do better when they can erupt into an arch that has enough room. When teeth do not have enough room, they can end up in positions that are more complicated to correct: they can become impacted, they can erupt through the wrong part of the gum tissue, and they can cause damage to the roots of adjacent teeth. These are all reasons to consider early treatment.

Braces Twice?

If nature has not already done so, it may be the case that the best tooth alignment will result from orthodontics with braces after the permanent teeth are all in. So, yes, sometimes a second phase of treatment to align teeth is desirable. A lot depends on the degree of “perfection” in alignment the patient or parents desire. Usually (if you can believe this coming from an orthodontic office), it is best to skip the full braces phase and accept minor discrepancies in alignment. But, when necessary, expansion, postural, or structural changes at that later age are generally more difficult, and keep the teen in treatment longer. Looked at from a health perspective, the structural changes that are achieved during the growth years are often more important than the final alignment of the teeth later on. We might recommend that the priority be put on the treatment at younger ages to correct the major issues: insufficient space, asymmetries, cross bites, impactions, poor oral posture, improper facial growth, etc.

Evaluate Early – Age 3-4 Is Not Too Young!

Avoiding extractions, surgery, more complicated treatment, tooth impactions, ectopic eruptions (teeth coming in at the wrong place), – and optimizing facial, jaw, and airway growth, – these are all good reasons to put the priority on working toward correction of problems we can address early treatment.

If you are interested in learning more about early orthodontic treatment, call our office at (925) 934-3434 to schedule an initial consultation with our dentists.

At Life Dental & Orthodontics, we are pleased to provide both general dentistry and orthodontic care for our patients from Walnut Creek, Clayton, Concord, and Lafayette, California, as well as the surrounding areas in the greater San Francisco East Bay and beyond.

Orofacial Myofunctional Disorders

Orofacial myofunctional disorders (OMD) involve problems with the posture and function of the muscles around the mouth. This includes the lips, the tongue, the facial and swallowing muscles, and the jaw muscles. Altered posture and function are common for both children and adults, but the effects on growth make their detection especially important as young as possible.

What causes OMD?

Causes of an OMD might include poor breathing habits, such as breathing through the mouth. Whatever the cause, your orofacial functions — the muscles of the mouth and face, as well as the tongue — adapt, creat

Many negative oral habits also classify as OMD, including the following:

1. Lips-apart posture

2. Sucking of the fingers or thumb

3. Tongue posture low or between teeth

4. Tethered oral tissue, such as tongue ties or lip ties

5. Mouth-breathing

Myofunctional Therapy

Myofunctional therapy has been proven as a sound treatment option for treating OMDs. Orofacial myofunctional therapy (OMT or MFT) consists of a course of exercises of the muscles of the face, mouth, and tongue. These exercises are simple and usually pain-free. A course of myofunctional therapy corrects the negative habits and behavior of an OMD by re-training the muscles to perform correctly.

Myofunctional therapy also can correct resting oral posture, including that of the tongue, lips, and jaw. These rest posture issues can cause problems with facial growth, as well as with the airway, which is a major contributing factor to a sleep breathing disorder, such as obstructive sleep apnea.

Consequences of an OMD

An OMD can affect swallowing, an action that occurs thanks to a balance between the tongue and muscles in the face, mouth, and throat. Abnormal behavior of the facial muscles can also affect your appearance, making a person appear dull, sluggish, or as if they are protruding a facial grimace. Speech issues, such as a lisp or difficulty articulating particular sounds, can also result from a misaligned posture of the tongue and lips.

Early intervention

To prevent these health consequences later in life, we recommend that children undergo routine dental checkups beginning by age one. Dr. Hockel can monitor the growth and development of your child’s jaw and mouth, and address any OMD issues as they arise.

If you notice the symptoms of an OMD in yourself or a member of your family, this problem will not just go away on its own. Call our office at (925) 934-3434 to schedule a consultation.

Life Dental & Orthodontics provides total oral care to patients from Walnut Creek, Clayton, Concord, and Lafayette, California, as well as the surrounding areas in the greater San Francisco East Bay and beyond.

What is Obstructive Sleep Apnea (OSA)?

Sleep apnea is a type of sleep breathing disorder that occurs due to obstructions in the airway while a person sleeps. These obstructions typically happen when the lower jaw falls backward, the muscles in the throat relax, and soft tissue collapses into the airway, cutting off the ability to breathe. This disrupts the sleep cycle, as the body and brain react in alarm to the blockage.

Sleep apnea patients also have a much higher risk factor for developing serious, potentially life-threatening health issues, such as obesity, heart disease, stroke, depression, or cognitive decline.

Sleep Apnea Symptoms and Diagnosis

Snoring is considered to be a major warning sign of a sleep breathing disorder, such as sleep apnea. Other symptoms of sleep apnea include:

1. Chronic fatigue

2. Problems concentrating

3. Irritability or mood swings

4. Impotence

5. Restless sleep

6. Bruxism (teeth grinding) while asleep

Children with sleep apnea often exhibit symptoms that mimic a hyperactivity disorder, such as ADHD.

The only way to know for sure if you have sleep apnea is to undergo an evaluate by a sleep apnea specialist such as Dr. Brian J. Hockel. By conducting a thorough evaluation of your oral health, bite alignment, and airway, Dr. Hockel can determine whether you suffer from a sleep breathing disorder. A sleep study may be necessary to aid in the diagnostics. The dental practice of Life Dental & Orthodontics offers at-home sleep studies that can be conducted in the comfort of your own home.

Sleep Apnea Treatments

CPAP – Force air into the airway

The most popular treatment prescribed for sleep apnea is to wear a CPAP machine. CPAP stands for Continuous Positive Airway Pressure, and this machine covers your nose and mouth, keeping air and oxygen flowing into your airway and forcing it open. However, CPAP users often find that the machine is bulky, noisy, and inconvenient to use. Therefore, CPAP uses often discontinue therapy after only a few months.

Oral Appliance – Temporarily reposition the jaw

In dentistry, the use of an oral appliance is another popular choice to treat sleep apnea. While we do prescribe oral appliances at times for sleep apnea patients, here at the dental practice of Life Dental & Orthodontics, we do not believe that oral appliance therapy is a one-size-fits-all approach to treating sleep apnea.

Oral appliance therapy does have its benefits. It is relatively inexpensive compared to other treatment options, such as surgery or CPAP; it is also more convenient, travels easier, and typically resolves cases of sleep apnea that are mild to moderate. However, prolonged used of an oral appliance may cause eventual issues, such as bite misalignment, and the results from an oral appliance can be a gradual process.

Surgery – Permanently reposition the jaw

For a permanent solution to your sleep apnea, surgery may be the best option. Surgery seeks to correct the issues that cause sleep apnea by moving the jaws into the proper position to maintain an open airway. Performed correctly, jaw surgery fixes sleep apnea by addressing the cause and eliminates the need for other treatments, such as CPAP or oral appliances. Surgery can also address any potential issues with the nasal airways or soft palate. The major negatives are that surgery is the most expensive and intensive treatment for sleep apnea, and any surgery carries a certain amount of risk.

If you or a member of your family is exhibiting the symptoms of sleep apnea, this disorder will not go away on its own. Call our office today at (925) 934-3434 to schedule an initial consultation with us for your sleep apnea treatment in Walnut Creek, California.

Dr. Brian Hockel and our team at Life Dental & Orthodontics are proud to serve patients from Walnut Creek, Clayton, Concord, and Lafayette, California, as well as from the greater San Francisco East Bay area and beyond.