The Missed and the Misdiagnosed

Upper Airway Resistance Syndrome (UARS), a sleep
disorder characterized by airway resistance to breathing
during sleep, often goes undiagnosed or masquerades
as another problem. Headaches, myalgia, sleep onset
insomnia, sleep maintenance insomnia,1 bruxism, anxiety
and depression are all symptoms of chronic stress
which can be related back to respiratory effort related
arousals and (UARS). According to Christian
Guilleminault, the researcher credited with naming this
disorder, “Partial obstruction of the airway is hard to
quantify. Research and clinical diagnosis and treatment
have not been integrated. The medical community is
slow to recognize the problem.”2

Because the medical profession does not fully recognize
the problem, many doctors are ignoring a condition
that could be affecting as much as 15% of our population.
3 This is great for Starbucks, but quite the opposite
for many people. Dentists do not need an M.D. to diagnosis
Upper Airway Resistance Syndrome. With a
strong background in craniofacial pain, we can recognize
the symptoms in our patients and provide effective
treatment protocols. Patients that exhibit symptoms of
chronic stress can be tested with ambulatory polysomnography
to determine if there is a pattern of arousal
and light sleep all night long. If we can break the pattern
of chronic stress and lower cortisol levels, it will take
our patients out of sympathetic mode and slow down
their pulse rate and give them a more restorative night’s
sleep. This can be done with appliance therapy treatment,
myofunctional therapy, and breathing exercises.

Small changes in the airway at night during sleep can
be interpreted by the body’s defense mechanism as a
threat. This is an ancient and highly integrated reflex
pattern, known as the hypothalamic-pituitary-adrenal
axis, starts with the hypothalamus and results with cortisol
in the blood.

Cortisol is the enemy. Cortisol is synonymous with
stress. We now know that chronic cortisol, can activate
tens or even hundreds of unexpressed genes in our
body,4 that produces a variety of hormonal changes with
a plethora of symptoms.5 Among these symptoms are a
reduction in leukocyte production and interleukin. Both
make us more susceptible to infection. The dentist is
possibly the best positioned medical practitioner to provide
a special service and to educate their patients in
relation to a sleep and breathing disorder.
Orofacial pain and breathing problems reduce the
quality of life of so many of our patients. Be sure to
make an effort to educate the community where you
live. We can make a difference.

Theodore R. Belfor, D.D.S.
New York, New York

References:
1. Sleep improvement in an insomniac patient with global pituitary insufficiency
after change from triple to quadruple cortisol replacement therapy.
Sleep Med 2007; 8(5):517-519. Epub 2007 May 18.
2. Interview with Christian Guilleminault, Tuesday July 26th; Dr. Steven Park,
Webinar. http://doctorstevenpark.com/?p=6268
3. Ogunrinde O, .Yue HJ, Guilleminault C: Upper airway resistance syndrome.
PCCSU 2011; July, Vol. 25. http://www.chestnet.org/accp/pccsu/upperairway-
resistance-syndrome
4. Ridley M: Genome; Harper Perrenial Edition published 2006
5. Wust S, Federenko I, Hellhammer D: Genetic factors, perceived chronic
stress, and the free cortisol response to awakening. Psychoneuroendocrinology
2000; 25:707-720. www.elsevier.com/locate/psyneuen.
JULY

Stuffed Noses: Why is it important to breathe through our noses?

All of us are familiar with a stuffed nose. Why is it important to breathe through our nose? We have sinuses that are spaces above, behind and alongside the nose that drain into the nose. When we are healthy and we breathe through our nose the air comes up the nose into the nasopharynx and down behind the tongue into the lungs. The passage of this air draws the air from the sinuses with it, thus creating circulation within the sinus cavities. As long as the openings between the sinus and the nose remain open there is a circulation of the air that takes place. A little known fact is that the sinuses generate and are the main storage for Nitric Oxide which is a gaseous molecule that has been shown to have vasodilator properties. In other words it is capable of relaxing the walls of the very small blood vessels, capillaries that are the site for oxygen and carbon dioxide transfer. When we breathe deeply through our nose we send the nitric oxide deep into our lungs and open the capillaries to allow for healthy oxygenation which is necessary to maintain the health of all the organs and systems of the body. If our nose is stuffed and we breathe through our mouth we are depriving our body of much needed oxygen saturation in our blood. 

Anthropologists today will confirm that we are developing smaller jaws along with our diet of refined and processed food, smaller nasal cavity and less room for our tongue. The smaller jaws and smaller nasal cavity mean smaller openings to allow for air to circulate. It is much easier for these openings to become inflamed and to be blocked. Polluted air and irritants of all kinds are present in our environment. Pathogens enter the nose and are trapped in the mucous and cilia. When we are functioning in a healthy manner the very same nitric oxide produced in the parasinuses will participate in the destruction of the pathogens. When there is no nitric oxide present the body will respond through our immune system response. The area infected will become inflamed and invaded with white blood cells that destroy the pathogens. When these infections get out of control we have what is commonly referred to as sinusitis or stuffed noses.

We are proposing that adults in the 21^st century would benefit from an orthopedic orthodontic dental appliance that is worn only at night. The appliance stimulates growth of the jaws and improved facial symmetry. This facial development allows for better sinus drainage and the proper circulation and use of nitric oxide to maintain the health of our bodies. This system does not rely on drugs for treatment. It is purely physiologic and relies on the expression of genes for facial development that have not yet been expressed. This is the science of the 21^st century. This is the body healing the body.

Many of us wake up in the morning and do not feel refreshed after eight or even 10 hours of sleep. You may be young and healthy and still require a cup of strong coffee to get you going. If your overnight sleep were to be tested we would find that the physicians report would say you do not have sleep apnea and are therefore perfectly healthy. In fact when your airway is compromised even a small amount the hypothalamus in the brain perceives a threat and send a signal to the pituitary master gland, which in turn sends a signal to the adrenal gland and cortisol, the stress hormone, is released into the blood. Our heart rate picks up and our sleep is interrupted. We awaken from deep sleep to light sleep. If this is happening all night long it is clear why we do not feel rested. 

The Homeoblock appliance is worn at night and makes more room for the tongue. It provides intermittent light force signaling to the periodontal membrane around the teeth and provides compression and torque to the cranial sutures. This change to the oral environment is the trigger to starting a cascade of events within individual bone cells that result in a size and shape change of our jaws. Larger jaws, better sinus drainage and more room for our tongue can result in a better night sleep. 

Enhanced Bone Health in Conjunction with Homeoblock™ Appliance Therapy Treatment

The Homeoblock™ treatment results in maxillary morphogenesis which is the growth and remodeling of the maxilla, which in turn requires healthy osteoblast and osteoclast function. To maximize these results, we must consider what keeps our bones healthy and strong.

Consumption of refined sugars, such as high fructose corn syrup, now added to virtually every packaged food and beverage, promotes acidic body chemistry and calcium excretion in the urine. Whenever the body becomes excessively acidic, it makes a withdrawal of calcium from the bones, which the body uses to maintain acid alkaline balance. Under these circumstanes, hydrogen bumps sodium and potassium off the bone surface to buffer the systems acidity as well, suppressing the capacity for additional bone formation. 99.9% of our genetic profile is still paleolithic, 70% of our average caloric intake of Americans comes from foods that did not even exist for our paleolithic ancestors, for example, cookies, French fries, corn chips or soft drinks. Soft drinks hit your bones with a double whammy since they dose you with not only refined sugars, but large amounts of phosphates and no calcium. When phosphate levels are high calcium is pulled out of your bones to restore balance.

Lack of estrogen and progesterone in menopausal woman directly affect bone strength.
Are you sure you are getting enough calcium?  In addition to calcium the vitamins D, K, B6 and B12 and folate are necessary as are the minerals boron, magnesium, zinc, copper, manganese, selenium, silicon and phosphorous.

Greens Give the Go-Ahead for Great Bones; Their Absence Slams the Brakes on Bone Building

Leafy green vegetables are packed with vitamins and minerals necessary for bone health, including calcium, vitamin K, Boron and Magnesium.

In addition vitamin C stimulates the activity of alkaline phosphatase, an enzyme that is a marker for the formation of bone building osteoblasts.

Are your bones getting enough sunshine?

Sunlight on exposed skin changes 7-dehydrocolesterol into vitamin D3. All you need is 20-30 minutes of sun exposure and 10,000 IU of vitamin D can be produced in your skin.
Aerobics, weight bearing, and resistance exercises have all been shown to be effective in increasing bone mineral density. Just walking briskly for 15-20 minutes a day can be a deciding factor as to whether you gain or lose bone mass.

What can you do?

Start with:

1. Vitamin D3   800 mg 2000 IU – 5000 IU daily
2. Calcium 1200 mg daily
3. Take a walk in the sunshine
4. Don’t have teeth extracted.

 

Many commonly prescribed patent medicines should be avoided. If you are taking medication for epilepsy, anxiety, insomnia, depression, schizophrenia, restless leg syndrome, type 2 diabetes, chronic pain, allergies, asthma, and autoimmune disease consult your physician to determine the risk for osteoporosis.

You particularly do not want to be prescribed a bisphosphonate e.g. Fosomax , Boniva, Reclast, they are a contraindication for Homeoblock™ appliance therapy since the interfere with osteoclast activity and hence bone remodeling.

 

Before                                        After

 

Note enhanced facial symmetry. The pattern of bone development is shown in red, increased bone volume in the left cheekbone and right mandible.

Bone Growth is generated by Homeoblock™ Appliance Therapy

 “Strain induces osteoblasts in the alveolus and fibroblasts in the periodontal ligament to upregulate growth factors such as IGF-1 (insulin-like growth factor 1) and TGF-B (transforming growth factor beta) that can stimulate in the region affected by strain to differentiate, proliferate, and excrete bone tissue.” Yang and Karsenty, 2002

TREATING TEETH CLENCHING AND GRINDING

The most common causes of teeth clenching and grinding are; stress, anxiety, suppression of anger and frustration, abnormal alignment of upper and lower teeth (malocclusion), sleep and breathing problems and the side effects of medication

The standard dental treatment is to provide an occlusal guard or splint. There is not sufficient evidence that these appliances are effective1.
However, a study on mandibular advancement devices (MAD) finds significant reduction in sleep bruxism.2 Short term results using MAD appliances are excellent, inferring that improving airway patency has a positive effect on teeth clenching and grinding. The latest research suggests a strong link between sleep disordered breathing and clenching and grinding. Unfortunately, clinically MAD appliances result in jaw joint as well as muscle pain along with tooth movement over long periods of time and have been discounted by the profession for treatment.

THE Homeoblock™ appliance has been used by patients up to 8 years without any side effects such as jaw pain or tooth movement. The appliance actually works as an orthodontic retainer.

References

Occlusal splints for treating sleep bruxism (tooth grinding). Macedo CR, Silva AB, Machado MA, Saconato H, Prado GF.
Universidade Federal de São Paulo, Department of Medicine, Rua Pedro de Toledo, 598, São Paulo, Brazil, 04039-001. crisrufa@uol.com.br


Int J Prosthodont. 2006 Nov-Dec;19(6):549-56.
Reduction of sleep bruxism using a mandibular advancement device: an experimental controlled study.
Landry ML, Rompré PH, Manzini C, Guitard F, de Grandmont P, Lavigne GJ.
Faculté de Médecine Dentaire, Université Laval, Canada.

THE HOMEOBLOCK APPLIANCE WILL OPEN THE AIRWAY MAKE ROOM FOR THE TONGUE AND STIMULATE AIRWAY DEVELOPMENT WITHOUT SIDE EFFECTS

Without Homeoblock™ appliance

With the Homeoblock™ appliance in place the soft palate drops down and the base of the tongue contracts opening the airway which is recognized by the Hypothalmus and Cortisol production is interrupted.




Here is how our endocrine system works:

Airway constriction is recognized by the Hypothalmus in the brain which controls the autonomic nervous system. The hypothalamus signals the pituitary gland which in turn signals the adrenal glands to produce cortisol.  The cortisol in our blood does not let us get a restorative night’s sleep it takes us from deep to light sleep. Cortisol and stress are synonymous.  The adrenal gland is the gas pedal that keeps our system in sympathetic mode. Its antagonist is the vagus nerve, which is the calming and relaxing nerve. The vagus nerve is the brake that puts us into parasympathetic mode.
The vagus nerve is the primary break on our heart rate. Without activation of the vegus nerve, the heart would fire an average of about 115 beats per minute. The vegus nerve helps slow the heart rate down.  When we are angry and fearful our heart rates literally jump five to ten beats per minute. The vagus nerve does the opposite, reducing our heart rates to a more peaceful pace.

How does the Homeoblock™ work?

1-By making more room for the tongue and by stimulating the production of acetylcholine

2-By stimulating the vagus nerve to release acetytlcholine, which reduces the production of inflammatory cytokines. It is the inflammatory cytokines that stimulate the HPA axis. If we can stimulate the vagus nerve to produce acetylcholine than we can reduce the amount of cortisol in our blood.and lower our stress levels. The vagus nerve innervates most of the musculature of the pharynx and the soft palate and also has a branch to the palatoglossus muscle of the tongue. It is postulated that wearing the HomeoBlock appliance affects the pharynx, the soft palate and the tongue in a way that stimulates the production of acetylcholine and reduces inflammation to shut down the production of cortisol. The effectiveness of the appliance can be demonstrated by the EmWave ll by Heartmath Corp. The Emwave ll is designed to measure our coherence or autonomic nervous system balance through an algorithm that is based on heart rate variability.



Coherence without the appliance

 

A research project is being planned for:

             Montefiore
\The University Hospital For
Albert Einstein College of Medicine


Upcoming presentations:

Upper Airway Resistance Syndrome – Screening Diagnosis and Management; connecting the dots



Instructors: Theodore R. Belfor, DDS,  Mark A. Cruz, DDS
Senior Certified Instructor International Association for Orthodontics Chairman & President OrthoSmile, Inc.

Date & Time: June 21 & 22 (Friday/Saturday); 8:30-5:00
Location: Ayers Hotel Los Angeles
Tuition: $975

Synopsis: Sleep disordered breathing is an anatomic illness caused by evolutionary changes in the human upper respiratory tract. A thorough understanding of the medical and dental implications of these evolutionary changes will provide a solid foundation for not only understanding the diagnosis and management of sleep disordered breathing (OSA/ UARS) but also provide novel, updated concepts meaningful to prosthodontics treatment planning and intervention as well as understanding the common  genesis of many TMD conditions. The concepts covered will be a “game changer” for the restorative dentist in how he/she will approach treatment planning going forward.

Topics to be covered:

OSA is the “tip of the iceberg”; UARS is the base
Understanding why sleep disordered breathing is a pandemic condition and why the dentist is on the front line in identifying, screening and managing this medical disorder.
Understanding the fundamentals of facial development and its role in the development of sleep disordered breathing
The appropriate use of high resolution pulse oximetry in screening for SDB and TMD
Proper interpretation of the CBCT study in airway function
Management of UARS using a physiologic approach for a physiologic problem.
Using an alternative “orthotropic” treatment protocol for the adult Sleep Apnea/UARS patient: Homeoblock™ certification.

Day One

Introduction
Screening for UARS: the exam
Screening for UARS: HRPO (high resolution pulse oximetry)
Does “constricted envelope of function” really exist or is it something else?
Appliance therapy and objective titration
The Homeoblock™ philosophy
 How it works
Facial Evaluation and Development
Demonstration of the Homeoblock™ Protocol
Demonstration of 3dMD Face
Demonstration of FantaMorph
Demonstration of Analyze 10.0 skeletal and bone analysis
The missed and the misdiagnosed (Upper Airway Resistance Syndrome)

Day Two

Developing the airway; case studies
The aging face and airway; case studies
Designing and delivering Cases.
Adjusting the Appliance
Treatment alternative discussion: To cut or not to cut.
Questions and Answer

Registration:

Please print out this page, complete it and fax to Pat Millonzi at 949-661-9454 or scan and email to patmillonzi@markacruzdds.com

Nasal and Oropharyngeal Airway Development Using the Homeoblock (TM) Intraoral Appliance

The physiological systems of the body are self- regulating and are capable of self- correction. The external body is programmed for symmetry, given the opportunity our body will correct in the direction of improved symmetry and function.

Case study 1

This patient presented with difficulty breathing through his left nostril.
Left external nasal valve improved after 12 months Homeoblock treatment.


                                              Before                                    After

Left nasal valve stenosis

Improved left internal valve patency after 12 months Treatment

Red shows improved nasal airway size and symmetry and hence enhanced function. CBCT scans are registered using bone threshold.

                                              Before                                After

Improved pharyngeal airway symmetry, tone and hence function after 12 months

Reduced inflammation posterior tongue and improved airway tone at the posterior pharyngeal wall on the left side.

                                              Before                            After

 Case Study ll

This patient presented with right side facial underdevelopment

Consistent with the lack of facial development we see a loss of pharyngeal airway tone on the patient’s right side.

                                              Before                             After

 

                                              Before                            After

Improved airway tone, reduced lateral pharyngeal tissue, after 12 months.

 

The red shows that the bone remodeled along with the airway and the ramus and gonial angle of the mandible are wider particularly on the right side.

Discussion

Rationale: Upper airway muscle function plays a role in upper airway patency. Homeoblock™ appliance therapy alters muscle function and can produce improved muscle tone similar to oropharyngeal exercises provided in the article published by Guimaeres.1 Appliance therapy alters breathing, swallowing and chewing hence the oral environment which provides epigenetic response upregulating genes for development.2

Furthermore, enhanced symmetry can result in autonomic system balance and system coherence. System coherence results in reduction in cortisol3 Cortisol levels are directly related to inflammation. Reducing cortisol can reduce inflammation.4 Appliance therapy along with tongue exercises activates the vagus nerve through the palatoglossal arch and palatoglossal muscle when the sides of the tongue are lifted.. The vagus nerve is your calming relaxation nerve. When the nerve is activated it releases acetylcholine, which reduces the production of inflammatory cytokines.5

References

1-Guimaraes KC, DRager LF, Genta PR, Marcondes BF, Lorenzi-Filho G, Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome;Am J Respir Care Med. Vol 179. pp962-966, 2009
2-Singh GD, Krunholtz JA, Epigenetic Orthodontics in Adults; Smile Foundation Chatsworth California 2009, Selane Products Inc.
3-McRary R,Barrios-ChoplinD, AtkinsonM,Watkins AD, The impact of a new emotional self management program on stress emotions, heart rate variability, Dhea and cortisol. Integrative Physiologic and Behavioral Science 1998;33(2):151-70
4-Pickering PG, Phil D, Stress, Inflammation and Hypertension; Journal of Clinical Hypertension; Vol 9 Issue 7, 567-71 july 2007
5-Hyman M, The Ultramind solution, Scribner 2009 page 181