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People write advice columns when they are at the end of their rope. As a result, scanning the advice columns provides a cross-section of years of human tragedy. That’s the feeling we got when we saw this question by someone who wanted to try to erase all the teasing that they and their siblings gave to their mother for snoring

We often talk about the problems snoring can cause in romantic relationships, but it’s important to remember that it can impact the relationships between parents and children, too. There’s no way to turn back the clock and undo what you’ve done, so it’s important that you handle snoring right from the beginning. 

Loud Snoring Leads to Teasing

The person writing in as “Restless Nights” said that they and their siblings would regularly make fun of their mom’s snoring. They said, “the noise seemingly could wake the dead,” and as a result, the snoring got turned into “one of our favorite family jokes.”

Teasing Leads to Anxiety and Guilt

It was only years later that Restless Nights learned that their mother almost didn’t go on a trip to Italy with friends because she was afraid she would snore. Her fear of snoring further led to anxiety, keeping the mother up at night. 

This, in turn, made the correspondent feel guilty. They tried to play down the importance of snoring, but the mother can’t accept that now–she doesn’t believe new statements that her snoring isn’t bad. Restless Nights now wants to make up for all the years of teasing. 

You Don’t Get a Second Chance to Deal with Snoring

The advice columnist, Annie, doesn’t really have any good insight into handling this problem. Annie says that we shouldn’t feel guilty over spilled milk, basically, and should try to focus on things the mother did right as they were growing up to help the mother feel more confidence and secure. 

However, it’s important to note that this could have been much worse. A few years ago, we read an emotional reflective piece from a man who’d lost his father at a young age partly due to sleep apnea. That’s a cause for regret where there’s actually nothing you can do to reverse the effect: they are gone forever. 

That’s why it’s so important to make sure you handle your loved one’s snoring right. While it’s tempting to treat snoring as a joke, don’t. While snoring might seem funny, it’s potentially the sign of a deadly condition. 

And while it might be tempting to just ignore or cope with snoring, this isn’t right, either. Snoring solutions that don’t actually address the snoring (like using earplugs or moving to a different room) still leave your loved one exposed to risk. 

Instead, it’s important to talk to a loved one about their snoring. Encourage them to get a sleep test to find out if they have simple snoring or if they have sleep apnea. In either case, support them in getting appropriate treatment so that they–and you–can rest easier and make the most of these precious days together. That way, you can look back with joy and comfort–not regret and loss. 

Let Us Help Your Family

Snoring doesn’t just affect one person. When you’re a snorer, it impacts the entire family. And it sometimes takes the entire family to come up with a good solution. 

If you have a snorer in your family, we can help them get the help they need. Please call (402) 493-4175 today for an appointment with a sleep dentist at the Advanced Dental Sleep Treatment Center of Omaha. 

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Many of us are accustomed to putting on a few pounds of winter weight. Fewer opportunities to exercise, combined with all the food-heavy holidays, plus a little bit of comfort eating to counter some seasonal moodiness has a tendency to leave us all a little heavier by the time spring rolls around (despite the attempt at a New Year’s Resolution or two). 

But that’s okay, because we’re used to burning it all off again over the summer. While the cycle might not be healthy, hopefully it’s not too unhealthy. But now that we’re deep into summer 2019, maybe you’re realizing that weight loss is not going as expected this year. Although there are many potential reasons for this, one serious possibility is sleep apnea. Sleep apnea could be making it hard for you to lose your winter weight. 

Reduced Exercise Ability

One of the biggest changes that leads to weight loss in the summer is that you’re getting more exercise. Walking, running, biking, hiking, fishing, volleyball, tennis–the list of fun ways to burn weight in the summer is seemingly endless. In the past, you might have let yourself indulge at family barbecues because you were burning more calories than you ate, thanks to all the activity. 

But one thing sleep apnea does is reduce your ability to exercise. Your lungs literally can’t take in as much air as they could when you didn’t have sleep apnea, so you become winded faster and get less exercise. In addition, you’re more tired if you’re not sleeping well at night, so you might be inclined to not even start exercising in the first place. 

Hormonal Changes

Another problem with sleep apnea is that it changes how your body messages you about food and how it deals with the food that you eat. 

When you aren’t getting enough sleep, your body produces more ghrelin, a hormone that tells your body to eat. In addition, it produces less leptin, a hormone that tells your body to stop eating. The combination is that your body is telling you to eat more food. 

In addition, this hormone imbalance can make your body more likely to store and less likely to burn the calories it consumes. 

Overall, the result is that you are more likely to eat more food and store more of that food as fat. This is a hard combination to overcome with casual activity. You need to make a plan and stick to it, but there’s a problem there, too. 

Less Willpower

Another problem with sleep apnea is that it can make it harder for us to stick to plans like dieting and exercise. When you’re not getting enough sleep, you are more likely to experience cravings, and less able to resist those cravings. 

Again, this is a recipe for adding more calories to your daily intake. You won’t be able to resist getting a second serving of those sweet-and-spicy ribs, marbled with fat. An extra pat of butter on my corn? Why not?

Fighting Fatigue with Food

And it isn’t just cravings that cause you to eat more. You might be trying to maintain your energy by eating more. Daytime sleepiness is a common symptom of sleep apnea, and when people feel tired during the day, they are likely to turn to sugary foods for a quick burst of energy. 

Or perhaps you make a Starbucks run. But those fancy drinks aren’t just full of caffeine, they’re full of sugar–as much as 20 teaspoons! That’s another way you might be making it hard for yourself to lose your winter weight. 

Treat Sleep Apnea to Support a Healthy Weight

If you have sleep apnea, it can contribute to weight gain. On the other hand, weight gain can make sleep apnea worse. This creates a cycle that can make it very hard to get back to your ideal weight this summer. 

While it’s common to recommend weight loss to treat sleep apnea, it’s often impossible to lose weight until you treat sleep apnea. Fortunately, there are comfortable, convenient sleep apnea treatments that can pair nicely with your efforts to get healthy this summer. 

If you want to learn more about how to break the cycle of sleep apnea and weight gain, please call (402) 493-4175 today for an appointment with a sleep dentist at The Advanced Dental Sleep Treatment Center in Omaha. 

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We know that sleep apnea is linked to diabetes risk, including both type 1 and type 2 diabetes. There are still questions about whether sleep apnea actually causes diabetes, but the risk seems to be independent of shared risk factors like obesity. 

However, the most important question is: does treating sleep apnea reduce diabetes risk? Now a new study answers that question: yes! It shows that treating sleep apnea can reduce the risk of type 2 diabetes down to normal. Unfortunately, the study isn’t all good news: it also highlights a major challenge in getting adequate sleep apnea treatment for people. 

Assessing Type 2 Diabetes Risk for People with Sleep Apnea

This study looked at over 1200 people who were given sleep studies for sleep apnea from 2006 to 2013. During the follow-up period (patients were followed for a median of 7.3 years), 152 developed diabetes. They found that people with moderate sleep apnea were 2 times as likely to develop diabetes, and those with severe sleep apnea were 2.6 times more likely to develop sleep apnea. 

Interestingly, this study didn’t show any interaction between obesity and sleep apnea. 

Treatment Reduced Risk

Researchers also assessed the effectiveness of sleep apnea treatment. The treatment used in this study was CPAP, and researchers found that regular CPAP use basically eliminated the increased risk of type 2 diabetes. People who used their CPAP regularly were statistically indistinguishable from people who didn’t have sleep apnea. In fact, regular CPAP use cut the absolute risk of developing type 2 diabetes by more than half, from 3.4 to 1.6 per 100 person-years.

This is in addition to previous studies showing that sleep apnea treatment can help people control diabetes once they develop it. 

The Challenge of CPAP Treatment

Unfortunately, the news from the study is not all good. Despite the effectiveness of CPAP treatment, it is actually a failing treatment in this case, because only one-third of patients actually used their CPAP machine regularly. In other words, two-thirds of people who were diagnosed with sleep apnea remained at high risk despite the use of CPAP.

This is why oral appliance therapy is such an important option. If two-thirds of people who are treated with CPAP remain untreated, we need some way to try to reach this remainder. Oral appliance therapy is a more comfortable and convenient alternative to CPAP, and it’s been shown in other studies to be as effective as CPAP. The compliance rates for oral appliance therapy are very high–more than 90% meet the standard for regular use established for CPAP. 

Are You Looking for Effective Sleep Apnea Treatment?

If you’ve been prescribed CPAP but find you just can’t use it, let us help. We can evaluate you for oral appliance therapy and design a comfortable, custom appliance for you. This can help you combat the risks of sleep apnea so you can enjoy better sleep, more rest, and fewer risks. 

Please call (402) 493-4175 today for an appointment with an Omaha sleep dentist at the Advanced Dental Sleep Treatment Center.

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Sleep is an essential piece in our body’s daily routine. It helps our body restore itself, remove waste, and regulate our metabolism. So it’s no surprise that when sleep apnea disrupts your sleep, the consequences for your health can be severe and far-ranging.

One of the potential effects of sleep apnea is an increase in cancer risk. Now a new study uses a large population to look at the link between sleep apnea and cancer. The study reinforces the link between sleep apnea and cancer risk for women. For men, the results are unclear.

Population-Based Study

Researchers at Aristotle University of Thessaloniki based their study on the European Sleep Apnoea Darabase (ESADA). This study includes data from more than 19,000 individuals over the age of 18 from 2007 to 2016. The data includes the age, BMI, smoking status, and alcohol consumption for each individual in addition to their sleep apnea status.

Researchers looked at the incidence of cancer in this group, which was about 2% overall–a total of 388 diagnosed cases of cancer for 160 women and 228 men. For women, breast cancer was the most common, while for men prostate cancer was the most common.

When researchers corrected for known risk factors, they found that women had a statistically higher risk of cancer if they had sleep apnea, while men didn’t.

Why the Gender Difference?

Researchers weren’t sure why the data showed a gender difference in cancer risk. However, there are other studies that imply women are more seriously impacted by sleep apnea than men.

In addition, researchers proposed that:

  • Women’s cancers (like breast cancer) might respond more to oxygen shortage
  • Smoking-related risk factors might be gender sensitive

Another possible explanation is that it could relate to underdiagnosis of sleep apnea. Since so many men are likely to have sleep apnea, there could be as many as four men with undiagnosed sleep apnea for each man diagnosed with the condition, which could make it hard to pinpoint risk. Since fewer women have sleep apnea overall, undiagnosed sleep apnea wouldn’t have as much of an impact.

Does Sleep Apnea Cause Cancer?

Of course, another important question is one that this study just doesn’t answer. Does sleep apnea cause cancer? It’s hard to say. But there are reasons for us to suspect that it might.

Cancer consumes disproportionate amounts of the body’s resources. Tumors rely on the growth of new blood vessels, which in turn depends on vascular endothelial growth factor (VEGF). VEGF levels increase when oxygen levels drop during apnea events. And whether or not sleep apnea actually causes cancer, it definitely makes it harder for cancer victims to survive the condition.

Do You Have Sleep Apnea in Nebraska?

This research is one of many studies that suggest a link between sleep apnea and cancer risk. Cancer is just one of many risks associated with sleep apnea. Sleep apnea treatment not only provides immediate benefits, it can be life-saving in the long term.

If you have sleep apnea and are looking for treatment, the Advanced Dental Sleep Treatment Center in Omaha is the leader in sleep apnea treatment in Nebraska. Please call (402) 493-4175 today for an appointment with a sleep dentist.

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Studies have demonstrated that OAT effectively treats OSA through reduction in apnea-hypopnea index (AHI) and respiratory disturbance index in patients. Studies have demonstrated similar effectiveness between OAT and CPAP, even among patients with moderate-to-severe OSA.

The post Oral Appliance Therapy for OSA: The Facts appeared first on .

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This is a big, important paradigm shift, one of which we truly believe will help your patients be healthier!

We are offering a treatment guarantee for all patients who come to our office for initial OSA treatment. In other words, if a patient tries an oral appliance as first-line treatment and doesn’t tolerate it or it doesn’t effectively treat their AHI, we will transition treatment to a CPAP, at no additional out of pocket cost to the patient.

The idea was conceived following a recently enforced Medicare rule which states Medicare will not pay for similar treatment within a 5-year period. This means if Medicare paid for a CPAP, and the patient has found themselves intolerant and unable to utilize it, Medicare will not cover the cost of an oral appliance for another 5 years. Unfortunately, this means for most Medicare patients, they go untreated and suffer the medical and social consequences of sleep apnea. We thought there must be a way to prevent this, but that would mean the patient would have to try an oral appliance first. We understand that in medical school and in practice, CPAP and Sleep Apnea go hand in hand. CPAP is fantastic treatment, so we understand that. However, seeing all the new studies that deem oral appliances equivalent when taking compliance into account, and seeing first-hand the number of people who go untreated after being prescribed CPAP, we are challenging providers to tweak their CPAP/Sleep Apnea association. We are challenging you to consider a patient for an oral appliance first for mild and moderate cases. If you do this and they are a good candidate, we will take it upon ourselves to make sure they are treated successfully regardless of modality – we don’t want cost to stand in the way of health. Not that we will be doing this for all patients, including both those with commercial insurance and Medicare. Please consider shifting your paradigm and begin to think about oral appliances first! Your patients and their families will thank you!

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This week marks an important anniversary in film history: May 25 is the 40th anniversary of the release of the original film Alien.

This film essentially reinvented the sci-fi/horror genre, which for years had languished as a B-film wasteland of cheap effects, poor writing, and weak scares. The strength of this film has led to five direct sequels, two crossover films with the Predator franchise, dozens of board, role-playing, and video games, and countless imitations and merchandise.

Much of the film’s popularity stems from its ability to portray a visceral horror that is hard to capture on screen. The way it represents that horror is a powerful reminder for why so many people with sleep apnea find it difficult, if not impossible, to adapt to CPAP.

Overpowered by the Facehugger

A quick plot summary can help remind you of the context. In the film, the crew of the freighter Nostromo lands on a small planet to investigate what they are told is a distress signal. When some of the crew enters a derelict alien ship, they find many eggs in the cargo hold. A crew member gets close to one of the eggs, and an alien leaps out of an egg and attacks.

The alien which emerges is usually called a “facehugger,” and it resembles a dismembered hand with a long tail. The alien excretes acid to burn through the crewman’s spacesuit. The fingers wrap around the man’s head like straps while the tail wraps around his throat. It inserts a tube into his mouth and disables him with a paralytic enzyme.

The man, who was the ship’s second in command, is completely taken down by the alien in a matter of seconds. As the man lies on the table, seemingly asleep, he looks very much like someone wearing a CPAP mask.

A Terrible Bargain

One of the important similarities between the alien facehugger and CPAP is constantly neglected: they’re both lifesaving. When the crewman’s spacesuit was broken open in the planet’s thin atmosphere, he would have died if left on his own. However, as we learn, the facehugger is actually supplying him with oxygen so he doesn’t suffocate.

It’s like the CPAP mask in this way: it provides a lifesaving benefit, but at what cost? And is that bargain worth it?

For many people, it’s just not. The sense of being smothered under the CPAP mask is too horrific (even without the consequence of having an alien egg implanted in you) to trade for the lifesaving benefit, which remains abstract and distant. It’s a nightmare-inducing setup, especially for people with PTSD. These people need an alternative, because without treatment, their condition can indeed be fatal.

Of course, for other people, this isn’t as important a detail. In fact, some people see this as humorous–there are CPAP masks actually designed to look like facehuggers. These people can and should use their CPAP.

Can’t Adapt to CPAP? We Can Help

Ironically, Dr. Roubal has been practicing dentistry almost as long as the movie has been out. Most of that time, he’s been helping people deal with their sleep apnea using a very effective alternative to CPAP. And if you find that you can’t adapt to CPAP–or can’t even try it–he can help you.

To learn more about the benefits of CPAP alternatives in Omaha, please call (402) 493-4175 today for an appointment with a sleep dentist at the Advanced Dental Sleep Treatment Center.

The post Alien Reminds Us Why So Many People Can’t Adapt to CPAP appeared first on .

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We think we know the story: men are snorers who disturb their wives with loud breathing throughout the night. Wives may employ elbows or pillows to try to wake him up, and may either force him into the other room or go themselves.

However, more and more research is pointing out that women may be almost as likely as men to snore. And they may snore just as loudly, too. The big difference? Women don’t admit it. That’s the finding of a new study showing that men and women referred to a sleep clinic have about the same incidence of snoring–and they snore just as loudly–but women don’t admit to being snorers.

Referred for a Sleep Evaluation

For this study, researchers compared the results of polysomnography with a survey for 1913 people who had been referred to a sleep center. All the people knew they’d been referred to a sleep center by a doctor when they were asked about their snoring.

Even so, more than a quarter of women (28%) reported that they were nonsnorers, four times the rate of men (7%). Despite the difference in the surveys, actual polysomnography data showed that most men and women were actually snorers (88% of women vs. 93% of men).

The incidence of snoring wasn’t the only thing that was the same. The average volume of snoring was also nearly identical: 50 decibels for women, 52 for men (a typical alarm clock is 60 decibels). Some of the discrepancy was among the loudest snorers: 37% of women who said they didn’t snore at all were described as “severe” snorers, with a snoring volume of 55 decibels or more! For comparison,  only 12% of men said they were nonsnorers when they were actually severe snorers.

It’s important to put this study in some context. It looked at consecutive patients, which means that it considered each patient who came into the clinic during the study period, not selecting patients in any way other than their order. The study did include almost twice as many men as women (1238 vs. 675), so the study isn’t saying that women snore just as often as men–just that the ones referred to this clinic did. While this remains a significant difference, it means that about a third of all snorers are women, and that they snore just as loudly as men.

Why Women Don’t Report Snoring

If a third of snorers are women, and they snore just as loudly as men, why are they more likely to report that they don’t snore?

Part of it is our perception that snoring is a man’s problem. Women might not recognize that they’re snorers. Women also don’t want to be linked to what’s seen as a masculine problem. They might not recognize the link between snoring and their sleep problems.

Another part of the problem is that men are often heavier sleepers than women. They might be more likely to sleep through the snoring of their partner. If your partner doesn’t report your snoring, you might never know you have a problem. And then you would potentially experience the risks of untreated sleep apnea.

Women Need to Get Evaluated for Snoring and Sleep Apnea

This study shows in no uncertain terms that women are often snorers, even though they might not know it or report it. This makes it clear that sleep tests are not just for men–women need to be told about these potentially serious health problems so they can be tested and treated.

At the Advanced Dental Sleep Treatment Center in Omaha, we are dedicated to ensuring that everyone gets diagnosed and treated for their sleep problems. If you want to learn whether you are a snorer or have sleep apnea, please call (402) 493-4175 today for an appointment with a sleep dentist

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It has been frustrating in recent years to see several studies that don’t show what we know to be true: sleep apnea treatment provides health and quality-of life improvements for sufferers. But now we’ve got a new study that shows the benefit: people who get sleep apnea treated can reduce their risk of death by 62%!

Not only does this study show this substantial benefit–it helps us understand why previous studies didn’t show benefit.

Improvements in All-Cause Mortality

This study looks at data from the Sleep Heart Health Study, which followed more than 6400 Americans from the late 1990s to 2010. However, for this analysis, French researchers analyzed 11 years of  data for 392 participants who had sleep apnea and were severely obese. Of these patients, 81 (21%) used CPAP (continuous positive airway pressure), while the other 311 left their sleep apnea untreated.

They found that those who used CPAP reduced their risk of all-cause mortality (dying from any cause) by 62% over those who didn’t use the device.

Why Couldn’t Previous Studies Find the Same Results?

These results seem clear enough that it’s hard to believe that previous studies haven’t been able to show the same level of results. Why have many studies showing little or no statistically significant benefit? The most likely reason is simple: they weren’t long enough. Most clinical studies are short, with one or at most a few years’ data. Studies started 20 years ago are hard to find, and few of them started out focused on the problem of sleep apnea, which wasn’t fully appreciated decades ago.

This study has the benefit of having a long follow-up period, allowing researchers to look at long-term data on the use of sleep apnea treatments. Since many of the effects of sleep apnea are chronic diseases, it takes time to stop and reverse the disease effects to the point where the benefits can be measured.

This fact shows again why people should make efforts to get their sleep apnea diagnosed and treated early to avoid the long-term harms that come from the condition.

CPAP Failed This Population

Another key insight from this study is much less discussed than the primary finding. Although the study shows CPAP has benefits, the study also shows that CPAP fails most of those who need it. In the study population, 79% of obese individuals with sleep apnea didn’t use CPAP. They weren’t randomly selected to not use CPAP. In fact, they were probably prescribed it by their doctor, since CPAP is the frontline treatment for sleep apnea, especially among obese individuals.

Why didn’t they use it? Most likely for the same reasons most people prescribed the treatment don’t: it’s uncomfortable, disruptive, and hard to use. If people can be given an alternative to CPAP, they are likely to take it.

That’s what makes oral appliance therapy such a lifesaver. There are people with a treatable, life-threatening condition that simply can’t tolerate the treatment. Giving them another option helps them to get treatment, which can then help them avoid some of the many consequences of sleep apnea.

If you have been prescribed CPAP, but can’t make yourself use it, we can help. Please call (402) 493-4175 today for an appointment with an Omaha sleep dentist at the Advanced Dental Sleep Treatment Center.

The post Sleep Apnea Treatment Extends Life for Obese People in New Study appeared first on .

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Snoring can be a huge disruption in your relationship. It is an unwelcome third in your bedroom every night, and it can complicate what used to be a loving relationship.

What used to be happy mornings become bitter, and the bed that used to bring you together can suddenly start driving  you apart.

However, you don’t have to let snoring hurt you this way. Follow these suggestions to overcome the obstacle of snoring and improve your relationship with better sleep.

Talk It Out in the Light of Day

We know that when snoring wakes you up, you want to address it right away. You hope to get back to sleep, and that means trying to stop it right away.

But that would be a mistake. In the middle of the night, you’re in no condition to have a conversation about snoring. One or both of you are going to escalate the discussion to a fight. And we’ve seen it happen many times: angry words become a fight, and a fight can turn into dangerous domestic violence: beatings, stabbings, and shootings.

Try to maximize your sleep in what ways you can, such as moving to another room. Then try to have a conversation about it at another time, when you are both more awake and in a better mood.

“It’s not you, it’s the snoring.”

Try to keep the conversation about the snoring, not focused on the other person. Don’t accuse them of snoring, as if it’s something they’re doing intentionally to you. Instead, you need to acknowledge that the snoring is something separate from the person you love, even if they’re the ones producing it.

Know How Snoring Impacts You Both

One thing that will help you keep from blaming the other person for their snoring is understanding that they are suffering from snoring, too.

They look like they’re sleeping peacefully, but they’re not. Inside, their body is starving for oxygen, and the snoring is the sound of them fighting to breathe. Their heart may be racing and their body full of adrenaline as they struggle to keep their airway open. That’s especially true if their snoring ends with a gasping or choking sound, clear indicators of sleep apnea.

They may not even be sleeping most of the night. If they have sleep apnea, they might wake hundreds of times a night, even if they aren’t getting to full consciousness. They may spend the entire night in bed, but never once reach the deep levels of restorative sleep they need.

This is not to minimize the fact that snoring is obviously keeping you awake, just to point out that they might be as sleep-deprived as you are, no matter what it looks like.

Focus on Controlling Snoring

It’s tempting to think that if you can’t hear the snoring, it’s not a problem, but that’s not the case at all. Any solution that just gets you away from the sound, such as earplugs, white noise generators, or moving to a different room, is only half a solution. As long as they are snoring, they are still not sleeping properly.

There are many options to control snoring, though, and many home solutions  you can try. Some simple solutions–like getting a snorer to sleep on their side or avoid drinking alcohol in the evening–can make a big difference.

We do recommend against over-the-counter or online snoring treatments. Sometimes these can cause trouble, and they may even silence the snoring but leave important health conditions untreated.

Seek Professional Help

If your at-home solutions aren’t doing the trick–snoring continues, as does the tension–it’s time to seek professional help. Fortunately, professional snoring treatments can be highly effective. Working with a professional also allows the snorer to get screened for sleep apnea, which is of critical importance to ensure you’re both healthy and happy.

Make Sure You’re Both Happy with the Solution

There are many tempting solutions that solve the problem from one person’s perspective, but not the other’s. They’re tempting, because, for example, you can just decide to sleep in another room without feeling that you have to clear that with your partner. You get sleep, so you’re happy, but if they’re not satisfied with this situation, it’s not really a solution. The conflicts can continue and may be as bad as or worse than before.

We Can Help

If you find that you’re struggling in a relationship because your partner snores, let us help. We offer effective, noninvasive snoring solutions so that you can both get all the sleep you need to stay happy, healthy, and in love.

To learn more about snoring treatment in Omaha, please call (402) 493-4175 today for an appointment with a sleep dentist at the Advanced Dental Sleep Treatment Center.

The post 6 Keys to Keeping Snoring from Destroying Your Relationship appeared first on .

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