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Tarun Agarwal, DDS

8304 Creedmoor Road
Raleigh, NC 27613
Telephone: (919) 870-7645

When Sleeping Is
Hazardous to Your Health

“I know our feature topic in this issue is self-inflicted adversity—focusing on obesity, smoking, and substance abuse,” notes Dr. Tarun Agarwal of Raleigh Dental Arts. “And I want to add to that list the issue of hazardous sleeping—called sleep apnea—which has been a factor in my own life.

“Most people think snoring is normal. Most people think being tired during the day is not really abnormal—they may blame their very active kids, the stress of work, or that they are busy, busy, busy. And many people have misconceptions about sleep apnea. They believe it is a heavy person’s disease—and that’s not necessarily true. In fact, very thin people can have sleep apnea if they have anatomical issues that limit the healthy, proper function of their upper airway.”

Further, he says, “it is a fact that sleep apnea is a co-condition with many other diseases in our bodies—such as high blood pressure, diabetes, Alzheimer’s disease, memory issues, moodiness, psychiatric issues, and more.”

Dr. Agarwal

Feeling Tired

Recalling his own experience, Dr. Agarwal says: “Years ago, back in my twenties, I was consistently feeling more tired during the day, sometimes resorting to taking brief naps. My snoring was getting louder at night, to the point where my wife wouldn’t sleep in the same room with me.

“My wife is a medical doctor, and she led me, with a lot of passion, to get a professional sleep study. At that point, I knew very little about sleep apnea. The sleep test was an eye-opener. It disclosed that I had severe sleep apnea, a very dangerous condition. A C-PAP—a Continuous Positive Airway Pressure machine—was prescribed. It’s designed to deliver pressurized air through a face mask while you sleep.

“That device was extremely helpful, and C-PAP remains the gold standard of sleep apnea treatments—when it is tolerated and faithfully used. I wore the device for about five months, and felt rested and restored to normal energy levels. After that, though, I slipped away from the routine. The face mask is uncomfortable and cumbersome, and because I travel a lot, it became an annoyance: you can’t easily go to the bathroom at night; you have to clean the device frequently. Eventually, I got out of the habit of using it as prescribed—which, unfortunately, is true of about 60 percent of sleep apnea patients.

“So I stopped wearing my C-PAP and my health condition reverted right back to my earlier state. About four years passed and age, children, and work stresses increased: I was starting to take naps at lunch time, becoming more irritable and moody, and putting on weight. That’s when I started researching my role as a dentist with an interest in sleep apnea.”

Multiple Issues

Symptoms of sleep apnea are varied, explains Dr. Agarwal. “They include irritability and moodiness due to poor sleep, elevated blood pressure, lowered immune system response, weight gain, lower sex drive, and more. An estimated 25 million Americans have sleep apnea—80 to 90 percent of which is undiagnosed.

An individually designed oral appliance, worn only while sleeping, keeps the airway open to permit healthy, undisturbed sleep.

Notes Dr. Agarwal, “oral appliances to
treat sleep apnea have been around for a long time. What’s new is the digital technology that allows us to make
acrylic appliances that are smaller, stronger, thinner, and better smelling.
And these newer devices result in better compliance. When something’s more comfortable, you’ll use it more.”

“Severe sleep apnea patients are candidates for cardiovascular problems because they’re not getting enough oxygen while they sleep. Sleep apnea stops your body from breathing and decreases your blood oxygen and subconsciously you will wake up, thus disrupting your sleep. Sleep cycles are extremely important because they release different hormones and chemicals that regenerate your body at night. If your sleep is disrupted, you’re either not getting to some of those stages, or not spending enough time in those stages for the body to do what it’s designed to do.”

Diagnosis and Treatment

Sleep apnea is diagnosed in lab sleep studies or with a home test, notes Dr. Agarwal. “Dentists do home sleep tests and work with a board certified sleep physician who interprets and scores the results. All of these tests are approved by the FDA, most insurances, and Medicare.”

The Apnea Hypopnea Index is used to diagnose sleep apnea, explains Dr. Agarwal. “Apnea is defined as breathing that stops for 10 seconds or more; hypopnea is defined as a drop in oxygen saturation of 3 percent or more. The sleep test records how many events—apneas or hypopneas—occur over a period of time, which becomes your index. For example, I have an index of 38—meaning I have 38 events per hour. A score of 0-5 is considered normal—and it is normal to have a few events through the night; 5-15 events per hour is considered mild and that’s where oral appliances are extremely effective; 15-30 events per hour is considered moderate, and oral appliances are effective but we may start looking at a C-PAP. Then there’s 30+, which is considered severe. At this point we send the patient directly to a sleep physician, where they will do much more comprehensive testing.”

Oral Appliances

“As a dentist with sleep apnea,” says Dr. Agarwal, “I wanted to make an oral appliance to treat myself, one that would be more comfortable to wear than a C-PAP device. This led me to using a specialized oral appliance, much like a mouth guard, that reduces the symptoms and risks of sleep apnea. The appliance is specially designed to fit only my mouth, positioning my jaw to create an optimal opening of the airway while sleeping.

“Once I was sold on my oral appliance, I implemented a screening questionnaire for my patients to identify those with sleep apnea. I now have a dedicated person who manages all of our sleep patients—from beginning to end—making sure they’re taken care of and that our notes are sent to their physician. If there are medications that need to be adjusted, we work with the physician. That’s part of the overall process. It’s not as simple as just coming in and making an appliance for you; it’s about testing you before and after, trouble shooting, and communicating with the physician and medical insurance. We want to make it easy and affordable for patients to be able to do this.

“I do not believe that oral appliances are the right solution for everyone; some people must have a C-PAP. In fact, a C-PAP worked better for me than an oral appliance; but an oral appliance is better than not using anything at all. Ultimately, the key is that you must do something: sleep apnea deserves your prompt and expert attention.”

When Neglect Is the Issue

“There’s another issue of ‘self-inflicted harm’ that dentists see a lot,” notes Dr. Agarwal. “And that is the issue of poor oral hygiene and neglect. Sadly, for some, neglected dental health is the result of other problems, such as addiction. However, it’s estimated that half the population is anxious about going to the dentist—and that anxiety can and does result in people avoiding the dentist and neglecting dental problems until they are severe.

“And, frankly,” he says, “I can understand that anxiety. I’m putting these two hands in your mouth; it’s a very private area. And although we’ve come a long way in dentistry in terms of technology, it’s still loud, and rattling—right here in your head, right near your ears.”

Health&Healing: When a patient comes to you after years of serious neglect, what do you do for them?

DR. AGARWAL: I think the first thing is to let them know they’re not alone—to give them a sense of hope, and not to dismiss or judge them. I can’t tell you how many times—once you break down that barrier and talk to them—they’ve said: “I sat in the parking lot for 30 minutes deciding if I was going to do this or not.” For those patients, fear of dentistry is the issue; for others it’s embarrassment about what has happened to them—possibly through no fault of their own. So, the first thing always is to give people hope.

The next thing you do is you ask them what they want because what I want and what they want can be two totally different things. And people are more likely to do the dentistry—get things taken care of—if they’re involved in the decision process. Finally, you give them options.

That’s the key: give them hope; ask them what they want; and then you can be the dentist and tell them what the technical choices are and see what fits in their life and in their budget.