Sleep fragmentation: a leading factor of anxiety, depression, TMD?
Posted by: Kelley Richardson
Dr. Mark Cruz, a leading airway dentist in Dana Point, CA, sheds light on how sleep fragmentation, disordered breathing and inflammation can be an underlying factor in many seemingly unrelated common symptoms that undermine health and wellness. As a featured speaker at the 2020 Dawson Academy Airway Symposium in January, he spoke with our Airway Curriculum Liaison, Kelley Richardson, to give us some insight on the topic of Airway Centered disorders.
Kelley Richardson: Your topic for the 2020 Airway Symposium is Integrated Dentistry and Medicine with an Airway Focused Approach to Wellness. Could you clarify the differences between obstructive sleep apnea and other airway centered disorders, specifically sleep disordered breathing?
Dr. Mark Cruz: I think this is a huge area of confusion. It has to do with the way we're trained in healthcare. We're in a healthcare system that largely focuses on managing signs and symptoms. Sleep medicine that has been in charge of dealing with the whole sleep problem and the obstructive sleep apnea patient. This focus is only the tip of the iceberg. A lot of those reasons have to do with the third-party payer. There's really little will from the patient to deal with the problem early on because it's perceived to be very expensive. However, it's a fraction of the cost of actually dealing with those downstream comorbidities that are because the problem wasn't dealt with earlier on. Putting that aside, everyone now in dentistry that's jumping into airway is really focused on the sleep part of it. It's not only sleep, it’s about breathing, and when you're not breathing properly because either there is a:
- Structural issue
- Functional issue
- Behavioral issue
These pose a risk factor for disordered breathing during sleep. So we have just focused on the sleep, as if that's really the issue, but that's actually just a symptom. I've had this discussion with sleep physicians and pulmonologists about it which they're focused on managing it with CPAP and things like that. Or dentists who are boarded, that are focused on using an appliance. That’s managing a problem that actually could be cured.
Dentistry can cure the problem, medicine must manage the problem. We have to work together in integrating care towards wellness.
If we deal with the problem very early on, we could change the health of an entire population, this is a public health concern. Having said all that, the bigger issue that I like to bring attention to is sleep fragmentation. Sleep fragmentation is very difficult to measure with the gold standard polysomnogram, lab polysomnogram or home sleep test. If you have sleep fragmentation for whatever reason, of which sleep-disordered breathing is only one factor. It is important to recognize that it’s pro-inflammatory and it affects the entire organism's health and wellness.
So the message I would like to impart at the Dawson Academy is to really understand sleep fragmentation. The people who are healthy are the ones that have sleep fragmentation more likely than sleep apnea. A person is really sick when they have full-blown sleep apnea. It's an end-stage diagnosis. If you catch it early on, the very symptomatic patient, the TMD classic profile patient who would otherwise go to the physician that would otherwise be considered a vision of health. Young, healthy looking, active, high functioning, but have a lot of symptoms that are reported. In general, no one really connects these dots:
- Muscle aches
- Irritable bowel syndrome.
These symptoms are treated separately with different medications, and therein lies the problem. So you deal with the symptom. The big thing is that sleep fragmentation is something that should be recognized, however it is very difficult to measure with our gold standard.
Kelley Richardson: How are you measuring sleep fragmentation?
Dr. Mark Cruz: What I teach is, we need three data sets:
- Structure (phenotype, craniofacial profiles)
- Function (myofunction, compensations, the recruitment of facial muscles in swallowing, oral posture, forward head posture, respiration)
- Behavior (breathing)
How we breathe is a behavior. It's not to be confused with respiration. People conflate the two and they confuse breathing and respiration as the same thing. One is a behavior because we breathe differently when we're upset, doing yoga, stuck in traffic, running, arguing, or singing. It's a behavior. We control it.
But ultimately, that affects gas exchange and could perturb how we breathe.
Chest breathing is less efficient than diaphragmatic breathing. That’s its own discussion, which I'll talk about at the Airway Symposium because there's a lot of confusion with the whole behavior piece that people are starting to recognize as well, and yet they don't understand the physiology. So taping your mouth at night, doing control pauses, and Buteyko breathing is not the solution.
Kelley Richardson: To treat the cause of fragmented sleep, where do you begin?
Dr. Mark Cruz: We know that every mammal can only exchange gas through the nose, and so the number one competency of nose breathing has to be dealt with very early on, from when you're born going forward. A lip seal fosters nasal breathing. You cannot have a lip seal if you don't breathe through the nose, but when you have a lip seal, it allows for the tongue to be on the roof of the mouth. The tongue must be on the roof of the mouth because it fosters orofacial growth and then, from there, flows non-collapsing pharynx during sleep and diaphragmatic breathing.
When we're chest breathing or when we're mouth breathing, we have to actually ventilate 20% more than we would otherwise. This starts causing a behavioral change where we're on this chronic respiratory alkalosis and we're in this whole metabolic compensation that causes all kinds of other problems.
There’s a difference between being well and not being sick, and we're all trained in not being sick.
A patient that doesn't have symptoms, they're not sick, and yet that's not the same as saying that you're well, and it starts with our kids. This is the first generation of children that will not outlive their parents. We do have a sicker and sicker population. The data's very, very clear. I'm going to actually go into data, from a 40,000 foot look at global wellness, what the top 10 causes of death are that didn't exist before. I'm going to start going into that whole mismatch disease discussion. Because it then starts becoming very clear what our role in the dental profession is. It's huge. But we can't do it by ourselves. We need to integrate with medicine. This artificial divide between medicine and dentistry must stop. If we agree with that, then we could start going down a path where we can really spend a little bit of time looking at a symptom, but let's not stay there. Let's always pull back and see what it means to the entire organism. That's the way I see the problem as it pertains to airway.
Kelley Richardson: What techniques will you be presenting at the 2020 Airway Symposium, and how will these cases help doctors identify airway conditions in their practice?
Dr. Mark Cruz: I will take a number of different clinical cases and tell the story as it being representative of a technique:
- A surgically facilitated orthodontic patient to deal with their airway problem to create more oral volume
- A maxillomandibular telescopic orthognatic patient that we dealt with that had an airway problem since they were a child with four bicuspid extractions and TMD
- A child that we treated with Biobloc orthotropics or orthopedic remodeling or ALF
- A patient that was just a myofunctional problem or somebody that was a breathing behavioral problem.
I'll select a case or two representative of each, so attendees will get an idea of how to treat patients on the Monday in their offices.
Kelley Richardson: The Dawson Academy curriculum is integrating the airway component into the treatment planning model. Other than not retracting when treating airway compromised patients, what other considerations you would suggest to doctors as they rethink their treatment options?
Dr. Mark Cruz: I would say that it is important to consider that pro-inflammatory event that happens very early on in gestation that sets the organism down a very specific path. It is inflammation and it starts very, very early on. And once you start that, you start having all kinds of epigenetic expressions. And if we don't recognize it for what it is, we go down a rabbit hole. The history between medicine and dentistry is kind of coming full circle now. We're coming back to where we should be in working together and collaborating. Dawson has been ahead of the curve in that regard for the longest time. There's just been a little bit of a piece that's been missing there, because we didn't know. I think it's coming together pretty nicely. Medicine is now starting to look at us in dentistry and saying, "Hey, you guys are really more than just teeth." And, of course, Dawson has known about that for a long time. It's an exciting time.