Tuesday, August 18, 2009

Sleep Apnea Raises Death Risk 46 Percent

WASHINGTON, Aug 17 (Reuters) - Severe sleep apnea raises the risk of dying early by 46 percent, U.S. researchers reported on Monday, but said people with milder sleep-breathing problems do not share that risk.

They said people with severe breathing disorders during sleep were more likely to die from a variety of causes than similar people without such sleep disorders. The risks are most obvious in men aged 40 to 70, Naresh Punjabi of Johns Hopkins University in Baltimore and colleagues found.

Sleep apnea is caused by a collapse of the upper airway during sleep. Strong snoring can be a symptom but what makes apnea different are numerous brief interruptions in breathing.

Sleep apnea is closely linked with obesity, high blood pressure, heart failure and stroke, but researchers have not been able to clearly quantify how much more likely it makes a person to die.

Punjabi's team studied 6,400 men and women for an average of eight years. Those who started with major sleep apnea were 46 percent more likely to die from any cause, regardless of age, sex, race, weight or smoking, they reported in the Public Library of Science journal PLoS Medicine.

Men aged 40 to 70 with severe sleep-disordered breathing were twice as likely to die from any cause as healthy men the same age, they reported in the study -- available online ">here

"Among men, 42.9 percent did not have sleep-disordered breathing, 33.2 percent had mild disease, 15.7 percent had moderate disease, and 8.2 percent had severe disease," they wrote.

They said about 25 percent of the women had mild sleep apnea, 8 percent had moderate disease and 3 percent had severely disordered breathing.

The researchers, funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health, said people with milder sleep-breathing disorders were not more likely to die early.

The NHLBI estimates 12 million adult Americans have sleep apnea, but most are not diagnosed or treated. The National Sleep Foundation puts the number at 18 million.

"In severe sleep apnea a patient's airway is blocked while the patient suffers for 20 to 30 seconds and wakes up.

"When it becomes this frequent -- 30 times per hour -- about every two minutes it is severe sleep apnea and can become a problem," said Dr. David Rapoport of New York University, who worked on the study.

"The best treatment for sleep apnea is weight loss. However, the most successful treatment can be a nasal CPAP (continuous positive airway pressure) mask that applies pressure to help keep the airways of a patient open while they sleep, allowing normal breathing," he added in a statement.

"Another possible helpful treatment is surgery. That may include tonsil removal," said Rapoport. "A mouth guard that pulls a patient's mouth forward is another option."

A small Canadian company, Victhom Human Bionics Inc. (VHB.TO), has filed a patent on a new device to detect sleep apnea, which must usually be diagnosed in a sleep lab and Medtronic Inc. (MDT.N) makes sleep apnea devices. (Editing by Todd Eastham)

NTSB Recomendation Regarding Sleep Apnea

NTSB Makes Safety Recommendation Regarding Sleep Apnea

Sun, 16 Aug '09

Mesa Airlines Hawaii Flight Spurs Call For Tracking OSA In Commercial Pilots

In a recently-released final report concerning a Mesa Airlines flight operating as go! Airlines in Hawaii, it was determined that the pilot acting as captain of the aircraft and the first officer both inadvertently fell asleep in flight, causing the airplane to overshoot its destination by 26 miles. As part of the investigation it was determined that the captains' sleep schedule had been interrupted by previously undiagnosed obstructive sleep apnea (OSA).

According the information released by the NTSB, if a commercial pilot is diagnosed with OSA, the Federal Aviation Administration (FAA) 2006 Guide for Aviation Medical Examiners states that an aviation medical examiner (AME) must submit all pertinent medical information and current status report and include sleep study with a polysomnogram, use of medications and titration study [in which the optimal pressure for CPAP is identified] results. The guidance further notes that an initial special issuance of a medical certificate for the disorder requires an FAA decision. Subsequent issuance of a medical certificate may be authorized through the AME if the applicant provides a report performed in the last 90 days from the treating physician that describes the present treatment and its effectiveness in eliminating or reducing symptoms, including daytime sleepiness. A maintenance of wakefulness test is required if there is any question about compliance with or response to treatment, and the AME must defer the certification decision if the individual demonstrates sleep deficiency on a maintenance of wakefulness test, has developed an illness associated with OSA, or if there is doubt about compliance with or effectiveness of therapy. Treatment can only begin, however, after diagnosis, and there is evidence that certificated commercial pilots are significantly underdiagnosed.

The FAA does not provide guidance to AMEs describing risk factors for OSA, nor does the FAA routinely use medical information (such as height, weight, and blood pressure) collected during certification examinations to screen for the possible presence of the disorder. Furthermore, the Application for Airman Medical Certificate asks applicants about their history of over 20 specific conditions or symptoms but does not specifically ask about a history of OSA or the presence of symptoms, such as snoring or excessive daytime sleepiness, related to OSA.

Except for the FAA, every U.S. Federal agency that oversees passenger transportation either gathers or plans to gather subjective information specific to OSA from transportation operators. By contrast, the FAA is not yet formally considering such changes. Objective medical data already gathered by the FAA could be used to measure risk for OSA using existing consensus guidance on screening, but the most effective screening would require the FAA to gather additional information and develop additional guidance.

The NTSB concludes that efforts to identify and treat the disorder in commercial pilots could improve the safety of the traveling public. Therefore, the NTSB recommends that the FAA modify the Application for Airman Medical Certificate to elicit specific information about any previous diagnosis of OSA and about the presence of specific risk factors for that disorder. The NTSB further recommends that the FAA implement a program to identify pilots at high risk for OSA and require that those pilots provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. In addition, the NTSB recommends that the FAA develop and disseminate guidance for pilots, employers, and physicians regarding the identification and treatment of individuals at high risk of OSA, emphasizing that pilots who have OSA that is effectively treated are routinely approved for continued medical certification.

FMI: www.ntsb.gov

Sunday, August 9, 2009

RLS Article From the National Sleep Foundation

Restless Legs Syndrome (RLS) and Sleep

Restless Legs Syndrome (RLS) is a neurologic sensorimotor disorder that is characterized by an overwhelming urge to move the legs when they are at rest. The urge to move the legs is usually, but not always, accompanied by unpleasant sensations. It is less common but possible to have RLS symptoms in the arms, face, torso, and genital region. RLS symptoms occur during inactivity and they are temporarily relieved by movement or pressure. Symptoms of RLS are most severe in the evening and nighttime hours and can profoundly disrupt a patient's sleep and daily life.

RLS affects approximately 10% of adults in the U.S. Researchers believe that RLS is commonly unrecognized or misdiagnosed as insomnia or other neurological, muscular or orthopedic condition. RLS may also be confused with depression. According to the Restless Legs Syndrome Foundation, approximately 40% of people with RLS complain of symptoms that would indicate depression if assessed without knowledge or consideration of a sleep disorder.

RLS runs in families and may have a genetic component. In a recent study, the first RLS gene was discovered and was shown to account for approximately 50% of RLS cases. However, the researchers who identified the RLS gene cautioned that having it does not guarantee RLS. Rather, there are likely to be medical, environmental or other factors involved in translating RLS genetic susceptibility into RLS symptoms. Another recent RLS study also found that a genetic variant may account for about half of RLS cases and revealed an association between RLS and a gene for limb development, suggesting the possibility that RLS has components of a developmental disorder.

What is RLS?

RLS also affects about 2% of children, according to a recent study of more than 10,000 families in the U.S. and U.K. The study also found a strong genetic component to RLS; more than 70% of children with RLS had at least one parent with the condition. There is also evidence suggesting that children with attention deficit hyperactivity disorder (ADHD) and a family history of RLS are at risk for more severe ADHD.

RLS affects both men and women and can start at any age. It may be confused with growing pains or restlessness when experienced by children. In addition, the severity of the disorder appears to increase with age. Older patients experience symptoms more frequently and for longer periods of time.

The exact cause of RLS is unknown but it has a primary form, not related to other disorders, and a secondary form related to an underlying condition such as kidney failure, pregnancy, or iron deficiency anemia. It may also be caused or made worse by certain medications. This is considered secondary RLS. When no other cause is found for RLS symptoms, it is considered a primary disorder. Primary RLS accounts for 40-60% of RLS diagnoses.

Recently, several research teams have taken a closer look at what might cause primary RLS. In particular, recent studies at Johns Hopkins and Pennsylvania State Colleges have found evidence for brain iron deficiency as a cause for primary RLS. This was first demonstrated in cerebrospinal fluid studies and more recently by the first-ever autopsy analysis of the brains of people with RLS. The autopsy studies reported that cells from the portion of the brain called the substantia nigra showed a deficit in one of the proteins that regulates iron status. However, this evidence suggests that the iron insufficiency in the brain of RLS patients comes directly from a failure of normal iron regulation. In terms of finding a cure, this is good news. The results of this study show that there is no brain damage in people with RLS and that drugs that target the problem of iron uptake may be one way to approach future developments of a treatment.

More than 80 percent of people with RLS also suffer from a condition know as periodic limb movement disorder (PLMD). Characteristics of PLMD include involuntary leg twitching or jerking movements during sleep that occur repeatedly throughout the night and result in disrupted sleep.

In addition to poor quality and short sleep at night, research has shown that people with RLS generally experience a reduced quality of life in the absence of treatment.


Symptoms include an urge to move the legs often associated with uncomfortable feeling in the legs (e.g. tingling, creepy, itching, pulling or aching) during periods of inactivity, including both sleep and wakefulness. Symptoms may also include involuntary jerking of the limbs that intensifies in the evening or at night and is relieved by movement. People with RLS tend to have difficulty falling or staying asleep and suffer from chronic sleep loss, leaving them with the cognitive and tired feelings that occur with sleep loss.


There is no specific diagnostic test for RLS. If you suspect you may have the disorder, talk to your doctor as soon as you can. If possible, bring a diary of your sleep as well as a record of the occurrence and severity of your symptoms with you. Your doctor will conduct tests to rule out factors that may be causing the symptoms such as pregnancy, iron deficiency and end-stage renal failure. You can expect that he or she will ask what time your symptoms occur, when they are most severe, what you were doing before the onset of symptoms, and how much time elapses before you are able to get to sleep due to your RLS. Your doctor will also need a record of your sleep quality and quantity during the time when symptoms appear and whether or not you experienced any pain along with the RLS symptoms.

Until recently, there were no FDA-approved drugs for the treatment of RLS. In May 2005, a drug called Requip® (ropinirole hydrochloride) that is commonly used to treat Parkinson disease was given FDA approval at lower doses for the treatment of moderate-to-severe primary RLS after patients in clinical trials enjoyed more and better quality sleep as early as one week after starting treatment. In 2006, a drug by the name of Mirapex® was also approved by the FDA for the treatment of moderate-to-severe primary RLS. In clinical trials of Mirapex® it was shown that lower doses (than used for Parkinson’s disease) improve RLS symptoms, sleep satisfaction, and quality of life. Both drugs may cause side effects such as nausea and dizziness and may cause patients to fall asleep without any warning, even while doing normal daily activities such as driving.

In addition to Requip® and Mirapex®, there are several drugs approved for other conditions that have been shown to alleviate RLS symptoms. They are:

  1. Dopaminergic agonists -- reduce RLS symptoms
  2. Dopaminergic agents -- reduce RLS symptoms
  3. Benzodiazepines -- allow for a more restful sleep
  4. Opiates -- induce relaxation and diminish pain

Side effects may include daytime sleepiness (dopaminergic agonists and benzodiazepines), hallucinations and nausea (dopaminergic agents) or constipation and dependency (opiates). Before taking any medication, discuss the possibility of side effects with your doctor.

In 1996, Drs. Allen and Earley from Johns Hopkins University described a phenomenon called augmentation, in which RLS symptoms are more severe, spread to parts of the body other than the legs, and begin earlier in the evening as a result of taking dopaminergic agents to treat RLS symptoms. If augmentation occurs it can be managed with dose and medication adjustments.

There are also a number of self-directed activities for managing the symptoms of RLS including walking, massaging the legs, stretching, hot or cold packs, vibration, and acupressure. Practicing relaxation techniques such as meditation or yoga have been known to alleviate symptoms. For many people, treating an underlying cause or effective pharmacological treatment of primary RLS and implementation of coping strategies provides relief from most symptoms. However, sometimes medications need to be changed over time or doses adjusted and regular consultation with a physician is recommended.


The following are some tips for coping with RLS:

  • Don't hide your symptoms -- talk to your friends, family, and colleagues about RLS so they know what to expect
  • Practice yoga, Pilates, or other stretching techniques regularly, preferably late in the day
  • Arrange your schedule to be able to sleep when your symptoms are least pronounced
  • Choose an aisle seat at the movies or on airplanes so that you are able to move around if necessary
  • Plan travel hours when symptoms are least severe and allow times for breaks

There are also a number of RLS support groups around the country and they can help you learn new information about how others cope with RLS. For a list of such groups, go to www.rls.org or www.rlshelp.org.


2005 poll: 15% of the adult population responding to the NSF Sleep in America poll have symptoms of RLS a few nights a week or more, which could include unpleasant feelings in the legs such as creepy, drawly or tingling feelings, and 10% met the criteria for being at risk for RLS because – of those who experienced these symptoms -- such feelings were worse at night (146 persons).

Of those who have symptoms of RLS, 86% are also likely to have insomnia symptoms and sleep just 6.3 hours per weeknight, which is less than the mean for all respondents of 6.8 hours. Almost half (47%) of those experiencing RLS symptoms also take 30 minutes or more to fall asleep at night. Although 28% of all adults state that they missed work because of being too sleepy, 52% of those with RLS symptoms reported missing work or other events due to a sleep problem.

2002 poll: Even though 40% of adults polled rated their sleep as very good/excellent, just 20% of those with RLS symptoms reported the quality of their sleep this way. Also, of the total number of adults polled, 16% report experiencing RLS symptoms at least a few nights per week; however, just 4% have been diagnosed with the disorder. 32% of those with symptoms have used a sleep aid while 46% of those diagnosed used a sleep medication. Persons with RLS symptoms are more likely (60%) compared to the total (37%) to have daytime sleepiness a few days a month or more. Quality of life is affected by RLS symptoms. Those with these symptoms report being tired (35% vs. 20%), pessimistic (16% vs. 10%), prefer to be alone (34% vs. 22%), stressed (37% vs. 21%) and be angry (15% vs. 6%) during a typical day.

Reviewed by Richard P. Allen, Ph.D.and Merrill M. Mitler, Ph.D.

Interesting Question - From the Division of Sleep Medicine at Harvard

Why Do We Sleep, Anyway?

At a Glance

  • Our bodies regulate sleep in much the same way that they regulate eating, drinking, and breathing. This suggests that sleep serves a similar critical role in our health and well-being.
  • Although it is difficult to answer the question, "Why do we sleep?" scientists have developed several theories that together may help explain why we spend a third of our lives sleeping.
  • Understanding these theories can help deepen our appreciation of the function of sleep in our lives.

Hunger and Eating; Sleepiness and Sleep

While we may not often think about why we sleep, most of us acknowledge at some level that sleep makes us feel better. We feel more alert, more energetic, happier, and better able to function following a good night of sleep. However, the fact that sleep makes us feel better and that going without sleep makes us feel worse only begins to explain why sleep might be necessary. One way to think about the function of sleep is to compare it to another of our life-sustaining activities: eating. Hunger is a protective mechanism that has evolved to ensure that we consume the nutrients our bodies require to grow, repair tissues, and function properly. And although it is relatively easy to grasp the role that eating serves— given that it involves physically consuming the substances our bodies need—eating and sleeping are not as different as they might seem.

Both eating and sleeping are regulated by powerful internal drives. Going without food produces the uncomfortable sensation of hunger, while going without sleep makes us feel overwhelmingly sleepy. And just as eating relieves hunger and ensures that we obtain the nutrients we need, sleeping relieves sleepiness and ensures that we obtain the sleep we need. Still, the question remains: Why do we need sleep at all? Is there a single primary function of sleep, or does sleep serve many functions?

An Unanswerable Question?

Scientists have explored the question of why we sleep from many different angles. They have examined, for example, what happens when humans or other animals are deprived of sleep. In other studies, they have looked at sleep patterns in a variety of organisms to see if similarities or differences among species might reveal something about sleep's functions. Yet, despite decades of research and many discoveries about other aspects of sleep, the question of why we sleep has been difficult to answer.

The lack of a clear answer to this challenging question does not mean that this research has been a waste of time. In fact, we now know much more about the function of sleep, and scientists have developed several promising theories to explain why we sleep. In light of the evidence they have gathered, it seems likely that no single theory will ever be proven correct. Instead, we may find that sleep is explained by two or more of these explanations. The hope is that by better understanding why we sleep, we will learn to respect sleep's functions more and enjoy the health benefits it affords. This essay outlines several current theories of why we sleep. To learn more about them, be sure to check out the "Bookshelf" feature at the end of this essay. There you'll find links to articles by researchers who are studying this fascinating question.

Theories of Why We Sleep

Inactivity Theory

One of the earliest theories of sleep, sometimes called the adaptive or evolutionary theory, suggests that inactivity at night is an adaptation that served a survival function by keeping organisms out of harm’s way at times when they would be particularly vulnerable. The theory suggests that animals that were able to stay still and quiet during these periods of vulnerability had an advantage over other animals that remained active. These animals did not have accidents during activities in the dark, for example, and were not killed by predators. Through natural selection, this behavioral strategy presumably evolved to become what we now recognize as sleep. A simple counter-argument to this theory is that it is always safer to remain conscious in order to be able to react to an emergency (even if lying still in the dark at night). Thus, there does not seem to be any advantage of being unconscious and asleep if safety is paramount.

Energy Conservation Theory

Although it may be less apparent to people living in societies in which food sources are plentiful, one of the strongest factors in natural selection is competition for and effective utilization of energy resources. The energy conservation theory suggests that the primary function of sleep is to reduce an individual’s energy demand and expenditure during part of the day or night, especially at times when it is least efficient to search for food.

Research has shown that energy metabolism is significantly reduced during sleep (by as much as 10 percent in humans and even more in other species). For example, both body temperature and caloric demand decrease during sleep, as compared to wakefulness. Such evidence supports the proposition that one of the primary functions of sleep is to help organisms conserve their energy resources. Many scientists consider this theory to be related to, and part of, the inactivity theory.

Restorative Theories

Another explanation for why we sleep is based on the long-held belief that sleep in some way serves to "restore" what is lost in the body while we are awake. Sleep provides an opportunity for the body to repair and rejuvenate itself. In recent years, these ideas have gained support from empirical evidence collected in human and animal studies. The most striking of these is that animals deprived entirely of sleep lose all immune function and die in just a matter of weeks. This is further supported by findings that many of the major restorative functions in the body like muscle growth, tissue repair, protein synthesis, and growth hormone release occur mostly, or in some cases only, during sleep. Other rejuvenating aspects of sleep are specific to the brain andcognitive function. For example, while we are awake, neurons in the brain produce adenosine, a by-product of the cells' activities. The build-up of adenosine in the brain is thought to be one factor that leads to our perception of being tired. (Incidentally, this feeling is counteracted by the use of caffeine, which blocks the actions of adenosine in the brain and keeps us alert.) Scientists think that this build-up of adenosine during wakefulness may promote the "drive to sleep." As long as we are awake, adenosine accumulates and remains high. During sleep, the body has a chance to clear adenosine from the system, and, as a result, we feel more alert when we wake.

Brain Plasticity Theory

One of the most recent and compelling explanations for why we sleep is based on findings that sleep is correlated to changes in the structure and organization of the brain. This phenomenon, known as brain plasticity, is not entirely understood, but its connection to sleep has several critical implications. It is becoming clear, for example, that sleep plays a critical role in brain development in infants and young children. Infants spend about 13 to 14 hours per day sleeping, and about half of that time is spent in REM sleep, the stage in which most dreams occur. A link between sleep and brain plasticity is becoming clear in adults as well. This is seen in the effect that sleep and sleep deprivation have on people's ability to learn and perform a variety of tasks.

This theory and the role of sleep in learning are covered in greater detail in Sleep, Learning, and Memory.

Although these theories remain unproven, science has made tremendous strides in discovering what happens during sleep and what mechanisms in the body control the cycles of sleep and wakefulness that help define our lives. While this research does not directly answer the question, "Why do we sleep?" it does set the stage for putting that question in a new context and generating new knowledge about this essential part of life. For more about why we sleep, watch the video Why Sleep Matters and explore Consequences of Insufficient Sleep.

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This content was last reviewed on December 18, 2007

Boston Globe - Dangers of Driving While Drowsy

Drowsy-driving tragedies preventable

RECENTLY, the National Transportation Safety Board announced that drowsy driving was the probable cause of the fatal collision of two MBTA Green Line trains in Newton last year. The safety board concluded that MBTA operator Ter’rese Edmonds, who was killed in the crash, did not respond to a red stop signal, likely because she briefly fell asleep at the wheel.The board concluded that she was at high risk for having an undiagnosed sleep disorder known as obstructive sleep apnea. Urine drug testing also revealed her prior use of a sedating antihistamine commonly used in over-the-counter treatments for insomnia, allergies, and the common cold, although the chemical was no longer detectable in her blood at the time of the crash.

Drowsy driving is one of the most common causes of crashes in all modes of transportation. The board has also found that fatigue is the most common cause of fatal-to-the-driver truck crashes - equal to drug- and alcohol-related crashes combined. Auto drivers are no exception. Every day in the United States, 250,000 motorists fall asleep at the wheel, causing 8,000 deaths and 60,000 debilitating injuries annually. Fortunately, such tragic drowsy-driving crashes are preventable.

Earlier this year, the Massachusetts Drowsy Driving Commission, chaired by state Senator Richard T. Moore of Uxbridge, made a series of recommendations to reduce drowsy-driving crashes. Education about the risks of drowsy driving is a critical first step, which is why the safety board faulted the MBTA for having an inadequate program for educating train operators about the risks of fatigue. The diagnosis and treatment of sleep disorders is a second critical step, which is why the board faulted the MBTA for having an inadequate program to identify and treat sleep disorders among train operators.

Sleep disorders and sleep deprivation - which affect 50 million to 70 million Americans - increase the risk of attentional failures and distraction, lengthen reaction time, degrade cognitive performance, impair immune responses, increase mood swings, and interfere with memory consolidation and learning. Yet the Institute of Medicine recently estimated that 90 percent of Americans with the sleep disorder known as obstructive sleep apnea are undiagnosed and untreated.

Sleep disorders medicine is given scant attention in most medical schools and academic medical centers, which chronically sleep-deprive physicians-in-training by scheduling them to work 30-hour shifts twice each week, to the detriment of both the trainees and their patients. Consequently, even when a patient seeks help from a doctor for the symptoms of obstructive sleep apnea, it can often take several years to be correctly diagnosed. Then, only half of those diagnosed comply with treatment, yielding a 5 percent success rate.

We can and should do better because obstructive sleep apnea is a serious disease. It robs individuals of the restorative value of sleep, since they have difficulty breathing during sleep. Many awaken more than 100 times a night in order to breathe. Choking off the air supply during sleep activates the sympathetic nervous system and increases blood pressure. In fact, untreated obstructive sleep apnea is the leading known cause of hypertension, or high blood pressure, likely accounting for an estimated one-third of cases. Obstructive sleep apnea alters metabolism and may increase risk of obesity, diabetes, atrial fibrillation, ventricular arrhythmias, and sudden cardiac death at night.

Obstructive sleep apnea increases the risk of motor vehicle crashes by 500 to 700 percent and raises medical costs. Schneider Trucking recently reported that introduction of a screening and treatment program for obstructive sleep apnea among drivers in its trucking fleet reduced fatigue-related truck crashes by 30 percent, cut medical costs in treated drivers by 58 percent, and increased its driver retention rate.

The effects of sleep disorders and sleep deprivation on driver performance are comparable to those of elevated blood alcohol concentrations, and should be taken just as seriously. Identification and treatment of sleep disorders such as obstructive sleep apnea can reduce the risk of crashes and improve public safety. It is time to implement the recommendations of both the safety board and the Massachusetts Drowsy Driving Commission to reduce the risks of one of the leading preventable causes of transportation crashes: fatigue.

Charles A. Czeisler, a professor and director of sleep medicine divisions at Harvard Medical School and Brigham and Women’s Hospital, was a member of the Massachusetts Drowsy Driving Commission.

NPR Story On Sleep Apnea

Larry Barsh is a man with a new mission. The retired dentist from New York City wants to help Americans recognize that they may have obstructive sleep apnea, a chronic condition among snorers that disrupts sleep. Dr. Barsh started a Web site, SnoringIsn'tSexy.com, to help educate patients and help dentists play a role in identifying patients with sleep apnea.

Barsh says the vast majority of people with apnea don't know they have the condition. Dentists are in a unique position to help patients who might suffer from sleep apnea, he says. Typically, dentists see patients more often than physicians, at least two times a year for teeth cleaning.

Disruptive snoring may signal sleep apnea.

For an estimated 12 million Americans, disruptive snoring signals the condition obstructive sleep apnea.iStockphoto.com

At Risk

The National Institutes of Health estimates that more than 12 million American adults have obstructive sleep apnea. Among older Americans, the rate is especially high: at least one out of 10 over the age of 65 has it.

Doctors don't know exactly why sleep apnea occurs, but it is associated with obesity, aging and anatomy, says Dr. Clete Kushida, a neurologist and director of the Stanford Center for Human Sleep Research and president of the American Academy of Sleep Medicine.

The obstructed breathing can result from a variety of factors, such as a large tongue, a large uvula (that cone-shaped projection of tissue in the back of the throat) or a lot of large, crowded teeth. As muscles relax, which they do when people fall asleep — especially on their backs — the tongue muscles tend to pull back and block the airway.

Snoring And Apnea

Snoring is a sign of apnea. Only about 5 to 10 percent of snorers actually have sleep apnea, says Barsh, but everyone who has the most common form of apnea — obstructive sleep apnea — snores. (People with central sleep apnea, caused by incorrect signals from the brain, may not snore.)

"Snoring is an indication of the possibility of a serious medical problem," he says, because sleep apnea is linked to heart disease, stroke, depression and diabetes.

Struggling For Air

During obstructive sleep apnea episodes, snoring patients become quiet for 10 seconds or more — and literally stop breathing. The silence is followed by choking or gagging sounds when the sleeper is partially aroused and breathing resumes. Finally, snoring resumes and the cycle starts over. This cycle can happen anywhere from five times an hour to sometimes hundreds of times a night. Because people with sleep apnea partially awaken to resume breathing, their sleep is fragmented and they are sleepy in the daytime. The lack of breathing also causes the oxygen level in the blood stream to fall, contributing to medical problems.

Treatments Differ With Severity

The gold standard of treatment for sleep apnea is called CPAP, which means continuous positive airway pressure. An air pump connected by a tube to a face mask, sort of like a vacuum cleaner in reverse, gently pushes air up through the nostrils and mouth into the upper airway, keeping it from collapsing.

But the CPAP can be loud and cumbersome, and many patients who could benefit from CPAP just don't use it. However, experts say, for those with severe apnea, it's the only effective treatment.

Surgical procedures can also help by removing excess tissue in the back of the airway or actually moving parts of the jaw or tongue forward. They're particularly effective with younger patients.

Oral appliances can help many sleep apnea patients maintain regular breathing.

Oral appliances that reposition the tongue and mouth help some obstructive sleep apnea patients maintain regular nighttime breathing.Courtesy Dr. Mark Friedman

The Mouthguard

The third treatment option is an oral appliance, which looks much like a mouthguard used in sports or a dental retainer typically used after orthodontry.

"Research shows the oral appliance works to treat mild-to-moderate sleep apnea," says Kushida. Studies have been limited, but the appliances appear to not only treat apnea but also conditions associated with apnea, such as high blood pressure, he says.

There are many brands of oral appliances, but all of them work basically the same way, says Dr. Mark Friedman, who specializes in treating snoring and sleep apnea in Encino, Calif. He's also a professor of dentistry at the University of Southern California. He says the appliances work to keep the airway open and allow for comfortable breathing. They move parts in the mouth out of the way. They move the tongue forward by moving the jaw forward. So, the lower jaw juts forward a certain amount.

One Patient's Experience

Rani Stoddard found relief with an oral appliance

Rani Stoddard found that an oral appliance drastically reduced her snoring and apnea. Courtesy Rani Stoddard

Rani Stoddard is one of Friedman's patients. She is a nurse who describes her husband as a gem, since he put up with her loud snoring for years.

"He says, on a scale of one to ten, I was like a ten plus on snoring," Stoddard says. Today, she wears an oral appliance, "and now I'm like a two," she says. "You know, a little mild, delicate (snoring) in the beginning and then ... it's quiet!"

Stoddard can't speak highly enough about the oral appliance. "I'm a believer!" she says, adding that now, she "sleeps like a baby." She says the appliance is comfortable and she can even take a drink of water while wearing it.

Although most sleep apnea is initially diagnosed after a study is performed at a sleep center and a physician evaluates the study, apnea can also be measured at home to determine how well treatments are working. To do this, the patient wears a compact device on an armband with two finger-sensors attached. The device measures a number of respiratory functions, including the amount of oxygen getting into the blood. Friedman reports that Stoddard's apnea has been dramatically reduced as a result of the appliance.

Friedman says the oral appliance is at least 60 percent effective for most patients. "For some patients, it's 100 percent effective," he says.

The Role Of The Dentist

Barsh says screening in a dentist's office takes only a few minutes and a few pointed questions, and dental hygienists can also be trained to screen for apnea. It involves asking whether patients suffer from high blood pressure, if their bed partner has ever observed them stopping breathing during the night, if they feel sleepy during the day and if they snore. A patient's neck size, particularly if it's large, can also be an indicator of apnea.

Friedman, a dentist who specializes in treating snoring and sleep apnea, also asks patients whether they are aware of dreaming during the night. Sometimes patients are confused about why a dentist would be asking such a question, he says.

"But people who don't dream often are not getting into REM sleep," says Friedman, If that's the case, he says, they're probably not getting good deep sleep either. And that, he says, can "lead me to have an inkling that the patient might have a sleep issue."

Since he started focusing on sleep disorders about six years ago, Friedman says the majority of patients with sleep problems are longtime patients. "You would be amazed at the number of people that we have diagnosed within our own practice," he says.

Special Training

Because a sleep-apnea appliance must be fitted precisely to the mouth, Friedman says it's important for a dentist trained in sleep medicine to fit the device. Dentists can take training at various academic centers, but the American Academy of Dental Sleep Medicine offers courses during its annual meetings.

Although there are many appliances advertised on the Internet and on TV, there are only about 60 FDA-approved devices. Of those, Friedman says, he considers only about six to be effective. And, Friedman says, if potential patients are interested in researching what types of oral appliances are available and most effective, the Academy website is a good place to start.