Upper Airway Resistance Syndrome: Symptoms and Effects

Teeth grinding can reveal a sleep disorder causing lack of oxygen to your brain.
Teeth grinding can reveal a sleep disorder causing lack of oxygen to your brain.

Imagine the sound of tooth enamel screeching against under 250 pounds of force per inch. That’s what dentists think when they see teeth grinding in patients. For a long time, I would prescribe a night splint to prevent damage to the teeth. To address the cause, I would talk about stress. These people usually work or study long hours or report stressful family situations. Stress plays a part, but teeth grinding also reveals how people breathe during sleep. To put it more correctly, teeth grinding hints at a set of sleep disorders and lack of oxygen during sleep. It’s a little-known condition known as upper airway resistance syndrome. And it is far more common than you’d expect.

Tooth enamel is the hardest surface in the body. The very idea that people would simply grind their teeth down didn’t make a lot of sense to me. Severe cases of teeth grinding can even wear the front teeth away. That’s right down to exposing nerves. When it happens, the experience is extreme tooth pain. It severely changes the height of the face and smile. Treatment is very difficult and expensive.

It’s estimated that 70 million Americans suffer from sleep disorders. You may ask how the number could be so big? Many people simply don’t know they are at risk. They also have sleep disorders that are hard to pick up and even define. The relatively small number of diagnoses are those with obstructive sleep apnea.

In this article, we explore the sleep disorder epidemic of people choking during sleep. And how a simple dental finding of teeth grinding can prevent a lifetime of sickness.

 

Typical teeth grinding and upper airway resistance syndrome presentation

Teeth grinding is a very common finding in the dental exam. Studies suggest that 8-31% of the people suffer from night or daytime teeth grinding. Often people are unaware of teeth grinding at night. For those that do know, it’s usually because a partner has told them. Or they have a headache or jaw pain in the morning.

People who have stressful jobs or home life seem more susceptible to teeth grinding. But a critical piece of the puzzle is breathing-related sleep disorders.

The people I would see who reported teeth grinding also had a similar set of symptoms. There were more females, with small jaws and necks. They had tiny mouths with crowded teeth who either needed or had orthodontics.

That was the dental findings, but another set of symptoms kept coming up. They would often describe another set of health issues. These included problems with digestive health, anxiety, depression, and daytime drowsiness. Not to mention problems concentrating or as they called it, brain fog.

Dig a bit deeper, and they would report sleeping on their stomachs. They have trouble sleeping on their backs and always wake up face down against the pillow.

Obstructive sleep apnea is often grouped with overweight, middle-aged males. But people with teeth grinding syndrome were slipping through the cracks.

The condition as it turns out was upper airway resistance syndrome or UARS.

 

Upper airway resistance syndrome and silent oxygen deprivation

Upper airway resistance syndrome (UARS) was termed by Stanford’s Christian Guilliminauilt in 1993. They described a group of young women and men who complained of fatigue and daytime sleepiness.

They all underwent a formal sleep study and did not test positive for OSA. However, by treating them as if they had obstructive sleep apnea, symptoms improved in many.

A range of symptoms is related to upper airway resistance syndrome (UARS):

  • Small jaw, crowded teeth or previous orthodontic work (especially extraction orthodontics)
  • Unable to sleep on back
  • Small mouth and neck
  • Low blood pressure
  • Fainting or light-headedness
  • Sinus pain or infection
  • Chronic stuffy nose
  • Deviated septum
  • Temporomandibular dysfunction (TMD)
  • Headaches or migraines
  • Digestive problems like irritable bowel syndrome, Crohn’s disease, diarrhea, constipation, bloating
  • Cold feet and hands
  • Depression or anxiety or chronic stress
  • Brain fog, daytime sleepiness or concentration problems
  • Allergies, skin rashes

Researchers have been unable to agree on an exact test or diagnosis for UARS. Tests cover a range of measurements. Including clinical observations and sleep tests such as polysomnography (PSG).

Different attempts define UARS, including:

  • Apneas (pauses in sleep)
  • Daytime sleepiness
  • Esophageal pressure
  • Respiratory effort related arousals (RERAs).

UARS symptoms have been found to sit alongside or mimic functional somatic syndrome.

This is a set of conditions or symptoms including:

  • Irritable bowel syndrome
  • Chronic pelvic pain
  • Fibromyalgia
  • Non-cardiac chest pain
  • Tension headache hyperventilation syndrome
  • Chronic fatigue syndrome

Any of these problems alongside teeth grinding may be signs of UARS. The concern is that you’re not getting restful and healing sleep. It’s all connected to oxygen and breathing.

 

Lack of oxygen during sleep

People with upper airway resistance syndrome have frequent respiratory effort related arousals (RERAs). It’s due to higher pressure in the airways that send a message of ‘choking’ to your brain. If you suffer RERAs all night long, your body cannot enter deep REM sleep.

Healthy sleep should move through the different stages throughout the night. As you enter REM stages, the brain undergoes cleansing processes. When an arousal from a closed airway goes to your brain, deep sleep can’t be achieved.

Obstructive sleep apnea (OSA) is diagnosed by polysomnography (PSG). The presence of pausing in breathing (apneas) is measured by the apnea-hypopnea index (AHI).

OSA suffers experience airway obstruction, apnea then arousal. In UARS, there is no apnea, but airway obstruction then arousal or RERA. So people with UARS have an AHI of 0, or in other words, they don’t have pauses in breathing.

RERAs tells the brain to activate the sympathetic stress system. This can open the airway – pushing the jaw forward – which can cause teeth grinding. People often don’t wake from sleep during a RERA. That’s why teeth grinding often occurs without you knowing it.

RERAs result in a disrupted and incomplete sleep. Instead of resting and healing the brain, the body enters fight or flight mode. Stress hormones then release throughout the night as airway constriction continues.

 

How sleep disorders cause inflammation and stress

Upper airway resistance syndrome helps to explain why some people experience teeth grinding. The body is in a state of survival. RERA’s and stress hormones create the precise opposite scenario to restful sleep. The problem becomes an imbalance in the autonomic nervous system (ANS).

The ANS is a balance between sympathetic and parasympathetic. Sympathetic excites the body to increase heart rate and blood to muscles. Parasympathetic relaxes and slows the body. It increases blood flow to the digestive system for absorption and rest.

During sleep, the nervous system should be in parasympathetic mode. Sleep disorder related RERAS send the body into an excited, defensive state.

Today chronic stress is very common. It’s easy to place teeth grinding in that basket. But it’s likely hiding the insidious presence of upper airway resistance syndrome.

The sympathetic release of stress hormones causes inflammation and metabolic unrest. During sleep, the body should be removing metabolites in the brain built up through the day. In survival mode, the brain can’t do this.

UARS nearly always present with daytime sleepiness. Brain fog, fatigue, and mood disorder are also common. Many people with UARS experience light-headedness and episodes of fainting. Studies show that 23% of UARS sufferers have low blood pressure. Sometimes dangerously low.

The sympathetic nervous system also switches the digestive system off. Stress and survival mode takes the body’s focus away from feeding. The brain sends blood away from digestion as it receives messages that it’s in danger. Teeth grinding is common with anxiety and digestive problems like irritable bowel syndrome. These also include diarrhea, constipation, ingestion, bloating or reflux.

This all might sound a bit dire. The good news is there is hope. Rectifying nighttime breathing is possible. It’s then common for digestive and stress-related digestive issues to improve.

Resetting the stress response can in healing inflammation and improving mental health. The first step is to find the cause of sleep disorders.

 

Breathing, oxygen deprivation and sleep disorders

During sleep, your tongue, throat and facial muscles all relax. The result is a decrease in the size of the airway during sleep. When you have a small jaw, you have less space for nighttime breathing.

Crooked teeth are related to mouth breathing and incorrect tongue position. The correct way to breathe is through the nose. Your tongue should press against the roof of the mouth. Daytime tongue posture helps tongue muscles open the airway during sleep.

A small airway with poor airway muscle tone decreases volume. This is when the pressure in the airway increases. The only difference between UARS and sleep apnea is that the body doesn’t stop breathing. Instead, arousals or RERAs wake the brain up to open the airway.

People with UARS don’t test positive for oxygen desaturation. That’s another reason why UARS has often been overlooked. The body is still struggling for air, but it can’t be diagnosed in the same way as sleep apnea.

In part 2 of this series, we’ll look at how upper airway resistance syndrome links to getting braces and crooked teeth.

Do you suffer from symptoms of sleep disorders like upper airway resistance syndrome? Let us know your experiences below.

For more information on Dr. Lin’s clinical protocol that highlights the steps parents can take to prevent dental problems in their children: Click here.

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24 Responses

  1. I’ve had emphysema for four years. I was taking Spiriva and Advair. I started with oxygen at night, and later all day long. Nothing seems to help. The minute I start to walk around the breathing gets bad. Even the oxygen doesn’t seem to help.I smoked for approximately four years, from age 18 to age 22. I am now age 66 plus. I had for some time now noticed having difficulty catching a deep breath. Never in my wildest dreams did it cross my mind that I may develop a serious lung disease, but here I was with a serious case of COPD. I am only writing this to inform others that nothing was really working to help my condition.I went off the Spiriva (with the doctor’s knowledge) and started on Emphysema herbal formula i ordered from Health Herbal Clinic, my symptoms totally declined over a 5 weeks use of the Emphysema disease natural herbal formula. i am now almost 68 and doing very well, my lungs are totally repaired!! Visit there website www. healthherbalclinic. net or email Info@ healthherbalclinic. net

  2. Hello,
    I wear a tooth guard at night to stop the grinding, I woke my partner every night with the sound!
    I have brain fog, trouble concentrating, get sleepy during the day, bloated, sleep on my stomach, crooked & over crowded mouth (had 4 teeth removed as a child). I have very cold feet and sometimes get light headed when I stand up.
    I’ve woken up gasping once or twice and wondered about some sort of apnea..
    I’m a 32 year old female who’s fit & has a good diet.
    Your article seems to point me in the direction of UARS…
    What would you suggest?
    Thank you!

    1. Hi there, many of the symptoms you do describe fit into the UARS spectrum. Have you tried the mouth-body quiz on the site? It will look at the triad of your vitamin D level, sleep health and gut health. All of these may underpin breathing dysfunction at night. I would suggest investigating them and seeking an airway focussed dentist and perhaps ENT to assess your airway. Both myofunctional therapy and a mandibular advancement splint can be an option too.

      Hope this helps
      Steven

  3. Most of these issues describe me. I was always told I had a small mouth with crowded/too many teeth. I had quite a few extractions as a kid/teenager. I wore braces with headgear for several years. And as soon as I got them off I was diagnosed with TMJD and fitted for a guard. But I couldn’t wear it without getting intense headaches and brain fog. I have low blood pressure (avg 80-90/50-60). My heart rate is also very low (high 40’s-low 50’s). Yes to cold hands and feet. Yes to anxiety and allergies. And I’ve only been able to sleep in my stomach most of my life and wake up that way as you say. But just a few months ago I bought a Pillow1 neck pillow as i started to have neck and upper back pain. It has helped a lot with my grinding/clenching. But not sure it’s done anything for my potential breathing issue. I do struggle with fatigue and muscle weakness. So this is very interesting. Thank you for posting your findings. I look forward to learning more and am going to share this with my dentist.

    1. Hi Sandra, thanks very much for sharing. Have you checked yourself for a tongue-tie or oral restriction? That would be the first port of call, alongside checking vitamin D levels. The Mouth-Body quiz on the website helps to identify your risk of the triad of Vitamin D, sleep and microbiome imbalance.

      Steven

      1. Interesting you mention tongue tie because I had that surgery back in 1979 at the age of 9. I will ask my dentist about oral restriction. I have low vit D. And am looking forward to following your work on this and will keep an eye out for more articles. Thank YOU!

    2. Hi Sandra,

      This is a story I’ve heard more than once. There is a new series of blogs going up on myofunctional therapy and breathing health that i’d recommend checking out. They can be quite useful in the long term.

      Steven

  4. Wow this is a real lightbulb moment for me – I’m fascinated. I have a LOT of the symptoms you list above and now it’s making sense. I live in the U.K., do you have any advice please? I’m about to take the test on your site. Thanks SO MUCH!!!! 🙂

    1. Hi Kirsty,

      You’d be amazed at how common this is. I’m glad you’re identified that it may be at the core of your issues. Check out orthoropics.co.uk – Dr Mike Mew is a world leader in facial growth orthodontics.

      All the best
      Steven

  5. Hi Dr. Lin,

    I’ve been battling with extreme fatigue for the last 6 months. I also have been clenching my teeth (have had bruxism since I was 5, now 32).

    I had an in Home sleep study done and it came back negative for OSA, apparently only 3 apnea’s an hour and oxygen as low as 90%.

    When I record my sleeps with the SnoreLab app, I’m waking very frequently throughout the night (but never remember). I snore (although according to the app not very loudly). But the episodes of waking coincide with snoring which increases in volume then a choking sound and me immediately turning over. Does this sound like UARS?

    I’m thinking of getting a MAD, what are your thoughts?

    Thanks.

  6. I estimate I’ve had UARS for over 20 years. My quality of life has been awful and in an effort to try and find what was wrong, I saw four ENT’s, three sleep specialists (who said my sleep study was normal), six neurologists, two endocrinologists, four chiropractors, two naturopaths, a neuromuscular dentist, several functional GP’s, and countless quacks costing thousands of $$$$. NOT ONE mentioned a possible sleep breathing disorder, despite my small mouth and narrow airways, increasingly severe insomnia, fatigue and other classic symptoms. I figured it out myself and requested a sleep study which as mentioned, was considered ‘normal’. I am now embarking on treatment with the help of a clued-up sleep therapist who taught me more about USRS in one hour and about what was happening with my airways during sleep than all the sleep specialists combined (who never mentioned UARS). Sadly, I suspect there are many like me out there, being poisoned with psychiatric drugs, being told they are anxious and depressed, while not knowing the real cause which has potential to be treated. So sad. Keep spreading the word. If you have fatigue and mental health symptoms, educate yourself about UARS!

    1. This is incredible Vicki. I have been on this exact same road for the past 5 years. Still struggling terribly. Was told in Feb that I have OSA and been on CPAP since, but stopping me waking up all night. Was just told yesterday after another sleep study that I also have UARS. Can you please tell me what treatment you received for it, if you did get any?

      Thanks
      Patrick

  7. This is amazing! I have almost all of the symptoms you listed (IBS, jaw pain, daytime sleepiness, brain fog, low blood pressure, light-headedness, cold hands and feet, fatigue, problems concentrating, and psoriasis). I also have a small jaw/mouth, have had Invisalign and several teeth extracted. I’m so grateful to have come accross this article. Thank you so much for sharing this valuable information. I live in New York City though. Do you have any recommendations? I don’t know where to begin – should I see a sleep specialist or a dentist or GI?

    1. I went to a sleep dentist first. They specialize in sleep dentristy. Google to find one. He xrayd my jaw and airway from side ways and from the top of my head looking down. My airway was half the normal size from both angles. I had signs of grinding and TMJ etc. As suggested, I then got a sleep study referal from my GP. You can request a copy be sent to your dentist.

  8. I’m scheduled for endoscopic sinus surgery next week and I believe it is a result of UARS – abscess on a tooth as a result of grinding. I can relate to most of the symptoms you’ve listed, and I’m sad that I didn’t find this information earlier. I’ve ordered your book. What else would you recommend?

  9. Your articles are always so fascinating, especially for someone looking to resolve a lot of tooth/mouth issues. I have all those symptoms except sinus and headaches. At age 50 I released my tongue, and I work on retraining it daily to be at the top of my mouth. I didn’t grind my teeth at night because…my mouth hung wide open so I could get enough air. That caused its own problems – severe dry mouth, so dry that my tongue was like paper. It’s not good to have teeth/mouth that dry. So I stumbled upon mouth taping, and I tape every night. HUGE difference – my mouth is no longer dry, and when I’m awake enough to think about it, I do find my tongue is at the top of my mouth now. However, I find myself clenching teeth sometimes – fix one thing, break another 🙂 I’m looking forward to reading part 2 of this article.

  10. My history with disordered sleep goes back over a half century to early childhood. I believe being exposed to cigarette smoke as a child often leads to chronic mouth breathing during developmental years, which leads to an abnormal airway. I think this is common as dirt and and I don’t understand why it hasn’t been studied or why so many practitioners are so oblivious to something that is so common.

    1. A small jaw, crowded teeth and small abnormal airway can also result from bottle feeding, dummies, thumb sucking, and sucking a lot on sippers. Those sucking movements are more piston like, instead of the squeezing mouth movements performed during feeding from a nipple.

  11. Thank you Dr. Lin for your clear-headed thinking and writing on this issue. Like so many other commenters, I was under the impression I was going crazy until I was recently tested and found out I had UARS. I’ve recently started on CPAP and am optimistic that it will help, but am curious what the best avenues are for following up with mouth treatment (I’m also in the NYC area). I’ve seen myofunctional therapy and a mandibular advancement splint listed above? Are there any others?

    Thank you again for all the great work you’re doing.
    – Rob

      1. Thanks for this Dr.! I’ve been reading up on tongue-tie since I read your comment and am looking into options around that. Once again, can’t tell you how helpful it has been to have your insight with UARS.

  12. A small jaw, crowded teeth and small abnormal airway can also result from bottle feeding, dummies, thumb sucking, and sucking a lot on sippers. Those sucking movements are more piston like, instead of the squeezing mouth movements performed during feeding from a nipple. The unnatural sucking changes the way the lower face grows.

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