Do you or does someone you sleep with snore? Snoring is a common problem affecting about 40% of men and 20 % of women in Canada. Snoring can be a nuisance to others within earshot but it also can be a sign that you may have a condition known as Obstructive Sleep Apnea, a health condition that can have serious consequences if untreated.
The reason why as a dentist I am writing this article is that a device that you can get through your dentist can be an effective treatment for snoring and OSA.
In this article I will discuss causes of snoring, indications when snoring could be a sign of obstructive sleep apnea and solutions for both.
What is snoring?
When we inhale, air passes in through our mouth and/or nose, into the back of our throat and down into our lungs. If anywhere along this path the airway becomes partially closed the air will vibrate through the narrowed space and the resulting noise is what we call snoring.
Causes of snoring:
If the strip of tissue hanging down at the back of your throat (called the uvula) is longer than normal this can vibrate and cause snoring.
If you are overweight or obese, fat can be deposited in your airway, narrowing it, and snoring results.
In many people snoring is caused by the tongue falling to the back of the throat during sleep.
The tongue can block the airway for a variety of reasons:
When we sleep our muscles relax, and the tongue being a muscle is no different. If you have a large, broad tongue it is more likely to cause blockage of the airway than a smaller tongue would.
If the roof of your mouth is narrow and high, your tongue may have nowhere else to go during sleep other than the back of the throat so this type of anatomy can make you more prone to snoring.
If you have a receded lower jaw or if your upper jaw is small in size your tongue may crowd the back of your throat as it has nowhere else to go while you sleep, again leading to snoring.
Alcohol use before bedtime or sedatives (ie sleeping pills) can make the tissues that line our airway relax more than they otherwise would during sleep causing them to collapse, narrowing the airway and leading to snoring.
Tobacco/smoking can cause inflammation of tissue in the airway which can also lead to airway narrowing, hence snoring.
Sleeping on your back can make you more likely to snore, with gravity causing the tongue and other tissues in the airway to sag and partial closure of the airway.
When is snoring a sign of a more serious sleep disorder: Obstructive Sleep Apnea?
In people who snore, we already know that there is partial airway closure. However in some cases, the closure can become temporarily great enough that the airway is significantly or completely closed.
If you are already prone to airway closure, due any of the reasons listed above that cause snoring, as you inhale during sleep, the pressure from your lungs trying to bring in air can draw loose tissues that line the airway together and create a stop at the top of your airway. It’s like putting a cork in the top of a bottle.
If the airway closes, your chest is attempting to breath air in but nothing is getting through into the lungs.
If this blockage continues for 10 seconds or longer it is called an apnea.
If the airway is not completely closed and some air is getting into the lungs but only 20 - 50 % of the normal amount, and this lasts 10 seconds or longer it is called a hypopnea.
In our lungs blood picks up oxygen which then gets pumped throughout our body.
If there is a complete or partial blockage of air entering our lungs the amount of oxygen in our bloodstream will decrease. Our brain eventually senses the lowered amount of oxygen in our bloodstream and awakens us from a deeper level of sleep to a lighter level of sleep so that we can take a breath.
As we take in air we may snort, gasp or appear to be choking, all which can be alarming if witnessed by a sleeping partner. We don’t remember these partial awakenings as we are still in a light state of sleep when they occur, however if they occur many times our sleep is said to be “fragmented,” and we will not be spending enough time in restful deeper stages of sleep.
Some people who snore do not suffer from airway blockage great enough to reduce their blood oxygen levels, that is, they do not experience apneas or hypopneas. But for people who do, the number of times they may have reduced airflows and awakenings can number from just a few times and hour to over 30 times an hour.
If you count the number of apneas and hypopneas that occur each hour during sleep you arrive at a score which is also called the Apnea Hypopnea Index (AHI).
If you have 5 or fewer sleep interruptions per hour this is considered insignificant, however if you have 5 or more you are considered to have Obstructive Sleep Apnea (OSA)
Note: A sleep event is a partial or complete airway obstruction lasting 10 seconds or longer followed by a partial awakening to take a breath.
Obstructive Sleep Apnea is categorized the following way:
sleep events per hour 0-4.......................................... snoring only 5-14 ........................................ mild obstructive sleep apnea 15-29 ...................................... moderate obstructive sleep apnea 30 or more ........................... severe obstructive sleep apnea
Symptoms of OSA
People who have many episodes of airway closures and awakenings during a night of sleep may wake up feeling tired, feel sleepy during the day, can be at greater risk for car and work related accidents, have morning headaches, have trouble concentrating and also can be irritable and depressed.
Who is Prone to OSA?
If you have the following physical features you may be more prone to developing OSA:
If your neck circumference measures more than 40cm (15.75 in)
This is an indication that you may have excess fat in your neck and likely also lining your airway.
2. If your lower jaw is receded.
3. If you are obese.
4. If you are a man.
5. As well, many of the items listed in causes of snoring above can make you more prone to OSA, such as alcohol use before bed, taking sleeping pills, or having anatomy such as a broad flat tongue or high narrow palate (roof of your mouth).
How does Obstructive Sleep Apnea affect your health?
OSA affects the health of your heart and other parts of your cardiovascular system.
If you have OSA, your breathing is interrupted during sleep and your blood oxygen levels drop. Each time this occurs this stresses your body and as a result your body releases adrenaline. If this occurs many times throughout the night, the high levels of adrenaline in your body can lead to high blood pressure.
Low blood oxygen levels caused by OSA during sleep stresses your body and heart. People with untreated OSA are more likely to have heart failure, atrial fibrillation, heart attack and stroke.
According to Harvard Health Publishing (Harvard Medical School) OSA is found in 47 to 83 % of people with cardiovascular disease, 35 % of people with high blood pressure, 12 to 53 % of people with who have had heart failure, atrial fibrillation and stroke. If you have untreated OSA, your risk of dying from heart disease increases by five times.
How do you know if you have OSA?
There are two simple questionnaires that can be taken to help answer this question.
1. The STOP-BANG questionnaire and
2. The Epworth Sleepiness Scale.
THE STOP-BANG QUESTIONNAIRE :
(developed by Dr. Francis Chung, University of Toronto, 2008)
Answer "Yes" or "No" to the following questions. A total of "yes" to 3 or more items on this questionnaire is considered high risk for OSA.
S Do you Snore loudly? T Do you often feel Tired, fatigued or sleepy during the daytime? O Has anyone Observed you stop breathing during your sleep? P Do you have high blood Pressure?
B Is your Body Mass Index (BMI) above 30? (Are you obese)? A Age: are you over 50? N Neck circumference over40 centimetres? G Is your Gender Male?
(developed by Dr. Murray John of Epworth Hospital, Melbourne , Australia, 1991) A score of 10 or more is considered sleepy. If you score 10 or more on this test, you may not be obtaining adequate sleep. These issues should be discussed with your physician.
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze or sleep 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping
Situation Chance of chance of dozing or sleeping
Sitting and reading............................................................................... ___ (0,1,2 or 3?) Watching TV........................................................................................... ___ (0,1,2 or 3?) Sitting inactive in a public place........................................................ ___ Being a passenger in a motor vehicle for an hour or more....... ___ Lying down in the afternoon ............................................................ ___ Sitting and talking to someone ...................................................... ___ Sitting quietly after lunch (no alcohol)........................................... ___ Stopped for a few minutes in traffic while driving...................... ___
TOTAL SCORE.. (add up all your answers) ____
(lowest score = 0, highest score = 24)
Depending on your score to each test you may be more or less likely to have OSA.
The way to properly diagnose whether you simply snore or indeed have OSA is to see your family doctor and discuss snoring or daytime sleepiness issues you may have. Your family physician may refer you to a sleep clinic that will often conduct a sleep study. That often involves having you attend the sleep clinic for one night while they can observe you while you sleep. They will measure your breathing, blood pressure and determine whether your sleep is interrupted by airway closure and if so, for how long, how many times an hour ands so on. They will also determine if breathing interruptions occur while you sleep on your side or only when you sleep on your back.
If you do have OSA they will let you know whether it is mild, moderate or severe, as discussed above.
The CPAP Machine with full face mask.
Treatment of Snoring and OSA
If you have been diagnosed with mild, moderate or severe OSA one treatment that is usually very effective is use of a CPAP machine.
CPAP stands for Continuous Positive Airway Pressure. The machine blows air through a mask that you wear on either your nose only, or nose and mouth together.
The pressure of the air flowing down your airway opens up collapsed tissues in the airway allowing air to pass into your lungs.
This eliminates snoring and also the other symptoms of OSA such as daytime sleepiness and as well lowers blood pressure and improves the health of your heart.
There are some problems that patients new to using a CPAP experience such as: finding the mask uncomfortable, feeling claustrophobic with the mask on, difficulty falling asleep with CPAP machine on, noise from the machine, dry mouth, removing the mask during sleep, finding the machine cumbersome to travel with or just not wanting to be connected to a machine during sleep.
There are usually solutions for all of these problems if you work with your CPAP provider, however despite this, 30 to 50% of patients that are prescribed CPAP quit using it.
The SUAD Appliance: One of many types of dental sleep appliances that bring the lower jaw forward to open up the airway.
Another treatment that can be used for people who snore or for those with mild to moderate OSA is a dental sleep appliance.
I mentioned earlier that one cause of snoring and OSA is the closure of the airway by the tongue as it falls to the back of the throat when we fall asleep.
Dental appliances are a recognized treatment for both snoring and mild to moderate obstructive sleep apnea, according to the American Academy of Sleep Medicine.
The most studied and accepted type of dental appliance used to treat these conditions is one that is worn in the mouth, bringing the lower jaw into a more forward position.
A technical name for this type of appliance is a “mandibular advancement appliance,” as “mandible” is the anatomical name for the lower jaw.
Professionally made dental sleep appliances work on the principle that if your lower jaw is brought forward, the base of your tongue (where your tongue attaches to your lower jaw) will also be brought forward, opening your airway during sleep and eliminating or reducing snoring and lessening or eliminating obstructive sleep apnea.
Dental sleep appliances can be very effective eliminating or reducing snoring and in the treatment of mild to moderate obstructive sleep apnea. There are several different designs of sleep appliances available to patients, and are made by dentists trained in delivering this form of treatment. One such appliance pictured here is the SUAD appliance, a popular sleep appliance I make for my patients.
Research has shown that the most effective dental sleep appliances have the following characteristics:
1. Those that are custom made by a dentist.
Custom made dental appliances are found to be better tolerated and more effective in reducing snoring and obstructive sleep apnea symptoms than simple appliances you can buy over the counter. Unfortunately you get what you pay for in this case.
2. Are adjustable: ie ideally the the distance that the lower jaw is brought forward can be increased or decreased in adjustable appliance.
Some patients can tolerate their jaw being brought more forward than others and it is nice to have the ability and flexibility to fine tune the distance rather than being confined to one setting.
3. Are composed of a separate upper and lower piece that fits over the teeth
4. The appliance opens the mouth minimally (you can open and close your mouth while wearing the appliance but the upper and lower piece will be closed together when your mouth is at rest.
The appliance design I favour has a soft inner material that contacts your teeth and a harder outer surface for durability.
Side effects of Dental Sleep Appliances for Snoring and/or OSA
Dental sleep appliances have very few side effects. They have been shown to be safe and effective and have been used for many years for patients who either snore or have OSA.
They do bring the lower jaw forward during sleep so in the morning your bite may feel different as your jaw settles back into its normal position over several minutes after waking.
Dental sleep appliances have been found to be safe for the jaw joint (TMJ) and have not been shown to causes changes in the joint.
Who is not a good candidate for a dental sleep appliance?
Research has shown that patients who snore or who have mild to moderate obstructive sleep apnea can be considered for these appliances.
If you have been diagnosed with severe OSA research has shown that CPAP is the most effective treatment, however if you can not tolerate CPAP, wearing a dental sleep appliance (MAP) in some cases is better than no treatment at all.
If your teeth and gums are not in good health this will ideally need to be addressed prior to making a dental sleep appliance, as the dental sleep appliance needs firm support from the teeth and or gums. Loose teeth and a dental sleep appliance are not a good mix.
Patients who are missing all of their teeth in one or both jaws can still be candidates for these appliances but may have to consider dental implants to help hold the appliance in place if they are missing all of their lower teeth.
If a person is are morbidly obese, dental sleep appliances have been found to be ineffective, as the airway cannot be sufficiently reopened merely by repositioning the tongue, as there is too much excess tissue in the collapsed airway during sleep.
Should I try a CPAP or Dental Sleep Appliance ?
If you snore but do not have OSA you may wish to try a dental sleep appliance. It is portable (fits in your pocket) and is not as cumbersome as CPAP. Dental sleep appliances can eliminate snoring or at least reduce the amount or volume of snoring.
If you have mild or moderate OSA, research has shown that patients do better overall if they are given a choice as to what type of treatment they prefer. Once they have been given all the pros and cons of CPAP and dental sleep appliances and they make an informed decision they are more likely to continue with the treatment ie they are more likely not to give up on CPAP if that is their preferred choice versus a patient who is only given the choice of using CPAP or no treatment at all, which does occur at some sleep clinics.
Although CPAP has been shown to be the most effective way to treat OSA studies have shown that it has to be worn at least 4 hours a night to be more effective than a dental sleep appliance.
Research has shown that many patients with CPAP do not wear it through the entire night whereas patients with dental sleep appliances are more likely to.
So even though CPAP is more effective while it is worn, the fact that patients who use dental sleep appliances get about the same amount of improvement in their symptoms of mild to moderate OSA ie they wake up as rested as the average CPAP user, have the same cardiac and health benefits and also rate their overall quality of life the same as patients who use CPAP.
Some CPAP users do not bring their CPAP machines while they travel as they find the machine too large to lug around or they may be somewhere without a reliable power supply (ie when camping or on an overnight flight). Research has shown that if a regular CPAP user has a dental sleep appliance as a backup for times they can’t wear their CPAP, they good relief of their apnea symptoms especially as compared to if they wore no appliance at all.
Research has also shown that sleep partners prefer dental appliances rather than CPAP for their sleep mates who snore or who have mild to moderate sleep apnea . However I don’t think this should be the overriding reason why someone should choose one mode of treatment over the other.
In a separate article I will discuss other ways that some people who have OSA or who snore can be further helped through surgery and also by using devices that prevent you from sleeping on your back, which in some people worsens snoring and apneas. If you would like further information on the dental sleep appliances or if you would like to book a consultation with me you can call our office at 416-691-2886 or email our office at BeechDental@gmail.com
No one should have to live with a snoring sleep partner or obstructive sleep apnea. You owe it to yourself, your sleep partner and your family to get treatment, whether it is a CPAP or dental appliance.
Can Gum Disease Cause Heart Disease and/or Stroke? By Dr. Jeff Shnall
If your dentist has told you that you have gum disease this is certainly not uplifting news. Gum disease can cause bleeding gums, pain, swelling and lead to tooth loss if untreated. However can gum disease be a direct cause of heart disease or stroke?
If you search this question online you will find that there are many articles suggesting that gum disease is indeed a direct cause of heart disease and stroke.
However there are probably just as many articles and studies online stating that gum disease does not cause heart disease or stroke.
My aim in this article is to provide some clarity to this question.
The short answer is there is no evidence or very weak evidence to support the notion that gum disease causes heart disease and stroke.
However statistics show that fact is that if you do have gum disease you do have a higher chance of also developing heart disease and /or having a stroke.
You may be asking how can this be? I just said that that gum disease not cause heart disease or stroke but now I am saying if you have gum disease you have a higher chance of having heart disease or stroke.
If you are confused that is understandable because a lot of people writing on this topic are also confused.
Medical research has found that that both gum disease and heart disease/stroke have a common cause that leads to both conditions.
A simple everyday example showing the same faulty reasoning in people who claim there is a causal link between gum disease and heart disease/stroke is as follows:
Statistics show that on days when the sale of umbrellas increase there is also an increase in the number of traffic accidents. But can we conclude that buying umbrellas causes car accidents?
Rather, both an increase in umbrella sales and an increase in car accidents have a common cause: they are both more apt to occur on rainy days. (I got this example from the website “The Straight Dope.”)
In the case of gum disease and heart disease/stroke, as I will explain below, the common cause is inflammation. Let's take a closer look at gum disease, heart disease and stroke and to a clearer picture of relationship of these three maladies and see if we can clear up some cause and effect confusion and as well give some advice on how to get your gums and heart healthier.
Figure 1: Gum Disease: red swollen gums
Gum disease is a common condition.
Mild to moderate gum disease affects 30 to 50 percent of adults in the US. The website of the Canadian Dental Association states that gum disease will affect 7 out of 10 Canadians over their lifetime.
Severe gum disease affects an estimated 5 to 15 % of the US adult population and almost one in three elderly. Canadian statistics are likely very similar.
Patients with gum disease may not have pain, at least initially but may notice some of the following:
Symptoms of gum disease:
Swollen, discoloured or bleeding gums especially when brushing or flossing
The teeth may look longer than they use to due to gum recession and bone loss
Development of spacing between the teeth, loose teeth or teeth that are sore to chew on.
Bad breath or bad taste.
Our mouths are home to billions of bacteria of many kinds and when we brush and floss we are trying to remove or brush away the bacteria or plaque form our teeth. However if you don’t brush or floss regularly or carefully bacteria/plaque can build up on the teeth, starting the gum disease process.
Figure 2 The gum disease process
The gum disease process
Figure 2 illustrates the gum disease process:
Part (A) in figure 2 above shows a tooth surrounded by healthy gums.
In part (B) above clumps of bacteria (otherwise known as plaque) have attached and multiplied on the tooth surface and are extending under the gumline.
In (C) the bacteria on the tooth has triggered the neighbouring gums to become inflamed or in other words, has triggered the process of inflammation.
Inflammation is part of our body’s defense system against foreign invaders such as bacteria and also is a mechanism that helps our body heal when our cells become damaged.
In (D) above, blood vessels in our gums release chemicals and white blood cells that attack and try to destroy the bacteria on the tooth.
These blood vessels also get leaky and release more fluid into the affected gums which can cause the gums to swell.
The strong chemicals released by the inflamed gums not only destroy foreign invading bacteria. They also destroy the bone that surrounds and supports the tooth.
If the inflammatory process goes untreated around a tooth the eventual result can be the loss of so much bone that the tooth needs to be removed.
What determines whether you will develop gum disease?
There are several factors that will determine whether you develop gum and some may surprise you:
It helps to keep your teeth clean. If you have a lot of plaque buildup on your teeth and don’t spend much effort keeping your teeth clean you are at higher risk of developing gum disease.
However, a big determinant in whether you will develop gum disease is related to how your body responds to bacteria..
We all react to bacteria differently. If you have a normal immune system you may develop a bit of inflammation in response to plaque on your teeth but not much else happens.
However, research has shown that some people are hyper responders to bacteria. A hyper responder can have an exaggerated inflammatory response to bacteria or plaque on the teeth, setting off swelling in the gums, bleeding and loss of bone when there are amounts of plaque that would not cause much of any reaction in a person with a normal inflammatory response.
Hyper responders are found to have signs of chronic inflmmation, that is, inflammation in their body on an ongoing basis.
This explains a strange phenomena that we dentists see in our offices: we can see one patient who always comes in for their dental cleaning with their teeth covered in plaque and hard deposits of calcium yet their gums do not exhibit gum disease while the next patient who comes in may have far less buildup of bacteria/plaque on their teeth yet have red, swollen and bleeding gums.
It is not merely the plaque or bacteria on the teeth that causes gum disease. It is how that individual's immune system (their inflammatory response) reacts to the bacteria that determines whether gum disease will result.
What makes someone a hyper responder?
Hyper responders have an exaggerated inflammatory response to bacteria, irritants and foreign bodies.
There are many factors that make someone a hyper responder:
Genetics can play a role. Some people are simply more prone to inflammation due to their genetic makeup. And they may or may not have any of the other risk factors below.
Other factors that can make some people more prone to stronger inflammatory responses are:
Smoking, excess alcohol use, obesity and stress. These all can increase the inflammatory response in our bodies, including in our gums and can increase the risk of gum disease.
In order to answer our original question regarding the link between gum disease and heart disease and stroke let us now turn our attention towards these latter two conditions.
One leading cause of heart attack and stroke is atherosclerosis, a condition in which the arteries narrow..
Arteries are the blood vessels that carry blood, delivering nutrients and oxygen to all the cells of our body.
Arteries are composed of tissue and are wall of the artery are lined by living cells.
The living cells that line our arteries are in direct contact with our blood inside the artery and it is in this layer of cells that problems can start.
Figure 3 Atherosclerosis
Fig 3 A shows a healthy artery with blood flowing through it unimpeded the way that water flows through a garden hose.
Fig 3 B If irritants make there way into the bloodstream they can lodge into the walls of arteries. One such irritant are small proteins called lipoproteins that carry fats in our bloodstream for use or storage in other parts of the body.
Fig 3 C Irritants such as lipoproteins that penetrate the lining of arteries can trigger an inflammatory response in which the body tries to wall off and contain the irritants.
The walling off of the irritant causes thickening of the artery and narrowing of the artery.
The damaged cells that line the artery can also be plugged up with platelets, fat cells and other blood components that can further clog the artery and cause blood clots in the artery.
Figure 4 Left side: Healthy heart, no blockage in arteries supplying the heart. Right side: Blocked artery in the heart (Large arrow) with damage in heart tissue in are that has lost its blood supply.
If one of these clots should break away in can travel further down the blood vessel and completely block it.
If this occurs in a blood vessel supply the heart it can cause damage to the heart muscle and results in a heart attack. (See figure 4)
If the dislodged clump of cells in the artery flow down stream and block an artery supplying the brain a stroke is the result. A stroke occurs when there is damage to brain cells in a region that have lost their blood supply. (See Figure 5)
Figure 5 Storke: Blockage in an artery in the brain causing damage to nearby brain tissue)
What increases your chance of having a heart attack or stroke?
There are a few factors that increase your chance of heart attack or stroke.
Just like in gum disease, research shows that the more prone you are to inflammation, the higher will be your risk of developing heart disease and stroke.
And the factors that increase the risk of having an exaggerated inflammatory response and therefore an increased your risk of heart disease are:
Genetics : some people have an innate tendency to be hyper inflammatory responders
Smoking, lack of exercise, excess alcohol use, and obesity all increase the chronic inflammatory response in your body and as well increase the risk of heart disease and stroke.
Note: It was previously thought that a diet high in fat/cholesterol would result in cholesterol being digested and carried to the lining of the heart by small proteins in our blood. These cholesterol laden proteins were thought to enter the wall of arteries of the heart.
Current thinking suggests that it is not a diet high in cholesterol but instead, one high in highly refined carbohydrates such as sugar, high fructose corn syrup, white flour and even white rice that are the culprit in atherosclerosis.
These sugars and simple starches are digested, converted into triglycerides and then carried by small proteins (lipoproteins) through the circulation where they can lodge into the lining of arteries in the heart.
So What about the link between gum disease , heart disease and stroke?
Well, we have now discussed that these three health problems are found in people who have exaggerated inflammatory responses. In gum disease the hyper inflammatory response causes gum disease and in the case of heart disease the hyperinflammatory response occurs in the arteries supplying the heart..
Given the fact that these three diseases have a common cause, inflammation, it is easy to confuse cause and effect when discussing the link between gum disease and heart disease.
I should note that some websites include claims that it is bacteria in gum disease that travels to the heart and causes blockages or plaques to build up in arteries. However research shows that the plaques or blockages found in arthersclerotic arteries do not contain bacteria found in infected gums.
It is important to treat gum disease. Managing and treating gum disease has many benefits. It can help save your teeth. Loss of teeth can affect your ability to chew, can affect your appearance and can make you self conscious when you smile. It can affect your ability to eat anything you like rather than softer foods that denture wearers sometimes have to settle for. It can also help allow diabetics to have better control over their blood sugar levels. Diseased gums has been shown to raise blood sugar levels.
However treating gum disease is not going to reduce your risk of heart disease or stroke.
In order to prevent heart disease and stroke you need to get the the cause of the problem. Someone predisposed to heart disease will benefit from reducing the inflammatory response in their body This can be done through diet, exercise, quitting smoking and reducing alcohol consumption, weight loss and managing stress.
In the following section I will provide a summary of research articles that point to the role of inflammation in the development of heart disease, stroke and gum disease and how researchers, and physicians and dentists are trying to treat these diseases by combatting inflammation .
Article #1: C-Reactive Protein Test to Screen for Heart Disease: Why Do We Need Another Test?
Appeared in Harvard Health Publishing March 2017, Harvard Medical School
This article discusses how measuring inflammation in the body can be a better predictor regarding our risk of developing heart disease or stroke than knowing our LDL cholesterol levels.
When you go for your annual physical your doctor may ask for a blood test to measure your cholesterol levels, including LDL and HDL cholesterol in order to assess your heart health. However only 50 % of people who have heart attacks have high levels of LDL cholesterol in their blood, so the theory that is high cholesterol levels that lead to heart disease does not seem to adequately explain heart disease.
The article supports the belief that high levels of inflammation appear to be causative in heart disease and that trying to reduce inflammation is one way of trying to prevent heart disease.
C- reactive Protein (CRP) is a protein found in higher amounts in the blood in people who have higher levels of chronic inflammation (hyper inflammatory responders). By measuring your CRP predictions can be made regarding your risk of developing gum disease and heart disease. (High CRP blood test results may put you in a higher risk category for inflammatory diseases).
This article makes the following key points: “Chronic, low-grade inflammation is closely linked to all stages of atherosclerosis.”The author discusses the process of atherosclerosis: damage to the lining of arteries in people with abnormally strong inflammatory reactions can lead to eventual narrowing or blockage of the artery which can lead to heart attack or stroke if this occurs in arteries supplying oxygen to the heart or to the brain. A link to the article:
Article: # 5: Clinical And Systemic Implications Of Periodontal Disease Susceptibility: The Importance Of IL-6 Polymorphism
Author: Herbert I Bader DDS, FACD, m FICD Clinical Associate, Harvard School of Dental Medicine Published : January 02, 2014 in the journal Dentistry
This article discusses patients with a hyper inflammatory reaction to bacteria on the teeth are more likely to develop gum disease than normal inflammatory responders. This article discusses a saliva test that can spot people with the genetic tendency to a hyper inflammatory response so that preventive measures can be employed before the patient develops gum disease or heart disease Here is the link:
This is a link to a few paragraphs from a popular textbook on gum disease that explains the relationship between hyper inflammatory responders and gum disease and , heart disease. Textbook: Clinical Periodontology 10th edition By Dr. Michael Newman (et al. chapter 18).
To conclude, the scientific evidence available points to a common cause for both gum disease, heart disease and stroke. These diseases are more likely to be caused by other factors such as a genetic tendency to be a hyper responder to bacteria, or other shared causes such as smoking and poor dietary and exercise practices.
Taking steps to reduce inflammation can be an important way to prevent gum disease and heart disease/stroke.
How is gum disease traditionally treated?
The aim is to eliminate inflammation in the gums and to heal diseased gum tissue and bone. Here are some of the ways gum disease is treated:
Professional cleanings by a dentist or dental hygienist to remove the bacterial coating and calcium deposits above and below the gum line.
Teaching pts to keep their teeth as bacteria-free as possible through proper brushing and flossing technique
Antibacterial rinses, antibiotics, gum surgery or sometimes extraction of one or more teeth is needed.
Research has proven that if patients can keep their teeth very clean at home, and if they see their dentist regularly this can help prevent or reduce the severity of gum disease.
Also, as discussed in this article, reducing generalized inflammation in the body can also play a role in controlling gum disease, especially reducing or eliminating smoking. A future article in this series will explore ways of reducing inflammationan as it relates to dental and overall health.
Some additional sources:
The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease, July 2009, Vol. 80, No. 7, Pages 1021-1032Vincent E. Friedewald,* Kenneth S. Kornman, et al. The link to this highly technical article is: http://www.joponline.org/doi/full/10.1902/jop.2009.097001
An interesting article was published by the the Royal College of Dental Surgeons of Ontario, in 2005, entitled: Is there a link between periodontitis (gum disease) and cardiovascular disease? This article is written for dentists but it has very important information that is consistent with the information that I have presented.
Cavities are preventable. Here are some of the products I recommend to my patients that can prevent or in some cases reverse cavities that are starting.
Some of these products can be purchased at supermarkets, selected pharmacies, online or from your dentist. In Toronto, Canada where I practise, dentists are not allowed to sell dental products to their patients at a markup, so buying through your dentist can save you money but may not be a convenient option.
So here is the list:
1. REMIN Toothpaste
This toothpaste contains calcium and phosphate. When brushed onto the teeth the calcium and phosphate get absorbed into the enamel and other parts of the tooth surface.
When a tooth starts to develop a cavity it loses calcium and phosphate so REMIN toothpaste can replace lost calcium and phosphate in the tooth and reverse early decay.
REMIN toothpaste can also rebuild and strengthen enamel that has been weakened by acid erosion from drinking excessive amounts of fruit juices, pop/soda or from acid reflux.
The active ingredient in REMIN toothpaste is called nanohydroxyapatite (nanoHA) which was invented by NASA’s laboratories in 1970.
NanoHA (composed of small particles of calcium and phosphorous) also seals up sensitive roots helping to decrease tooth sensitivity.
REMIN has only been available in CANADA since 2015 however it has been a popular toothpaste in Japan for the past 35 years and has been extensively researched. In Japan it was marked under the name “Sangi’s Medical Hydroxyapatite toothpaste.”
Remin does not contain fluoride. This may be a benefit to those who are reluctant to use fluoride products although as you will see in this article, there are many fluoride containing products that I do recommend to my patients.
2. X-Pur Xylitol Gum and Pastilles (Lozenge)
If you like to pop a mint in your mouth to freshen your breath do yourself a favour. Try a xylitol containing piece of gum or lozenge instead.
Sugar promotes cavities however xylitol is a natural sweetener that can actually help prevent cavities. Xylitol is a naturally occurring “sugar alcohol” that is found in small amounts in most plant material and in the fibres of various fruits and vegetables such as berries, oats and mushrooms and corn cobs.
Products that are sweetened with xylitol such as sugarless gum and sugarless candies have been show to actually reduce the number of cavities people get and also can help stimulate the flow of saliva in people with dry mouth.
Xylitol prevents cavities by interfering with the way that bacteria produce acid on the surface of our teeth. The bacteria on our teeth usually feed on sugar and other carbohydrates and produce acid as a byproduct, which then can lead to cavities.
However when this same bacteria is exposed to xylitol it cannot use the xylitol as a food source. When the bacteria consumes xylitol it cannot convert it to acid and because the bacteria cannot derive energy from the xylitol the bacteria starves, resulting in reduced amount of bacteria on the teeth. This further reduces the chance of a cavity forming on our teeth.
The effect that xylitol has on bacteria is unique and not other sugar substitutes such as sorbitol and aspartame, so if you chose a mint or gum sweetened with xylitol you get the cavity reducing properties.
If you have one piece of X-Pur gum or a few x-Pur lozenges after a meal or when your mouth feels dry and let it dissolve in you mouth can be beneficial, whereas having a mint that contains sugar will increase the chance of a cavity developing.
There are other xylitol containing gum and candies on the market. You want to be sure they contain a sufficient amount of xylitol to be effective in reducing cavities. For comparison Each piece of X-Pur gum contains 1 gram of xylitol.
As with most things, use moderation in the amount of xylitol you consume since consuming more than 30 more 40 grams of xylitol per day can lead to diarrhea or gas.
X-Pur products are available through your dentist (if they stock them) or can be purchased at Shopper’s Drug Mart and other pharmacies outside of Toronto. See additional information at the end of this article regarding sourcing X-Pur products.
One caution: Xylitol is very toxic to dogs in even small amounts so keep any xylitol containing products out of their reach.
3. Xylimelts: For people who suffer from dry mouth while they sleep
When we sleep our saliva glands produce less saliva. As well, some people take medications that dry the mouth so as a result some people complain of their mouth getting very dry during sleep.
A dry mouth during sleep can result in an increased amount of bacteria/plaque on the teeth as saliva washes our teeth and as well bathes our teeth in minerals such as calcium and phosphate. Dry mouth can result in cavities.
Xylimelts are a small lozenge that you can “glue” to a spot in your mouth (i.e. the side of a tooth or gums) so it can slowly dissolve in your mouth while you sleep.
The lozenge releases xylitol into the mouth which stimulates your saliva glands to produce more saliva during sleep. The xylitol also interferes with the production of acid by bacteria/plaque in the mouth which can reduce cavities.
Xylimelts are actually a small adhesive disc that sticks to your gums or teeth.
The disc stays in places while the xylitol slowly dissolves over several hours.
You can either attach the xylimelt disc to the side of a molar or to your gums. I was a little skeptical when I first heard about this product and was wondering if it would actually stay in place. However if applied properly it does stick and I have had good feedback about this product from my patients who have tried it.
Where to buy it: Dentists who stock it or participating pharmacies ie Shopper’s Drug Mart.
4. Sodium Fluoride Rinse (.05%)
I recommend this fluoride containing rinse to patients who are cavity prone (especially older patients who are getting cavities on the roots of their teeth), to patients who have a lot of dental work in their mouths (crowns, bridges), or to patients that are not doing an optimum job at removing plaque when they brush.
A one minute swish and spit, once a day can strengthen roots and prevent cavities. After use be sure not to drink or eat anything (including water) for 30 minutes so the fluoride has a chance to penetrate your tooth surface.
Where to buy it: Dentists who stock it or participating pharmacies ie Shopper’s Drug Mart.
5. Plaque HD Plaque Identifying toothpaste
This is an interesting product. It does everything that a normal fluoride containing toothpaste does with the added benefit of staining any bacteria/plaque that you miss when you brush . You simply brush with it, spit out thoroughly and look in the mirror. Any plaque that you missed will be stained blue. Simply go back and brush some more until the blue stained plaque is gone.
This is a product can be used for young children that are old enough to spit out, teenagers (especially those with braces who may be missing spots when they brush), adults and as well as the elderly who may need a help detecting spots they are missing when they brush.
This product is more expensive than standard toothpaste so you can either use it as a once off educational tool or use it as a regular toothpaste. Because it promotes better, more thorough brushing if it even prevents one cavity HD toothpaste will pay for itself many times over.
Where to buy it: Dentists who stock it, or see below.
very product I mentioned in this article is manufactured and/or distributed by the company “Oral Science.” You can visit the online sales site: https://x-pur.com/ and check them out. I don’t get a commission from Oral Science but I do like their products and recommend many of them to my patients.
I hope this article has provided you with some useful information.
If you have any questions, comments or ideas for other topics you would like me to discuss in this blog please feel to fill out the form below or email me at BeechDental@gmail.com
Dr. Jeff Shnall
Dr. Jeff Shnall is a dentist providing general, cosmetic and implant dentistry in the Beach neighbourhood of Toronto. For an appointment please either email us at BeechDental@gmail.com or call our office at 416-691-2886.