Why Sleep Matters for Midlife Women

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Hi everyone, it's Natalie. Welcome back to  the podcast. Today we're having the kind of   conversation I wish I had had years ago. It's  with Dr. Shireen Lim. She's not only a dentist,  

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she's someone who has dedicated her entire career  to understanding the deep link between breathing,  

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sleep, and our overall health for ourselves and  for our families. I know so many of us have tried  

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all the things. Sleep hygiene, supplements, fixing  bedtime routines, maybe even snoring remedies for  

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us or our partners. But Dr. Liam opened my eyes  to how our jaw structure and how we breathe,  

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even habits from infancy, can quietly shape  our sleep quality and impact everything from  

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brain fog to mood energy and those subtle signs we  might just be missing. And before we get started,  

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you are going to learn about sleep, but I want  to share something I've been trying because when   something actually helps, I like to talk about  it here on the podcast. Sleep has been a moving  

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target for me most of my adult life. Many of you  know I worked a ridiculous shift on the morning  

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news for many years, decades, and that really  messed with my sleep and my circadian rhythm.  

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But even after that, my body wasn't sure when  it should be sleeping and when I should be wide   awake. And if you're a midlife woman, you probably  know what I mean. Waking up in the middle of the  

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night, restless sleep, feeling tired even after a  full night in bed. I had someone reach out to me  

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after hearing my story. And they offered to send  me some products to help. Well, I was skeptical  

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because as a journalist, that's what I am. But if  you know me, you know that I'm open to things that   will improve health and I like to do my research.  This company is Blue Sky CBD. Now, hear me out.  

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They sent me their sleep gels and I've been taking  them and I have noticed a real difference since I  

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started them. I take one about 30 minutes before  bed and not only does it feel easier for me to  

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fall asleep, but my Aura sleep numbers have been  trending in the right direction and I'm a total  

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nerd about reading those numbers every morning  when I wake up. So, I know that it's working.  

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What makes these gels different is the  combination of CBD and what's called CBN.  

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CBD helps calm our nervous system, while CBN is  often used specifically to support sleep. Now,  

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nothing intoxicating, nothing addictive,  not even trace amounts of it. I wanted to   be sure of that. Just clean lab tested  formulas focused on better sleep. So,  

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if sleep has been harder for you to come  by, I encourage you to take a look at   what they offer. And they want to give my  listeners 30% off of your full order. I'm  

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Use the code Natalie30 for that discount or you  can get the link in the show notes here of the  

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podcast. Again, blue sky-cbd.com code Natalie30  or grab the link in the show notes. Don't forget  

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to use the code for that discount. Please let me  know how your sleep improves. I love hearing your  

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success stories. Today's episode all about sleep  and sometimes there are underlying issues that  

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we don't know exist. My hope is that you will  come away feeling a little less alone and more   curious and ready to move on to a better night of  sleep. If you find these conversations helpful,  

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I'd love for you to subscribe to my newsletter.  It is weekly. You will get more honest insights,  

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real stories, and resources that I am personally  using and loving. You can find everything at  

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natalietisl.com. Let's get started today  with my guest, Dr. Shireen Lim. Dr. Lim,  

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thank you for your time today. Yeah, thanks  very much for having me. It's a pleasure. So,  

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sleep issues are so often the problem of  um our health, our weight, our hormones,  

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all of those types of issues, but we don't  often recognize that it's sleep issues. Yeah,  

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that's right. Or a very overlooked area  is how well are we breathing during sleep?  

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Because how well we are breathing will affect  our sleep quality and how restored we feel.  

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Let's get a little bit deeper into all of this and  tell me how this became a focus of your dentistry.  

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Yeah. Uh about 14 years ago, my husband's snoring  was driving me pretty crazy. So, it got me out of  

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bed and I started researching all about dental  sleep appliances. You can get these appliances  

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that are worn overnight that reposition the lower  jaw forward and it helps open up the airway and it  

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can help alleviate snoring and also obstructive  sleep apnoa. and I decided I was going to become  

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one of Australia's first dentists to qualify in  this area so that I could help myself and other  

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spouses in that same frustrating situation. Why  is this when you talk about this device? Why is  

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this not more common? Is it just because we're in  America and you figured that out? Because I hear   of mouth taping and you know the CPAT machines are  the big thing that so many people end up having to  

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get. But what is what is this device and is it  something commonly available? Yeah, so it's an  

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upper and lower piece. um that is worn inside the  mouth like it's supported by the teeth and then  

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it can actually put the jaw in a forward position.  So as the jaw comes forward what it does it brings  

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the tongue forward because the base of the tongue  is a common site of airway obstruction and it also  

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stretches open the walls of the throat. So what  this does it helps keep the airway open. So yes,  

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it's very well recognized but maybe not as  you know in the research for example the um  

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American Academy of Sleep Medicine or Dental Sleep  Medicine they recognize this is a frontline option  

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um for obstructive sleep apnnea and snoring. And  what is what is that device called? Can you can  

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you just search for it and buy it and something  would you recommend it as something people try or  

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do they need to have a diagnosis and uh have this  recommended for them? Yeah. So medical legally  

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here, you need to have a sleep study before you  get one of these appliances made. Um it's better  

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to have a custom fitted appliance. So if you can  get one that is properly formed for your teeth,   it's going to be the best fit and the most  comfortable and therefore it will tend to be  

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more effective. But you can also get them over  the counter. Um they tend to be more bulky. And  

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so if you use one of those ones that are over-  the counter and it doesn't really work well,   it doesn't necessarily mean that you have  to rule this out as an option. But yeah,  

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in sleep medicine, CPAP is regarded as the gold  standard. Uh but yet many people cannot tolerate  

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it or they won't wear it all throughout the  night. So this has become a frontline option to be  

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able to manage that problem. What is that device  called? A mandibular advancement device. Yeah. Oh,  

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mandibular advancement splint. Yeah. Okay. Okay.  So, let's talk about what happens. Yeah. So,  

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what what's happening in the mouth? You mentioned  the position of the tongue and is that is that  

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you're saying is the most common thing that  causes snoring. Yeah. Snoring is the um sound  

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of vibration of air as it passes through an airway  narrowing. And it can really happen anywhere. It  

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can happen from the nose um down the back of the  throat as well. And so there there is actually  

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uh it's multiffactorial. It's really related  to the size of the airway um which is formed  

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by uh the outer borders of the the outer borders  of the airway sorry are formed by our jaws. uh  

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so our top jaw it forms the floor of the nose uh  and the space for our tongue and it's also forms  

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the rigid support for our collapsible upper airway  or our throat. Um so the problem can really arise  

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in any of those areas um you know from the nose  down the back um and the jaws have a significant  

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contribution as well as anything inside the  airway. Um, for instance, if there's, you know,  

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in children, it could be addenoids on tonsils  or deviated septums or any of the things that  

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an ENT surgeon would look inside the airway or  it can also be dictated by the um the function of  

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the muscles as well. Um, so how well is our tongue  working? How strong is it? Is it sitting correctly  

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in the roof of our mouth? Um, are we breathing  through our nose? Are we using our nose to breathe  

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or our mouth to breathe? because uh if we use our  mouth, we're going to have a more floppy airway.  

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Everything is going to be more relaxed, all our  muscles uh and our tongue is more likely to be  

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sitting low as well. So, it's actually quite  a multiffactorial problem. Um and even the  

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jaw devices that we use, it really addresses the  tongue and the throat. But at the end of the day,  

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what we don't recognize in health care is that  nasal breathing is the key to optimal health and  

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optimal sleep. And really, these problems with  obstructive sleep apnoa, they're developmental.  

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They start from infancy. And they're determined by  how the jaw structures are growing as well as how  

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are our muscles working and how we're breathing.  Are we breathing through our nose? Because  

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problems really begin once mouth breathing begins.  So, we hear a lot lately about mouth taping to  

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force your mouth closed. Do you think that works  in some ways as a band-aid for adults? Um, yeah,  

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there people are using these porous um tapes to  seal their lips together. And for some people,  

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yes, it will actually help them feel better in the  morning. They their sleep feels more restorative.  

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Um, so for some people it will help, but really  the more ideal situation is if we can promote  

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closed mouth nasal breathing from infancy. And so  I know that's something you're passionate about.  

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Is that something that if you promote that from  infancy and a child learns to breathe that way,  

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does it prevent snoring and issues in older or  midlife people? Yes. Uh, yes. The key would be  

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to promote nasal breathing uh from early on. Um  because if you try to snore with your mouth open  

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and with your mouth closed, it's much easier to do  so with once you start opening your mouth. Yeah.  

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And so yes, we want to establish this early on  in childhood because you know, mouth brea nasal  

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breathing, it's really the way that we're designed  to breathe. Uh the nose is especially designed to   warm, filter, and humidify the air. uh and then  as we breathe through our nose we will get nitric  

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oxide from our paranasal sinuses uh which is a  antimicrobial and it's also a vasoddilator so it  

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promotes optimal oxygen exchange but the reason  why we want to pay particular attention to this  

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in childhood is because form follows function  and so the what our muscles of our mouth and  

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our face do during rest are those light persistent  muscular forces they really influence the way our  

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jaw structures are growing. So we know that for  instance if a child has their mouth open or their  

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lips apart uh what's actually happening is their  muscles are more relaxed and their lower jaw is  

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swinging uh down and backwards and that promotes  down and backwards growth and development of the  

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face and that more recessed jaw compared to  if we have our mouth closed. It actually helps  

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stimulate proper expansion of the pallet as well  as forward development of the face. And so why is  

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that important? Because those jaw structures and  the way that our face grows, that's really our  

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container or our outer borders of our airway.  And so we want to promote good nasal breathing  

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so that we can actually have good jaw and facial  development in those first six years of life. And  

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that sets up our optimal uh airway and breathing.  And so if we have closed mouth with our tongue up  

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um that tongue up is the most stable position  for our breathing as well during sleep when  

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everything is floppy, more collapsible. We're  lying on our backs. We want that tongue up with  

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our closed mouth nasal breathing to provide  optimal uh and more restful sleep. I never  

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would have considered the um the infancy and  the childhood and the development leading to  

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better sleep throughout your life. We just think  it's something we have to deal with in midlife.   But the the funny thing about snoring to me is  that half the problem is our own and half the  

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problem is our spouse because if they're snoring,  you're not sleeping and then you don't know you  

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half the time you don't even know if you're  snoring. That's right. Right. and unless it   wakes you up because it's so loud. But if you  have a spouse that has a problem, what would  

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you suggest in um in helping them? Is a sleep  study the first thing that someone should do?

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Yeah. So yes, I think uh for an adult which is  quite different from children who are largely  

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wet with a sleep study can be more useful to get  an idea of how well we are breathing and sleeping  

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because for example obstructive sleep apnoa it's  estimated that 85% of the population that have it  

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have not had a diagnosis. Um and yet it's linked  to increased risk of virtually every chronic  

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inflammatory disease. uh and it really affects  people's mental uh and physical health and their  

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energy levels as well. Uh so yes that can actually  provide some insights as to the degree of uh  

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breathing but in healthcare uh you know there's a  lot of focus on endstage problems and obstructive  

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sleep apnnea really is an endstage problem.  To get a diagnosis you have to stop breathing  

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uh for 10 seconds or more uh five times per hour.  So an average of five times an hour to meet the  

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threshold for a diagnosis of obstructive sleep  apnnea. And so you could go there and there's  

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a lot of information when you get a sleep study.  You get all these sensors and leads and it gets   all this information but quite often it comes down  to a final report with all these numbers. Um and  

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unless the sleep physician is really studying and  examining all that raw data, they may actually  

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miss out uh more subtle breathing disturbances  that are occurring. So for instance, premenopausal  

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women, they may be more protected uh from these  more severe disturbances like sleep apnoa because  

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of their hormones and progesterone. It's an upper  airway dilator. I mean it helps with the dilation  

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of our muscles. So it's quite protective of  sleep apnnea and so women may not necessarily  

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reach the arbitrary limits but they may still  be having interruptions in sleep. They may be  

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more responsive anytime the air flow is getting  restricted. There's a stress response and it may  

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be accompanied by grinding. So there's an arousal  from sleep. Grinding it opens up the airway. It  

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can protect us against sleep apnoa. Um so we  never entered that more prolonged collapse that is  

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defined um that defines sleep apnnea but it's just  more broken sleep. So it doesn't allow us to enter  

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the um deeper phases of sleep and it can also lead  to similar symptoms. So that unrefreshed sleep  

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uh women may present more with fatigue rather than  sleepiness. They may not necessarily have snoring.  

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just fatigue and feeling, you know, unrefreshed.  And a lot of it gets put down to busy lifestyles,  

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being parents or moms, uh, hormones. And it may  play out with things like anxiety, depression,  

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uh where females may be more likely to get  medicated for those or even functional sematic  

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syndromes where we have things like IBS or chronic  my u fatigue myalgas and the TMD the jaw joint  

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dysfunction all those type of uh problems where  there's low stimulus but more significant pain and  

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dysfunction um related to increased sympathetic  nervous system or fight orflight response because  

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that breathing has become a chronic stressor night  after night. Well, that's uh what I was going to  

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ask you next and you hit on a few of these  things is what are some of the indicators in   your life that you might not be sleeping as well  as you think? You mentioned anxiety, depression,  

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maybe even weight gain. Um but it's so often  dismissed. You think I go to bed at the same time,  

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I get up at the same time. Why would it be my  sleep? But that broken sleep, what are some of the   other things that you see especially in women that  could be because of poor sleep? Yeah. So the teeth  

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grinding, the morning headaches, um the nocturia,  which is getting up to go to the toilet, why  

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are we getting up? Uh you know those unexplained  awakenings. Yeah. Feeling unrefreshed. Um tossing,  

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turning, even insomnia. uh difficulties getting  to sleep. Um because sometimes sleep is not  

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particularly refreshing or peaceful. Uh so that  can lead to difficulties getting to sleep on an  

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you know unconscious level. Uh and then people  may be taking supplements or sleeping aids  

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um when we haven't really looked at is there a  breeding condition. Yeah. So, talk to me about  

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um dentists diagnosing this issue because I know  that's not as common and I I love it that you do  

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that that you focus on that. Um but I'm I'm  wondering because for most people they don't  

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know where to start. Maybe their their u general  care doctor um but it might be overlooked by even  

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um some of those people. So is that something  that people can seek out or ask their dentist  

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if they can help them with or it is I know  you have specialized training in it but how   common is that? Yeah. Uh well the dentist is  really in a frontline position to be able to  

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identify many of the risk factors. So in  2017 the American Dental Association they  

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uh published a policy statement which says  that dentists have a frontline role in  

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identifying these problems in our children and in  adult patients. Um so risk factors that an adult  

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um that a dentist may identify in an adult uh is  the jaw structures. um we want to look if there  

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is underdeveloped jaw structures um you know that  is a risk factor for poor breathing as I mentioned  

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it's a poor nasal passage poor tongue space  poor support for this throat and so what we can  

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identify is a high arch pallet for instance  if we have a narrow pallet that is a narrow   nasal passage reduced tongue space um if we have  receded jaws uh that is also going to lead to a  

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more pinched airway where there's less space for  all our airway structures. Um so any orthodontic  

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problems that we see where there's crooked  teeth or the the jaws aren't fitting in correct   um position that is really an underdevelopment  of our jaws or an underdevelopment of our  

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airways which leads to a reduced air flow and  increased collapsability of our airway. So the  

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jaw structures are a big thing. But then  we can also look at the tongue. You know,  

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uh one of the things that we might see is tongue  scalloping. So some people will have indents  

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uh on the sides of their tongue. Uh which is a  good sign that the tongue is not sitting correctly   in the roof of the mouth. It's sort of sitting  in between the teeth. Low tongue and posture. Uh  

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so if we have this um that has been shown to be  linked to um well it's predictive of obstructive  

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sleep apnoa. So that's what the research tells  us. If we see that, we can probably tell that   a person is not getting good sleep. We can have  a look at the back of their throat and how open  

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does it look or if there's any blocked tonsils. If  there's any signs of teeth grinding for instance,  

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um that will actually uh indicate that they may  be that protective response that I was talking  

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about. Um yeah so tongue tie if the tongue is  restricted uh we have inability to lift correctly  

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and that tongue is sitting low inside our mouth  that's going to be more linked to um obstructive  

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breathing during sleep. So there's many signals  inside the mouth. Um and in terms of what role do  

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we as dentists have to play, we were talking about  those mandibular advancement devices that bring  

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the jaw forward. But you know becoming involved in  that I can see yes when we address that and manage  

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um that with this nighttime solution to position  the jaw forward uh yet uh a lot of people their  

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sleep quality will improve. And I've had women  tell me, you know, they don't have this brain   fog. Mentally, they feel clearer and they're  able to function better. Um, but I actually am,  

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even though I have these qualifications, I'm  no longer involved in that aspect of treatment  

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because it really is a band-aid solution. We are  managing poor jaw structure to get that lower jaw  

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forward. we can actually intervene or develop  the jaw structures early on in life if we pay  

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attention doing early interceptive orthodontics uh  or if we actually promote better oral function. If  

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we can actually get the muscles working better  promoting nasal breathing, good tongue posture,   good tongue tone. If we get that very early on  in life, it will promote those jaw structures  

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to grow. uh and then we can actually uh promote  airway health which is 247 good breathing not just  

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something that we wear uh at nighttime only. So  dentists really can help to promote that through  

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early interceptive orthodontics recognizing that  if we have crooked teeth we don't need to wait  

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until a child is 12 years old to have braces and  straighten them sometimes taking teeth out. we can  

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actually develop those jaws properly. And if we  miss that boat, one of the big things that we're  

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seeing the big shifts that's occurring in sleep  medicine is pallet expansion for adults. Um when  

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we for adults say my kids have done that, but  yeah. Yeah. So, you know, it was thought that  

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it wasn't possible to expand or widen the jaws in  non-rowing people like in adults because we have a  

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mid pallet suture um and where the two halves of  the pallet join and it fuses around age nine. Um  

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so in very young children uh we can actually  separate the two halves of the pallet with a  

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orthodontic appliance. We it's attached to the  teeth and there's a screw. Do you remember that?  

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I do. I remember doing that every night. Yeah.  And what that does, it separates the two halves  

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of the pallet, stimulating new bone to form in the  mid pallet or the floor of the nose. And what that  

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does uh you know that it alleviates um obstructive  sleep apnnea. Um if if there is a narrow palette,  

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it's one part of the uh solution and it also can  reduce snoring as well. And so because it's so  

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effective in children, people worked out how to  do this in adults um without doing invasive jaw  

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surgery to sort of separate the two halves of  the pallet. You can actually use mini screws or  

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temporary anchorage devices. Uh what they are done  is right up close to the mid pallet in the roof of  

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the mouth, you put these little mini screws.  um they're drilled into the bone temporarily  

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and so then it it can uh be used to attach an  orthodontic um appliance or the screw mechanism.  

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So that screw mechanism rather than sitting on  the teeth, it's really sitting high up in the  

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bone near that suture and then when you turn the  screw, it actually can more predictably separate  

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the two halves. How long does that generally  take to to happen? Uh yeah. Yes. So it's a lot  

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of people are getting that immediate sort of  improvements in their nasal breathing within   the first month. And so this is what I love to see  in sleep medicine because we are really addressing  

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or getting to the root of the problem for adults  offering them a solution that really targets that  

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narrow pallet. Um and it helps promote good tongue  space and nasal breathing 24/7. So it's not just  

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something that they can wear at night to minimize  uh the breathing disturbance at night time. It's  

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something that can help them all throughout the  day because what we find is when we can get better   tongue space um a lot of people can actually  function better even with their eating, their  

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chewing, their swallowing um and even just having  room for their tongue to function during speech.  

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um you know there's a lot of benefit functionally  to have this addressed and even with that lower  

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jaw repositioning device uh we can actually  promote more airway health or 24/7 looking  

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at jaw surgeries that bring the jaws forward.  So there's a whole spectrum of options that as  

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dental professionals, if we're working together as  orthodontists, maxillo facial surgeons, you know,  

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combining with our ENT colleagues, we can actually  have more options for people so that they're not  

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relying on these nighttime crutches like CPAP  and the dental devices that bring the lower jaw   forward. The band-aids that that are so common,  but what we're going for is just better sleep.  

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That's where for me I started seeing um just  interrupted sleep. So I would be in bed for  

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eight hours but only get six. I wear um an Aura  ring so I can see um that I'm waking up five, six,  

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seven times a night and my deep sleep is is 30  to 40 minutes a night which I know is not enough.  

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And I think for people who who aren't necessarily  tracking it like I am, they just don't know that  

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maybe that's what's causing so many other issues  in their in their health. Definitely. I think we  

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all are so busy and you know not getting the best  sleep hygiene a lot of the time. Um so we don't  

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always recognize that there could be an underlying  issue. Yeah. Okay. So um for someone listening  

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thinking that's me, that's my husband, that's  my friend, where would you tell them to start?

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Yeah. Uh so for adults you know um I guess that's  one of the reasons why I actually decided to see  

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more children because sometimes as a dentist  that I know how to identify these risk factors.  

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Uh but yet I only had a narrow option these dental  devices uh where if you go to a sleep physician,  

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they're going to prescribe CPAP uh a lot of the  time, you know. Uh so you go to a dentist that's  

28:11

trained in these appliances, they're going to  offer these appliances. uh and it's very hard to  

28:20

get someone that can recognize the full spectrum  of options to be able to offer the most targeted  

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uh intervention. But if I was to say who  would I go to, I would probably choose  

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um this is my opinion only like a someone that  looks at adult expansion. If any if someone can  

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do adult expansion uh to widen the upper jaw um  with the mini screws, the mini implants or mappy  

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if anyone wants to look it up, m a r p e. One of  those dentist or orthodontist that offers that is  

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probably going to have more backgrounds in sleep.  Um, and you can look for dentists that have uh got  

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credentiing with the American Academy of Dental  Sleep Medicine. Um, but anyone with that type of  

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um background that offers that solution probably  also understands the various other options in  

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terms of surgery and the CPAP and you know those  type of things that they're managing around um  

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limitations. Yeah. Well, I I would I would suggest  I'm all about the knowledge and so if you're not  

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feeling well for anyone listening, you're tired or  your hormones are waiting gaining weight or you're   having issues you just can't get to the root of to  find out if sleep is the problem. And there are so  

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many ways you can do that from trackable devices  to sleep studies and do that first and then find  

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someone like you're suggesting um who can help.  But don't just suffer through it. That's that  

30:01

to me um that's where I really advise people is to  find an answer or keep asking the questions. Yeah,  

30:09

I I would say especially for women uh really  recognizing that obstructive sleep apnnea is that  

30:16

severe endstage problem and there are many other  subtle abnormalities that can occur as well. So  

30:24

if you don't have a diagnosis of obstructive sleep  apnea with your sleep um study uh really exploring  

30:34

just understanding that the key to optimal  breathing is nasal breathing. Yeah. So we want to  

30:39

have closed mouth nasal breathing. And as much as  an ENT surgeon can look inside our nose and throat  

30:44

and clear out anything inside it, we also want to  make sure that the outer borders of the the airway  

30:51

uh our jaw structures are really welldeveloped  if we want to have that option to have uh optimal  

30:58

health. There are new options um to make sure that  people can have personalized solutions that really  

31:05

address the root of the matter. Yes. Well, thank  you so much for the information, for educating  

31:11

us. I learned so much today and um I just  appreciate your time. Thanks so much, Natalie.