What Really Causes Obstructive Sleep Apnea?

Last Updated: 10 December 2022.

When I asked the sleep specialist who diagnosed me with severe obstructive sleep apnea what the cause of my condition was, he said that the muscles in my airway collapse during sleep. The Mayo Clinic, WebMD and Healthline all agree, but in my mind this doesn’t really identify the root cause. So I asked why my airway was too small to tolerate the collapse of the muscles in it, and he replied with: genetics.

I thought that sounded a bit odd given that neither of my parents suffered from obstructive sleep apnea, and as far as I was aware we had no family history of it. One of my siblings has since been diagnosed with it, at least one cousin has it, and I’m pretty sure my mother had it before she died but I wasn’t successful in getting her tested. Nevertheless, at the time I was determined to take my root cause analysis further because I thought that knowing the underlying cause would better inform me as to what the best treatment for the condition might be.

In the several years since I was diagnosed with severe obstructive sleep apnea, I’ve done a lot of research into the root causes of and treatments for the condition. I’ve even tried quite a few. Sandra Kahn and Paul L. Erlich’s book Jaws: The Story of a Hidden Epidemic summarizes much of what I have discovered quite nicely. They have also published their research along with other colleagues from Standford University in The Jaw Epidemic: Recognition, Origins, Cures, and Prevention. Despite going against conventional nutritional, societal and orthodontic wisdom, this information is now (finally) making its way into mainstream scientific publications.

It turns out that we’re currently living through an epidemic of obstructive sleep apnea which has suddenly appeared largely within the current generation. The name for the disease was only coined in the 1970s, yet by 2017 the incidence of obstructive sleep apnea in the general population was somewhere between 9% and 38%, with the massive margin of error being because the vast majority of people with the condition are undiagnosed. Even by the most conservative estimates that’s tens of millions of people living with a chronic health condition with potentially devastating consequences which has arisen mostly during a single generation.

What could cause such a common disease to arise so quickly?

The previously cited review of the prevalence of obstructive sleep apnea identified increases in obesity and longevity as causes, but didn’t consider other factors that might affect airway development. My sleep apnea got worse as I got older but I’ve never been obese. Prior to the invention of CPAP and maxillomandibular advancement surgery, the only effective treatment option for a patient like me was a tracheostomy. I didn’t know anyone in my parent’s generation who had one, but I know a lot of people in my generation on CPAP. The review notes the difficulty comparing incidence rates over time due to changing diagnostic criteria, so solid scientific evidence that rates of OSA are increasing is lacking, but anecdotally the problem seems to be getting much worse as the market for CPAP machines is growing by 7.4% per annum.

Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets identifies four pathophysiologic causes of OSA:

1. an anatomically compromised or collapsible upper airway
2. inadequate responsiveness of the upper-airway dilator muscles during sleep
3. waking up prematurely to airway narrowing
4. having an oversensitive ventilatory control system (high loop gain)

Sleep apnea is clearly multi-factorial and identifying a single root cause is impossible. Researchers often end up analysing the straw that breaks the camel’s back, but what causes the camel’s back to be too weak, or the airway be too small, in the first place?

So I did a bunch of research to see what’s going on. Here’s my summary of the chain of causal factors that I believe lead to obstructive sleep apnea, none of which my sleep specialist even mentioned:

Inadequate Breast Feeding

It turns out that breast feeding is about a lot more than just feeding a baby. In addition to the vital emotional bonding that takes place during the process, an infant learns the appropriate tongue and oral posture for swallowing, and exercises important facial muscles because they must suck reasonably hard to get milk from the breast. Breastfeeding is important for correct orofacial development and breastfeeding for a longer duration lowers the risk of malocclusion, which is associated with small jaws, whereas poor facial morphology is linked to obstructive sleep apnea.

Our ancestors didn’t have access to processed baby foods so their infants were weaned directly onto essentially the same food the adults ate. Modern infants generally aren’t breastfed long enough to develop the tongue posture required to widen the maxilla, and then get fed processed baby foods which don’t require sufficient chewing to develop their jaws. John Mew describes this in more detail in this mini-lecture:

Dentist Dr Brian Palmer covers this in his article The Importance of Breastfeeding as it Relates to Total Health. In the Sleep Apnea Stories Podcast interview with Myofunctional therapist Renata Nehme at 15:38 she mentions that feeding infants baby food came about during World War II when mothers had to go to work and could no longer breastfeed. This explains the rapid rise of small jaws causing the epidemic of obstructive sleep apnea in the baby boomer and future generations.

Processed food is as bad for an infant as it is for an adult. A better approach is for the baby decide when it’s time to move directly from nipple to solid food, as described in Baby Led Weaning by Gill Rapley and Tracey Murkett.

Fun fact: unlike adults, infants can swallow and breathe at the same time because their airway hasn’t fully developed yet. Breast feeding teaches them to breathe through their nose while simultaneously sucking milk through their mouth.

Mouth Breathing

While breast feeding teaches an infant to breathe through their nose, a bunch of things ranging from allergies to poor oral posture while not feeding can lead them to habitually breathe through their mouth. This sets you up for a whole swathe of chronic health conditions and literally impairs the development of your face and airway. You can’t breathe through your mouth if your tongue is resting where it should be, on the roof of your mouth. Try it for yourself now: it’s impossible. Mouth breathing forces us to adopt poor oral posture and this changes the skeletal structure supporting our airway.

Dr Egil Harvold’s Primate experiments on oral respiration conducted in the 1960’s and published in 1981 showed that if you force monkeys to breathe through their mouth, they develop crowded teeth similar to most modern people. For a more contemporary look at this, check out James Nestor’s book Breath: The New Science of a Lost Art and his interview with Dhru Purohit.

Poor Oral/Tongue Posture

The proper resting position for the tongue is on the roof of the mouth, and this is particularly important when swallowing. Mouth breathing requires the tongue to be on the floor of the mouth, and when this habit is maintained during swallowing the tongue no longer presses into the hard palate like an infant learns during breastfeeding. This pressure of the tongue being sucked onto the palate during swallowing helps drive the expansion of the maxilla. Without this routine force every time you swallow, you end up with an underdeveloped maxilla and a long face.

Proper tongue posture is impossible to attain if you have a tongue tie, which restricts movement of the tongue and is often not recognised. Tongue tie can be released with simple surgery a trained dentist can perform and tongue posture can be improved with Good Oral Posture Exercises (GOPex). You can then start to unwind the disastrous chain of consequences listed below.

The Soft Western Diet

In 1939, a dentist named Dr Weston A. Price published Nutrition and Physical Degeneration: A Comparison of Primitive and Modern Diets and Their Effects, which documented his research showing that the western diet causes a lack of jaw development, leading to the epidemic of malocclusion in western societies. His mistake was to attribute this to nutritional differences, when in fact the important difference in the diets he studied lay in how much chewing they required. The western diet is too soft and doesn’t require the chewing necessary to fully develop facial muscles and jaws.

His message has largely gone unheeded and things have gotten even worse in the meantime. Many of today’s fruit and vegetables have been bred to make them softer and sweeter than the diet of our ancestors, and much of our modern diet is made up of soft grains and mushy cereals which require very little chewing.

Anthropologist Robert S. Corruccini summarises extensive anthropological evidence regarding the current epidemic of malocclusion in his book How Anthropology Informs The Orthodontic Diagnosis of Malocclusion’s Causes, concluding that disuse of mastication due to an overly soft diet is the cause.

James Nestor explains this most succinctly in this excerpt from his interview on Dhru Purohit’s Broken Brain Podcast:

He gives more details in his interview with Joe Rogan: Blame Modern Diets, Not Genetics, for Your Crooked Teeth and Breathing Problems. For a modern diet that matches our biology, read Steven Lin’s book The Dental Diet: The Surprising Link between Your Teeth, Real Food, and Life-Changing Natural Health.

Underdeveloped Maxilla

All the proceeding issues lead to underdeveloped jaws that are too small for the teeth encoded in our genes, and positioned too far back, resulting in a retrognathic maxilla. It’s an epigenetic conflict between jaw development which is dependent on proper oral posture and adequate chewing, and teeth that grow the same size they always did in our ancestors. The difference is that they had the right diet for jaws to fully development, whereas in modern society we end up with crowded and crooked teeth, also known as malocclusion.

However, crooked teeth are preventable with simple diet and lifestyle changes that address the factors above during childhood. Otherwise, it the effects continue to cascade as shown below.

Here’s a video showing the result, courtesy of orthodontists John Mew & Derek Mahony:

Orthodontic Extractions

Old-school orthodontic thinking was that crowded teeth were too big for the jaws, and the solution was to remove some teeth and use braces to close the resulting gaps by retracting the front teeth backwards. The problem with this is that the tongue grows to the appropriate genetic size for the teeth and jaws, assuming that the jaws have had the right environmental factors to facilitate proper development. Also, when teeth are removed the surrounding bone shrinks, making the jaw even smaller.

This ultimately leads to a myriad of health problems that orthodontist Dr Bill Hang has labelled Extraction Retraction Regret Syndrome™ (E.R.R.S.™). He discusses the impact of orthodontic extractions on obstructive sleep apnea in the interview on Dr Steven Park’s Breathe Better, Sleep Better, Live Better podcast episode Can Orthodontics Cause Obstructive Sleep Apnea?

This is what happened to me: I had the typical four bicuspid extractions and braces when I was 13 years old. The result was straight teeth, which didn’t entirely last, and a compromised airway that set me up for years of unnecessary suffering caused by obstructive sleep apnea which then took years to diagnose as an adult. Also, my braces hurt a lot, which meant I was completely unable to eat the hard foods that I now know were essential to the development of my jaws. In other words, the “treatment” made the problem even worse.

This is controversial in the orthodontic industry, with many orthodontists claiming that there is no link between orthodontic extractions and obstructive sleep apnea, and citing a retrospective study of health records that agreed. However, this study has some serious flaws, including the assumption that people who hadn’t been diagnosed with OSA mustn’t have it because they all had health insurance, despite research showing that 80% of moderate-severe cases are undiagnosed despite adequate access to health care. Dr Hang describes the study as “flawed” in the interview with Dr Park at 13:10.

This isn’t the first time that the dental industry hasn’t told the truth to protect its lucrative income stream. It’s impossible to do a double-blind placebo controlled study on this, and the timeframes involved are extremely long since the impact of the compromised airway may not be felt until middle-age when the muscles of the throat begin to lose tone; as happened to me.

Underdeveloped jaws will compromise your airway, and orthodontic extraction and retraction treatment makes this problem even worse. Astonishingly, no longitudinal studies have been done on extraction/retraction orthodontic treatment to demonstrate its safety. For a deep dive into this, see Extracting Premolar Teeth for Orthodontic Treatment: What are the Risks?

Some people may have sufficient genetic reserve capacity in their airway for this not to be a problem, but there is no way to determine this ahead of treatment. Orthodontists have the opportunity to identify patients at risk by the presence of malocclusion and recognise it as a risk factor for future obstructive sleep apnea which can then be prevented with expansive orthodontics, rather than making it worse with extraction/retraction.

British orthodontist John Mew studied the impact of conventional extraction/retraction orthodontics versus expansion orthodontics using identical twins back in the 1990s, and found that those who had the extraction treatment developed longer, less attractive faces with poorer airways:

The devastating effects of orthodontic extractions have long been denied by many conventional orthodontists but is slowly starting to filter into the mainstream orthodontic community. However, it’s still often portrayed as somewhat fringe; check out the New York Times article How Two British Orthodontists Became Celebrities to Incels and Mike Mew’s reaction, for example.

For a deep dive into the full consequences of orthodontic extractions, see Karin Badt’s article Extracting Premolar Teeth for Orthodontic Treatment: The Risks.

Retruded Mandible

The position of the lower jaw is set by the way the teeth it carries mesh with the teeth of the upper jaw. Given that my maxilla is too small and too far back, my mandible is also too small and too far back. The result is that my airway behind the back of my lower jaw is compromised and during sleep my tongue, which is too big relative to the size of my underdeveloped jaws, has nowhere to go other than backwards, sealing the deal by blocking what little airway I have remaining.

Craniofacial Dystrophy

It’s not just the jaws though; the whole face is affected which is why many people now summarize the cause of obstructive sleep apnea as craniofacial underdevelopment or craniofacial dystrophy. One of its many side-effects is a compromised airway that leads to Obstructive Sleep Apnea (OSA) and it’s elusive sister condition, Upper Airway Restriction Syndrome (UARS).

CBCT scan slice showing the left side view of my head, including jaws, top of spine, and compromised airway (coloured orange) which is blocked by my tongue during sleep.

So thank you mum, society, my childhood dentist who did the extractions, and the orthodontist who put him up to it. Together, they put the nail in the coffin of my ability to breathe properly, and fucked my life up.

Obstructive Sleep Apnea

The chain of events listed above culminates in obstructive sleep apnea, but it’s unlikely your sleep physician is going to even talk about many of the factors involved, let alone try to address them.

Some dentists such as the late Dr Brian Palmer have known about all this for a long time though; see his presentation Sleep Apnea from an Anatomical, Anthropologic and Developmental Perspective. It’s also discussed in depth on Dr Steven Park’s Breathe Better, Sleep Better, Live Better podcast, particularly in the episode Integrative Orthodontics with Dr. Barry Rafael.

The Solution?

OK, so that’s the problem nailed. But what’s the solution? I can’t go back and breastfeed again; my mum is still alive but I don’t think she’d be up for it, and the critical period of development for me has well and truly passed. I make sure I don’t mouth breath now I know how important that is and tape my mouth at night, but again that’s not likely to alter my skeletal structure much at age 52. I’ve changed my diet to include more foods that require chewing and done some hard-core mewing, but these are not likely to fix my jaws now either. Nor can I go back in time and be assertive with my orthodontist and insist that he expand my jaw instead of having my precious teeth extracted because I don’t have a time machine.

Nevertheless, the optimal solution needs to address the underlying problem of underdeveloped jaws, which is why I explored many options for maxillary expansion to treat obstructive sleep apnea. My sleep apnea is quite severe at an AHI of 39 on a sleep study conducted on 27 June 2019. After exploring all the alternatives I ended up choosing the Vivos mRNA appliance to expand my maxilla and mandible, and allow my lower jaw to move forward to provide sufficient space in my mouth for my tongue, along with adopting The Dental Diet, regular exercise, singing practice to maintain muscle tone in my airway, and doing myofunctional therapy to strengthen my tongue and airway muscles twice daily.

Unfortunately the Vivos mRNA Appliance tipped my teeth and made no impact on my obstructive sleep apnea, so now I’m exploring maxillomandibular advancement surgery to cure me, and using CPAP in the mean time.

To learn more about the real causes of obstructive sleep apnea see this YouTube playlist.

French readers can find a translation of this article here courtesy of Stephane from Blog Fatigue Chronique.