Hamidreza Nassery , DMD, FICOI, FAGD, FICCMO  
Male, 55
Miami Beach, FL

Interests: My family, Dentistry, all sports, Travel
Miami Beach, FL
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Feb 25, 2009 - 13 comments

For many years we have known that heavy snoring causes major increase in risk of carotid Atherosclerosis and stroke. This has been widely established through published research. One such reasearch published in "Sleep" the journal of sleep disorders shows that this risk in independednt of the risk for sleep apnea and nocturnal hypoxia. Carotid Atherosclerosis( hardening or clogging)  is a major cause of storkes.

In a recent published study in Sleep, it was shown that heavy snoring in abscence of sleep apnea also seriously added to the risk for carotid Atherosclerosis and stroke. In this study a group of 110 volunteers were broken down into three groups based on the severity of their snoring. Mild snorers , snored less than 25% of the time, moderates snorers, snored 25-50% of the time and severe snorers snored more than 50% of the time. The prevalence of carotid artery hardening increased along with the severity of the snoring. Non of the volunteers showed oxygen desaturation.

A previously published article in JAMA, reported that snorers have a 300% increase in motor vehicle accidents. Both  snoring and sleep apnea are associated with increased daytime sleepiness and reduced mental abilities in both adults and children. Further more, snoring in children has been associated with poor performance in school and ADHD. Sleep apnea has been shown to permanently affect brain development in children. It is well known that emotional , hormonal, cognitive and autonomic nervous system changes occur in patients with OSA. A recent study in July issue of Sleep, showed that many of these problems remain even after successful treatment of the sleep apnea.

It is estimated that 15-54% of middle aged adults snore. Snoring is a major warning sign for sleep apnea, a much more serious and life treathening  disroder that affects 4% of middle aged males and 2% of middle aged females.
While the gold standard of treatment for this problem is CPAP, or continous Positive Air Pressure machines , it also remains one of traetments with the poorest complaince rates. A properly trained Sleep Apnea dentist who is also trained in the treatment of TMJ can provide these patients with another alternative treatment. Patients generally preferre Oral applainces to CPAP machines.

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by Kirsen, Feb 26, 2009
I am a 48 year old woman diagnosed with Sleep Apnea about 4 years ago.  I have been using a CPAP ever since although I do find there are nights I just can't stand it and have to remove it.  I also have a history of grinding my teeth as I sleep - we first noticed it when I was 13 - and I have a tooth protector provided by my dentist that fits very snugly on my upper teeth.  I have a VERY difficult time using both and am curious about the Oral appliances you mention as a treatment for sleep apnea.  Would it help to resolve both issues?  

How do I find a dentist with the right qualifications?  I live near Baltimore, MD

Thank you.

Avatar universal
by Steven Y Park, MDBlank, Feb 26, 2009
I have the same question for you, Dr. Nassery. Can mandibular advancement devices for sleep apnea help with TMJ as well? I hear conflicting information.

I also wanted to add one more thing to your informative article: In a study on rabbits, they induced loud snoring sounds on the carotids and found high rates of plaque and narrowing. It was thought that the endothelium lining of the carotid was being damaged and the repair process and inflammation is what caused the narrowing.

One of my own theories is that the vibrations themselves, as well as chronic inflammation from throat acid reflux that frequently occurs in sleep apnea patients, causes a numbing or desensitization of the protective pressure receptors in the throat, which leads to worsening snoring and apneas.


Hello Krisen, and Dr. Park.
As per an earlier conversation we had with Dr. Park, the most frequent common denominator between Sleep disorder patients is not their weight, but it is the presence of TMD.. I just sorta explained this on the blog I wrote about TMD, our jaws have been moving backwards for the past 250 years.. well documented in Orthodontic research. thats all I am gonna sayt about that..
The common missconception Dr. park is that the MAS, or MAD whichever you want to call it screws up the bite or TMJ. In actuality what happens overnight is that the person re-captures their disc into the correct position. This is a good outcome , actually what I am looking for when I treat TMD patients.. sometimes it has taken me 2 years to do this..
If yo noticed in my blog, at the end I made sure to include that he sleep dentist should be trained in TMD as well.. too many people out there just making these appliances and have no clue what they just did to the person..
I ususally start by explaining all these to my patients, soem do not choose to correct their jaw position, and for those  I just do a quick pharyngometer test and if I get 300-400% improvement to their airway just by manipulating their jaw then we make the appliance. I have to tell you this is only 25-30 % of the times..without true correction most cases will not be very successful with the repositioning appliance.
Conversely the patients who have gone thru Nueromuscular or other succesful physiologial repositioning of their jaw, all report better sleep..this got us to think and the why?  The logical explanation we think is that " we know if correctly repositioned, the jaw effects the position of C1 and C2, which in literature we know if positon corrected can take off pressure from the brain stem,,and even lower BP. Could that be the real correction?? but to stabilize there the TMD has to obviously be addressed.
Now to answer wheather Krisen can go without her CPAP, depends on her case and how bad the apnea is , I would not certainely go there unless an appliance was properly titrated during a lab study.. I also have pt. that are on CPAP and we have made them an appliance to keep airway more open, which has allowed their doctor to re-adjust their CPAP to a lower pressure and that has made it more tolerable to them.

Avatar universal
by VaBreeze, Feb 28, 2009
Hello Dr. Nassery -

I've read about the oral devices and understand the realignment of the jaw being a major part of it's success.  What i'm curious about is, would this procedure work with someone who has a pronounced overbite?  Would the misalignment of teeth make a difference with this technique?

Thank you for your response.


You should read all the post on my other blog on TMD, not that I am diagnosing you over the web but if you have a big overbite and very crowded teeth, then you are what we call a Class2, type 2. Just a  classification for us to understand..not only these patients have a very posteriorized lower jaw but also a very posteriorized upper as well. I find that most would have forward head posture which means straightening of the neck and subluxation of cervical spine and that means pressure on vital nervous structure in your spine at all levels in your neck..
correction of malocclussion should be part of a comprehensive treatment plan, but mean time that is being done If my patients have been diagnosed with Apnea I ask them to remain on their CPAP if that is the case until we can finish their realignment. Remember the misalignment of the teeth is why the jaw where it is today..
I hope this makes sense, and answers your question.

Avatar universal
by VaBreeze, Mar 02, 2009
Dr. Nassery -

I believe the above would be an appropriate description.  This could very well be the cause of my neck symptoms.  

Realignment would be a dream...at this stage in life i'll be looking at dentures next *huge smile*.  Thank you so much for this information.

Have a wonderful evening.

Avatar universal
by kingdomh, Mar 03, 2009
Dr---what specific type of Dr would I see with the following scenario-----I had sinus surgery 2 years ago to align deviated septum, remove 2 large cysts in sinus cavity and shrink turbinates. I can breath better through both nostrils now. So herein lies the problem at the present time. I hear myself snore occasionally, but it seems like when I lie flat down, my throat closes off and I can't breathe until I sit up---I am now sleeping propped up on 3 pillows to keep my head elevated. I had a sleep disorder test 4 years ago, prior to the sinus surgery, and it was negative for sleep apnea. It seems like at night, I need to breathe through my nose and mouth to get enough air for comfortable breathing. I don't get the "throat closing" feeling every night, but several nights a week. I am 46, 5' 3" and 143 lbs and work out regularly. What type of Dr should I see? Dentist? Neurologist? ENT? Thank you so much!!


How are your dental arches? if you had all these issues with breathign thru your nose all your life I would bet that you have very narrow arches , high palatal vault and much crowding .. if the description fits then yo need to correct that . your palat is the floor of your nasal air passage way the highr it goes the smaller the passage gets , even if you clear the tissue out of there it is still very small, the next problem is this narrowing of the upper arch will dictate your lower jaw to be more posterior , and that my friend will take your tongue right into your pharyngeal space or lower airway. I hope this makes sense.. you need to orthodotically expand your arches and then orthopedically move your lower jaw down and forward.. No surgeries unless the exhuste all options. Find yourself an orthodontist that is TMD trained, or a TMD specialist that knows orthodontics.
Good luck.

Avatar universal
by abbyadden, May 04, 2010
Very informative post on snoring. Snoring is a serious issue in our social life also. It can cause gaps also in real life. It is necessary to get rid of snoring and to stop snoring at any cost. Visit my site for more useful information on stop snoring

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by Ysnore, May 18, 2010
Great articles and comments on snoring. Over Singapore, Ysnore is also providing education and information about the consequences of snoring. Ysnore (www.ysnore.com.sg) help people to understand more on snoring for Asian snorers.

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by dwayne987, May 24, 2010
Highlight first what factors might cause your snoring then list it down and do something about each of them. Alcohol and smoking can be a major cause of snoring plus it can ruin the liver and the lungs thus making it a killer.

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by Snoringisboring, Jul 09, 2010
i had snoring problems until i had a very minor surgery on it. Now i have no problems with snoring or getting restful sleep. However a little problem with sleep walking...?
Snoring Treatment

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by Snoringisboring, Jul 09, 2010
If snoring is affecting your life and the life of your loved ones, if you are unable to use a CPAP machine, if surgery isn’t the path you want to take, we have great news for you! Dental Sleep Medicine Associates utilizes a breakthrough oral appliance to treat snoring and sleep apnea;

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