SNORING and SLEEP APNEA

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During normal breathing, air passes quietly through the nose and past all the soft tissue structures of your throat, such as the tongue, uvula, and soft palate. Normally, the airway is kept open so that air can pass silently when you breathe.

WHAT IS SNORING?

Snoring is the sound created during sleep when there is some type of obstruction to regular breathing. It occurs when the muscles in the throat relax during sleeping and this causes the airway to narrow. When the airway is narrowed, there is a partial obstruction to the airflow. As air tries to pass through this narrowed air passage, the throat structure vibrate. This causes the sound we know as snoring. If there are large anatomic features present, such as large tonsils, a large tongue and/or a long uvula present, these will exacerbate the snoring problem. Another thing which will worsen the snoring is excess fat deposited in the tissues of the neck. These fat deposits usually develop as we age.

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Snoring can disrupt marriages and cause sleepless nights for bed partners. It has also been linked to hypertension. However, it can be a sign that a more serious medical problem, obstructive sleep apnea is developing.

OBSTRUCTIVE SLEEP APNEA
If a person has developed obstructive sleep apnea, then the tongue is sucked against the back of the throat whenever the person breathes in or out. The air cannot flow into or out of the person’s nose or mouth although efforts to breathe continue. There is a complete stoppage of breathing. When the oxygen level in the brain becomes too low, the person partially wakes up, just enough to clear the obstruction in the throat. The person starts to breathe again, usually with a gasping or choking sound. This choking or abrupt waking up cycle goes on much of the night. People with untreated sleep apnea are generally not aware of the awakenings that have happened the previous night. The person never gets a good night’s sleep and wakes up tired and unrefreshed.

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Unfortunately, many people with obstructive sleep apnea never get properly diagnosed and treated.  This is a potentially life threatening condition that also affects the quality of one’s life.

Sleep apnea symptoms include:

• daytime sleepiness

• daytime fatigue

•  strokes

• heart attacks

• morning headaches

• high blood pressure

• fatigue related motor vehicle and work accidents

• decreased sex drive

• poor concentration

• poor memory

• poor learning ability

• depression and anxiety

• increased nighttime urination

• irritability

• gastric reflux

• choking or gasping for breath during sleep

Risk Factors of Obstructed Sleep Apnea and Snoring

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• Increasing age

• Increasing weight

• Male gender

• Disproportionate upper airway anatomy
    i.e. large tongue, large uvula, large tonsils

• Neck size..more than 17inches in men, and 16 inches in women

• Smoking

• Alcohol and sedative use

• Recessed chin

What Causes  Obstructive  Sleep Apnea?

People who are overweight tend to develop Obstructive Sleep Apnea more than other people. Also, a person who has a physical abnormality in their nose, throat or upper airway is more prone to develop it. The use of alcohol at night or sleeping pills also increases the frequency and duration of the sleeping pauses.

When Should Sleep Apnea Be Suspected?

Spouse many times are the first people to suspect there is a problem. They witness the chokings and the struggles to breathe of their partners. Coworkers may notice that the individual is sleepy all the time at work and/or has trouble concentrating or remembering to do things. People might notice the person falling asleep at inappropriate times such as while watching TV or talking. The person may not believe they have a problem, but should be told that they need to be evaluated by a health professional.

How Is Obstructive Sleep Apnea Diagnosed?

Diagnosis of sleep apnea is not simple because there are many reasons for a person’s disturbed sleep. A thorough sleep history and physical exam is the first step to diagnosing a sleep disorder. If it is determined that you need a more detailed assessment, one test that your health professional might refer you for is the polysomnograph test, or PSG.  This is an overnight sleep study that records a variety of bodily functions while the person sleeps. It is usually done in a hospital, although new technology may allow some sleep studies to be performed at home. Functions that are recorded while you sleep are electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, air flow and blood oxygen levels. These recorded values are needed to diagnose sleep apnea and to determine its severity. Physicians that are specially trained in sleep medicine will be involved in making a definitive diagnosis of sleep apnea. Once it is diagnosed, it must not be ignored.

How is Obstructive Sleep Apnea Treated?

Behavioral therapy

     In cases of mild sleep apnea, behavioral changes may be all that is needed to control things. The individual should avoid the use of alcohol, tobacco and sleeping pills. These things tend to cause the airway more likely to collapse during sleep and cause the apneas to increase in frequency and duration. Overweight persons should be encouraged to lose weight, as only a 10% decrease in body weight has been shown to reduce the number of apneic events. For patients who like to sleep on their backs, this should be discouraged because sleeping in this position increases apneic events. There are devices the person can use to reduce the amount of time spent on their back.

Surgical Therapy

Although several surgical procedures are available to increase the size of a persons’ airway, none of them is completely successful or without risks.

Removal of adenoids and tonsils, nasal polyps and other growths can result in a larger airway, especially in children.

Uvulopalatopharyngoplasty (UPPP) is a procedure that removes excess tissues from the back of the throat. Success ranges from 40-50% but the long term benefits of this procedure are not known.

Laser-assisted uvulopalatoplasty (LAUP) is a procedure that uses a laser to eliminate tissue in the throat. It has been shown to help with snoring but not with sleep apnea.

More complex oral surgery can be used to surgically reposition a persons’ jaws in cases where there is a gross deformity, but these cases are very rare.

Appliance Therapy

Nasal continuous positive airway pressure (CPAP) is the most common effective treatment for obstructive sleep apnea. The person wears a mask over the nose during sleep, and the pressure of the air blown in by the connected air blower physically holds open all the structures in the back of the persons’ throat. The air pressure is adjusted so it is just strong enough to do this without being too strong and uncomfortable for the patient. The pressure needed varies according to the patient. While CPAP is a very effective treatment for obstructive sleep apnea, not every patient can get used to the machine and wear it the entire night.

Side effects of CPAP include:

Nasal congestion

Conjunctivitis

Sinus involvement

Skin Irritation

Gastric Distension

Claustrophobia

Constriction of movement by the hose attachment

Compressor noise

Oral appliances are now considered to be the first choice of treatments for mild to moderate obstructive sleep apnea. They are also used for severe apnea where the patient can’t or won’t use CPAP.These appliances are similar to orthodontic retainers or sports mouthguards. They fit over the upper and lower teeth or tongue. They reposition the lower jaw so that when the person sleeps, the airway is kept open and doesn’t collapse. This improves breathing and reduces snoring and apnea. The appliance is fabricated and customized for each patient.

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Advantages of Oral Appliance Therapy

-Oral appliances are comfortable and easy to wear. Most people find it only takes several days to a week to become used to wearing the appliance.

-Oral appliances are small and convenient making them easy to carry when traveling

-Treatment with oral appliances is reversible and non-invasive.

Types of Oral Appliances

The two types of oral appliances are the mandibular advancement devices and the tongue retaining devices.

The mandibular advancement devices are made to fit each patients’ upper and lower jaws. They hold the lower jaw in a slightly forward position. This position holds the tongue and soft tissues of the throat open so that the airway will allow normal unobstructed breathing during sleep. The is a built in mechanism that will allow for fine tuning of the forward position. If it is determined that the patient needs to move his/her lower jaw more forward, than this adjusting mechanism is used. It is important to find just the right jaw position for the patient to have the most comfortable sleep position.

The tongue retaining device is made with a softer material and has a compartment that fits over the end of the patients’ tongue. The tongue is held forward due to suction that is created within this compartment. This device is used primarily with a patient who wears denture or can not tolerate the amount of jaw advancement needed with the other type of appliance. Patients with severe TMJ symptoms might need this type of appliance. With this type of appliance, the patient must be able to breathe adequately through their nose or they may have trouble tolerating this type of appliance.

The type of appliance the patient receives is based upon many factors. Some of these factors include the severity of the apnea condition, patients jaw structure, size of the tongue, whether or not the patients grinds their teeth, range of motion of the jaw, any TMJ pain and health of the teeth and gums.

Adjustable PM Positioner--

Custom made appliance that fits over the upper and lower teeth. Has an adjustment mechanism on the side that can be used to change the amount of jaw advancement.

Has good room for the tongue to fit in.

SUAD--

Custom made appliance that has a metal framework inside to reinforce with extra strength. Good appliance to be used when the patient bruxes or grinds their teeth during the night. Adjustment mechanism is on the side and consists of a piston that slides within a tube. The length of the piston can be changed using small rings that determine the amount of jaw advancement.

EMA--

Another custom made appliance that has both an upper and lower part. The parts are held together by rubber straps, one on each side. The straps come in different lengths and the jaw position is determined by which size strap is used. This appliance allows for good jaw movement.

SOMNOMED--

This is a two part, custom made appliance that allows a large amount of jaw movement. The adjustment screws are on the side and allow for precise movement of the lower jaw.

TAP—

The TAP appliance is a two part appliance where the upper and lower pieces are placed in the mouth independent of each other. They are connected together once inside the patients’ mouth. By turning the screw located in the front, the proper jaw position can be determined.

Tongue Retaining Device

This appliance is used by people with very few or no teeth. The tongue is held in place by the bulb at the end. If the patient has trouble breathing through their nose, this appliance might not be indicated.

Following insertion of any snore appliance, the patient must have a follow up sleep study to determine if the appliance is effective at controlling the obstructive sleep apnea.

Side Effects of Oral Appliance Therapy

• excessive salivary flow

• joint pain

• dry mouth

• muscle pain

• dislodgement of ill fitting crowns and other dental restorations

• loosen teeth

• sore teeth

• temporary change in the bite when the appliance is removed in the morning

• spacing developing between teeth

Some of these side effects will be only temporary. Others will require some minor adjustment of the appliance.

Follow up is required for all patients using oral appliance therapy. After the appliance is fitted, a recall visit in one month is needed. Then the follow up is every six months for two years. Then the follow up is yearly. Appliances will last anywhere from 2-5 years depending upon design and usage.