OK, should I take melatonin or not?
December 10, 2013
I would like to say that I have a definitive answer for that question, but as it turns out, the answer is: “It depends”. There is a plethora of research out there on the effects of melatonin, and most studies show it to have benefits even beyond helping you sleep. However, I will keep my comments related to sleep, as this is the reason most of you are taking (or have taken) melatonin.
First, let’s talk about dosage. This study, primarily among older patients, showed that .1 mgs, was too little, while the typical pharmacologic dose (3 mgs) is too much, so .3 mgs appears to be the best. Speaking of dosage, this study showed that even if you get a perfect dosage for yourself, after a few weeks, if you begin to lose the effects, you may need to actually decrease the dosage (I’m sure that won’t make sense to you, but play along with the research, OK?). Speaking of finding the best dosage for you, this study showed that everyone is different, as various psycho-somatic conditions might require different dosages.
Another consideration is the presence of other sleep disorders. For example, if you also have sleep apnea, there is little chance melatonin will help you, as is shown in this study. Oh, and if you are a rat (I am unaware of any rodents with the ability to read, so maybe this is a moot point), you might get constipated if you take melatonin.
Now to what really matters. According to the literature, just how helpful will melatonin be? A meta-analysis was done, looking at 15 past studies to get an average, and these were the conclusions:
- Sleep onset was improved by 3.9 minutes. This means that after your head hits the pillow and you attempt to fall asleep, melatonin gets you to sleep about 4 minutes faster. sleep efficiency improved by 3.1% and sleep duration increased by 13.7 minutes
- Sleep efficiency improved by 3.1%. Sleep efficiency is measured like this. Let’s say you went to sleep at 10 and awoke at 6, but had 2 hours of wake time in between (getting up to use the restroom, reading, lying there awake, etc..), your sleep efficiency would be 75% – this means you were asleep for 6 out of the 8 hours. If you used melatonin, your efficiency would have been 78.1% instead of 75.
- Finally, sleep duration increased by 13.7 minutes. I think that speaks for itself.
Basically, there is considerable controversy out there, but MOST believe that there is no negative feedback (down-regulation) that will slow down endogenous melatonin production. That means that your own body won’t necessarily make LESS melatonin just because you are taking it by mouth. However, with the minimal effects it has when looking at 15 studies (in the meta-analysis), with the narrowed (and confusing) window of dosages in some populations and with the limited use when other issues are present, I am not sure I can ever suggest long term use of melatonin to my patients. I can support taking it for the short term, but if you really want to take it every night over a long period of time, please consult your physician, and I hope he or she has some knowledge in the area of sleep medications beyond what the pharmaceutical salespeople have taught them.
Kent Smith DDS, D-ABDSM
Correspond with sleep physicians
September 12, 2013
Q: I know that quite a few board certified sleep physicians send you patients who are CPAP non-compliant or don’t qualify for CPAP. How did you gain their trust? I can’t find any in my area who will send me these patients!
Dr. Smith: I send letters after seeing every sleep patient to the MD who diagnosed the sleep apnea, detailing everything I checked, my findings, treatment attempts, etc.. . If there is one common complaint I heard from the sleep physicians at Sleep 2009 in Seattle, it’s the fact dentists do not follow up with the sleep physician after they receive the patient. That is so sad, after the grief we give them for not involving dentists. If you are a dentist reading this, PLEASE keep the sleep physician in the loop!
How Does Exercise Affect Your Sleep?
August 29, 2013
Working out especially cardio improves the length and quality of your sleep. Yes, getting sweaty during the day can help your slumber that evening….just be sure to take a bath or shower before crawling under the covers!
In the National Sleep Foundation 2013 Sleep in America Poll, up to 83 percent of exercisers reported getting fairly good or very good sleep, while only 56 percent of non-exercisers did.
A study out of Appalachian state showed that if you exercised in the morning (7AM), you had increased sleep efficiency over those who exercised at 11AM. However, regardless of the time you exercise, you will sleep better than if you didn’t.
A recent Finnish study showed that even if you ride a stationary bike for 3 hours right before bed, even though your heart would be accelerated, you would go to sleep faster and sleep more deeply.
Another recent Sleep Medicine study showed that exercising 4 times per week can increase sleep time over an hour per night.
Another study showed that moderate exercise in the older population with a sedentary lifestyle significantly improved sleep quality. Yet another showed the same with our teenagers.
Research by Feinberg School of Medicine at Northwestern University found that aerobic exercise resulted in the most dramatic improvement in patients’ reported quality of sleep, including sleep duration, on middle-aged and older adults with a diagnosis of insomnia.
How does exercise help you sleep better? Exercise releases endorphins that can boost mood and reduce stress, depression, and anxiety.
Whether you visit the gym, use a home elliptical, or just go for a walk and walk the dog, exercise can help you clear your mind, reduce the stress in your life, and get a better night’s sleep.
Oh, and no, tossing and turning all night is not considered to be an acceptable form of exercise.
Pilots And Sleep Apnea
July 18, 2013
Question:
I know somebody who is a pilot. They can not be diagnosed with sleep or it is immediate disability and they can’t pilot the plane. MY question is have you ever done the MAD for this type of person without the diagnosis? What would the liability be if you said it was just for snoring?
Dr. Smith:
This is one reason we have ambulatory (home) monitors, so we can rule out anything more severe. I would insist on at least this, and you can keep it away from insurance and any official diagnosis. The liability would be pretty heavy if he fell asleep at the controls, thinking he was cured, when in fact you had created a “silent apneic”, so you really need to get at least a Level 4 study done on this patient.
Anti-depressants & Sleep Studies
June 27, 2013
Question:
I have a patient who has opted to seek counsel with their physician regarding a sleep study. She has tremendous daytime drowsiness among other symptoms.
Originally, her doctor persuaded her to not visit a sleep center for reasons I can only imagine. In the meanwhile, at my prodding, she has visited her doctor again and he wrote a script for a PSG study at her local hospital. However, the doctor also prescribed Lexapro to ‘keep her alert’ during the day so that she would have a nice sleep the nite of the study. If I remember from your class, that class of drugs limits or reduces REM sleep. Do I recall correctly?
Dr. Smith:
Lexapro and other anti-depressants will remove REM sleep, which indirectly improves the AHI, but at the expense of a valuable segment of sleep. They will sleep better if their anxieties are preventing sleep initiation, so it can be helpful, but will not give a true picture of the patient’s sleep architecture. That may or may not matter to the sleep physician, but I would ask the expert before deferring to the general MD.
Screening For Sleep Apnea
June 20, 2013
Question:
I seem to have a couple of patients who complain of snoring and want me to make them a snoring appliance, but are reluctant to spend the time & effort to go to the sleep clinic for a baseline.
How would you feel about screening these patients with a home monitor to r/o significant apnea? If the screening is negative, I would go ahead and make the snoring appliance with some degree of confidence that I was not ignoring an apnea problem. If it is positive, then use the results of the screening to encourage them towards complete diagnosis for sleep apnea.
What monitor would you suggest for this? Also, would I need to be certified to read the results?
Dr. Smith:
That’s an OK plan, as long as you follow them up with home monitoring to make sure the appliance is removing any events. That way, you can treat anyone up to about 30 events per hour, and even higher numbers if they have failed CPAP. There is no certification for reading the studies, but it does take some education. I love the Watch-PAT 200, but it’s more robust, and you may want to spend less. The ApneaLink is a “screener” at a lesser fee, but it all depends on what you want.
In great shape, but sleep apnea exists?
June 6, 2013
Can a healthy 200 lbs bodybuilder have sleep apnea?
Q: I don’t get it, thought in order to have sleep apnea you had to be old, over weight and ugly, not in that order… I went to the Doc about restless leg syndrome and she said we need to do a sleep study and see just how bad you got it. Well I got it worst than I thought. I walked in to the waiting room at 8:45 pm and 5 other guys were sitting there cracking jokes about how their wife’s don’t put out any more and waiting to be escorted back to our rooms.
Well here I am 200lbs bodybuilder sitting there waiting my turn and the nurse walked out and said your father will be in good hands so you can go home now… Well, I’m here for a study, and this black lady towers over me and asked is this a joke, because I’m not in a joking mood, I thought to myself you’re going to die.. She came back out to the waiting room and gave me a long look, “your with me”.. So I’m sitting in this chair in my room and she walks in with a 1000 wires and starts gluing them on every inch of my body and talking about uncomfortable..
So at 1:45 she put me to bed and said I can see everything so not make a move unless I tell you too. This room is dark and so quiet that I can hear my ears ringing from the years of racing I guess.. … finally the adrenine level comes back down and I fall asleep. She comes running in, wakes me up and tells me we’re putting this mask on you before you die,, OK.. I asked is this going to help my restless legs, she said “baby this going to save your life”. So here I am, can’t stand to have anything touching me while I sleep and I’m told I have to have it.. can you help me with any advice on how I’m going to live with a mask on my face….. Poor Poor pitiful me…
Surrounded By Snorers
May 30, 2013
Q: What is it with men and snoring??!! I don’t know many men who can honestly say that they don’t snore. My father-in-law did it; my dad does it. And, now, I am double-whammied, because I have not only one man in my house who snores but two!
Prior to having kids, I was a pretty deep sleeper. My mom used to say that I could sleep through World War III and never even know it. Once kids came along, though, I started waking up at the drop of a hat. Now, I’m lucky to sleep throughout an entire night without someone or something disturbing my slumber.
It started out with my husband being the sole snorer in the family. It used to be just when he slept on his back. Now, it’s whether he’s on his back, his side, or standing on his head — it makes no difference. To give him credit, he has tried to rectify the situation by testing out the Breathe Right strips, the mouth sprays, etc., but, unfortunately, nothing seems to work. I, too, have tried to better the situation by nudging him, yelling at him, and even kicking him in the night, of course to absolutely no avail. I have finally resorted to wearing those stupid foam ear plugs each and every night to block out the noise.
And, wouldn’t you know, my other little man in the house has now followed in the footsteps of his father. Over the past couple of years, my son has become a mouth breather. Translation: the kid saws logs like nobody’s business at night. I can often hear him all the way down the hall even though his bedroom door is closed. My mom made me ask the pediatrician about it to see if he might have a problem with his adenoids. The doctor said that he really doesn’t recommend removing them unless sleep apnea is involved. He definitely doesn’t seem to stop breathing in his sleep — I’ve listened intently on many occasions. He’s got a steady and very excruciating rhythm going on with his snoring.
So, why is it that men are typically the ones who snore? My daughter doesn’t snore, and I certainly don’t either. Am I really doomed to stuff foam in my ears for the remainder of my nights? I don’t want to become like Lucy and Ricky and sleep in two different beds! I guess I just answered my own question — foam forever it is….
Dr. Smith: Don’t know where you live, but you should not take either your husband’s, nor your little man’s snoring lying down, and get some help. If your husband is now snoring regardless of sleep position, this has almost certainly elevated to obstructive sleep apnea, and if you don’t know the complications related to this, feel free to read all about them on my web site.
As far as your son, mouth breathing is not healthy, and can mean his adenoids are swollen. When this happens, he is forced to breathe through his mouth, which swells the tonsils even more. It also causes some structural changes in his mouth over time, as his upper arch begins to narrow, the roof of his mouth rises up, and before you realize it, there is even MORE constriction of the nasopharynx, and he becomes a permanent obligate mouth breather.
So, for your husband’s health, energy level, weight complications, etc.., get him some help. For your son’s future, get HIM some help. Let me know if I can help guide you somewhere.