Sleep Update

SleepWise

This week’s guest was Dr Harry Ball. Harry is a dentist whose practises SleepWise, the SleepWise clinic in Melbourne, exclusively focuses on sleep-disordered breathing conditions. He has been in the dental world lecturing and teaching dentists and doctors, and other health practitioners for many years about the connection between the jaw and the development of the lower half of the face and the impact that has on sleep-disordered breathing conditions and the role that the dental profession has to play in all of that. 

It’s always interesting to catch up, and I always learn something new. I certainly did in this episode. I’ve been in this area for many years. It was a great opportunity to meet Harry for the first time and learn from him and share that knowledge with you.

Sleep

Sleep is such an incredible topic that it’s a very underdiagnosed problem. People come to accept it as just the way it is. I would guess that something like 80 to 90% of people with sleep-disordered breathing conditions goes undiagnosed, and many, many people dismiss it as, “Oh, this is just the way my life is.” And don’t even give it any second thought. 

I often wonder about health practitioners themselves because, very often, I will see a new patient. And as I’m taking their medical history and finding out what medications they’ve been on, I’m surprised at how many people, for example, are on anti-depressants. 

Anti – Depressant

Now, anti-depressants are huge… A lot of people in Australia, a third of the population or something like that, are on antidepressants in some form. What surprises me is that one in seven Australians are on antidepressants, and that’s a figure that comes from 2018. I would think that post-pandemic, that figure is even greater. Certainly, depression and anxiety have increased, and that was a huge and growing problem before the pandemic. 

Exacerbated by the pandemic, the American Society of Psychologists estimated the impact on people’s health of social isolation was equivalent to smoking 15 cigarettes a day. You didn’t get lung cancer, but the negative impact on a person’s health was equivalent to that. So 13 to 14% or, say, 15% of the population is on antidepressants, according to Martin Whitley, who wrote the book Overprescribing Madness.

We did a programme with him. Something like 90% of antidepressant prescriptions is prescribed by GPs, whose average consultation time is something between 7 and 12 minutes.

Mental Health Problem

Diagnosing a mental health problem in 7 to 12 minutes is a challenge. That’s putting it mildly. As is so often the case in modern medicine, the prescription pad is the first port of call, and hence people are on anti-depressants. It surprises me when I talk to people who have been on antidepressants for many years, and I ask them about their sleep quality. No one has ever explored how well they have slept. 

It fascinates me why more health practitioners don’t focus on this. It really comes down to a very simple fact, I think, or a few simple facts. One is obviously they don’t have the time, but the second one is that unless you, yourself as a health practitioner, focus on this in your own life, then you will not focus on it with your patients. 

I know this is personal as in my own case, I mean, I’ve been in practise for 45 years, but it’s only really been in the last 15 or 20 years that I’ve focussed on sleep. The reason I have is because of the impact that that has had on my own life. It’s huge. I have more energy now at the age of 67 than I did at the age of 47. I feel rather passionate about the potential for this to have a dramatic impact on people’s health. 

And people’s health is… If you are not sleeping well, you are predisposed to so many other problems. That part of your DNA that improves immune function is down-regulated. So your immune system is affected by a poor night’s sleep. That part of your DNA that promotes chronic inflammation is upregulated. 

So your chronic inflammation goes up as you sleep poorly. We know that insulin resistance goes up when you don’t sleep well. In fact, after a week of sleeping 6 hours or less, a lot of people’s blood sugar levels are at pre-diabetic levels. Other hormones that help us metabolise fat – leptin, for example, go down. So you are much less able to metabolise fat because that hormone, which helps you metabolise it, is downregulated.

Ghrelin

Another hormone in the stomach is called ghrelin, which makes you hungry. It becomes more abundant. And so you make irrational decisions not because you’re weak but because the hormone that tells you you’re hungry has gone up. Libido goes down. Testicular size. How’s that, for a statistic, go down? 64% of people who have been diagnosed with obstructive sleep apnoea have erectile dysfunction. Obviously men. 

This has a huge impact. That part of our brain which processes memory, the hippocampus, is downregulated. Your ability to remember things on a short-term basis goes down. Another part of your brain called the amygdala, which makes you far more emotional, is upregulated. 

So not surprisingly, when you are tired, you become far more emotional and irrational. That part of our brain the prefrontal cortex, which is one that part of our brain that’s used for reasoning and higher levels of thought, is downregulated in the reptilian part of our brain and becomes more active.

So much goes on with a poor night’s sleep. As we’ve said many times before, a consistently good night’s sleep is a function of both quantities. Getting enough sleep, which for the vast majority, over 90% of the population, means 7 to 9 hours of sleep. Getting and putting your head on the pillow is not enough. It has to be quality as well. So breathing well while you’re asleep is critically important.

Issue of Insomnia

Another aspect that is really important that we are going to be doing more programmes on is the issue of insomnia. There’s a difference between just not getting enough sleep and being sleep deprived, meaning you have the ability to sleep, that you’re giving yourself insufficient time. That is not insomnia. 

Insomnia is when you have, or you are giving yourself the time, but you’re unable to sleep well. Insomnia comes in several forms. It can be difficult to fall asleep. It should probably take you around 20 minutes to fall asleep. But if you’re lying in bed there for 30 minutes, 60 minutes, an hour or two, that is difficulty in falling asleep. And that’s a form of insomnia. So that’s sleep onset insomnia.

And another form of insomnia is when you wake up, and we all wake up at night and maybe go to the bathroom. Any regular listeners of this podcast will know that that may be a reflection of disordered breathing at night. And to those that have used mouth tape, you may have reduced your visits to the bathroom, but that’s a whole other story. 

Go back to the website and search, breathe and explore that. But for people who wake up at night and have trouble falling asleep again and may lie in bed for 30 or 40 minutes or an hour or so, that’s called sleep maintenance insomnia.

There’s a third type of insomnia, which is you don’t feel refreshed by sleep. You don’t get the restorative sleep that you need. And that’s now looking at things like obstructive sleep apnoea, etc. But the two main types are sleep onset, not being able to get to sleep, and sleep maintenance, not being able to get back to sleep. 

There are lots of ways of diagnosing it. The way that it’s generally diagnosed is that if you’re suffering from insomnia and it’s quite a common condition, 10% of the population at any one time will suffer insomnia. It’s sobering to know that 30% of the population has suffered from insomnia at some point. 

There are many reasons why you might be suffering from insomnia. It could be that you actually may have a genetic predisposition. Yes. Something like 20 to 25 to 45% of people have a genetic predisposition. But that’s not deterministic. That’s not enough. There’s also got to be precipitating factors like a breakdown in a relationship – grief, bereavement, work, stress.

These are precipitating factors. There are also perpetuating factors, which is what we’ve spoken about many times in terms of sleep hygiene and your relationship with sunlight, in particular with blue light from technology, from phones, laptops, from other devices. 

Insomnia is an interesting topic which we’re going to be exploring. But this week’s episode was an opportunity to touch base with a real expert in sleep medicine from a dental perspective. It was interesting to note that obstructive sleep apnoea is a problem and that there are grades of it – mild, moderate, and severe. And there are different forms of treating it.

One is CPAP, which is the mask on the facial nose which has which is effective, but it has a very poor compliance rate, meaning people do find it awkward to use, particularly if they suffer from mild or moderate obstructive sleep apnoea and you’ve got this mask on, and you’re thinking, what the hell? I just can’t. 

It’s not that big a problem that I have to wear this mask. If you suffer from severe obstructive sleep apnoea and you are dog tired, and this mask has literally revolutionised your life, well, then you are motivated to use it.

CPAP Machine

A lot of people are diagnosed with mild and moderate obstructive sleep apnoea, but they have been only offered a CPAP machine. And this is where this discussion with Dr Harry Ball was so important and interesting, and this is what I do in my own clinic, and that is the use of various types of appliances which maintain the airway and a much easier to use, much more portable than carrying around a CPAP machine, much more usable and effective. 

They are meant to be called mandibular advancement splints. But there are other devices that perform similar functions. This week’s episode was an opportunity to touch base with an expert to remind you that there were other types of treatments out there besides CPAP. It was a reminder of the importance of sleep. 

It reminded me that we’re going to be exploring insomnia in the coming episodes, and it was just a really interesting chat. I hope you thought so as well. So until next time

This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.