The Neurological Consequences of a Misfit Mouth on Sleep | Jerald Simmons | TEDxSugarLand
Well, I've always been fascinated by neuroscience and the science behind medicine. I've mostly been interested in the brain, because the brain is the microprocessor that controls your whole body, and that interest is what led me to become a neurologist. But I didn't want to become blinded with a telescopic view of my specialty, I wanted to learn how the brain interacted with other parts of the body, and that's what led me to become a sleep specialist. So during a sleep study, we're measuring multiple organ systems, and we're measuring what goes on during the night throughout the body, and we're seeing all the different interactions that may be disturbing our sleep.
Well, over the last 30 years, the field of sleep medicine has evolved tremendously, and I've been part of that process, and I've watched my whole professional career transform over the last 30 years. There's been a lot of new breakthroughs and a lot of new concepts that have come about, some of which are life-transforming, some of which I want to convey to you today. To exemplify this, I'm going to tell you about little Johnny.
Johnny's the product of a normal pregnancy, and Johnny's mom was concerned, though, because Johnny didn't seem to sleep too well. When she looked at him at night, he had his mouth open. He was breathing through his mouth and he had little raspy kind of sounds. And he would toss and turn, and he just didn't seem to be getting much rest. During the day, he was very fidgety and he was very irritable. She was concerned, and Johnny seemed to not breastfeed too well, so she resorted to bottle feeding. Well, Johnny grew.
A couple years went by, still not a good sleeper, and now he's getting ready to go to kindergarten. So mom's still concerned, and she goes to the pediatrician, and he's got to get his shots before he goes off to kindergarten, and she's conveying that Johnny just seems to not sleep too well. He's tossing and turning, and he's always getting congested, and he makes a little bit of a snoring, rasping kind of sound. During the day he's very fidgety and he doesn't want to sit still. He seems sort of hyperactive. Well, the pediatrician sort of discounts this and says, "Don't worry, Johnny is like a lot of other kids that I see. It'll probably go away. He'll outgrow it."
Well, about a year goes by, he's now in first grade, and he's still sleeping poorly, and the reports from school don't seem to be so good. The teachers are concerned because Johnny isn't very focused. He can't keep up with the other students. Actually, he's pretty disruptive in class. So the teachers are telling mom, "I think you should take Johnny to the pediatrician and see if there's some medication that maybe he can take to make him better." So she brings him to the pediatrician, she conveys the concerns that were told to her from the schoolteachers, and the pediatrician pulls out a prescription and then writes for a stimulant medication and says, "Here you go."
Well, he doesn't ask any questions about his sleep, doesn't do any kind of test. No measurements of his sleep, and he just wants to write a prescription. What are we missing here? Well, mom takes the prescription and she gives him the medication and she's a little bit concerned, but a lot of kids are getting the same recommendation, so she feels sort of, it's not too out of line of what's the current practice these days. Well, lo and behold, the reports come back better. Johnny's more focused in school, and he's actually starting to fit into the normal class environment better, not as disruptive. Still not sleeping well, but he's doing quite better.
About a year goes by, he's not doing so well. The medicine doesn't seem to be working so much. The dosages have been increased, and he switched to newer forms of medication, but he just doesn't seem to give the same good response that he got initially on this medicine. Well, there's concerns, but he is just the way he is. And so he's put into a special education program. And mom goes back to the doctor, the doctor doesn't seem to be doing any tests but just keeps on modifying the medications, and before you know it, Johnny's in junior high. And the dentist, seemingly unrelated, the dentist says, "I think Johnny's going to need braces. We want to give Johnny a nice smile."
So she takes him to the orthodontist and the orthodontist says, "Look, there's not enough room for Johnny's teeth, and it's a lot of crowding, so we're going to have to pull some of his teeth and put him in braces, and we're going to have to bring things back to give him a nice smile." Well, she goes ahead with the recommendations. Some time later, Johnny's had his orthodontic work done and he has a really nice smile. His sleeping's getting worse. Now he's grinding and clenching his teeth at night, and his behaviors during the day seem to be getting worse. The medications are now increased, and that's changing now, his behaviors are changing, he has highs and lows, and sometimes he's having little violent outbursts.
Well, now the psychiatrist that he's now seeing has said that he's got bipolar disorder and now they're putting him on medication to treat that, as well. Well, time goes on and Johnny's not doing that well, and he's waking up in the middle of the night, and he's hard to get up to go off to school, and he's hard to get to go to bed at night, but this is sort of the way he is. Well, now it's about his senior year of high school, and it's clear that Johnny just doesn't have the focus or follow-through to take on an academic career path, and he's probably going to go into something that's going to keep him busy moving around all day long.
And so about a year or so later, Johnny's off doing his job in construction, and he's busy all day long, and then after work, he goes out with his buddies. Goes out drinking, goes to fast food restaurants, comes home and falls asleep in front of the TV. Mom looks over and sees him sleep on the TV, mouth open, snoring. He's gaining a little bit more weight. What are we missing? So Johnny's going on with a lifestyle that seems to not be all that productive. Well, some time later, Johnny has a girlfriend. He moves out of the house, and now he gets married, and his wife's a good cook. He keeps on the same behaviors where he's going out drinking at night and then he eats a lot of good food that his wife makes, and he's getting heavier.
Well, now his wife can't sleep because his snoring is so bad it's destructive to her. And he starts getting heartburn, and waking up in the morning with gastritis. So his wife says, "You should go off to the doctor." So Johnny goes to the doctor, and doctor says, "Oh, look, I'm going to give you medication for your heartburn, but I also want you to take this little, simple, small sleep study. Go home, wear it at night, and let's see what we can do about that snoring situation." Well, Johnny wears the device, comes back to the doctor, gives it to him. He analyzes the results, and the results come back inconclusive. Didn't really show much.
Johnny's not surprised because he didn't sleep that well that night, because he didn't drink the way he normally does. Well, so nothing really comes out of that whole evaluation. Well, what are we missing? So a few more years go by, and Johnny's starting to get depressed, and he's realizing that life hasn't really brought him to that point where he really thought he could be at that point, at that certain age, and he's getting more depressed. He's gaining more weight, and he's starting to develop high blood pressure. And now the doctor says, "You have early signs of diabetes. I want you to go back and I want you to get another sleep study, but this time we're going to go into the lab and I want them to monitor you more closely." So he does that. And the results come back showing that he has something called obstructive sleep apnea.
So the doctor says, "I want you to wear this little mask on your nose at night to help your breathing." Johnny looks at that and says, "I can't do that, that's going to make me more depressed than I already am." So he doesn't follow those recommendations. A few more years go by, Johnny's getting really sick. Now he's got bad hypertension, and he's got diabetes, and now the doctor says that he has atrial fibrillation, an abnormality of his heart. So the doctor wants to put him on a blood thinner that's going to prevent him from having a blood clot that may develop from his atrial fibrillation. But Johnny's so depressed he doesn't follow those recommendations.
Well, the consequences of that is that Johnny developed a little blood clot in his heart. The blood clot traveled up through his carotid artery into his brain, and left him with a stroke, causing paralysis of the left side of his body. Undergoing a hemiparetic stroke is one of the most stressful things that a person can go through, and to go through a rehab process to get better after having a hemiparetic stroke is extremely stressful for any individual, likewise for Johnny. As Johnny was going through his rehabilitation, he developed chest pain, had a heart attack, and he died at the age of 45. What were we missing?
What if I told you that Johnny's problem was primarily due to a small jaw, a small mouth, a small maxillomandibular airway complex. His small mouth compromised his breathing his entire life and led to the cascade of events that I told you about. So to understand this problem a little bit better, I first want to talk about breathing, okay? So when a person breathes, air rushes in and out through your mouth and goes to the back of your throat. As air flows to the back of your throat, it creates a vacuum, a negative pressure. It's called the Bernoulli Effect. Whenever you have any kind of flow through any kind of space, you're going to get this negative pressure. A good example of that would be in a shower. So in the shower, you know when the water flows how the curtain can pull in towards the water? That's from the vacuum from the flow. It's called the Bernoulli Effect.
One of the principles of the Bernoulli Effect is if you have the same amount of flow going through a smaller space, you're going to get a stronger negative pressure. If you open up that space, there's going to be less of a negative pressure, and that's why they have the shower curtains that bow outward, because it opens up the space and decreases the negative pressure. So when you're breathing right now, you're developing negative pressure in the back of your airway. That's true always. Right now, you're probably pulling just a negative two or three centimeters of negative pressure right now. When you fall asleep, the muscles relax, and when the muscles relax, the jaw goes back. Now as the jaw goes back, your tongue goes back because your tongue is attached to the inside of your chin right here, and it goes to the back of your throat and goes forward.
So when your jaw falls back, your tongue goes back, and the space in the back of your throat becomes compromised. It's smaller. So when you're breathing through the smaller space, there's a stronger vacuum, a stronger negative pressure. At a certain point, the negative pressure's so strong that it pulls in the soft tissue, making it vibrate, and that vibration is what causes snoring. Snoring is an indication that there's increased negative pressure in the back of the airway. At a certain point, the negative pressure's so strong that the airway will completely collapse. At that point, a person's asleep, they're trying to breathe, but they can't. So the brain recognizes that there's a problem. There's a brief awakening. With the awakening, the airway opens up and breathing starts up again.
And frequently the oxygen level may drop when that kind of event occurs, so that's complete obstructive sleep apnea, right? And that could occur repetitively throughout the night. Now when the problem is really bad and you're going to have complete obstructive sleep apnea, then that's easy to diagnose. And if you're on this end... Let's put a spectrum where you have complete blockage of the airway. Put normal breathing on this end of the spectrum, and realize that there's a lot of things in between. There are episodes where the airway's only partially blocked, and a person's working harder to breathe. Their oxygen's normal, they're getting air, but they put more effort into breathing. Just by putting more effort into breathing, the brain recognizes that there's a problem, and there's a brief awakening. With the awakening, airway opens up, and now it's easier to breathe.
The point I'm trying to make here is that breathing can disturb your sleep, even without a complete pause of your breathing, even without your oxygen level falling all the way down. So when you have a problem that's real clearcut where you do have the pause, and you do have the oxygen drop, a simple device that you go and wear home can easily make the diagnosis. But if you're on the other end of the spectrum where it's more subtle, it may go under the radar screen, and it might require someone to come into the sleep lab to be evaluated. And sometimes the problem is so subtle that we actually have to put a little catheter down someone's nose to measure the negative pressure, and we can see the increased effort causing the disruption of sleep. And when it's this subtle, it's something called the upper airway resistance syndrome, which is a form of obstructive sleep apnea, but it's frequently missed.
Now when this is going on throughout the night, it's fragmenting the continuity of the person's sleep, and it's going to cause a lot of symptoms during the day. And so what does the body do? It will clench and brux. Clenching and grinding your teeth is one of the things that may happen as a preservation process because when you clench and grind, you're bringing your jaw, you're bringing your tongue forward and you're opening up your airway. So people are clenching and grinding at night to help their breathing, and as a result, what are they going to do? They're going to destroy their teeth. I'm a neurologist, and I look at teeth. Why? Because this destruction is a sign of behavior, behavior that's occurring at night, grinding and clenching.
So what's so important that your body's going to sacrifice the teeth, sacrifice the jaw? Well, it does it to preserve the breathing. So when this is occurring throughout the night, it's very detrimental. And so there are many problems that can occur with this condition. So let's start off on this end of the spectrum with Johnny when he was younger. He didn't have real obvious pauses, he was just working hard to breathe. He was mouth breathing throughout the night. That's a red flag. The pathway of least resistance is through your nose, and if a person opens their mouth, they're doing what's call rescue breathing. They're opening up their mouth to help breathe. And as time goes on, he starts having a little fragmentation of his sleep and the tossing and turning is a sign of disrupted sleep. That disrupted sleep decreases the effectiveness of what sleep's supposed to provide, and there's difficulty with attention deficits during the day, and there's hyperactivity, which is a way of compensating for this problem.
But as time goes on, the person may start waking up with headaches, or they're going to wake up with nasal congestion because of the negative pressure in the back of the airway causes swelling. But the swelling may go away shortly after they wake up, but it happens only at night. But as this problem gets worse, now there's more of a vacuum that's getting created in the chest. And as a result, it may suck the gastric juices up into your esophagus, developing heartburn in the middle of the night. And then as the problem gets worse, that vacuum is affecting the heart. It increases the risk of hypertension, stroke, heart attack, cardiovascular disease. So we really don't want to break your heart. Don't let snoring break your heart. Don't let it disrupt the bedroom environment with your spouse or loved one, but don't let it affect the cardiovascular disease that could be developing, because there's multiple medical problems that can be occurring.
And we can be identifying this problem at an earlier age. But why is this problem so common nowadays? This problem is common nowadays because we found out that actually our mouths are smaller. As a species, we're having more occurrence of obstructive sleep apnea. Anthropologically, studies have been done where they're seeing the skulls of people from hundreds of years ago actually had larger mouths, larger airways. And it's thought that through the industrial revolution, we've gone to processed foods and we're not challenging our mouths when we're very young, and we're resorting to bottle feeding, which is not working our mouths. So these little kids are not having the normal growth and development of their mouths. Well, along those lines, there are things that could be done orthodontically at an early age. You could do orthodontics on a four-year-old. There are people that are doing that now, pediatric dentists and orthodontists are doing orthodontics on four-year-olds because that's when the bony structures are soft and they're more malleable, and you can open up the airway. You can anchor onto baby teeth to use that to open up the airway.
And it's not about the teeth, it's about the airway, and when you're not breathing normally, it's going to affect the brain. And when it affects the brain, it can affect your whole body. So imagine, if you will, a future where all dentists are aware of how to screen for this condition, and they look at the child's mouth and they start seeing the signs. Beyond that, what if all pediatricians were aware of this and started asking the right questions and doing the right exams, and started identifying this at an earlier age? Let's go beyond that. What if we taught this in the schools, and to the public, so there's more awareness of this kind of condition going on so we can make more awareness so we can have early intervention and do certain maneuvers that will open up these kids' airways, and we won't have unfortunate situations like with had with Johnny.
We could decrease the occurrence of ADHD, we could decrease the occurrence of hypertension, cardiovascular disease, and a whole host of other symptoms. And that's the future we're working for, because if you get a good nights' sleep, and hopefully our future generation will sleep better, and they'll live better. Thank you.