Peripheral Neuropathy and Obstructive Sleep Apnea

March 16, 2014

I just saw a patient 5 weeks after major tongue and soft palate surgery for obstructive sleep apnea, and as expected more often than not, his sleep quality was significantly improved. He did not suffer from brain fog anymore, and was able to think clearly again, something he was not able to do for more than 30 years. He was very happy with the results. As he was leaving the exam room, he wanted to show me something. He took off his shoes, and then his socks, and asked me what I thought.

I was a bit confused by his request, but then I remembered that he showed me his feet many months prior to his procedures. Compared to his right foot at that time, his left foot was more dusky, red and scaly, and not too healthy looking. He had peripheral neuropathy with pain, burring and numbness, for which he was being treated by another doctor. On the post-operative visit, his left foot looked much healthier. He also noted proudly that although he still had some numbness, his burning and pain were completely gone.

Peripheral neuropathy is a common condition seen usually in diabetics, but can also occur in non-diabetics. I wasn’t surprised by his result, but it was a bit unexpected. It not something that’s routinely described as a potential benefit of treating obstructive sleep apnea. We know that sleep apnea causes a stress response that clamps down on blood vessels of the distant extremities. 

I did a quick literature search of the connection between obstructive sleep apnea and peripheral neuropathy and found a handful of studies. One report found that patients with obstructive sleep apnea without any symptoms in the feet had objective measures of diminished nerve function, which improved significantly after CPAP therapy. Another paper described resolution of peripheral neuropathy pain (but not numbness) in a non-diabetic after CPAP. 

Knowing that obstructive sleep apnea and diabetes frequently go hand in hand, and that diabetes and peripheral neuropathy also go together, there’s a good possibility that the first and the last can also be linked as well. The real question that needs to be asked is, how many people with peripheral neuropathy have obstructive sleep apnea, and if treated adequately, how many can be helped or even cured? Another question that follows is, should all diabetics be routinely screened for obstructive sleep apnea? Knowing that obese diabetics can have up to an 80% chance of having obstructive sleep apnea, perhaps the answer should be yes.

If you’ve been diagnosed with obstructive sleep apnea, did your foot pain or numbness get any better after using CPAP, dental appliances or surgery?


Inflammation, PTSD and Sleep Apnea

March 5, 2014

Post traumatic stress disorder, or PTSD, is a commonly seen condition, especially in victims of sexual abuse, or in military personnel after deployment. For the most part, it’s categorized as a mental health disorder that’s treated with medications and/or psychotherapy. Personal or family history of anxiety or depression is though to increase your risk of developing PTSD.
In this new study, the presence of inflammation was found to predict later development of PTSD. In particular, each 10 fold level of C-reactive protein (CRP) was associated with a 51% increased likelihood of showing at least one PTSD symptoms after deployment to Iraq or Afghanistan.
When I came across this study, the first thing that came to mind was the numerous previous studies showing that having obstructive sleep apnea (OSA) is strongly associated with elevated levels of CRP, and that treating OSA with CPAP can lower CRP levels. 
In addition to higher levels of CRP, OSA is also associated with elevated levels of IL-1, IL-6, and TNF-alpha. CRP is a general marker of inflammation and can even be elevated after surgery.
A good analogy is to say that having a fever increase the chances that you have a cold. Your temperature can also go up if you have pneumonia. There’s nothing special about having an elevated temperature, since it’s a general marker of inflammation. In a similar way both obstructive sleep apnea and PTSD are both associated with elevated levels of CRP. 
But what if obstructive sleep apnea increases your chances of developing PTSD? Not too coincidentally, there’s a study showing that veterans with PTSD have up to 50% rate of OSA. Treating OSA can oftentimes improve PTSD symptoms. I’ve had numerous veterans report that their PTSD was completely gone after starting CPAP.
Something to always think about when you’re dealing with PTSD.

If You Sleep Less Than 6 Hours, You Must Read This…

February 26, 2014

I haven’t talked a great deal about sleep deprivation, so when I came across this article on Medscape, I thought the overview of the various epidemiologic findings related to sleeping less than 6 hours was worth reviewing:

“Sleep deprivation has a profound impact on multiple disease states. For example, if you sleep less than 6 hours, epidemiologic studies show the following:

• Stroke is increased by a factor of 4 times.

• Obesity is increased by an increase in ghrelin, which is a hunger hormone.

• Diabetes is increased because sleep deprivation increases insulin resistance.

• Memory loss is accelerated. Epidemiologic studies show that there is not only permanent cognitive loss but also evidence of early brain deterioration.

• Osteoporosis is increased, at least in an animal model, with changes in bone mineral density. Even changes in bone marrow are evident within 3 months of a study in a rat model.

• Cardiac disease is increased. There is a 48% increase in early cardiac death, as well as increased cardiac-related mortality.

• A 4-fold overall increase in mortality.

As it relates to gastrointestinal disease, there is an increased risk for colon cancer, and at least 1 epidemiologic study shows an association between sleep deprivation (or lack of sleep) and an increase in the likelihood of precancerous (adenomatous) polyps.”

The author also summarized the results of this finding that sleep deprived mice had higher rates of tumor growth.

More and more studies are linking sleep deprivation and obstructive sleep apnea with numerous medical conditions, including cancer.

If you sleep less than 6 hours, something else to sleep on…

The Missing Link in Insomnia and Sleep Disordered Breathing: Interview With Dr. Krakow

February 12, 2014

Insomnia is treated by sleep specialists as a completely different condition from obstructive sleep apnea. Similar to how sleep problem is now considered a “co-morbid” condition to depression and various other medical conditions, insomnia is now beginning to be considered a “co-morbid” condition alongside obstructive sleep apnea.  I’ve interviewed Dr. Barry Krakow in the past on upper airway resistance syndrome and complex insomnia (click here for the interviews; search for Krakow). Here’s a must-read interview that was just published in Sleep Review Magazine. The magazine interviews Dr. Krakow on complex insomnia and how everyone with severe insomnia should also be considered for a possible sleep-breathing disorder.

The Link Between Asthma, Reflux, and Mood Disorders

January 6, 2014

About one in 12 people in the US (about 25 million, or 8% of the population) had asthma in 2009. More than 1/2 of all adults and children with asthma had an attack in 2008. 185 children and 3,262 adults died from an asthma attack in 2007. These numbers are likely to be higher in 2014 (source: CDC).

Asthma is thought to be a chronic inflammatory disorder of the lungs. Symptoms include chronic cough, wheezing, chest tightness and shortness of breath. 

A recent study out of Taiwan reported that teenagers with asthma had a significantly higher chance of developing depression or bipolar disease 10 years later. After adjusting for other conditions such as allergic rhinitis, atopic dermatitis, and other confounders, patients with asthma were 1.81 times more likely to develop major depression, 1.74 times more likely to develop any depressive disorder, and 2.27 times more likely to develop bipolar disorder than patients without asthma. This was the first prospective study linking asthma with mood disorders.

Not too coincidentally, another study came out that showed that pepsin, a stomach enzyme, was found in 71% of  bronchial washings in children with chronic lung diseases. In contrast, healthy children had no cases of pepsin in bronchial washings. 

Obstructive sleep apnea is found in up to 10% of chidden and about 25% of adults. During an apnea, tremendous vacuum forces are created in the chest cavity, leading to a suctioning effect of normal stomach juices into the throat. These juices can then go into the lungs or the nose and ears. Stomach juices not only contain acid, but also bile, digestive enzymes, and bacteria. Even microscopic amounts of these materials can wreak havoc inside your lungs or nose.

Here’s a review of the link between asthma and obstructive sleep apnea. Not too surprisingly, the peak time for the highest levels of restricted breathing in asthmatics is during 3 to 5 AM. This is also the same time that REM sleep peaks, when apneas are most common. There are countless studies showing strong associations between obstructive sleep apnea and mood disorders. 

This is another great example of  how everything comes together when you start to connect the dots.


Longer Breastfeeding Tied to Better Development

January 2, 2014

There’s no doubt about the benefits of breastfeeding, but most of the benefits that are written about in medical journals is related to the nutritional and immunologic benefits of human breast milk. Here’s one more of many articles touting the developmental benefits of breastfeeding over bottle-feeding. Most of the studies compare breast milk (including pumped milk) to formula, but this study specifically states that children who where specifically breast-fed had significantly higher scores in cognitive development, receptive communication, expressive communication, and fine motor development. Children who were breastfed for more than 6 months had the highest scores compared with children that were never breastfed.

There’s a general consensus within the dental community that bottle-feeding can potentially promote dental crowding. The physical act of swallowing is very different when sucking from an artificial nipple vs. suckling from a mother’s breast. Dr. Brian Palmer has an excellent explanation on his website. 

In the original study, nowhere is where any mention of the biomechanics differences with breast-feeding versus sucking from an artificial nipple from a bottle. Poor swallowing mechanics leads to improper tongue motion, which can cause malocclusion (dental crowding), which in turn can increase your chance of narrowed airways and sleep-related breathing disorders (such as obstructive sleep apnea). This is also why using a pacifier or even thumb sucking has similar, detrimental effects. 

What are your experiences with breast or bottle feeding and dental crowding issues in your children?

A Small Taste of My Own Medicine

December 30, 2013

It’s been a while since my last post. With all the holiday season activities it’s been quite busy. But the main reason I haven’t written is that I just underwent minor surgery. Not just any surgery, but something that I do on a routine basis—a lingual frenulectomy. In other words, I just had my tongue tie cut and released. 

The medical term for tongue tie is ankyloglossia. Many people have a band of tissue that tethers the bottom of the tongue to the floor of the mouth in the midline. This prevents proper tongue movement and normal resting posture in the mouth. My condition was mild to moderate in degree and I had no significant effects that I knew of, but since my son was scheduled to undergo this procedure, I decided to have it done as well, just to show him my support. 

The procedure was performed by an oral surgeon DDS and MD, in his office. After a topical anesthetic was applied, Novocaine (an anesthetic) was injected. Getting the numbing medication was the most uncomfortable part. Afterwards, he used a CO2 laser to make the cut and remove the thin band of tissue.

Is was a bit rough for the first few days, but by day 5 to 6, I was able to eat normal foods. It’s been about one week since the surgery, and I’m slowly beginning to feel better and better. My speech is still a bit affected, but I can talk relatively normally. I’m now feeling things in my mouth that I could never feel before.

Newborn infants came to me in years past with severe tongue tie, which prevented them from latching on to their mother’s breast. After a simple cut in the office, infants are usually able to latch on and start feeding immediately. It’s a wonderful feeling to see this. Since the tongue is your most important orthodontic appliance, it’ important to have good tongue mobility. Having underdeveloped jaws can lead to dental crowding and sleep-related breathing disorders such as obstructive sleep apnea.

Not all cases of tongue tie should to cut, but if there’s any significant tethering, it’s something to bring up with your doctor. Oftentimes, the younger you are, the easier the recovery. This  ended up being the case for my son—he’s healing much faster. Having undergone even this minor procedure is a great reminder for me what my own patients must experience, especially with much more aggressive procedures. Sometimes, a doctor needs a taste of his or her own medicine once in a while.

For a great resource on tongue tie, take a look at this article on Dr. Brian Palmer’s website.

Six Percent of All Children Are On ADHD Medications!

December 9, 2013

The number of children with attention deficit hyperactivity disorder (ADHD) has risen 42% in the past 10 years. These findings were reported online in the Journal of the American Academy of Child and Adolescent Psychiatry. Currently, 11% of children in the United states have a diagnosis of ADHD. In addition, 6% of all 4 to 17 year olds (3.5 million children) in this country are reported by their parents to be taking medication for ADHD, which is a 28% increase from 2008 to 2012. 

What’s more frightening than these statistics is that the real incidence of hyperactively and behavior problems probably goes underreported and under-diagnosed. What frustrates me every time I hear or read about this epidemic is that sleep is almost never mentioned as a major possible cause of this condition. Sometimes, good sleep hygiene is mentioned, but only rarely is the possibility of an underlying sleep-related breathing disorder ever addressed.

In a past study, 28% of children scheduled to undergo routine tonsillectomy were found to have ADHD. After tonsillectomy, 50% were cured of their ADHD diagnosis. 

ADHD has many different causes and it’s likely that there are multiple factors that add up to produce symptoms in a child, but poor sleep due to any reason can definitely affect memory, focus and attention. Not breathing well during sleep with lack of oxygen to the brain can make things even worse.

It’s also not too coincidental that the estimated rate of snoring for children in this country is about 10%. Another study showed that the presence of snoring in young children predicted behavior problems in later school years. We know that a significant number of people who snore have undiagnosed obstructive sleep apnea. We also know that snoring without obstructive sleep apnea can still significantly affect sleep, with increased risk of attention problems, car accidents, and even stroke in adults.

Given all the evidence, it’s important to at least screen for obstructive sleep apnea in any child with a new diagnosis of ADHD. 


CPAP Can Improve HDL Cholesterol Levels

November 21, 2013

With all the talk about sleep apnea and its’ association with high blood pressure and diabetes, little has been mentioned about how obstructive sleep apnea can affect your cholesterol and other lipid levels. We already know that OSA is linked with fatty liver syndrome. It’s not surprising that treating obstructive sleep apnea with CPAP has been shown to raise your HDL levels (the good kind of cholesterol). 

Have your cholesterol or other lipid levels changed after using CPAP?

An In-Depth Look at DIY Snoring Mouthpieces

November 18, 2013

Guest article 

Types of OTC oral appliances for snoring

There are literally dozens of over-the-counter (OTC) mandibular advancement devices (MAD) available, which means that making a decision can be anything but easy. One should consider several factors before making such an important decision. After all, an oral appliance is a medical device that is used to treat conditions such as snoring and sleep apnea; so naturally you should desire what is best for your health.

Over-the-counter  mouthpieces are available in a variety of designs from the simple boil and bite units to more complex models which allow you to create an impression using dental clay and then have a custom piece created at a lab. Then there are Tongue Stabilizing devices (TSD) which attach to the end of your tongue, preventing it from falling into the back of your throat. Finally, there are more complex devices which use both mandibular advancement and a tongue stabilizing device. Such mouthpieces have proven to be effective in many cases of snoring and sleep apnea.  Here is a bit more information on each of these devices and a few reasons why you may want to choose them.

Boil and bite mouthpieces

SnorbanBy far, boil and bite mandibular advancement devices have dominated the market over the years. They are constructed from a unique type of thermoplastic material that becomes moldable when heated in hot or boiling hot water.  This type of device typically comes pre-shaped to fit closely around your teeth. Once exposed to hot water for the specified amount of time, the user inserts the device into their mouth and bites down while moving their lower jaw forward. This position is held for up to one minute before the unit is removed and cooled, typically using a bowl of iced water.

Thermoplastic devices are often criticized due to their bulky nature. Some models are intrusive and uncomfortable while others are bearable and can be tolerated by the user. They are often almost twice the thickness of the more expensive OTC devices and can cause excessive drooling and dry mouth in some cases. Some have issues with these types of mouthpieces while others do not.

Some OTC oral appliances come with holes which allow for breathing while others do not. Breathing holes are generally considered a good feature to have while some prefer to have no holes due to issues dry throat issues. This sometimes occurs because a concentrated stream of air that constantly enters and exits your airway and dries out the saliva in the mouth.

One desirable feature that is not so commonly found is the ability to make advancement adjustments. Being able to adjust the jaw position forward 1 mm at a time enables one to find a desirable position which is comfortable yet still effective. With most devices, once the molding process has been completed, making adjustments can be difficult if not impossible. This means that one must locate the ideal position during the first fitting or they will end up with a piece that is unusable.

Boil and bite devices are typically the least expensive type of OTC mandibular advancement devices available, costing anywhere from $35 to $60 including shipping. The length of time that they last depends on how they were manufactured. In general, most last between 6 months and 24 months. Boil and bite devices are often used by those who are interested in testing the waters to see if a MAD will be an effective solution. If proven successful, many eventually choose to move up into a better constructed and more expensive unit.

If you are considering purchasing a boil and bite mouthpiece, be sure to carefully examine the manufactures sales page for these potential pitfalls before making a product selection.

Laboratory created OTC oral appliances

prosnore 2Some find that a better solution is the lab created OTC mouthpiece. These types of devices are typically more expensive than their boil and bite counterparts with an average selling price of $120 to $200.

While they still work exactly the same as the boil and bite types, a custom created mold allows them to fit much better in the mouth. When ordered, a custom impression kit is sent to your home which contains 2 dental trays and impression clay among other items. The impression clay is loaded into the trays and then inserted into the mouth where the person gently bites down and releases. After creating the impression, the tray is removed from the mouth and then placed into a shipping container where it is then sent off to a laboratory where it will be created. Within a couple weeks it is returned to your home and should be ready to use.

Perhaps the greatest advantage of this type of oral appliance is a closer, less intrusive fit. In comparison to the standard boil and bite model, these take up much less room in the mouth and overall are not nearly as bulky.

In some cases they can be adjusted while in other cases they remain in a fixed position.

Tongue stabilizing devices

AveotsdA newer type of mouthpiece that is gaining momentum is the tongue stabilizing device (TSD). While far less popular than the mandibular advancement device, the TSD is making big strides and gaining market share.

Technically speaking, the TSD is not a mouthpiece in a traditional sense. It resembles a pacifier and actually attaches to the end of your tongue using the power of suction and rests between the lips and outer teeth. This device works by holding your tongue forward as you sleep to prevent the tongue from falling to the back of the throat and causing an obstruction in the airway.

Good Morning Snore Solution currently markets and sells an OTC version of this mouthpiece which can be purchased for around $120 including shipping.

Hybrid mouth guard

ZyppahRecently, Zyppah has created a unique hybrid B&B device that also contains a tongue stabilizing strap which stretches from one side of the tongue to the other and is used to hold the tongue in place. These types of MADs provide both jaw advancement and tongue stabilization.

It works like any other MAD by holding the lower jaw in the forward position in order to prevent tissues form obstructing the airway. The stabilizing strap is an additional measure that is used to keep the tongue from relaxing and migrating towards the back of the throat.

Which type is most effective?

When it comes to snoring prevention, all four types of mouthpieces have been proven to be effective. While choosing a snoring treatment, consider which type will be the most comfortable for you and weight this against the total price of each device. Boil and bite devices are the most affordable yet some find them to be uncomfortable. Laboratory molded devices along with TSDs offer a more comfortable solution yet can cost more than twice as much as other alternatives.

OTC mouth guards can be a less costly alternative  when compared to more expensive devices that are custom made by your dentist. As always, please speak with your doctor before using any oral appliance to treat snoring.


Robert Thomas is an expert writer and reviewer for He writes on topics such as snoring, sleep apnea, CPAP treatment, Mandibular Advancement Devices, and natural snoring therapy.

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