The American Heart Association recently reviewed 537 articles on this subject and published a review, stating that there’s no scientific evidence that gum disease causes heart disease, heart attacks, or stroke. Past studies were mainly observational, and not based on prospective studies. They also state that there’s no evidence that treating periodontal disease can prevent heart disease.

What’s the missing link? You guessed it: Obstructive sleep apnea. We know that obstructive sleep apnea can cause reflux and inflammation in the mouth. Mouth breathing due to craniofacial narrowing and inflammation also dries out saliva, which helps to protect your mouth from pathogens. If you’re missing teeth, then your mouth gets smaller, narrowing your airway even further. We also know that obstructive sleep apnea significant increases your risk of heart disease, heart attack, stroke, and death.

So it makes sense that if you treat sleep apnea, you’ll have less gum disease, and less heart disease. Obviously a prospective, randomized, placebo-controlled, double-blinded study is needed to prove this point.

Again, there’s not one mention of the likelihood that there’s any chance of obstructive sleep apnea. 

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This study followed over 52,000 Norwegians who initially complained about insomnia. After 11 years of follow-up, those that said they had trouble falling asleep daily for over one month were 45% more likely to have suffered a heart attack. Those that couldn’t stay asleep all night had  a 30% increased risk, and those that reported unrefreshing sleep had a 27% increased risk. After adjusting for age, sex, marital status, education, blood pressure, cholesterol, diabetes, weight, exercise, shift work, depression and anxiety, people with sleep troubles were found to have the highest risk of having a heart attack.

Something to sleep on.

Dr. Stephen Kopecky, professor of medicine and cardiovascular diseases at the Mayo Clinic, and author of the paper published in Archives of Internal Medicine, quotes, “It’s a fascinating thing, but all the arteries are connected. We know that the risk factors for stroke are the same as for heart disease. We know that the risk factors for ED are the same as for heart disease. And we are finding that the risk factors for dementia and Alzheimer’s are the same as for heart disease.”

It’s frustrating that doctors are connecting all the dots, but rarely ever include obstructive sleep apnea as a major component of all these conditions. In this vein, having ED could mean that you’re at higher risk for obstructive sleep apnea, which causes diminished circulation to various parts of the body, including the penis and the brain. You can make a strong argument that everyone with ED should be screened for obstructive sleep apnea. 

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It you accept the fact that postmenopausal women will have a higher likelihood of developing obstructive sleep apnea, then it’s likely that they will also be at higher risk of having depression, anxiety, hypertension, heart disease, etc. The researchers have done a great job in linking two of the end consequences of untreated obstructive sleep apnea, but failed to look at the common root of both conditions. 

I’ve written before that I often see hot flashes and night sweats in young men. They also have irritability, mood swings and insomnia. These symptoms are neurologic events that occur due to a relative change in the status of the involuntary nervous system. These young men are typically gaining weight quickly. This causes a rapid relative change in their sleep-breathing status, due to more frequent breathing pauses at night. Rapid weight gain is known to contribute to obstructive sleep apnea.

In menopausal women, not only do most gain some amount of weight, their progesterone levels begin to drop in their early 40s. Progesterone is a known upper airway muscle dilator, increasing muscle tone to the tongue. As progesterone slowly drops, the tongue relaxes more, especially when in deep sleep. This causes more frequent micro-obstructions and arousals, leading to the typical neurologic (vasomotor) symptoms commonly seen in perimenopausal women. It’s this relative change in the sleep-breathing status that irritates the involuntary nervous system (which regulates temperature, sweating, heart rate, blood pressure, digestion, and various other body functions).

Dr. Guilleminault of Stanford University states that people with obstructive sleep apnea have diminished nervous systems in the throat. Vibrations from snoring or reflux from obstructive events can damage the protective pressure and chemical sensors in the throat. If you already have some degree of obstructive sleep apnea as you approach menopause, it’s plausible that as progesterone levels drop, the additional breathing pauses don’t have as much of an effect on the involuntary nervous system, since it’s been happening already for years or decades. If your nervous system is intact, then the sudden increases in breathing pauses can lead to more severe vasomotor symptoms.

What this study suggests is that the more you’re susceptible to obstructive sleep apnea, the less likely you’ll suffer hot flashes and night sweats early in menopause. This can explain the higher rate of cardiovascular disease in post-menopausal women.

This is another example of interpreting scientific studies based on my sleep-breathing paradigm. If you’re not familiar with this concept, you can read my articles, or for a more in-depth explanation, take a look at my book, Sleep, Interrupted.

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What was surprising to me is that we have lots of studies showing that most cases of pregnancy-related complications such as preeclampsia and gestational diabetes may be caused by untreated obstructive sleep apnea. Since weight gain is a major risk for sleep apnea, why should pregnant women be excluded from having a sleep-breathing disorder? By definition, pregnancy will cause you to have temporary sleep-breathing problems, whether or not it’s officially obstructive sleep apnea.

The one thing that protects against sleep apnea during pregnancy is the rise in progesterone, which acts as an upper airway muscle stimulant, but this can only help so much. As progesterone drops after delivery, what do you think will happen to women who still have most their pregnancy weight? I’m willing to bet that if you do the same study looking at post-partum complications such as postpartum depression, you’ll see the same increased rate of heart disease later in life.

The shocking thing was that nowhere in these general guidelines do they even mention looking for obstructive sleep apnea. I won’t begin to talk about the link between stroke and sleep apnea–there are just too many studies to mention. I encourage you to take a look at the recommendations of the American Heart Association’s website. Tell me what you think about this glaring omission.

This finding is not surprising, since sleep apnea causes a hyper-coagulable state, with blood being more stagnant and tending to clot, in addition to additional inflammatory factors that can cause damage. It’s also been shown that blood is thicker and more viscous in people with sleep apnea. In fact, a recent study showed that people with obstructive sleep apnea had thicker blood than normal, and by diluting the blood concentration with saline, auditory brainstem reflexes improved to the point of being normal. Placing these people on CPAP also normalized hearing reflexes.

Recent brain imaging studies have shown that hypoxia in the brain from sleep apnea can cause major vascular and tissue damage, affecting critical areas of the brain, including the brainstem. The risk of stroke is also increased by more than 3 times if you have sleep apnea. Knowing all this, it’s not surprising that you can have either brainstem damage or peripheral inner ear vascular damage from untreated obstructive sleep apnea. One study showed that people with sudden one sided hearing loss from nerve damage have a higher risk of having sleep apnea.

I think that nerve deafness is part of the cardiovascular-metabolic process, going along with hypertension, diabetes, hypertension, high cholesterol, and heart disease. What you you think? If you have sleep apnea, do you have any hearing loss?

Since 99.9% of western medicine is based on studies that occur only in the daytime, it’s not surprising that sleep may be a common denominator amongst a variety of familiar medical conditions. For example, this study showed that women with preeclampsia had a 2-3 times increased risk of developing heart disease later on. It’s not too surprising, since obstructive sleep apnea can occur in pregnant women, especially as they gain weight. We know that rapid weight gain is a major risk for sleep apnea.

One protective aspect of pregnancy that I commonly write about is that progesterone increases significantly during pregnancy. Progesterone is a powerful upper airway muscle dilator as well as to respiratory stimulant. Sometimes the weight gain can overwhelm the protective effects of progesterone, and sleep-breathing problems can surface. In many cases obstructive sleep apnea can develop, but more often than not, the severity and duration of these breathing pauses won’t be long enough to be called apneas on formal sleep studies. Multiple obstructions and arousals that don’t qualify as apneas or hypopneas are seen in upper airway resistance syndrome.

We also know that untreated obstructive sleep apnea is strongly linked to increased risk of heart disease, heart attack and stroke. So the results of the study mentioned in the NY Times article is not too surprising. There’s plenty of research showing that preeclampsia can be effectively treated with CPAP, but this idea hasn’t caught on in mainstream obstetrics.

Of the women reading this who have obstructive sleep apnea, how many of you had preeclampsia if you were ever pregnant?