Snoring and Sleep Apnea - A Dentist's Perspective

Mon, 08/06/2007 - 4:41am — Health Dimensions


The following is a radio transcript from an interview performed my Dr Schiesser with Dr Steve Carstensen, a dentist in Bellevue, Washington.

 
Dr. Michael Schiesser: Welcome back. It's Dr. Michael Schiesser, and we're looking forward to a wonderful second half of the show here. We've got a great guest that you haven't heard yet. Dr. Steve Carstensen is a dentist in Bellevue, and he's going to be coming on in just a minute.
 
But I want to remind people of what they're listening to. Our show focuses on health issues, and this week, we're focusing on sleep-related breathing problems. And we've learned a little bit about snoring as both an annoyance and a relationship problem.
 
And we've learned that snoring can also relate to a more serious problem, where people are not getting both the oxygen that they need at night for their tissue, but also their brain is waking up too much during the night.
 
They may not be aware of it, but if we do a very concrete monitoring overnight, we can actually see that this person is waking up due to breathing problems quite a bit. And we haven't really talked about what to do about that.
 
But a lot of people are into natural therapies these days, and what can be more natural than air? So we're going to be talking, in this quarter-hour, about how people can get air at night.
 
One of the things I think is really interesting, being in sleep medicine, is that the monitoring that we perform, we can actually see oxygen levels fall. And when people are not breathing, we can watch airflow, and then we can watch oxygen levels fall in response to each breathing event. And oxygen is not the only important issue.
 
The point here is that if I were to try and plug my nose and cover my mouth, during the daytime, to get my oxygen level to go down to what I measure at night in these persons who are asleep -- like 92% or 88% or whatever -- I would freak out. It is extremely uncomfortable to not breathe. Now, at nighttime, people are asleep, so they don't necessarily experience the level of discomfort.
 
But that's the whole point, is that when you're asleep, you can have this dangerously low level of airflow, without really knowing about, and it's up to your body to wake you up and get you out of that. And so this happens all night long for many, many people. It's a major public health problem, and that's what we're focusing on today.
 
I'm here with my co-host, Dr. Amy Lazar. And we also have, waiting on the line, Dr. Steve Carstensen, who's a dentist from Bellevue, Washington, and has advanced expertise in treating patients with sleep-related breathing problems.
 
Dr. Carstensen graduated from Baylor College of Dentistry in Dallas, Texas, in 1983, is a member of the American Academy of Dental Sleep Medicine. And Dr. Carstensen, are you there?
 
Dr. Steve Carstensen: I'm here. Good morning.
 
Dr. Amy Lazar: Good morning.
 
Dr. Schiesser: Good morning. And Dr. Carstensen, it's nice to have you on "Health Dimensions" this morning, on Seattle's Progressive Talk AM 1090. And I want to ask you, if somebody has a sleep-related breathing problem, what are the options for managing that?
 
Dr. Carstensen: Well, that's a great question, because there's actually quite a few things that can be done. And while I was waiting on hold, I Googled for a while, and I found out that if you type in "snoring," you get like 4.6 million hits, and "sleep apnea" is 1.5 million. And so if you look around, there's lots of different ways of treating it.
 
But there's really three main things that you can do to fix breathing problems while you sleep. The three major categories are surgery, and some little devices you can use to hold your airway open called CPAPs -- it's an air pressure device -- and then, what I do is mouth appliances to hold the airway open.
 
Dr. Schiesser: What should people do first? What's the thought there?
 
Dr. Carstensen: Sure. The first thing to do, and actually the toughest part, is getting it diagnosed. Dr. Jacobs and Dr. Zemplenyi were both talking about some excellent points about getting testing done to find out what the problem is. And a point that Terry Jacobs made that I thought was most important is that some sleep problems aren't obvious.
 
Dr. Schiesser: And so what should people do about it, when they have a sleep-related breathing problem?
 
Dr. Carstensen: I think the first thing to do is visit with a sleep specialist, like yourself, Dr. Jacobs, and say, "OK, what is my problem here?" That way, we can direct the right kind of treatment to the right kind of problem.
 
Dr. Schiesser: And suppose they have that evaluation there, and they have been handed an interpretation by the doctor that, yes, you have a significant breathing problem; it's waking you up at night, or it's causing impairment during the day, or it's putting your health at risk in some way.
 
You mentioned three things: surgery, and a breathing device, and a dental appliance. What should people do first?
 
Dr. Carstensen: Well, depending on how their physician says something. When my dad went in, he had a huge problem with sleep apnea. And actually, I was onto him for like eight years before he finally went and got tested.
 
But he uses a CPAP machine. And what that is, it's a little box that plugs in, it sits next to your bed while you sleep, and it has a little air hose and a mask, and the mask goes over your nose. And what happens there is a little bit of air pressure is blown in while he breathes while he sleeps, so he breathes on his own. But the air pressure holds that airway space open, behind the tongue, where the air has to flow back and forth.
 
Dr. Schiesser: Wow. Probably, if somebody's considered that or never heard of that, it sounds like a fairly extensive apparatus. Can you tell me more about your dad's experience and why he would choose to go ahead and do that, after he was so resistant for so long?
 
Dr. Carstensen: [laughs] It was interesting, because the major reason he went in is because he discovered he was falling asleep driving home from work every day. And he and my mom were going to live in an RV after he retired, and so he decided he didn't want to fall asleep in the RV. And so that's how I got him to go to the treatment.
 
The CPAP machine, the breathing box with the tube, a lot of people find them to be just fine. My dad loves his, but he's the kind of guy who does what the doctors tell him to and doesn't really question it too much. Other people have a lot of trouble with the nose mask because it's kind of cumbersome; it's got a hose, you have to plug it in.
 
That's where dentists got involved, because we realized, actually from the days of CPR training, where the first thing you do is open the airway. Dentists can hold the lower jaw forward with special appliances, special mouth guard things, and that can keep the tongue off the back of the throat and some other things - keep the air space free of obstructions.
 
Dr. Schiesser: So this is effective with sleep-related breathing problems?
 
Dr. Carstensen: When you look at some studies you'll see that nothing works 100% on everybody. Oral appliances can work great for people who just snore. For people who have mild forms of apnea, it can control it all the way to where they're normal.
 
Dr. Schiesser: So people who are stopping breathing can simply use a modified form of mouth guard to help them breathe better.
 
Dr. Carstensen: Right. A modified mouth guard is a way to put it. If you look around you can see lots of different ones of these kind of things. Some are better than others. I've got a lot of extra training to help folks sort that out.
 
Dr. Schiesser: Is this something people can buy at Bartel's?
 
Dr. Carstensen: You can actually buy them over the Internet. Like a lot of things you can get there, it's maybe not quite custom fitted enough.
 
Dr. Schiesser: Yeah, I don't think I'd be that comfortable with something that I put in my mouth that I got on eBay.
 
Dr. Carstensen: No, I certainly wouldn't be in favor of that.
 
Dr. Schiesser: In my experience, each one of these is custom fit to a person's mouth. I think that the issue I've learned from talking with you over the years is that unless they're adjusted appropriately, people can have pain or headaches or this sort of thing. It really is a delicate maneuver to get people to be fitted appropriately and treated well using one of these devices. Is that correct?
 
Dr. Carstensen: Yeah. One of the things that gets in the way of all those people out there who need some help with their breathing while they sleep is that they either believe they don't have a problem, or they're worried about what they're going to have to do to fix it.
 
Like that breathing box, with the hose: a lot of people have heard about those things, and they think that doesn't sound like a good idea. If they're not aware of other choices, like surgery issues that can work really well, or mouth appliances, then they stop right there and they don't ever get treated. That's really dangerous.
 
In the mouth appliances, if they get one from Bartel's or over the Internet and it doesn't fit well, then they're going to be uncomfortable, or their jaws are going to hurt, or their teeth are going to move, or other bad things can happen.
 
What I guess I'd like to say is the most carefully prescribed treatments are going to be the most effective, and the most comfortable for people. Whether it be what Dr. Zemplenyi can do, or the breathing machine like Dr. Jacobs can prescribe or you can prescribe, or a mouth appliance like I do, the more carefully matched that is to the actual person, the better off and more chances they're going to be healthy during the daytime so they won't be sleepy.
 
Dr. Lazar: Dr. Carstensen, a question on mouth appliances: do any of these work for children?
 
Dr. Carstensen: Not too well. The problem with children is a couple of things. One is that they're growing a lot. As we think about mouth appliances going in, we certainly don't want to cause trouble when teeth are coming out and having new ones come in. Would that mouth appliance be in the way?
 
Also, it's sometimes hard to get him to wear an appliance like that because they're not very small. They're comfortable for adults, but kids seem to have a little more trouble with that. The kids' treatments are probably more... The breathing machines work better for a kid's troubles.
 
Dr. Zemplenyi has pointed out that surgery with tonsils and adenoids is usually the best thing for kids. Again, it takes that careful diagnosis.
 
Dr. Schiesser: Dr. Carstensen, I'd like Dr. Jacobs to have an opportunity to tell us a little bit more about the treatment that you mentioned: pressure treatment and a box next to your bed. If I lose you, I appreciate you coming on the show today and I'm going to see if I can have you both on at the same time. Here's Dr. Jacobs.
 
Dr. Jacobs, Are you there?
 
Dr. Jacobs: Yes, I am.
 
Dr. Schiesser: It looks like Dr. Carstensen is gone. Can you tell us a little more about the treatment he was describing, and why patients may choose to use it, or like it or not like it, and what some of the misconceptions might be, as far as patients bring to the table?
 
Dr. Jacobs: The CPAP therapy that Steven described is a treatment where a box blows room air, so there's not an oxygen tank, through a mask into your nose and holds open the upper airway. It's an air splint.
 
What's best about this therapy is that it should be able to make breathing normal in just about everyone who uses it. That's important, because the more normal your breathing is, the lower your risk for those severe medical problems like heart disease and stroke.
 
But it's cumbersome, and it's annoying, and there are people who can't get used to it.
 
Dr. Schiesser: I actually find the opposite. A lot of people enjoy using it. That's a surprise to me to some extent, because it is so cumbersome. It underscores the benefit that people are getting from it. I talk to people who say they don't like to go to sleep without it anymore because they enjoy their sleep so much better. Also, their spouses are now happier because it helps with the snoring as well. Is that all consistent with your experience?
 
Dr. Jacobs: That's very consistent. There's no question that when you have significant symptoms and daytime problems from sleep apnea, and you get a consolidated night's sleep of more than four hours or six to eight hours, you're going to feel better. Then you don't dread putting the funny mask on at night because the benefits are right there and are realized very quickly.
 
Dr. Schiesser: I appreciate you coming on our show today. What we learned so far today is that snoring is a major problem. Snoring is also associated with a deeper problem which is frequent awakenings and the problems that are due to not having enough oxygen at night.
 
Your point initially was that if people are concerned about that, they should be tested. We also talked about various treatments for snoring and the deeper problem of sleep apnea that's present in some people which include surgery, dental devices, and the air device called CPAP. I really appreciate you coming on our show today. We're going to take a break right now. This is "Health Dimensions." I'm Dr. Michael Schiesser with Dr. Amy Lazar, on Seattle's Progressive Talk, AM 1090.