“I am continually reminded—with every patient—of the central role that sleep plays in our overall health,” says Dr. Charles Ferzli, of TMJ & Sleep Therapy Centre in Cary, “and of the complex web of factors that can impair our sleep, and therefore our health.

“Quality sleep—in all its stages—is essential to good health,” he emphasizes. “When we don’t sleep, we don’t learn, we have trouble remembering things, and we don’t heal. We have more inflammation, we feel more pain, we’re more tired and irritable. We have more anxiety and suffer more from depression.

“So, the focus of my practice is to understand—and address—the sources of my patients’ sleep problems. And that can be a challenge,” he admits, “because it’s rarely possible to pinpoint a single ‘cause’ for sleep problems. Rather, there is more likely to be a cascade of causes-and-effects, culminating in severe sleep and health problems. And that chain reaction of causes-and-effects very often accelerates with age.”

Many Contributing Factors

Many of the problems contributing to poor sleep may seem minor, notes Dr. Ferzli, “and may not seem connected to each other or to sleep issues. In fact, the list of possible factors often surprises my patients, because it includes such a range—from nasal congestion and allergies to missing teeth and antidepressant medications. Again, it’s never just one thing—but how various problems and symptoms produce other problems, culminating in serious health issues.”

The complexity is evident when Dr. Ferzli describes one of the age-related problems he encounters. “It often happens,” he says, “that, as people age, they have more diseases and chronic health conditions—for which they take medication, sometimes multiple medications. Now, the condition itself—such as chronic pain—may interrupt sleep, which is a problem. But what’s not so obvious is the role medications play in sleep impairment.”

Many medications cause dry mouth, he explains, “which means that there is less saliva protecting the functions on the teeth. That, in turn, makes some people more prone to cavities and other dental problems. Other medications—such as anti-depressants—affect the quality of sleep, interfering with the deep sleep and REM sleep stages, which are critically important for cognitive health, learning, and memory.”

Mouth Breathing, Aging Muscles, Missing Teeth, and More

“The connections between interrupted sleep and health problems are many, and cycle back and forth,” notes Dr. Ferzli. “Poor sleep increases inflammation and impairs our ability to heal. And with inflammation comes a whole slew of comorbid conditions—from high blood pressure and diabetes to heart problems and acid reflux. Hormone dysregulation, digestive issues, and many psychological conditions—including anxiety, stress, and depression—are also worsened by poor sleep and, in turn, impair sleep.

“Increased inflammation also results in a major health problem that contributes significantly to sleep issues—mouth breathing,” notes Dr. Ferzli. “Inflammation produces nasal congestion, which results in mouth breathing. And mouth breathing is simply not conducive to good sleep. People who breathe through their mouths while sleeping not only have dry mouth issues, but are more prone to clenching and nighttime bruxism—habits that result in jaw pain, cracked teeth, and possibly tooth loss.

“Actually, mouth breathing has many negative effects—some of them surprising. If we’re not breathing well from the nose,” he explains, “there’s more inflammation causing more forward head posture, something you’ll see in a lot of elderly folks. For every inch the head is forward, it adds 10 pounds of pressure to the neck and back muscles. The result is pain, more inflammation, more sleep disturbance—a vicious cycle.”

“The loss of muscle tone in the body that often comes with age, also affects breathing and sleep,” notes Dr. Ferzli. “Loss of muscle tone can cause the airway to collapse, for example, leading to the serious problem of obstructive sleep apnea. And, since 99 percent of patients who have obstructive sleep apnea also have periodontal disease, still more health problems result.”

Tooth loss is another problem common in older patients, whether because of cavities, repeated dental work, or clenching and grinding. “Whatever the reason,” says Dr. Ferzli, “when people lose their posterior teeth, it puts more pressure on the front teeth, causing the jaw to rotate, and create more compression on the jaw joint. The result is more inflammation, making them more prone to headaches or referred pain, sometimes in the shoulder or the back.”

Reversing the Tide

“As this list of intertwined problems and symptoms illustrates,” says Dr. Ferzli, “sleep issues are complex and can be challenging to unravel. But it can be done. And it’s a ‘one step at a time’ process.”

Typically, he says, the most important task is education. “I need to understand all the contributing factors, and my patient needs to understand the conditions and choices that, collectively, impair their sleep and health.

“So, the first step is: I listen. I want to know why they’re coming to see me; and whatever their chief complaints are, they’re the ones I’m going to focus on, because that’s their motivation for getting better. They may say ‘I have headaches and jaw pain,’ so we’ll focus on that. And we measure recovery based on improving the symptoms.

“In the long-term,” says Dr. Ferzli, “our goals will include not only reducing inflammation and improving sleep, but eating a healthier diet, and getting rid of problem medications. But meeting those goals is a process—step by step—and we typically work on one goal at a time.

“The first step is to review the medical history, to rule out conditions that require medical care and to find out what medicines they’re taking. We’ll do blood work, checking for vitamin D, iron, and magnesium levels. And we’ll identify the holistic things they might be able to do to address symptoms naturally without medications—and there are plenty of such options.”

The next steps will be to address, one by one, the individual patient’s concerns. “For an older patient who’s missing teeth, for example, we may recommend dentures; it’s a solution that will resolve many, many problems. An orthotic to position the jaw properly may be useful for another patient. We have had great success in overcoming the problem of mouth breathing by teaching simple breathing exercises. Helping patients understand the role that diet plays in their sleep issues is also important.

“Ultimately,” acknowledges Dr. Ferzli, “the patient will decide what changes to make. Our job is to guide the process.”