Snoring and Sleep Apnea, Part I

Recently, we had some close relatives staying with us for the weekend.  At some point, in the middle of the night, I got up to have something to drink only to find someone sleeping on the couch in the den.  “Jeff” I said “What are you doing here?  Is the couch any more comfortable then the bed?”  “No,” he responded.  “Carol threw me out because I was snoring and she couldn’t sleep.”  I asked him, “Could I offer you anything more comfortable than the couch?”  “No,” he said, “That’s not necessary.  At home, when she throws me out I end up sleeping in the closet.”

How many of us can relate to the scene of one of the partners snoring and the other being forced to find a quieter place to sleep, or vice versa?  Let me assure you that you are not alone.  Of all adults above the age of 40, about 40% snore.  Of the general population, about 87 million Americans snore, and 45 million of them snore every night.  Needless to say, snoring is a socially embarrassing habit which is often made fun of.  You would be surprised to learn that the socially embarrassing aspect of snoring is the least of the problems. Snoring can indicate much more serious medical issues that cannot be ignored because they are life threatening.  Because of the extent of complexity of sleep apnea, I cannot discuss the entire topic in one article.  Therefore, in this column I plan to deal just with sleep apnea and its relationship to snoring.

To being with, psychologists will tell you that snoring can and does lead to breakups in relationships between couples, including marriage, and for obvious reasons.  The psychological impact from such situations cannot be discounted.  More directly related in a medical sense are the underlying complications which are indicated by snoring, and that is, obstructive sleep apnea (OSA).

Under normal conditions, air passes through the nose and the flexible structures in the back of the throat, including the soft palate and tongue.  While these muscles relax during sleep, the airway remains open.  However, if under certain circumstance, the muscles constrict, leading to a narrower airway, airflow is partially, or even worse, totally, blocked. Snoring results from the vibration of the soft tissues in the back of the throat under such conditions.  This interruption of airflow, particularly if each episode lasts 10 seconds or longer and occurs 30-40 times per hour, is called obstructive sleep apnea (meaning, without breath).  Conservatively speaking, with each episode lasting 10 seconds, 30 times per hour, eight hours a night, a person’s brain is deprived of 40 minutes of oxygen per night.

In my next column, I plan to discuss the medical ramifications of this problem.

Recognizing Gum Disease

The Dental Educator

Recognizing Gum Disease

In previous writings on this topic I focused on the connections between gum disease and other systemic ailments such as heart disease, diabetes and obesity, to name but a few.  My point was that oral health, and in particular gum health, cannot be relegated to being isolated health issues, but rather, everything is intimately related.  In a way, while we may be dentists, i.e. physicians who specialize in treating the oral cavity, in effect we treat systemic health as well, albeit in an indirect way.

That said, what exactly is gum (periodontal) disease?  Why is it harmful?  How does it manifest itself, both to the patient as well as the doctor?  How is it treated?  I don’t promise you that I’ll answer all these questions today, because of space constraints.  Instead, I can only advise you to stay tuned.

I remember seeing a cartoon many years ago picturing a dentist seating his patient up following his examination of her.  The caption underneath read as follows:  “Well, Mrs. Jones, I have some good news and bad news.  The bad news is that your gums are so bad that all your teeth will have to be taken out.  The good news is that you have no cavities.”  In my nearly 30 years in private practice I’ve seen the truth of this caption borne out time and time again.  Most denture wearers today have lost their teeth because of gum disease, not cavities.  And, in fact, patients in my early years considered tooth loss to be as inevitable as hair loss, part of the aging process.  Because of the dental profession’s increased concern regarding periodontal disease, and the importance of saving teeth, as well as the public’s acceptance of these concerns, dentures are becoming a thing of the past. 

So, what exactly is periodontal disease?  Periodontal disease is ultimately the loss of the supporting tissues of the teeth, the supporting tissues being the jaw bone into which the roots of the teeth are embedded, the pink tissues overlying the bone which we call the gums, and the (periodontal) ligament that attaches the teeth to the bone.  In the early stages, when tartar, which contains bacteria, settles on the teeth near the gumline, it releases toxins that eat away at the tissues that attach the teeth to the dental ridge (bone).  As time goes on, less and less of the tooth is attached to the ridge.  Even worse, the bacteria begin to eat away at the supporting bone around the tooth so that there is less bone available to hold the tooth in place.  Eventually, there is so much loss of attachment tissue and bone that the tooth loosens up and falls out.  Often, these teeth are virgin, having no decay or previous fillings. 

One of the problems with gum disease is that it often goes unrecognized, there being little pain, especially in the early stages, and even later on.  The patient may notice some bleeding when he brushes his teeth or flosses, and in a more advanced state some loosening of his teeth.  Only in a more extreme state, such as a gum abscess (infection), will he realize that something is terribly wrong and consequently have it looked at by a dentist.  By that time, it’s often too late to save the tooth through conservative means, or even save the tooth at all.

What can be done to address, or even prevent periodontal disease?  We’ll address that question next time.

The Dental Educator – Seal Out That Decay

The Dental Educator – Seal Out That Decay

Hello Everyone, My past few columns have dealt with the relationship between oral health and general health. This time I would like to focus on a strictly dental item of interest, sealants. I’m sure that most of us have heard of them but are not familiar with how they work. I only wish that they had been around, along with fluoride, when I was a kid. I would have saved myself countless hours in the dental chair having my teeth fixed. So what are sealants? How do they work and who are they for? Before I tell you, let me relate an incident that happened to me a few years ago. My wife had been urging me, for some time, to get a snow blower. I was resistant because big machines really scare me. “Look,” she said, “You’re not getting any younger, and the boys have moved out. How long do you think you can continue shoveling the drive way with a plain snow shovel?” Well, my resistance finally caved in and I got a good snow blower for several hundred dollars. At the end of that winter, which, of course, saw no snow, my wife asked me sheepishly, “Are you upset that I made you go out and buy a snow blower that you ended up not using?” “No,” I said. “I sort of looked at it as an insurance policy. I’m sure that had I not gotten the snow blower we would have had plenty of snow this past winter, so it was worth the investment.” Hypothetically speaking, sealants would be for anyone with adult molars. Practically speaking, however, sealants are not for everyone. Lets first see how they work and then we can see for whom they would work. When an adult tooth, particularly a molar, and less so with a bicuspid, has deeply pitted grooves on its biting surface, which would be prone to cavities, the dentist, with the approval of the patient (or the parent if the patient is a child) may elect to apply a sealant to that tooth. Deeply pitted grooves are prone to decay (cavities) because food debris and consequent bacteria accumulate in those grooves which, in the first place, are difficult to clean and be kept clean. The bacteria in those grooves begin to release toxins which eat away at the sound tooth structure, thereby causing a cavity to form. In the application of sealants, the dentist, or hygienist, applies a tooth conditioning agent which etches the tooth structure in and around the grooves, thereby providing a surface to which any bonding material, including sealants, will stick. The sealant, which is usually a clear liquid resin, is then painted onto the etched surfaces and subsequently flows into and fills the grooves. The dentist then shines a bright light onto the surface, and the liquid material, through a chemical reaction, then hardens, forming a smooth plastic-like biting surface, thereby sealing out decay. Bear in mind, sealants do have limitations. They cannot be applied to surfaces in between teeth (inter-proximal surfaces) to prevent cavities from forming in those areas. Who would be a good candidate for sealants? Anyone with virgin teeth (i.e. no previous decay or fillings in the teeth in question) and who tends to form cavities easily would be a good candidate for sealants. Usually, people who fit into this group range from young school children who have already gotten their first molars to late adolescence, when cavities become less common and the incidence of gum disease begins to rise. The decision to apply sealants is not based on a blanket approach. Each situation is based on a case by case basis, dependent on the circumstances relevant to that patient at that time. Having sealants placed is painless, both physically and monetarily. In a way, they should be looked upon as insurance policy against decay, much like the snow blower that I bought a number of years ago, but without the cost.

When a Headache Is More Than Just a Headache

When a Headache Is More Than Just a Headache

Shortly before his death in 1945, our 32nd president of the United States, Franklin Delano Roosevelt had been vacationing in Warm Springs, Georgia, and was heard to remark, “I have a terrific pain in the back of my head.”  Moments later he was comatose, and by that Thursday evening, April 12, Harry Truman was the 33rd president.

Massive cerebral hemorrhage, i.e. a burst blood vessel in the brain, otherwise known as stroke, was what caused Roosevelt’s headache and subsequent demise.  In this country, after heart attacks and cancer, it is the leading cause of death.  Given our fast-paced lifestyle in this region of the country headaches are a manifestation of stress and tension.  And because headaches are so common, the term itself has worked its way into our vernacular, often used to describe a person or situation that we would sooner like to avoid.

But headaches can be serious and portend deeper and more deadly problems than one would assume, especially in later middle age.  According to Harvard Men’s Health Watch, and I quote that source verbatim, the following are some of the warning signs that indicate the need for prompt medical care:

 headaches that first develop after age 50;
 a major change in the pattern of headaches:
 an unusually severe “worst headache ever”;
 pain that increases with coughing or movement;
 headaches that that steadily get worse;
 changes in personality or mental function;
 headaches that are accompanied by fever stiff neck, confusion, or neurologic symptoms;
 headaches after a blow to the head;
 headaches that prevent normal daily activities; and
 headaches that come abruptly.

Fortunately, most headaches are simply that, a nuisance and minor inconvenience that can be self treated by simple lifestyle changes, relaxation techniques, and over the counter medications.  But for more persistent or painful headaches consult your physician, and PLEASE, do not ignore the warning signs.

The Perio-Cardio Connection

The Perio-Cardio Connection

In February I sent out a newsletter explaining the connection between periodontal (gum) disease and diabetes, a metabolic disorder involving how the body handles sugar and the complications resulting from that disorder.  Diabetes compromises the healing capacity of the body and predisposes that person to periodontal disease.  However, the converse is also true.  Periodontal disease increases the vulnerability of that patient to diabetes by introducing additional bacteria into the body.

Periodontal disease leads to other systemic complications, most notably, heart disease.  Those with a history of rheumatic fever or heart murmurs would know.  The protocol for those patients prior to a dental prophylaxis (cleaning) is to pre-medicate with antibiotic so that bacteria which exist in the gums do not, as a result of the cleaning or extraction, penetrate through any openings in the gum and enter the blood system and travel to the heart where they can further damage the heart valves, possibly leading to Endocarditis (a heart infection) and even death.

The connection between periodontal and cardiac health, at one time considered possible, is now accepted knowledge.  Not only are they connected, they are, in fact, interdependent and even genetically linked, as borne out by studies in Germany last year.  In addition to diabetes, the two also increase a person’s risk to smoking and obesity.

Oral health and general physical health are no longer considered two separate and independent entities.  It can be inferred that by treating gum disease early a person can lower his risk to heart disease and other systemic ailments.

DIABETES AND ORAL HEALTH

All too often, when seeing my patients, I’m asked why I take blood pressures, examine for oral cancer or even take a health history in the first place.  In other words, what connection exists between “filling a cavity” and one’s physical health that would prompt me to do all of the above in a routine dental check-up.

The connection between oral and physical health is well documented. 
Heart attacks, many times, manifest themselves as jaw pain.  Systemic diseases, such as herpes, often appear as oral lesions.  The administration of the wrong type of anesthetic or prescribing drugs when a patient is on other drugs for other medical conditions may precipitate a medical emergency.  And these are but a few.

This week I’d like to discuss diabetes mellitus (simply, diabetes), a syndrome in which carbohydrates (sugar), fat and protein are abnormally metabolized, thereby leading to absolute or relative lack of insulin and abnormally high blood sugar.  According to the American Diabetes Association 23.6 million children and adults (7.8% of the total population) have diabetes, and the number is growing.

How does diabetes impact on one’s oral health?  For one thing, both diabetes and periodontal (gum) disease are intimately related through a shared inflammatory response.  As I mentioned above, diabetic patients have increased blood sugar which causes decreased saliva flow thereby leading to:

• Tooth erosion, i.e. loss of tooth structure near the gum line, particularly on the sides facing the cheeks or lips. 
• Extensive cavities on the roots of the teeth
• Tartar buildup and consequent gum disease leading to tooth loss
  Prolonged healing times which exacerbate infections both in the mouth and other places in the body.

On the other hand, gum disease exacerbates diabetes, the presence of bacteria from gum infections making glucose control more difficult to achieve. As you can see, it’s a vicious cycle, each exacerbating the other and never ending.  Needless to say, with tooth loss there are quality of life issues as well.

Oral health is only one aspect of one’s general health, but an integral part.  It’s more than just filling cavities.