Full Transcript Introduction: Sleep and Brain Health 0:00 Sleep is so important. 0:01 That's when the brain does the work that no supplement, no exercise routine, or diet can replace. 0:09 And at night, our brain needs to get into a deep, uninterrupted sleep in order to reset, to repair, to consolidate our short-term memories into long- term memories. 0:23 Even people who are doing everything correctly, they're taking supplements, eating cleanly, exercising daily. 0:32 If they are not getting that deep, restorative sleep, then everything else is going to kind of fall apart. 0:44 Welcome to this episode of the Think Well, Age Well podcast. 0:48 I am your host, Dr. 0:49 Heather Sandison. 0:50 And today's guest sits at the fascinating crossroads of oral health, airway science, sleep medicine, and of course, the brain health that comes with that. 1:00 Dr Urella Katz-Rappaport began her journey in New York. 1:04 She earned her biology degree at SUNY Binghamton and went on to complete her dental training at The University of Pennsylvania. 1:11 From there, she's built a career marked by curiosity and innovation. 1:15 She's contributed to research on everything from chemical approaches to decay, removal and to helping the Department of Veterans Affairs create a national 1:25 dental implant registry. 1:27 she now practices here in San Diego and she is a diplomat of the American Board of Dental Sleep Medicine. 1:35 And she's a leading clinician exploring how airway function, inflammation, and the oral microbiome shape long-term cognitive resilience. 1:43 Her book Breathe Easy, Sleep Deep brings the science to the public in a way that empowers people to reclaim restorative sleep and protect their brain. 1:52 When she's not busy transforming lives one airway and one mouth at a time, you'll find her gardening, traveling, or being a champion of organizations that 2:02 uplift women. 2:02 Dr. 2:03 Rapoport is here to help us understand something that many people miss. 2:07 I see this all the time in my practice. 2:09 People are doing all of the right things, the diet and the exercise and taking supplements. 2:13 But the way they breathe at night can be one of the most crucial, unrecognized, but most powerful drivers of cognitive health. 2:22 So, Dr. 2:22 Rappaport, welcome to the show. 2:24 Thank you for having me, Heather. 2:26 You and I obviously agree on this. 2:29 But you've said that sleep is the missing link in brain health, what do you mean by that? 2:34 What do see people overlooking or not being diligent about when it comes to their sleep hygiene or their asleep health? 2:42 Well, sleep is so important. 2:44 That's when the brain does the work that no supplement, no exercise routine, or diet can replace. 2:53 During the day, our brains are under constant demand. 2:56 We're thinking, we're responding to questions, were managing emotions, where processing information and at night, Our brain needs to get into a deep uninterrupted 3:09 sleep in order to reset, to repair, consolidate our short-term memories into long- term memories. 3:18 Even people who are doing everything correctly, they're taking supplements, eating cleanly, exercising daily. 3:26 If they are not getting that deep restorative sleep, then everything else is going to kind of fall apart. 3:34 If you think about sleep as kind of the foundation of your house, you can paint the walls, decorate the rooms, but if the foundations is not solid, 3:45 if it's cracked, then everything else, the structure will eventually fail. 3:50 So without good restorative sleep, your brain is staying in a low-level stress state.
How Dentistry Reveals Airway Problems 4:00 instead of resting and rejuvenating. 4:04 So over time, that low-level stress state is going to erode your resilience and could increase your risk of cognitive decline. 4:14 Sleep is essential. 4:16 It's a foundation for everything. 4:18 Without a doubt, I could not agree more. 4:20 But now you're a dentist, and it started with sleep. 4:24 What is the connection between sleep and dentistry, your profession? 4:29 Well, I've been practicing dentistry for years, and as a dentist, we concentrate on the teeth, the gums, or oral structures of the mouth. 4:40 But just beyond the tooth is the opening to the airway. 4:45 And the Airway is basically that's what's going to help determine your quality of sleep. 4:52 And we can see problems having to do with sleep apnea in the mouth. 4:59 So for example, people with Sleep Apnea will be grinding their teeth. 5:04 We can notice flattened teeth or cracking teeth, a lot of times people would Sleep apnia will come in and they're grinding, 5:13 besides the grinding seeing the teeth that are flatten, we see that the muscles on the cheek, the masseters, are very big and tight. 5:22 That's a sign that people are grinding their teeth. 5:25 You might wonder, well, what does grinding teeth have to do with sleep apnea? 5:29 So what happens is your tongue, which is attached to your lower jaw, when you fall asleep and everything relaxes, your tongues can fall back and block 5:39 your airway. 5:39 And when your not getting oxygen, you're brain is going to go into your fight or flight mode. 5:47 It's going to tell your mouth, find a way to open up my airway. 5:50 So the mouth is going start grinding the teeth. 5:53 You're going be tense because you're in this fight-or-flight mode and so we see these issues in the mouths. 6:01 One of the other things that is very common, we people with sleep apnea is their tongue is basically too big for their mouth. 6:09 What do you do about that? 6:11 Well, there's not a whole lot you can do about that, but there is a sign, because we can see the indentations on the tongue. 6:19 So if the is too big, it will press against the teeth and create these indentation in the tongues, creating like a scalloped edge on tongue Sometimes we'll 6:31 especially notice that in people who have had braces in the past, because the way orthodontics used to work is if there wasn't enough room for all the teeth, 6:41 a lot of teeth were taken out, especially premolars or bicuspids. 6:46 And that shrinks the jaw, really. 6:50 So now we have this box for the tongue that is intentionally made too small. 6:57 Now, these days, orthodontics tend to not do that. 7:00 What they'll do is expand the palate and make the whole tongue box or the mouth bigger. 7:06 So we have less falling back of the tongue blocking the airway. 7:13 Every dentist, every hygienist can see this happening in people's mouths. 7:19 And in my office, as soon as we see, this we start asking questions to the patients. 7:24 what's your sleep like? 7:25 Are you snoring? 7:27 Is anyone telling you that you stop breathing while you're asleep? 7:31 Do you feel rested in the morning? 7:33 You need to nap during the day? 7:35 So these are, you know, once we see these signs, we start asking questions. 7:41 So for everybody who just stuck their tongue out to see if they have developed edges, I'm curious for you, for the hygienist, 7:48 when you look in someone's mouth, are there other clues that tell you that the airway might be an issue? 7:56 You mentioned a couple symptoms that people might have or some signs, but is there a comprehensive list of what you're looking for in the mouth of signs 8:05 and symptoms, that can help us catch this kind of thing, apnea or disordered breathing at night before cognitive symptoms show up? 8:15 For sure. 8:15 You're right, everyone stick their tongue out. 8:17 See what the edges of your tongue look like. 8:19 I have cellophane on my tongue, I know it. 8:22 Yeah, so we also take a look at the palate, because usually, like I said earlier, with orthodontics, what they do now is they make a broad palate. 8:33 But in the past, that didn't always happen, or some people just didn' have braces. 8:37 So we look the palette, What is the shape? 8:40 Is it broad and flat or is it vaulted? 8:45 Is there like a... 8:48 you know, like a teepee shape to it? 8:50 Or is it just, even if it's narrow, is the lower jaw narrow? 8:54 The lower jar fits within the upper jaw. 8:57 So if that upper jar is narrowed, then the low jar also narrow. 9:01 Some people will have a receding chin. 9:04 That's also something that can lead to sleep apnea. 9:08 We'll see, you now, just also, looking at someone's face, You can kind of see, are they not sleeping well? 9:17 Do they have a lot of dark circles under their eyes? 9:21 They just not seem very energetic. 9:23 And there's also something called a stop-bang score. 9:28 Stop-Bang is an abbreviation for eight different things that we look at. 9:34 This is for snoring. 9:36 T is are you tired? 9:39 O is has anyone observed you stop breathing during your sleep? 9:44 P is do you have high blood pressure? 9:47 B is for your BMI. 9:49 That's basically your weight. 9:52 Your age is the A. 9:55 It's much more common in people over 50 and in post-menopausal women. 10:00 N is next size. 10:02 people with large necks tend to have sleep apnea, and G is for gender. 10:06 It's more common in men until women hit menopause, then we basically even out with men. 10:14 And women are famously under-diagnosed with sleep Apnea. 10:18 I have seen this firsthand, I have very thin women who, you know, they don't have that enlarged neck. 10:24 No one tells them they snore either because their partner about passed away or maybe their to partner takes their hearing aids out at night. 10:31 So they're not aware that they Snore or they maybe they Don't snort at all. 10:36 and no one's ever ordered a sleep study for them. 10:39 I've literally had patients go in for a study and be told, I can tell by looking at you, you don't have apnea. 10:47 And 48 hours later, we've got a report back saying they have some severe obstructive sleep apneas. 10:52 Once we treat it, We see a really big impact on cognitive function. 10:56 So I'm just curious from your perspective as a dentist, but a dentists highly focused on understanding the airway.
Women, Sleep Apnea, and Underdiagnosis 11:03 What is the behind this underdiagnosis for women. 11:07 What do you think that that means for woman's brain health as they age? 11:11 It's so true. 11:12 I see it every day. 11:14 Sleep apnea has been traditionally defined by male symptoms, loud snoring and daytime sleepiness. 11:23 But in women, sleep apnea often presents very, very differently. 11:28 Women struggle more with insomnia, either initiation insomnia, which is having a hard time falling asleep. 11:36 You know, it could take 30 minutes, an hour, even longer. 11:39 It really should not take that long. 11:40 Or what we call maintenance insomnia,which is waking up in the middle of the night, sometimes several times and sometimes having hard times going back 11:49 to sleep. 11:49 Now, just to take a step back, people do take certain medications that do increase urination. 11:56 They do have to get up middle night, especially medications for blood pressure or prostate issues. 12:02 But insomnia is very, very common in women. 12:05 Anxiety and depression is a sign of sleep apnea in woman. 12:11 brain fog, I'm sure you hear that term all the time, or weight resistance, you know, women having a hard time trying to lose weight. 12:23 You know, a man can just think about losing weight and they do, and a woman can diet and exercise and be lucky to lose a couple pounds. 12:31 So, it just, apnea just presents itself very, very differently in women. 12:36 Women are often told, oh, its stress or its hormones, but a lot of times it's sleep apneas. 12:42 Sleep apnoea just affects every system. 12:44 in the body. 12:45 It affects your stress level, your mood, it takes a toll on your blood pressure and your heart, and brain health, obviously. 12:54 So for a woman to be told it's normal for women, just stress or just your hormones is really doing a big disservice to women. 13:05 Now, as women move into perimenopause and menopausal with hormonal changes, that also makes the airway less stable. 13:14 And it's almost like you have a tent and you're losing some of your support poles for your tent. 13:21 So things can collapse much more easily. 13:24 When these breathing problems go undiagnosed for years, the brain is exposed to chronic, poor sleep, low oxygen, and inflammation. 13:35 And all these things can increase the risk of cognitive decline. 13:40 Yeah, absolutely. 13:42 I'm curious what you think of mouth tape. 13:44 One of my New Year's resolutions was to wear it every night. 13:47 But I noticed that I have less anxiety, that feel clearer, I sleep better when I use mouth-tape. 13:53 My understanding of the literature is that It can be helpful for mild sleep apnea and for people that don't have apneia to encourage nose breathing at night, 14:02 but not for moderate or severe apnoea. 14:05 It's not going to be useful. 14:07 What is your perspective on that? 14:09 And as a clinician, what do you tell patients? 14:12 Well, I definitely have some patients that I recommend mouth taping for them. 14:17 The main reason is first you have to make sure that you can breathe through your nose. 14:22 Yeah, some people, you know, they just have blockages, big turbinates or deviated septums. 14:29 But for people who can breath through their nose, mouth tapping will encourage that nasal breathing, which is much It's really how we're meant to breathe. 14:39 I mean, we can breathe through our mouth, but we are meant breathe our nose. 14:44 Our nose will filter the air, it warms the hair, prepares the heir to be readily accepted by our lungs and to extract the most amount of oxygen. 14:56 So I do encourage mouth taping, not to help with sleep apnea, just to encourage that nasal breathing instead of mouth breathing. 15:07 Also, mouth breathing, if you're breathing through your mouth or your is open all night, you wake up with a very dry mouth, 15:15 which is not good for your teeth and your gums. 15:18 You want that saliva constantly bathing your tooth and the structures of your mouse, because saliva naturally cleanses your tea, 15:27 although I hope people go to sleep with clean mouth. 15:31 But it also, saliva will neutralize acids in the mouth, so you don't want to have a dry mouth. 15:37 And we do want that, like I said, that nasal breathing to get the most out of each breath that we take. 15:44 Most people actually, the snoring sound that you get is usually actually from the back of the throat. 15:52 So taping also can help prevent some of this snorring. 15:55 But I wouldn't use mouth tape just to treat even mild sleep apnea. 16:00 Okay, good point. 16:02 Yeah. 16:02 We need to open up the airway somehow, even with mild sleep apnea. 16:06 In fact, I don't even like using that term because it makes it sound like it's not significant, but even mild Sleep apnea is divided into mild, 16:20 moderate, and severe. 16:21 And the ranges are basically just kind of a certain amount of times per hour that you stop breathing. 16:32 The mild range is 15 to 14 times an hour and moderate is 29 and severe is over 30. So if you stop breathing 14-times-an-hour, 16:46 which is a lot, that's still mild sleep apnea. 16:49 There's no such thing. 16:51 15 times- an-hours, That's moderate sleep Apnea, so I would say any type of sleepapnea needs to be treated somehow. 17:00 Yeah, this inappropriate use of the word mild, right? 17:03 This comes up with mild cognitive impairment. 17:04 There's nothing mild about it, it's this is life changing. 17:08 This really has an outsized impact on the trajectory of your health as you age. 17:13 And so even if I get frustrated because I see some reports come back from sleep medicine that say mild sleep apnea, you know, 17:21 if clinically relevant treat. 17:23 And they're sort of giving people this option, like, oh, it's probably not that big of a deal. 17:27 You don't have to get a CPAP, you don' have do anything about this. 17:30 I am thinking the opposite, right? 17:32 Like, let's get this under control immediately. 17:39 For listeners who have never heard of that or don't fully understand it or appreciate it, how does sleep-disordered breathing interfere with the brain's 17:48 kind of cleanup crew at night? 17:51 Sure. 17:51 The glymphatic system is something that was actually discovered fairly recently, and it's what's called the dishwasher of the brain.
Mouth Taping, Sleep Testing, and Wearables 18:01 So at night when you go to sleep, basically the dish washer gets turned on and fluid comes in and it cleans out the gunk in the brane, 18:13 including things that cause dementia like tau proteins and amyloid plaque. 18:19 If you stop breathing with sleep apnea, you're turning off that dishwasher mid-cycle. 18:27 And if you're doing that night after night, you know, your dishes are not getting clean and your brain is not, is getting rid of these toxins and proteins 18:38 that can, we know that have been implicated in Alzheimer's and dementia. 18:44 So that glymphatic system is very important and it's not going to work properly if we're not get into those deep levels of sleep, 18:53 which sleep apnea does prevent. 18:57 Amazing. 18:57 That's super helpful, and I think it's inspiring, right? 19:01 We all know that we need good sleep, I get it, I hear you, but I can't sleep and you mentioned women struggle more with insomnia, 19:12 both initiation and maintenance of sleep. 19:14 I know in your book, Breathe Easy, Sleep Deep, you blend some practical guidance with certainly with the science. 19:20 Is there one habit or insight from the book that either consistently surprises people or consistently helps them get better sleep? 19:33 I have many, many suggestions. 19:37 The first one is, you know, some people think, I sleep enough. 19:42 I, sleep seven to eight hours, but they're working up and they are exhausted all day. 19:46 So if you have If you suspect that you have sleep apnea or your bed partner or somebody in your household is telling you that, 19:57 you sleep, they see you stop breathing or that your snoring, get tested. 20:02 These days it's very easy to get test. 20:05 What do you think of the at home sleep studies? 20:08 There's lots of different kinds. 20:10 I have several types in my office. 20:14 There is one type that I particularly like because I just feel I trust the data. 20:20 You know, there's in-lapse sleep studies where you go into a sleep center, they connect you to a whole bunch of electrodes. 20:27 And we get great data from that, but it is expensive and not everyone is really needs to have all that information. 20:35 But a home sleep test, it's fairly easy. 20:38 The one that I use has a strap or a belt that fits on your torso. 20:44 There's an oximeter that sits on you finger. 20:47 This little cannula that goes in your nose. 20:49 I've done it myself several times. 20:51 I'm not a great sleeper, and I was able to sleep with the sleep test on. 20:56 So it's not that difficult. 20:59 There's other ones now that are even simpler, that're based on algorithms, which, you know, they keep getting better and better, 21:07 but I still like to get the real data from some of these home sleep tests. 21:13 It's easy to give. 21:15 doctor, you can get a prescription from your doctor. 21:18 There's even companies that will, once they get the prescription, from their doctor can send it right to your house. 21:24 Or even you go online with these companies and get asleep test sent to you. 21:30 They'll ask you questions. 21:32 see if you're a candidate for it. 21:33 In terms of testing, what do you think of some of the wearables? 21:37 The Oura Ring, the Whoop Strap, The Fitbits, Apple Watches. 21:41 Do you have thoughts about those? 21:42 You know, I've had patients come in and say, well, my sleep scores are great, so I can't have apnea. 21:48 Or can I do that instead of a sleep study? 21:51 And what are your thoughts on those wearable? 21:54 Wearables are a great addition, but they're just the trigger. 22:01 They're really not going to tell you if you really have sleep apnea. 22:06 It's really impossible for them to you that. 22:08 But if it's telling you your oxygen is dropping or you're moving around all night and you are not getting into those deep levels of sleep where essentially 22:19 you were paralyzed and not moving, then at least it is a warning sign to have a proper sleep test done. 22:26 So I love that people can wear these things and can be aware that they might be in danger, but it's not the final test. 22:36 It's just the signal that you need to further testing. 22:40 Are there any sleep myths out there that have come across on social media or anywhere else? 22:46 And are there are any that make you cringe that want to just like put a stop to right here right now today? 22:52 Yeah, for sure. 22:53 First, early, I touched upon that I sleep enough. 22:57 Even when you're waking up exhausted, you might think that you are getting enough hours of sleep, but you aren't getting good quality sleep. 23:04 You're not going into those deeper levels of REM sleep and that deep level of non-REM sleep so that's one thing. 23:12 Just because you get eight hours sleep here and you still having brain fog and not feeling like yourself, then that is one myth. 23:21 Another one is believing that poor sleep is just part of aging. 23:28 It's not. 23:28 I mean, it doesn't matter what your age. 23:31 Look, we'd all love to sleep like we did maybe when we were five, but poor asleep is not just inevitable as we get older. 23:39 Another thing that I see a lot still is that people think that sleep apnea only affects overweight men. 23:47 And that's part of why a lot of women get misdiagnosed or people who just appear healthy. 23:55 They're thin, they exercise, but anatomically they still have certain features of their airway that creates that sleep apnea effect. 24:05 Particularly with hypermobile women, right? 24:09 Yes, very much so. 24:11 I'm curious if someone is in this category of feeling like they sleep enough hours, but recognizing themselves and what you're describing, 24:19 waking up foggy, unrefreshed, still tired, what's the first thing they should do? 24:24 And how do they advocate for proper testing? 24:27 Should they just come see you or how did they find the right provider to solve this? 24:34 Yeah, it's getting easier than it was. 24:37 I used to get a lot of backlash from physicians when I would tell my patients, I suspect that you have sleep apnea, you need to gets tested, 24:47 see if your physician will test you. 24:50 Like I said, unless they are an overweight male, over 50, sometimes they wouldn't get tested. 24:55 So I decided, okay, this can't go on.
Sleep Apnea, Glymphatic Clearance, and Cognitive Risk 25:00 tests for my office, but I'm seeing less pushback now from physicians. 25:06 I see that they're really kind of more readily testing people more frequently. 25:12 Sometimes I still will get push back from, oh, it's just mild sleep apnea. 25:17 You don't need any treatment for that. 25:19 But it is getting easier. 25:21 to get tested. 25:22 Yeah. 25:22 So, you know, like we were saying, if you suspect or somebody in your family suspect, your bed partner suspects, it's an easy test. 25:31 And if have sleep apnea and you get treated properly, It is life-changing quality and quantity of life. 25:39 That is not an overstatement. 25:41 It has been one of the most profoundly impactful things, interventions that we can make is to treat sleep apnea for our patients. 25:49 At this stage, anyone at risk for or struggling with cognitive impairment, I order a sleep study on because I cannot miss it, 25:57 right? 25:58 As a provider focused on your brain health, if I miss sleep Apnea, and I think I don't think you can see it in someone all the time. 26:07 We're just, we've been historically missing too much of it and it has too big of an impact on cognitive function. 26:12 Yeah, yeah, I mean, half the population could be affected by sleep apnea. 26:22 Oh, crazy. 26:23 I'm curious, you know, in that book, Breath, which was James Nestor's book which is a great read, great audible listen, if anybody hasn't been exposed 26:31 to it. 26:31 But he talks about the palate and when what we chew on, especially as children and how we don't, we tend to chew in softer foods. 26:38 We're given baby food when our palate is developing, our teeth are developing. 26:43 Our jaws are developed. 26:44 Instead of chewing on twigs and bones and things like that, like our ancestors did, how much of that do you buy into? 26:51 Is there sort of this shift in this increase in sleep apnea and in mouth breathing versus nose breathing that is because of our diet? 27:00 Absolutely. 27:02 When we were hunter-gatherers and we we're eating raw food, our jaws were very strong. 27:11 Our tongues were in the correct position because they weren't crowded out by our too narrow jaws. 27:17 But as we evolved and were eating more processed foods, softer foods it is affecting the way our jobs are being formed. 27:30 As babies, babies who are nursed tend to have better palate and jaw development than babies are bottle fed. 27:40 It's just the difficulty extracting the milk and the shape of nipple and all that really affects the proper growth of the palate, 27:51 and jaws, the tongue. 27:53 The tongue is kind of what guides everything. 27:58 So when we are at rest, our lips should be together, teeth are apart, and our tongue is resting gently behind our front teeth on our palate. 28:09 And kids who are mouth breathers, the tongue resting low, it's not resting high on the palate, palate does not form properly. 28:18 We have a lot of allergens in the air, toxins in air that can also affect our nasal passages and how everything develops. 28:29 That way you have to think about the top of our mouth, our palate, is the floor of nasal passage. 28:36 So they're separate but they work together. 28:40 Our modern society has kind of changed the way we grow. 28:47 So yeah, it's true. 28:51 Chewing on harder things that require more force and movement of our tongue can help our jaws and tongues develop in a more proper way. 29:00 What are examples of this? 29:01 Like raw carrots? 29:02 What comes up for you? 29:03 what do you think of? 29:04 Yeah, I mean, real food, you're right. 29:09 carrots, and you know, just not the package that you just rip open and put in the microwave. 29:16 Yeah, the pasta and all the stuff. 29:20 Right. 29:21 The nuts and seeds and, you now, salads and... 29:27 Things that require mastication. 29:29 Correct. 29:30 Even a tougher piece of meat, things that required chewing. 29:35 Not gum, but real food. 29:38 One of the myths I see come up in treating sleep apnea is that the CPAP is the only option. 29:44 So I have people say, why would I even bother with a sleep study? 29:47 Because I know I'm not going to wear a CPap. 29:49 What do you say to someone who suggests that in your office? 29:54 I say that all the time. 29:56 all the time. 29:56 Basically, CPAP is a blower.
Practical Sleep Strategies and Treatment Options 30:00 It's a machine that will blow air into your airway. 30:05 You'll wear a mask, it's strapped onto your head, its attached to a hose, to machine by a host. 30:11 And that machine just blows air through your nose and opens up the blockage in your airway and keeps that air way open. 30:19 And it works beautifully. 30:21 The problem is, like you said, people don't use it. 30:24 They have a feeling of claustrophobia, they don' like something on their face, They don''t want the straps on the head. 30:32 they dont like being tethered to a machine. 30:35 Sometimes the mask doesn't fit well and they'll get breaches in the masks, and air will be blowing out, it will get bloated. 30:42 There's lots and lots of reasons why people don't like using a CPAP. 30:47 It works great for people who use it. 30:49 I don' want to discourage anyone. 30:52 If they're happy with it, please keep using it but a lot of people just can't tolerate it or sometimes don''t even want try. 31:00 So there are some alternatives and a lotta times that's where a dentist comes in. 31:06 we can make an appliance that will help with sleep apnea. 31:11 Now, earlier I said that the tongue is connected to the lower jaw. 31:16 If we bring this lower job forward a little bit with a dental appliance, the tongues will come with it and that we'll open up the airway. 31:26 So that's a very practical, easy way to open the way. 31:33 We have other things that sometimes we use in connection with that oral appliance or even with CPAP, and that's myofunctional therapy. 31:43 Think of myafunction therapy as physical therapy for the mouth. 31:47 It's therapy that will strengthen the tongues, lips, all the muscles of the mouse that can strengthen everything that is leading up to the airway. 31:58 There are things that could be done instead of a CPAT. 32:01 If you are diagnosed with severe sleep apnea, you really should try a CPAP first. 32:08 And there are lots of different masks on the market, and there's different kinds of CPaps which can make it a little more comfortable to use. 32:17 But people with mild to moderate sleep apnea, generally, we can treat it with a sleep appliance, a mouth appliance rather than a C-PAP. 32:27 Wonderful. 32:29 One other thing is if someone is overweight, losing weight can reduce. 32:36 It may not go away completely, but it can reduced sleep apnea. 32:41 I feel like this is sort of a chicken and egg thing, right? 32:44 It's like sleep apnea can contribute to weight gain. 32:48 Weight gain contributes to sleep Apnea impaired breathing can contributes insulin resistance. 32:54 It can Contribute to cardiovascular risk. 32:56 Of course, the brain health risks that we are discussing. 32:59 I'm curious how this whole metabolic storm, when you see someone who kind of does pick that classic picture of overweight, 33:07 maybe obese, large neck. 33:10 I think of them as very red, like red in the face, tired, irritable, probably looking to caffeine and sugar to get through the day, 33:18 right? 33:18 They're under a lot of stress because they're never fully rested. 33:20 And so they are looking for those pick me ups. 33:23 Where do you start with sort of unraveling this metabolic storm that's feeding cognitive impairment? 33:30 Yeah. 33:30 Yeah, it's very true. 33:34 Sleep pain plays a major role in regulating sugar. 33:39 When your sleep is disrupted, your body becomes less sensitive to insulin. 33:46 So even if your diet is good, when your blood sugar levels and your insulin levels stay elevated, that's going to stress the brain. 33:55 Sleep apnea also messes with your appetite hormones and can, you know, so it's harder for you to eat properly because you're getting these mixed messages 34:09 that you are hungry even though you really are not hungry. 34:11 These high insulin levels also interfere with the brain's ability to clear those harmful proteins that we talked about earlier and those proteins associated 34:24 with Alzheimer's. 34:26 So, you know, the poor sleep doesn't just cause the fatigue. 34:29 It's causing this whole, like you said, metabolic storm that increases heart risk, heart attack risks, and stroke risks and Alzheimer's risks. 34:40 So if we can get the sleep apnea under control, it's a lot easier to lose weight. 34:47 We decrease the risk of heart disease and stroke, besides just feeling a lot better and clearer, less fatigue, and less brain fog. 34:59 And when you feel good, you're more inclined to want to exercise and do the things that you know you should be doing for your health. 35:08 What do you think the role of GLP-1, so the Ozempic semiglutides that bound, or Monjaro's, Terzapatide, these injectable weight loss medications, 35:19 do think that they have a role to play here? 35:22 ZipBound, which is one of them, has actually been FDA approved for treatment of sleep apnea. 35:29 And the way it treats sleepapnea is by reducing weight. 35:33 So when you gain weight, you're going to gain in your neck. 35:38 You're also going gain fat in you tongue. 35:42 Yeah, and so, you know, the last thing we need is a bigger tongue blocking an airway. 35:48 So, things like the GLP-1s, they have a place to help reduce the obesity and can help with sleep apnea. 36:01 If we have somebody who has severe sleep apnea and is struggling with a CPAP, if they could lose weight and bring their sleep down from severe into mild 36:14 to moderate, we'll have a greater success with something like a sleep appliance, which is much more comfortable and easier to use than a C-PAP. 36:24 So there is a place for it. 36:28 So we've spent 40 minutes talking to a dentist about sleep, which I think it's what I want to emphasize. 36:35 And so I'm so grateful that you do as well. 36:38 I our listeners, I wanted the takeaway to be that sleep is one of the most crucially important things to optimize if you want healthy brain age as you 36:48 get older. 36:48 So that's why we really spent the time to dig into this. 36:52 And you're a dentist. 36:54 I want to talk about gum disease and oral pathogens and amalgams and how this interacts with the microbiome and all of the other good stuff that's really 37:03 also really, really crucially important to discuss with your doctor when you are looking to optimize cognitive function as you age. 37:10 So let's dive into it. 37:12 How does gum diseases, oral pathogen that can accumulate either in the gums or in teeth even with decay, How does that impact or affect brain health? 37:25 I'm glad you asked that question. 37:26 People think that, oh, a little bit of bleeding of the gums when I brushing my teeth or flossing is normal. 37:33 It's not normal, it's a sign of gum inflammation. 37:37 And when you have this type of inflammation in your gumbs, you can get into your bloodstream. 37:43 The inflammatory components from the gum disease can go into the blood stream and can affect your brain. 37:51 that's in your mouth that is overgrown and causing that inflammation can get into your bloodstream and can affect your heart muscle and your brain tissue.
Metabolic Effects, Weight Loss, and GLP-1s 38:00 Studies have shown that there's actually DNA from oral pathogens. 38:07 especially something called P. 38:08 gingivalis, has been found in the brains of patients with dementia. 38:14 So there is a direct link between the mouth and your brain health and heart health. 38:19 I mean, if your heart is not healthy, your brushing and flossing. 38:27 So how important is this to brain health? 38:30 Do you have any tips or tricks for people who maybe floss occasionally, but not usually and are pretty good about brushing? 38:37 I would say that's the majority of my patients because I ask everyone, do you help bleeding with brushing or flossing? 38:42 And do your brush and floss every day? 38:44 What if someone says no to that question? 38:47 Why do tell them? 38:49 Well, I'm glad that everyone is mainly brushing and you really should brush at least twice a day. 38:56 Bacteria, you always have bacteria in your mouth. 38:59 The issue is how much bacteria and how of that bad bacteria do you have. 39:03 If you imagine bacteria as colonies. 39:07 They build on top of each other. 39:09 If you're not disrupting those colonies of bacteria every day by brushing and flossing, you are going to be building a big colony. 39:18 So let's say we want colonies the size of houses. 39:22 We don't want apartment building size colonies or bacteria. 39:26 Brushing is important, very important. 39:31 But brushing is not going to get under the gum tissue. 39:35 And that's where the big culprits are. 39:38 That's were the really bad bacteria is under gum line. 39:43 If you're flossing properly, hugging the tooth, getting it under a gumline gently, and just breaking up those colonies of bacteria, 39:51 you won't have as much of those bad bacterias that can get into your bloodstream. 39:57 So I know people think, oh, it just takes so long and it's difficult. 40:03 Once you start doing it every day, you get good at it and you got quick at. 40:07 At this point, I mean, i didn't know anything about flossing until I got to dental school. 40:11 I don't think I've missed a night since then. 40:14 at this Point,I don' need to watch what I'm doing.I will sit there, reading or watching TV and I am flossing. 40:20 So it takes no time out of my night to floss. 40:23 it really makes a huge difference. 40:26 Brushing, obviously very important, and a lot of people actually don't know the proper way to brush their teeth. 40:34 They're thinking, okay, you got to point the bristles at your tooth. 40:39 You actually want to So if you imagine that you want to go at a 45 degree angle, so up at 45 degrees angle for your upper teeth and down at the 45-degree 40:52 angle your bottom teeth, you actually want brush where the tooth and the gums meet. 40:57 Because like I said earlier, that's where plaque and bacteria is hiding. 41:02 Underneath the gum and in between the teeth. 41:05 So I recommend a Sonicare toothbrush, it's an electric toothbrush. 41:10 I think it cleans better than any other toothbrush out there. 41:13 The thing that you need to understand with a sonicare is it is brushing for you. 41:18 It is vibrating very very quickly, you can't even see how quickly it vibrates with the naked eye. 41:24 and it's cleaning the teeth for you. 41:27 But because it is doing that, you don't want to scrub while you're cleaning with a Sonicare, because you could actually be doing damage. 41:35 You could be scrubbing so hard, in addition to the toothbrush scrub, that you can actually cause some gum recession and wear of your enamel. 41:44 So basically, it just holding the Sonicair, pointing it at the gum line, and moving it around your mouth. 41:50 The other thing I like about the Sonicare is it will stay on for two minutes and it'll pause after 30 seconds. 41:58 So if you imagine you can divide your mouth into four sections, so you clean one section, the toothbrush will pause for 30 second,
Oral Health, Gum Disease, and Brain Health 42:07 it's a signal, move on to the next section. 42:10 So two minutes is really how long it takes to clean all your teeth, front, back, chewing surfaces, inside, out of all of your tooth. 42:20 And the Sonicare also has, some of them, has a pressure sensor built into it. 42:27 So if you are pressing too hard or scrubbing too, hard it will let you know that you got to back off. 42:34 You're pressing to hard. 42:35 Also the toothbrushes itself, the heads have a indicator that lets you now that it's time to change your toothbrush. 42:46 Some people will see that because the bristles of their toothbrush are splayed. 42:51 So, you know, they've been scrubbing too hard. 42:53 It's time to change that toothbrush. 42:54 But even if it's not, the edges of the Brussels will get dull over time. 43:01 About every three months, it is time change your toothbrush, whether it a manual or a head of an electric toothbrush Do you have a recommendation for a 43:10 type of toothpaste? 43:12 I have been turned on to the remineralizing kind of Japanese style of toothpaste. 43:18 Is that a good thing, bad thing? 43:20 What do you think we should use in terms of toothpastes? 43:24 Any kind toothpaste that you feel comfortable using. 43:27 I do like fluoride toothpaste because fluorides can help prevent cavities. 43:32 Don't like the toothbrushes that are toothpaste, excuse me, that abrasive ones that claim that they're whitening. 43:40 The way they can claim that they're whitening, excuse me, is they are abrasive so they could help take off some of the surface stain of a teeth, 43:47 but they not really whiten your teeth from the inside out, which is what professional whitning will do in a dental office. 43:54 Also, toothpaste that contain baking soda are very abrasives also. 44:01 So those are the two things that I avoid. 44:03 I haven't seen great studies about the re-mineralization. 44:09 Remineralizing toothpaste. 44:17 So I'm not saying that they don't work. 44:19 I just have not seen great studies saying they do what they are claiming to do. 44:26 That's helpful. 44:27 What about root canals? 44:29 Where do you fall in your opinion on that? 44:33 I feel like some people are Like, what's the big deal? 44:35 Everybody's got root canal. 44:36 It's not an issue. 44:37 And then other people are on the entire other side of the spectrum saying no one should ever have a root canals. 44:44 You should have all of them removed. 44:46 Where do you fall? 44:48 I have seen thousands of root-canal teeth over the years. 44:53 If the root channel is done properly with the proper filling material, got a percha, it can last for years and years without issue, 45:03 You don't want to ignore a tooth that's infected that needs a root canal or that need an extraction. 45:09 That's really the dangerous thing is that infection that is present in your body. 45:15 You know, if you have an infection in you jaw, this is not that far from here. 45:20 The geography of the head and neck. 45:23 Right. 45:23 I mean, we try to save teeth as much as possible because even though we have really great ways to replace teeth with implants, 45:32 there's nothing like your own natural tooth. 45:35 So as long as the root canal is done properly, I'm fine with it. 45:41 I would never recommend that a tooth be taken out just because it needs a root cannel. 45:47 i'd rather you keep your own natural tooth with the proper root-canel treatment and a crown if needed. 45:54 Implants are great, but Some people don't keep them as clean as they need to. 46:00 And we have seen something called implant periodontitis, basically. 46:06 It's inflammation around the implant, which is inflammation. 46:10 Doesn't matter if it's around a tooth or an implant. 46:12 That's not going to be good for your health. 46:15 So we're lucky we live in a time where we had implants that can pretty easily replace missing teeth, but there's nothing like your own natural teeth. 46:25 Yeah, a properly done root canal is, in my opinion, is a good way to keep your teeth and stay healthy. 46:36 What do you think about amalgams? 46:37 So these are mercury-containing fillings that I don't think happen anymore, right? 46:42 That's kind of been phased out of dental practice, but many people have them from 20, 30 years ago. 46:48 what do say to someone who comes in with some of those and is exploring the option of getting them out? 46:55 Well, if it's a healthy person and the amalgam restoration is small and isn't deteriorating, I will generally just leave it, 47:06 but if it's a large amalgam restoration, certainly if its starting to break down, I would always recommend to replace it. 47:15 We don't want that toxin, we don�t want the mercury in our system. 47:20 If someone like you who tells me, �Okay, this patient has had a toxine panel taken and they have high mercury levels,� then I'll say, 47:32 You'll be watching their diet in terms of what kind of fish they're eating and things, but I will want to take all the mercury out of their mouth. 47:41 Yeah, we don't want that leaking into your system. 47:46 But thankfully, I don' remember the last time I did an amalgam. 47:49 Oh, nice. 47:50 Yeah. 47:50 Good. 47:51 I'm glad those are a thing of the past. 47:52 You have worked across research and clinical care and systems level innovation. 47:57 What do you see the future of dentistry, especially whole health dentestry, right?
Root Canals, Amalgams, and Whole-Health Dentistry 48:03 This understanding of that some dentists are looking in the mouth and they're just looking at the teeth and really just interested in that. 48:10 you're really focused on how that impacts the entire system. 48:15 Do you have hope about the future of that? 48:16 Do see that being more widely adopted? 48:18 What do you see in 10, 20 years in your profession? 48:23 Yeah, I think that it's not going to be something that's unusual to find a dentist who will be talking to their patients about their diet and their sleep 48:35 and what their cognitive level is. 48:38 The mouth is the gateway to the body. 48:41 It's where everything that comes in comes through the mouth generally. 48:46 So I think that this newer generation of dentists and physicians are seeing that we need to work together and not in our separate silos, 48:59 you know, dentistry with teeth and gums and medicine with all their specialties. 49:05 I we will be working more in tandem. 49:08 For example, myself as a practicing sleep dental medicine, The airway is really a connection between dentistry and medicine. 49:20 I have a lot of interactions with different types of doctors, people like you, functional medicine, with sleep medicine with cardiologists and pulmonologists. 49:36 I think people are realizing that we're not in our separate silos. 49:42 We're just, we are there to help the patient in all their various issues. 49:49 You know, it's not this and nothing else. 49:52 It's all intertwined. 49:54 So, I, think that that's the way it is going to be seen in the future. 49:59 And I it think it getting there already. 50:02 That's very hopeful. 50:04 I ask everyone, what brings you joy at this stage of your life? 50:10 Let's see. 50:11 This might sound like a cliche, but when I mean, I've been treating patients in dentistry for many years. 50:18 And of course I get the patient who feels better, looks better and they're happy about that. 50:23 But the joy that I got from somebody telling me that they are finally sleeping through their night or that their husband is not snoring any longer and 50:35 they're able to sleep through the night. 50:36 It's so life-changing to people and the fact that I can help them either by discovering that that was an issue or they found out that it was and issue 50:52 and being able treat that issue in a way that someone will stick with the way that we're doing it with a sleep appliance or a CPAP or however. 51:01 And it's just the joy that someone gets from helping another person. 51:08 The joy is more for yourself even than the person that you're helping. 51:14 It's such an amazing feeling to help somebody who was kind of lost before they met you. 51:21 A selfish selflessness, right? 51:25 Exactly. 51:26 That's a perfect way of putting it. 51:29 Well, Dr. 51:29 Rapoport, thank you so much for shedding light on this part of health that so often I think hides in plain sight, right? 51:36 That so many people I even know that this is an issue for them, but they don't know who to see or where to go. 51:42 And I think you've given us a new appreciation for the way that breathing and sleep and inflammation and the microbiome and, 51:48 well, the mouth, of course, all weave together to shape long-term cognitive resilience. 51:53 And they're really crucial. 51:55 We cannot miss this piece. 51:57 It's incredible how, I mean, just blown away all the time, how fundamental, something as fundamental as airflow at night can influence and impact everything
The Future of Dentistry and Final Takeaways 52:08 during the day, right, throughout our lives. 52:10 And so for everyone listening, if this conversation sparked a little curiosity about your own sleep or your loved ones, pass it on to them. 52:18 Pass this episode on them, but consider this an invitation. 52:22 Today is the to call and make that appointment to take a closer look So maybe put on your CPAP tonight if you've already got one. 52:31 Or to get that sleep study done, to schedule with the dentist. 52:36 Better sleep, better oral health. 52:38 This isn't just about feeling rested tomorrow or about having pretty teeth. 52:42 It's about really like aging. 52:44 it is about thinking well and aging well.It is About clarity and vitality and connection for the decades ahead of us. 52:52 So Dr. 52:52 Rapoport, again, thank you for sharing your expertise for this in-depth conversation. 52:58 And for your mission, I feel so delighted to be collaborating with you in the care of patients. 53:03 Thank you to all of our listeners for tuning in. 53:06 Dr Rapaport where can people find your book? 53:10 You can find Breathe Easy, Sleep Deep on Amazon. 53:14 It comes in paperback and Kindle and hopefully soon the audiobook. 53:20 Fantastic, congratulations. 53:21 Yeah, it answers a lot of questions. 53:24 It's a great book for somebody who might be worried that they have sleep apnea or somebody they know or they were just diagnosed. 53:30 it Answers a lots of question about sleep Apnea. 53:34 The name and website of your dental practice. 53:38 My dental Practice is Complete Health Dentistry of SoCal. 53:42 I also have a sleep practice, Complete Help Sleep of SOCal and we're in San Diego. 53:48 Fantastic. 53:49 And we'll put all that in the show notes. 53:50 Thank you to all of you for tuning in and for being part of our Think Well, Age Well community. 53:55 Until next time, I wish you good sleep, deep breaths, and taking slow, steady steps towards a healthier brain and a healthier life. 54:10 If you enjoyed today's conversation, please take a moment to subscribe, leave a review, and share this episode with someone you care about. 54:18 It's one of the best ways to help others discover tools and inspiration for aging well. 54:26 To stay connected, get bonus resources and never miss an episode, head over to drheathersanderson.com and join my email list. 54:36 Until next time, keep thinking well and aging on purpose.
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