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.
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.
Sleep Apnea results in Hypertension, Diabetic like body response to food, Heart Disease, Gastric Reflux, ADHD type of behavior
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.