GERD is a chronic condition. Once it begins, it usually is life-long. If there is injury to the lining of the esophagus (esophagitis), this also is a chronic condition. Moreover, after the esophagus has healed with treatment and treatment is stopped, the injury will return in most patients within a few months. Once treatment for GERD is begun, therefore, it usually will need to be continued indefinitely.

Actually, the reflux of the stomach’s liquid contents into the esophagus occurs in most normal individuals. In fact, one study found that reflux occurs as frequently in normal individuals as in patients with GERD. In patients with GERD, however, the refluxed liquid contains acid more often, and the acid remains in the esophagus longer. Sometimes, it reaches the area of the tonsils, and can create ulcerations. As is often the case, the body has mechanisms to protect itself from the harmful effects of reflux acid. For example, most reflux occurs during the day when you are upright. In this position, the refluxed liquid is more likely to flow back down into the stomach due to the effect of gravity. Additionally, while you are awake, you swallow repeatedly, whether or not there is reflux. Each swallow carries any refluxed liquid back into the stomach. Finally, saliva contains bicarbonate. With each swallow, bicarbonate-containing saliva traverses the esophagus. The bicarbonate neutralizes the acid that remains in the esophagus after gravity and swallowing have removed most of the liquid.

Gravity, swallowing, and saliva are important protective mechanisms for the esophagus, but they are effective only when you are in the upright position. At night while sleeping, swallowing stops (for the most part), and the secretion of saliva is reduced. Therefore, reflux that occurs at night is more likely to result in acid remaining in the esophagus longer and causing greater damage to the esophagus, as well as the throat and teeth.

Certain conditions make a person susceptible to GERD. For example, GERD can be a serious problem during pregnancy. The elevated hormone levels of pregnancy can cause reflux by lowering the pressure in the lower esophageal sphincter. At the same time, the growing fetus increases the pressure in the abdomen. Both of these effects can increase reflux.

What many people do not realize, however, and what some physicians fail to recognize, is the role of snoring and sleep apnea in the creation of GERD. If you find yourself taking antacids on a regular basis, please see your physician and let him or her know about the condition. If you are one of our patients, we are specially trained to notice any oral symptoms of this dangerous condition.

I was discussing [preliminary] with the national cricket team coach reg. PPM mothguards and mentioned to him that some of the players could be suffering from sleep apnea which is affecting their performance. He agreed and told me that no screening is done for sleep apnea. Cricket is a very big game here and India is in the top three positions along with Australia and South Africa. I told him that incorporating treatment for their sleep disordered breathing could help India to retain the top slot. It would be a big breakthrough for dental sleep medicine in India if I am able to treat a few of the players. Some of them I am sure will have OSA because of their anatomy and I have watched them in action, always with their mouth open.

Dr. Smith: I don’t have much, Krishnan, but here are two that may help you. Football Players OSA, Tackling Sleep Problems in Athletes

Dr. Smith: I send letters after seeing every sleep patient to the MD who diagnosed the sleep apnea, detailing everything I checked, my findings, treatment attempts, etc.. . If there is one common complaint I heard from the sleep physicians at Sleep 2009 in Seattle, it’s the fact dentists do not follow up with the sleep physician after they receive the patient. That is so sad, after the grief we give them for not involving dentists. If you are a dentist reading this, PLEASE keep the sleep physician in the loop!

Dr. Smith: I read 2 or 3 of these every day, and rarely do they resemble each other. However, I can help with some of the acronyms and numbers even without seeing the study.

AHI: Stands for the Apnea-Hypopnea Index. Very simply, this means the number of times you stop (or significantly hinder) breathing for at least 10 seconds every hour. These “events” can be due to an obstruction or due to your brain’s respiratory center being a bit lazy.

RDI: This stands for Respiratory Disturbance Index. There is some controversy here, but generally this number is derived from adding the RERAs to the AHI. So, the RDI should always be higher than the AHI.

RERA: Respiratory Effort Related Arousal. These do not need to last 10 seconds, but they are related to an obstructed breathing effort that created a sleep arousal. If you have many RERAs but a low AHI, this is called Upper Airway Resistance Syndrome (UARS)

ODI: Oxygen Desaturation Index. This is generally considered to be the number of times per hour that your oxygen became desaturated at least 4%. This usually occurs concurrently with or shortly after a respiratory (breathing) interruption, or apneic event.

If you (or anyone) would like to know more about the numbers or acronyms on your sleep study, just let me know. There are far too many possiblities to list them here.

Excess weight can be sleep related

Dr. Smith: If your snoring has elevated into a more dangerous condition called sleep apnea, that is indeed true. (Only a sleep study can give you this information) There are various theories, most of which have sketchy research behind them, but what we know is that the link is real. One thought revolves around the hormones leptin and gherlin. Leptin tells you when you are full, while gherlin tells you to eat. When you don’t get proper sleep due to sleep apnea, leptin levels drop, gherlin levels rise and you keep eating. Many ask me if there are leptin pills available, but I’m afraid these are not yet on the market. They may be close, using a medication meant for diabetes to hold the leptin, but all they have been able to do is help keep weight off once it has been lost. Having said that, it’s a long way from FDA approval, so in the meantime, just eat less and exercise I’ll post other theories on weight gain due to snoring and sleep apnea in future blog posts.

Dr. Smith: Eye infections are common due to minor mask leaks, and sinus infections can get serious real quick. If there is rhinorrhea, this is a sign of trouble. Obesity and OSA can predispose someone to cerebrospinal fluid leak. OSA can cause an increase in intracranial pressure, and this is exacerbated with nasal CPAP. The cribiform plate is very thin, and this excess pressure can expose defects. Bottom line – make sure they are monitored very closely.

Dr. Smith: Excellent questions! I’ll address each numerically.
1. Most sleep centers are well equipped to handle children’s sleep studies, so if you suspect sleep apnea in your child, a study would be a good idea.

pediatric sleep room at Comprehensive Sleep Medicine

If they prefer no sleep study, I would suggest an allergist first, to rule out any allergens that could be disrupting the immune system, creating an inflammatory process that swells the pharyngeal tissues. It’s also a good idea to find an ENT with good knowledge of the child’s airway and the negative developmental changes that can occur when the airway is restricted during growth.

2. Tonsils (palatine – the ones you can see, out of 4 sets) should only be removed if the cost-benefits are weighed appropriately. Studies show that tonsillar tissue helps in creation of T-Cells, which are important for cancer prevention. However, if they are impeding the airway, and if inflammatory processes have been addressed, I would have them removed. Remember, the child does have 3 other sets. Oh, and one more thing. The adenoids are FAR more likely to be obstructing the child’s airway, so THIS set of tonsils should be studied by the ENT, if anything! The ENT’s organization has a set of guidelines for when they will remove tonsils. They can be found here. Finally, yes, most will “outgrow” large palatine tonsils and adenoids. Actually, the tonsillar tissues usually shrink, unless there are inflammatory processes present. The usual suspect is a mouth breather, who has to use the tonsils to trap pathogens as they enter the oral cavity. Without the valuable nose filters, which are set up to do this job with regularity and expertise, the tonsils take on this arduous responsibility, and become enlarged to house the many bad guys. This can be seen in the “pocked” tonsils with “crypts”. Does that conger up a lovely thought?

3. Can snoring in children cause ADHD? You bet. Email me or comment here if you would like to read some studies. Additionally, a Johns Hopkins study showed that children with OSA average a 16 point drop in I.Q. What parent wants this?

How would you feel about screening these patients with a home monitor to r/o significant apnea? If the screening is negative, I would go ahead and make the snoring appliance with some degree of confidence that I was not ignoring an apnea problem. If it is positive, then use the results of the screening to encourage them towards complete diagnosis for sleep apnea.

What monitor would you suggest for this? Also, would I need to be certified to read the results?

Dr. Smith: That’s an OK plan, as long as you follow them up with home monitoring to make sure the appliance is removing any events. That way, you can treat anyone up to about 30 events per hour, and even higher numbers if they have failed CPAP. There is no certification for reading the studies, but it does take some education. I love the Watch-PAT 200, but it’s more robust, and you may want to spend less. The ApneaLink is a “screener” at a lesser fee, but it all depends on what you want.

Dr. Smith: OK, here are some articles, Ross.
1. http://ajrccm.atsjournals.org/cgi/content/full/163/6/1294 (not compared to CPAP)
2. SLEEP 1995;18:501-10 Oral Appliances For The Treatment Of Snoring And Obstructive Sleep Apnea: A Review
Summary: This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee’s parameters for the practice of sleep medicine in North America. The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and obstructive sleep apnea.
3. http://findarticles.com/p/articles/mi_hb4345/is_3_35/ai_n29337679 (compares to CPAP)
4. http://www.journalsleep.org./ViewAbstract.aspx?pid=26465 Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review
Abstract:
We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suitable for inclusion in the evidence base, including 15 Level I to II randomized controlled trials and 5 of these trials with placebo-controlled treatment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment adherence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been compared favorably to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP.
Citation: Ferguson KA; Cartwright R; Rogers R et al. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. SLEEP 2006;29(2): 244-262.

5. http://www.springerlink.com/content/j4w6r21256314131/fulltext.pdf Review of oral appliances for treatment of sleep-disordered breathing
Abstract Between 1982 and 2006, there were 89 distinct
publications dealing with oral appliance therapy involving a
total of 3,027 patients, which reported results of sleep studies
performed with and without the appliance. These studies,
which constitute a very heterogeneous group in terms of
methodology and patient population, are reviewed and the
results summarized. This review focused on the following
outcomes: sleep apnea (i.e. reduction in the apnea/hypopnea
index or respiratory disturbance index), ability of oral
appliances to reduce snoring, effect of oral appliances on
daytime function, comparison of oral appliances with other
treatments (continuous positive airway pressure and surgery),
side effects, dental changes (overbite and overjet), and
long-term compliance

Dr. Smith: OK, Susan. First, does he happen to be left-handed? Just curious.

Here are some references:
http://www.springerlink.com/content/vp5glr1chmjydadm/ (I can get you the whole article if you want)
http://www.ncbi.nlm.nih.gov/pubmed/16600788?dopt=AbstractPlus
http://www.aafp.org/afp/20040301/1147.pdf
http://www.ijporlonline.com/article/S0165-5876(01)00463-3/abstract
http://www.med.umich.edu/pediatrics/ebm/cats/enuresis.htm

Plenty more, but that should be a good start. Get that stepson’s airway open!