Dr. David Lawler of the Center for Sound Sleep

This chat was initially conducted by the Herald-Times on Wednesday, January 14, 2009:

QUESTION: MODERATOR: Welcome everyone to our sleep-related disorders live discussion. Dr. David Lawler of the Center for Sound Sleep is here to take your questions. David, could you please tell us a bit about the Center?

DAVID LAWLER: The Center for Sound Sleep exists as a part of our regular general practice dental office and we focus on helping people who have sleep-related breathing disorders such as snoring, upper airway resistance and sleep apnea. These disorders are epidemic in the adult population effecting as many as one one in five adults at a level significant enough to be affecting their health.

These disorders happen during sleep when the muscles throughout the body, particularly around the base of the tongue, relax which allows the airway passage to progressively close. This leads to the annoying sound that we know of as snoring. In some people this sound is merely a nuisance and for other people this sound is literally the sound of someone fighting for their life.

We manage these disorders by using removable and comfortable dental retainer-like devices that hold the lower jaw slightly forward during sleep. When the lower jaw is moved forward, the tongue base moves forward as well and opens up the airway.

QUESTION: I have sleep apnea and was given the mask to wear at night but I can't stand it. It's been sitting in my closet for months. Is there any way to get used to that thing over time? I know I have a sleep problem but don't know how to deal with it.

Lori, Bloomington

DAVID LAWLER: You are not alone in struggling with CPAP (continuous positive airway pressure). This device has been the standard way of treating sleep apnea for many years and has been a godsend to untold thousands of people. However, there are a great many people who absolutely cannot tolerate the therapy. While CPAP is a very effective therapy, if it is not used, it obviously does you no good.

Oral appliance therapy that we offer is easily tolerated. It is recommended by the American Academy of Sleep Medicine as a firstline therapy for mild to moderate sleep apnea and for those with severe sleep apnea who cannot tolerate CPAP.

QUESTION: My husband uses a CPAP machine. How would your procedure replace that appliance, and does it work for everyone? And why do you think doctors still recommend CPAP if there is a more convenient alternative?

PJ, Bloomington

DAVID LAWLER: If your husband uses CPAP and is successful with it, there is no reason to change therapies. Again, CPAP is a very effective therapy for those people who tolerate it. However, if he is not tolerating CPAP then oral appliance therapy is a very viable option. No one treatment therapy works for everybody. We have patients who respond beautifully with oral appliance therapy by itself. Other patients are enormously helped with oral appliance therapy but not optimally. For these people we can combine oral appliance therapy with CPAP in a way that eliminates the mask, which is the most objectionable part of CPAP treatment. So in these situations, we can combine the best of both therapies to obtain optimal results.

Now, to answer your question about doctors' recommendations, your physician is more concerned with effectiveness as opposed to convenience. CPAP is most effective worn during all hours of sleep. Most people, however, will wear CPAP only four hours a night. Oral appliance therapy is easily tolerated all night long and is usually the most effective treatment for people who will not wear CPAP all night long.

QUESTION:

My husband snores horribly and I'm concerned he has sleep apnea. Sometimes I'm sure he has stopped breathing for a short while and it scares me to death. His doctor says that he probably does not have sleep apnea because he is not overweight and most people with apnea are overweight. Is that true? And what do we do if we still think there's a problem?

Sondra, Bloomington

DAVID LAWLER: Unfortunately, many physicians equate sleep apnea with obesity. While obesity increases the probability of sleep apnea, there are a great many very slender people who suffer from these disorders. The characteristics of sleep apnea are long periods of pauses in breathing that lead to a decreases in blood oxygen levels. These occurrences have significant health consequences that range from cardiovascular disease and stroke to diabetes.

However, it is not necessary for people to stop breathing in their sleep to have significant health issues from snoring. If your husband snores loudly, at the very least he is likely to suffer from upper airway resistance syndrome. This condition is similar to having to breathe through a very small straw for a period of time. It takes a lot of effort to suck air in through this small diameter straw. Our greatest moment-to-moment need is oxygen. If anything happens to disrupt the flow of oxygen, alarm bells go off all over your body. So, at the same time your husband is snoring loudly, whether he stops breathing or not, his body is quite stressed during sleep. I would imagine that when he wakes up in the morning he does not feel refreshed. I would urge you to make sure that he is evaluated by his physician. I would consider loud snoring to be sleep apnea unless it's proven otherwise.

By the way, "second-hand" snoring is also a health issue for you. Studies initiated by the National Sleep Foundation show bed partners of snorers losing on average about an hour of sleep a night, whether they realize it or not.

QUESTION: 1. How do sleep disorders relate to dental care?

2. What percent of sleep disorders can be helped by your particular kind of help?

3. Who is your ideal client?

Ann Smith, Bloomington

DAVID LAWLER: First, the source of the sleep-related breathing disorders, like snoring and sleep apnea, occur inches away from that part of the body that dentists spend their whole professional career treating. A dentist well-trained in sleep medicine has many advantages in identifying patients who may be predisposed to these disorders. For example, the way some patients' teeth come together is an identifier that physicians are generally not trained to see.

Almost all people who have these sleep breathing disorders are helped by oral appliance therapy. The issue is to identify how much they are being helped. We are able to use sophisticated and easy to use sleep monitoring devices that patients use in the privacy of their own home to help us assess the level of effectiveness that we are able to achieve. For those patients who are not optimally managed with oral appliance therapy we have the option of combining our therapy with a surgical therapy that an Ear Nose and Throat physician can perform. Or we can combine our therapy with CPAP as I've mentioned earlier.

Many people are extremely reluctant to go to a Sleep Lab or Hospital for a sleep study. These home monitoring devices that we use are very helpful for these people as a screening tool.

Regarding the profile of our "ideal client", that would be anyone who snoring is loud enough to bother a bed partner. Or it could be anyone who does not wake up feeling refreshed. Also, anyone who is being treated for high blood pressure should make sure their physician has ruled out sleep apnea. Studies show that sleep apnea as an independent risk factor for high blood pressure and that 40% of people with high blood pressure have sleep apnea.

QUESTION: I have had a problem sleeping throughout the night the past few years. I wake up about once an hour. Sometimes I wake myself from not breathing. I will awaken in a big gasp. I also recently had surgery and stopped breathing a few times in the OR, and while in recovery, the nurses had to continuously awaken me for the same reasons. Could this be sleep apnea? I am fairly young (28). Also, is there somewhere around here to get checked out at a reasonable cost, as I have no insurance? Thank You!!!

JC, Bloomington

DAVID LAWLER: Everything you have described indicates a high likelihood of sleep apnea. This situation is particularly dangerous in a hospital environment where you have any form of sedation. It is extremely important for you to have this condition evaluated. Cost is always a concern. But you have to look at this issue more broadly. Those people with undiagnosed and untreated sleep apnea will have medical expenses that easily will double the expenses of those who have their sleep apnea managed properly. Unattended sleep monitoring that we offer is very inexpensive and, while it does not provide an "official" diagnosis, you could then be more confident in investing your time and resources in a more comprehensive diagnosis offered by a sleep lab. For your health's sake, please have this addressed.

QUESTION: I have sleep apnea and have recently spent some time reviewing information available thru your website. I understand the treatment using the mouthpiece but wondered how your treatments plans deal with someone who 'mouth breathes' at night? I have been told I have a deviated septum also, how does that affect the treatment options.

Steve, Bloomington

DAVID LAWLER: I'm glad that you found your way to our website. We've spent a lot of time trying to make it as informative as possible. The fact that you are a mouth breather would not prevent you from obtaining significant relief with an oral appliance. Having said that, treating your deviated septum and allowing more air flow through your nose can only help, as well.

QUESTION:

I've always been told that if you have sleep apnea you don't dream. Is this true?

Susan, Gosport

DAVID LAWLER: People who have sleep apnea may be less likely to dream because they are not able to access the deeper levels of sleep. Your body, craving sleep, attempts each night to go repetitively to the deepest level of sleep where dreaming takes place. When you approach the deeper levels of sleep, this is when the muscles at the base of the tongue relax, allowing the airway to close. Those people with sleep apnea whose airways have closed, have to continually reawaken to lighter levels of sleep in order to get air. It's possible for them to go through the entire night with little or no access to REM sleep, where dreaming takes place. These people also may have difficulty with their memory because memory is consolidated in REM sleep.

QUESTION: Hello Dr. Lawler,

Ever since I was a teenager I have had an extremely difficult time in falling asleep. A few decades later it is still the same. I can literally lay in bed for several hours. However, once I am asleep, I am out for the count.

I have noticed my sleeping difficulty is actually made worse by higher daily physical activity. When I was younger I was put on sleeping pills, however I spent most of the morning hours feeling like a zombie. I understand that there has been greater progress in pharmaceutical solutions, however I cannot always count on devoting a full 8 hours to sleep.

Is there any other realistic options for sleep aid?

Thank you in advance.

Jermaine, Bloomington

DAVID LAWLER: In some people sleep apnea and insomnia go hand in glove. There is a significant number of people who have sleep breathing problems who actually make little or no noise. In other words, they don't snore. I strongly suggest a sleep study to have your sleep carefully evaluated to rule out sleep breathing problems or other disorders that could be interfering with your sleep. Sleep is far too critical to have to rely on pharmacological aids. There are many good books on how to deal with insomnia and much reliable help can be found on the internet. Good luck in your search for answers to finding restorative sleep.

QUESTION: I am only able to sleep about 3-4 hours a night. But I am not tired the next day. I fall asleep around 2:00 am and get up, at the latest, at 6:15 am. If I do fall asleep earlier, I wake up earlier but it is always around 3-4 hours total sleep. While this certainly sounds abnormal, should I be worried even though I feel well rested?

Mike, Bloomington

DAVID LAWLER: You are indeed unusual! But there are a few people out there who need very little sleep. Not getting "enough" sleep has become a national health issue. Our society discounts the importance of sleep. It is only relatively recently that medical science has turned its attention to the importance of sleep. If you wake up feeling refreshed and do not feel sleepy during the daytime, I wouldn't be concerned. However, to the rest of the readers, if you don't wake up refreshed and feel tired or sleepy during the day, you are either not getting enough sleep or the sleep you are getting is not good sleep. Remedying this situation is one of the most important things you can do for your health.

QUESTION: MODERATOR: Thanks for all of the great questions today, and thanks to Dr. Lawler for joining us.

Is there anything else you'd like to add?

DAVID LAWLER: I just want to thank you for inviting me to talk about this very critical subject. I guarantee everyone reading this knows at least ten to twenty people who are suffering from sleep related breathing disorders without their knowledge. The vast majority of people who have these disorders are completely unaware. Occasionally, a bed partner may say something but usually this is to complain about the noise that's interfering with the quality of their own sleep.

By providing this opportunity to discuss these issues, the H-T has indirectly enhanced the health of this community. Sleep well!