Sleep apnea,
gastric reflux and ADHD
Of
late one of the areas of focus amongst Dental continuing education programs is
in the field of Sleep Apnea. Most medical doctors are not yet aware of the role
the dentist can play in identifying potential Sleep Apneic patients. Likewise a
lot of dentists are just coming into information that correlates the Sleep
Apnea with host dental complications. In fact there is a term for this area of
focus –“Sleep Dentistry”. The implications behind this
connection is of such profound nature that I believe that this is one area in
which dentists can truly play a valuable role in participating to help patients
with a condition if left unchecked can result in consequences where are at the
very least affecting the quality of life or at the very worst can affect the
longevity of life itself. That sounds a little too bombastic a claim. But wait
till I lay out the connection and implications in the paragraphs below and then
judge for yourself the value of the information.
What is Sleep Apnea?
Apnea, the term refers
to lack or shortage of oxygen to the brain. Sleep Apnea is therefore a
condition that results when there is deprivation of oxygen to the brain. Put it
simply when the body is functioning at its optimum the driving force behind the
regular breathing that we do is usually the amount of carbon dioxide that
builds up in our systems. More carbon dioxide results in more forceful or rapid
breathing. Thus when we dive into a deep body of water, we hold our breath until
we can no longer hold it and then surface to breathe. This is the classic
example of the power of CO2 buildup in our system. It is not the lack of oxygen
that forces us up but rather the accumulation of CO2. But what if we were
unconscious or mentally in an altered state? Then the CO2 build up has less of
an influence. However if we do not breathe in time the Oxygen levels will
deplete to the point of a crisis and this is when the Brain issues its most
powerful waking up stimulus in order to make us breathe.
During sleep our bodies
are designed to undergo a partial state of a paralysis. This is partly to
prevent us from physically acting out our dreams. As a result of this most of
our body musculature becomes flaccid. When one sleeps on their back and they
are in this state of partial paralysis the tongue tends to fall to back of the
throat. This obstructs or at least constricts the opening at the back of the
throat. Furthermore the back of the palate also flops down and further
constricts the opening. In this constricted space as the air moves at great
speed it causes the soft palate to vibrate like a flag fluttering in the wind.
This fluttering noise is what we all recognize as a classic snore. Snores might
be loud but not necessarily with any medical implications (other than to the
sleeping partners who tend to get inadequate sleep).
But what if the opening
at the back of throat was already compromised with unduly enlarges tonsils or
residual adenoids or anatomically a small passage to begin with? In this
scenario a slack tongue might almost completely block the airway passage. In
this condition the sleeping individual progresses from loud snores to complete cessation
of breathing for a while followed by an explosive cough induced resumption of
breathing. I am sure some of you have encountered someone in the family who
tends to do this.
So what is it that is
happening in this person? When we fall asleep, as we enter the deeper stages of
sleep, our muscles relax to the point of near paralysis. At or just before this
stage the tongue begins to fall back accompanied by increasingly loud snoring
until at a particular stage the tongue completely blocks the opening at the
back of the throat. The body continues to try and breathe but is increasingly
met with resistance because of the blockage in the throat. The CO2 build up
continues and in response to this the muscles of the chest futilely continue to
try and expand and drawn in air. Finally after a few precious seconds the brain
begins to notice the depletion in the Oxygen level and that is when it triggers
the emergency mechanism which forces the person the wake up with an explosive
cough. Once the person resumes breathing he falls back to sleep and the cycle
repeats itself over and over again.
As a consequence of
this style of eventful sleep, the person wakes up after 8 hours of sleep not
feeling rested at all. Disturbed Sleep has consequences to the body. During normal
sleep a variety of things happen to the body. Starting with the mind, it is the
phase during which the memory banks of the brain are cleaned up and sorted out.
Problems for which an answer had not been found while awake get the
subconscious mind’s help and sometimes helps to refocus the mind and perchance
arrive at the solution. The brain also releases hormones during sleep that
helps in repairing the body. The body itself is allowed to rest and recoup.
Therefore in the absence of adequate sleep a series of rippling effects happen
to the body.
Effects
of Lack of Sleep: Lack of sleep triggers inflammation in the cardiovascular system.
It also skews the body’s capacity to deal with Carbohydrate intake. It creates Diabetic like responses to sugars. In
addition the Sleep Apnea episodes cause shortage of oxygen to the brain
multiple times every night and in response to this the body spikes the blood
pressure- over time this can lead to Hypertension.
This along with the potential for inflammatory response in the cardiovascular
system can eventually lead to life threatening events like strokes or heart attacks. A large percentage of people with
moderate to severe Sleep Apnea also happen to be overweight. These are people
with either poor food habits and/or tend to eat late just before going to bed.
Obesity is also accompanied by a lack of desire for physical activity or
exercise. In these individuals the Basic Metabolic Rate (BMR) is low resulting
in easy accumulation of excess calories in the form of fat deposits. In obesity
one of the place where fats concentrate there deposition is in the neck region.
This aids in constricting the available airway space even more and this makes
Sleep Apnea more pronounced.
Gastric Reflux:
Our Gastro-intestinal
(GI) tract is designed to pass food and water in one direction only. To
facilitate this the musculature of the GI tract in conjunction with
appropriately positioned uni-directional valves help to keep the flow in one
direction. The portion of the GI tract that traverses the chest cavity ends in
the stomach just beneath the chest cavity. In sleep apnea when there is an
obstruction at the upper end of the breathing tube (esophagus), the chest wall
and diaphragm continues to expand to prepare for the air intake. If the
obstruction is quite significant then it results in a lot negative pressure
building up in the chest space. Persistence of this pressure can cause the food
in the stomach to get sucked up the esophagus much like what happen during a regurgitation
episode. Sustained and repetitive reverse flow of food eventually weaken the musculature
and the check valve at the stomach to esophagus connection. Eventually it
becomes easy for stomach contents to travel up the food tube to the mouth. This
is called Gastric Reflux.
The results of gastric
reflux is that the patient begins to suffer from heartburns, sour taste in the
mouth from acid being brought up, even worse is the danger of aspirating
stomach content during an explosive breathing event during sleep. The latter
can result in conditions like pneumonia. Chronis acid regurgitation can result
in pre-cancerous conditions in the esophagus. While all of these are medical
complication it does a lot dental damage also. The high amount of acid in the mouth causes erosion of
tooth material, increases the activity and aggressive effects of bacteria in
the mouth.
Tooth
Grinding and Sleep Apnea: Most people who snore or have
classic Sleep Apnea symptoms would invariably disagree with any tooth grinding
tendency.
“But Doc. How can I grind my teeth when my spouse complaints of their
inability to sleep due to my loud snoring. I cannot grind and snore at the same
time, can I?”
Counter intuitive as it might seem, people with sleep
apnea do snore and grind their teeth. Disruptive snoring as
explained earlier is due to the constriction of the airway passage at the back
of the throat due to the tongue falling back and blocking it. People with
classic Sleep Apnea never attain the true deep sleep required to produce atonic
paralysis of their muscles. They merely drift between superficial levels of sleep
and the beginnings of the deep atonic sleep. Just as they enter the deeper
sections of the sleep the tongue relaxes enough to fall back band begin the
process of choking the airway passage. The body learns fairly early that to
keep the person alive it cannot allow the person to drift into a really deep
sleep. Therefore it tries to keep the person just hovering about the early
stages of sleep and one of the way it does this is by grinding the teeth. In
grinding the teeth the jaw is constantly kept in motion and to do so the brain
has to retain some of it conscious activities. The grinding therefore usually
happens interspersed with the explosive coughing and snoring.
Teeth Grinding and
Gastric Reflux can occur independent of Sleep Apnea. The long term risks to
health and dental management are still just as important. As we became aware of
these conditions and the signs to look for, we in the dentist community have
come to realize that these are not the maladies of the minority of patients but
appears to be much more prevalent in the general population. In most instances
they occur symptomless and silent. The signs are there for us see, but devoid
of real associative symptoms it becomes difficult to convince patients on the
need to monitor and sometimes seek treatment.
This level of tooth
wear is due to a combination of high acid content in the mouth and grinding.
ADHD (Attention Deficit Hyperactivity Disorder):
This is another
controversial topic. I am not qualified to make the case for or against the
practice of diagnosing ADHD. However in adults and children who have classic
sleep apnea or similar sleep disturbances their behavior would mimic the patients
being diagnosed with ADHD. To briefly summarize, Sleep Apnea is the shortfall
in the amount of oxygen being made available to the body due to a disruption in
the patient ability to breathe normally. When the patient is awake this
situation either never occurs or is easily compensated by the patient. Sleep is
risky for this patient. Given a choice the brain would like to keep the patient
awake as this ensures uninterrupted breathing. In a sleep deprived individuals
the only way they can remain awake is to be constantly physically active.
Some of you might have
noticed how infants who miss their regular sleep become hyperactive. The reason
for this is that if they were to sit down or calm themselves there body will
initiate the process of falling asleep. The stages of child sleep onset has
been fairly well observed by us all. First is the regular sleepy phase which if
disrupted will make the child irritated. But if the child is also exposed to a situation
where sleep is not possible, like being at a loud party, then they will join in
and soon be running around in circles and start showing signs of hyperactivity
and later crankiness. This is because the body is getting exhausted but the
mind wants to keep going on and the child is becoming frustrated when the body
does not seem to want to co-operate. The same child as soon as he or she gets
strapped into a car seat will fall asleep even before the vehicle has changed
through its gear sequence.
This is pretty much
what happen to sleep deprived adult or a child. They will appear to be full of
life and energetic until they sit down or are forced to physically quieten down.
Then they almost immediately fall asleep. The sleep deficit makes them more
likely to fall asleep anywhere but since the mind is aware of danger of allowing
them to slip into a deep sleep it keeps trying to keep them floating in a
shallow sleep. (This is where they clench and grind their teeth). In children
they also realize that they can only stay awake if they are constantly in a
state of motion. This becomes interpreted as Hyperactivity Disorder. Most
School and learning activity requires a level of mental concentration which can
only happen if they are physically also calm. But for these sleep deprived
children any physical calmness will lead them to start getting sleepy and makes
them to zone out frequently. This will be interpreted as Attention Deficit.
All children with ADHD
type of conditions may not have a co-related sleep apneic issue. But I think it
warrants that every child who is being suspected of ADHD be at the very least
be evaluated for Sleep Apneic conditions. Children with allergy history,
chronic sinusitis, asthma, are also likely to show Sleep Deficiency. If
diagnosed early and treated, might not only change their sleep routine but
may also help them become more productive in general.
To summarize:
Sleep Apnea results in
Hypertension, Diabetic like body response to food, Heart Disease, Gastric
Reflux, ADHD type of behavior
And
Dental implications are
damage from tooth grinding, complications from Gastric Reflux disease.
Since in most cases the
Gastric Reflux and Sleep apnea symptoms may not be that apparent for anyone to
seek medical attention they rarely get diagnosed by the Medical Community.
These same patients however get seen more regularly at the dental office. Which
is why dental office are now becoming critical in screening patients for Sleep
Apnea, Gastric Reflux and Hypertension.
