Sleep Apnea From a Dentist’s Perspective

Dentists play a very important role in the team approach to the treatment of obstructive sleep apnea. Physicians, dentists, psychologists, and respiratory therapists all combine their collective knowledge to treat each patient properly and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of immense help to physicians in treating sufferers with sleep disordered breathing problems.

Snoring

Nearly one-half of all adults snore. The problem is exaggerated with overweight persons.
Snoring occurs when there is a partial obstruction to the free flow of air through the mouth and nose. The sound occurs when loose structures in the throat, like the uvula and soft palate, vibrate as air passes over them. Snoring can get worse when the muscles in the back of the throat are too relaxed either from drugs taken to help induce sleep or alcohol intake. Snoring can also be caused by an overly large uvula and soft palate, nasal congestion, a deviated septum or other obstructions in the nasal and pharyngeal airways. In children, large tonsils and adenoids can be the cause of snoring. Pregnant women often snore because of a narrowing of the airway and increased weight due to the pregnancy.

Is Snoring Serious?

Yes, snoring can be serious both socially and medically. Snoring can bring great disharmony to marriages and cause sleepless nights for our bed partners.

Medically, snoring can be the forerunner of obstructive sleep apnea that has been associated with heart failure, high blood pressure and stroke. On its own, snoring has been connected to Type II Diabetes. Sleep apnea typically interrupts loud snoring with an episode of silence in which no air passes into the lungs. Eventually the lack of oxygen and the increase of carbon dioxide will awaken you forcing the airway to open, usually with a loud gasp.

Sleep Apnea

Obstructive sleep apnea (OSA) is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. In central sleep apnea, the airway is not actually blocked; however the brain fails to signal the muscles to breathe. Mixed apnea, as the name implies, is a combination of the other two. With each apnea event, the brain briefly arouses the person with sleep apnea in order for them to resume breathing, but accordingly sleep is extremely fragmented and of very poor quality.

Sleep apnea is very common, and it is estimated to affect more than twelve million Americans, according to the National Institute of Health. Some risk factors include being male, overweight, and over the age of forty, and having a short neck, however sleep apnea can strike anyone at any age, even children. Several treatment options exist, and research into additional options continues. The link to dental issues has proven to be significant, and we will be looking further into those treatment areas in this and future articles.

The person suffering with sleep apnea may be unaware of these events, even though they may happen as many as hundreds of times a night, however if snoring is involved, their family is almost certainly aware of the problem!. Unaware or not, these airless episodes last 10 to 30 seconds and may cause the patient lots of trouble, especially in the daytime, having been robbed of a restful nights sleep.

Some Symptoms of Obstructive Sleep Apnea (OSA)

• Severe snoring. Most people with obstructive apnea are likely to snore between episodes. Of course, not everyone who snores has OSA, but severe snoring combined with one or more of the following symptoms is a good suggestion that that person should see their physician and request a sleep study.
• Dry, sore throat and nasal passages in the morning upon awakening. A look in the mirror may expose a swollen and red uvula.
• Sore jaws, headaches, neck aches and ear aches when arising in the morning. These are symptoms of TemperoMandibular Dysfunction which is mentioned in our articles covered on TMJ disorder, also.
• Multiple sudden awakenings during sleep. When a person ceases to breathe during sleep, they may wake up, often with a gasp, several times during the night. This may happen literally hundreds of times a night, or perhaps just a few dozen. Not everyone with severe OSA experiences sudden awakenings since many sufferers are simply brought to a lighter level of sleep in which they regain the muscle tone in their throat so that breathing may begin properly again.
• Excessive daytime sleepiness. (hypersomnia) Even if a person with sleep apnea does not completely awaken many times a night, he or she must continuously rise to a lighter level of sleep in order to regain enough control of the throat muscles to relieve the obstruction. This severely reduces the quality of the sleep. Patients with OSA often complain of waking up feeling like they had never slept at all. They often feel worse after taking a nap than they did before napping.
• Sleepiness leads to traffic accidents. Long distance drivers, such as truck drivers, must be especially cautious, and seek treatment if they suspect they may suffer from OSA.
• Restless muscles during sleep. A lack of oxygen in the blood causes muscles to become restless. Persons who suffer with sleep apnea often find their legs in nearly continuous motion during the night, or they may notice themselves kicking during the night.
• Impotence, and/or decreased interest in sex. Sleep apnea has wide ranging physiological and psychological effects, including high blood pressure, slowed heart rate, changes in appetite and diminished sexual arousal.
• Morning headache
• Difficulty staying asleep (insomnia)
• Impaired memory
• Irritability
• Personality changes
• Depression
• Impaired concentration
• Poor job performance
• Sudden death from heart attack or stroke.

Diagnosis of Obstructive Sleep Apnea

Since OSA is potentially a very serious medical condition, it should be diagnosed by a physician. Diagnosis is usually based on the results of an overnight sleep study, called a Polysomnogram (PSG). Other factors of determining OSA are patient evaluation and history.

Treatment Options

Practice good sleep hygiene, meaning no television in the bedroom, no working on the computer the last hour before bed, no alcohol at bedtime, et. Weight loss if necessary and sensible exercises are some helpful OSA treatments a sufferer can practice on their own. However, medical and dental treatments include Continuous Positive Airway Pressure, Oral Appliance Therapy, and surgery.

Continuous Positive Airway Pressure (CPAP)

The Continuous Positive Airway Pressure (CPAP) is pressurized air generated from a bedside machine. The air is delivered through a tube, connected to a mask, which covers the nose. The force of the pressurized air splints the airway open. The CPAP, pronounced C-Pap, opens the airway like blowing air into a balloon; when air is blown into the balloon, it opens and gets wider. This is how the CPAP clears the airway.

Oral Appliance Therapy

Oral appliances are worn in the mouth to treat snoring and OSA. These devices are comparable to orthodontic retainers or sports mouth guards. Oral Appliance Therapy involves the choice, design, shaping and use of a custom designed oral appliance that is worn during sleep. This appliance then attempts to maintain an opened, unobstructed airway in the throat. There are several different oral appliances available. Approximately 40 appliances have been approved through the FDA for treatment of snoring and/or sleep apnea. Oral appliances can be used alone or in combination with other ways of treating OSA. These means include general health, weight management, surgery, or a CPAP unit. Oral appliances work in several ways:

• Repositioning the lower jaw, tongue, soft palate and uvula
• Stabilizing the lower jaw and tongue
• Increasing the muscle tone of the tongue

Dentists with specialized training in Oral Appliance Therapy are familiar with the numerous designs of appliances available. They can decide which one is best suited for your specific needs. The dentist will work with your physician as part of the medical team in your diagnosis, treatment plan, and on-going care. Determination of appropriate therapy can be best made by joint consultation of your dentist and physician. Initiation of oral appliance therapy can take from several weeks to several months to complete. Your dentist will continue to monitor your treatment and evaluate the response of your teeth and jaws.

Surgical Procedures

In addition to Oral Appliance Therapy, dentists who are oral and maxillofacial surgeons may consider a mixture of methods to evaluate, diagnose and care for your upper airway obstruction. These dental specialists treat upper airway obstructive disorders by utilizing both minimally invasive procedures as well as more complex surgery, including jaw advancement. Additionally, an ENT specialist may evaluate you for other types of surgery, primarily the removal of the excess tissues in the throat. It may be required to remove tonsils and adenoids (especially in children), the uvula, or even parts of the soft palate and the throat.

Who treats OSA?

While a dentist may be the first practitioner to identify patients who have sleep apnea, they seldom treat these patients without medical guidance. Pulmonologists and sleep specialists are qualified to certify and treat the disorder; however dentists are becoming more and more accepted by the medical profession as qualified OSA treatment providers.

The CPAP

The most frequently prescribed medical treatment for OSA is the “Continuous positive airway pressure” unit, or CPAP (pronounced “C-Pap”) and a newer variation called BiPap. These apparatuses have a high flow fan, a hose and a sealed nasal mask to which the patient is attached to while sleeping. Clinical studies have shown that CPAP is highly effective in relieving most apnic episodes. In addition to the CPAP unit, physicians usually prescribe a weight loss regimen, and abstinence from tobacco and alcohol. Unfortunately, patient compliance is generally a problem due to the noise of the air compressor, the constriction of movement caused by the hose attachment, stuffy nose and skin irritation caused by the nose-piece, and complaints of being able to have less intimacy with a bed partner.

Due to these and many other complaints from users of the CPAP units, OSA research teams carried out extensive trials on mandibular advancement appliances (airway dilators, or “snore guards”). These projects and trials resulted in a 1995 review by the American Sleep Disorders Association. The review determined that oral appliances are a good alternative to CPAP in cases of mild to moderate obstructive sleep apnea.

The dental treatments for obstructive sleep apnea are superior to the CPAP unit from the point of view of patient compliance. Dentally oriented treatments for this problem fall into two groups; detachable appliances that advance the lower jaw while the patient is asleep, (airway dilators, more commonly known as snore guards) and surgical solutions, some of which advance the lower jaw permanently.

If an actual case of obstructive sleep apnea is assumed, the dentist normally uses his skills in conjunction with the help of a qualified physician specialist who can assess the need for, and ultimately the success or failure of the treatment. This makes sense since it is the physician who can order and construe the medical tests involved in the institution of the foundational diagnosis.

Detachable OSA Appliances (Snore guards)

Anything that advances the lower jaw forward (bringing it into protrusion) will cause to lift the tongue and epiglottis away from the back of the throat relieving some of the limitation caused by the relaxation of the muscles during sleep. In order to wear such an appliance, it is crucial that the patient have adequate numbers of healthy teeth in both upper and lower arches for the appliance to attach to. If the patient lacks healthy teeth, dental implants may still make it possible to wear a detachable snore guard.

Note that detachable snore guards separate the upper and lower teeth and therefore perform the functions of a bruxing guard in addition to those of the snore guard. Consequently, a snore guard may not only treat snoring and obstructive sleep apnea, but it may well treat the symptoms of TMJ disorder as well. However, in very severe cases of organic joint dysfunction due to TMJ, the forward repositioning of the lower jaw may aggravate the damage to the jaw joint and thus a snore guard may not be appropriate for those sufferers.

To create a detachable snore guard, an impression will be taken of both the top and bottom teeth, and models are poured in plaster. Then the patient may be instructed to bite into a slab of wax with his lower jaw protruded as much as possible without actually straining. This is called a protrusive bite registration. Both the models and the protrusive bite registration are then sent to the lab. The laboratory returns the finished appliance, which can take a number of different forms depending on what your dentist orders.

Different Types of Snore Guards

There do exist different types and brands of snore guards, and many orthodontic laboratories have their own brand of appliance that they use. You, together with your dentist, must decide on the correct type of snore guard for you, based on specific needs. Some snore guards are very effective at relieving the obstructions causing OSA, but they are limited by the ability of the TMJ to move forward. As a general rule, the maximum advancement of the lower jaw that can comfortably be achieved with a fixed-jaw-relation snore guard is in the range of 3 to 5 millimeters. This is normally enough to relieve the airway, and will work quite well for most people. The drawback to a fixed relation guard is that the appliance cannot be adjusted to bring the lower jaw further forward as the joints (TMJ) relax over time. Adjustability is very desirable since obstructive apnea is a progressive disease and further jaw protrusion often becomes possible as the joint ligaments stretch further.

Oral appliances (OA) that treat snoring, UARS, and OSA are devices worn in the mouth similar to sports mouth guards or orthodontic retainers. They are made of plastic and fit partially or completely within the mouth. Currently there are over 40 different types of oral appliances available. OA’s may be used alone or in combination with other means of treating sleep apnea, such as weight management, surgery and CPAP. There is no one particular appliance that will work for every patient. Any dentist supplying oral appliances will be familiar with several different types.

Categories of Appliances

There are currently two categories of appliances in general use.

1. MRD – Mandibular Repositioning Device

• A more commonly prescribed appliance.
• It repositions and stabilizes the lower jaw, tongue, soft palate, and uvula.
• It also helps to increase the muscle tone of the tongue.

2. TRD – Tongue Retaining Device

• This device advances the tongue and actively holds the tongue forward to open the airway, thus preventing it from falling backward and blocking the airway.
• These devices are most useful in patients with large tongues, poor dental health, no teeth, and chronic joint pain.

Indications for Use of an OA:

• Primary snoring
• Mild OSA
• Moderate / Severe OSA sufferers who are intolerant or refuse the CPAP unit ( as set forth by the American Sleep Disorders Association)
• Poor tolerance of nasal CPAP
• Poor surgical risks
• Non-successful UPPP surgery
• Use of appliance during travel

Advantages of using an Oral Appliance:

• Oral appliances are much small and convenient making them easy to carry when traveling
• Treatment with oral appliances is reversible and non-invasive
• After becoming acclimated to wearing the appliance, most people find them easy to wear and more comfortable than the CPAP unit.

• Quiet
• Easily adjustable
• More comfortable than the CPAP unit, generally resulting in increased compliance

Are There any Side Effects From Using Oral Appliance Therapy?
Patients using oral appliance therapy may experience the following side effects:

• Excessive salivation or dryness.
• Morning soreness in the teeth or jaw muscles.
• Tooth movements (generally minor)

Most of these side effects improve within just a few weeks of regular use and some adjustments of the appliance. Patients with arthritis and chronic jaw joint dysfunction may experience more difficulty tolerating an OAT.