By Emma Cooksey
I suspected I had a very compromised airway before I saw it. I was a habitual mouth breather as a child and have struggled with sleep apnea as an adult. Last year I went to see a dentist offering palate expansion to expand the airways of people with sleep apnea. On our first consultation, we looked at my cone-beam computed tomography (CBCT) scan on a big screen. It was good the screen was big because my airway wasn’t.
I had heard people describe breathing through a compromised airway as similar to breathing through a cocktail straw. However, my airway didn’t look like a cocktail straw. It looked more like Chile. The long, incredibly narrow South American country clinging for dear life to the side of Argentina. An elegant whisper of a country, but the last thing you want your airway to resemble.
The dentist and dental assistants were very professional. They stared straight at the screen and didn’t disclaim, “how on earth are you breathing?”. We all knew what we were looking at, though. The color-coding on the scan ran from bright red, indicating an extremely compromised airway, to blue, representing a healthy airway. It’s a kind of traffic light system for airways. Mine was completely red, the sign of a severely compromised airway. There has never been an agreed-upon definition of a normal airway size. Looking at my scan, my dentist was sure the volume of my airway was far below what could be considered normal. We had work to do, and I was ready to get started.
How did I end up at age 44 in a dentist’s office talking about my airway in the first place? I had a long and twisty journey through sleep apnea diagnosis and treatment. During my twenties, I was plagued by daytime sleepiness, morning headaches and persistent anxiety. Despite seeing a lot of doctors over a ten-year period and reporting all the symptoms of sleep apnea, I went undiagnosed. When I asked if it could be a sleep problem, I was told that those were rare and that sleep apnea usually affected older, overweight men, not young, slim women like me.
My sleep apnea became difficult to ignore at age 30 when I fell asleep at the wheel with my baby daughter in the back seat. I was on a busy bridge surrounded by traffic. I slammed on my brakes in time to avoid a collision, but it was such a close call that it made me search for answers about my sleep. The results of my polysomnogram confirmed I had obstructive sleep apnea.
Like so many sleep apnea patients, I was prescribed a CPAP and went home to try to get used to it. I had every possible PAP therapy problem, but I had most issues ironed out by the end of the first year and was struggling less with morning headaches and anxiety. I still found daytime sleepiness a continued challenge, but I felt better knowing I was keeping my AHI under 5 and keeping a multitude of health problems at bay.
I began a podcast called “Sleep Apnea Stories” after 12 years of CPAP therapy. I was in my early forties and still didn’t know anyone else in my life with sleep apnea who used a CPAP. When I started my podcast, I felt isolated and alone. I wanted to provide a platform for people with sleep apnea to tell their stories. That included the stories of people trying a wide array of different treatment modalities to improve their sleep apnea.
One of those guests was Chandra Hartman. Chandra had successfully treated her sleep apnea, taking her AHI from 41 events per hour to under 5 events per hour after undergoing two years of palate expansion. The more we talked, the more I realized how similar our dental and orthodontic histories were. We had both been mouth breathers as children and developed high, narrow, vaulted palates. Simply put, our tongues never sat at the roof of our mouths and never acted as the natural palate expanders they were supposed to be. We both had four bicuspid teeth extracted and retractive braces as teens. This is a very controversial topic among some orthodontists, but common enough for Dr. Bill Hang to have coined the term “Extraction Retraction Regret Syndrome” to describe the patients he sees with compromised airways after orthodontic treatment.
I started palate expansion treatment with upper and lower Vivos DNA appliances. The upper appliance looks like a palate expander you might remember from childhood. I was given a key to turn gently in tiny amounts every 3 days to gradually expand my palate forwards and outwards. Unlike traditional orthodontic expanders, this appliance isn’t putting pressure on teeth. It has small wire coils which gently stimulate new bone growth. This theory of “epigenetic orthodontics” is controversial, to say the least.
One thing which makes obstructive sleep apnea so vexing to treat for clinicians, and frustrating for patients, is the vast array of reasons behind why airways are collapsing or becoming blocked in the first place. The truth is there is no one size fits all treatment for sleep apnea. Suppose a patient develops sleep apnea because of significant weight gain and loss of muscle tone, but they have a wide palate, good nasal breathing and correct tongue placement. In that case, palate expansion is unlikely to help them.
The big question is, does palate expansion work? We are waiting for enough scientific data to say for sure. However, I just saw my eight month CBCT scan and the results were very encouraging. I saw my airway volume more than double from 31.8mm to 81.9mm. It’s important to bear in mind that it’s going from an extremely compromised airway to a very compromised airway. I still have around a year left of palate expansion, so I feel hopeful that we will get more space in my airway and more improvement in my sleep.
I sometimes describe getting to the root causes of sleep apnea as a highly complex game of chess with a lot of moving parts. I have been a CPAP user for 14 years and have continued PAP therapy along with my palate expansion. The hope and goal are to get enough expansion of my airway that I don’t need CPAP therapy anymore. Whether or not I get there, at the very least, I hope my airway will look a lot more like Florida and a lot less like Chile.
Emma Cooksey is a writer and hosts Sleep Apnea Stories, a weekly podcast featuring guests coping with sleep apnea and the medical experts who treat them. She lives in St. Augustine, Florida.
Source: Sleep Lab Magazine Mar/Apr 2022
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