Sleep apnea is a type of breathing disorder which is a serious, potentially life-threatening condition characterized by brief interruptions of breathing during sleep.
The American Academy of Sleep Medicine stated in the January 2006 issue of the medical journal. Sleep, that oral appliances are the first treatment option for patients with mild to moderate sleep apnea, and continuous positive air pressure (CPAP) the option for the treatment of sever sleep apnea.
It has been estimated that 60% of men and 40% of women between the ages of 40 and 60 years of age snore. Snoring occurs when there is a partial obstruction of the airway which causes the palatal tissues to vibrate. Obstructive sleep apnea occurs when the airway is completely blocked for certain periods of time. As many as 20 million people in North America may have sleep apnea. Snoring is a social problem, particularly for the spouse, but obstructive sleep apnea poses a significant health risk for the patient in that it can lead to irregular heartbeat, high blood pressure, heart attacks and strokes.
Oral appliances are only indicated for use in patients suffering from obstructive sleep apnea (OSA). The signs and symptoms of OSA include snoring, excessive daytime sleepiness, gasping or choking during the night, non-refreshed sleep, fragmented sleep, clouded memory, irritability, personality changes, decreased sex drive, impotence, and morning headaches.Factors that affect obstructive sleep apnea are as follows:
Sedative Hypnotics (sleeping pills)
Children can also snore and suffer from obstructive sleep apnea. Often they are highly allergic and their airway is blocked due to enlarged adenoids, tonsils or swollen nasal mucosa. Clinical signs would indicate a turned up nose, allergic shiners under the eyes, mucous draining out of the nose, mouth breathing, and a nasal sound to the voice. Other signs are bed wetting, irritability, difficulty in concentrating at school and hyperactivity.At the present time, obstructive sleep apnea is defined as a medical problem and the diagnosis must be made by a medical doctor or sleep physician (pulmonologist) who is specially trained in the area of sleep medicine.
The dental profession has an important role to play in the treatment of patients with snoring and sleep apnea. If 60% of men and 40% of women between forty and sixty years of age snore, this is a huge problem. Snoring is a serious social problem for the spouse, but obstructive sleep apnea can be a life threatening situation for the patient in that it can lead to irregular heartbeat, high blood pressure and strokes.
At the present time, obstructive sleep apnea is a medical condition that is being controlled and treated mainly by the medical profession. Despite the fact that in September 1995, the American Sleep Disorder Association finally endorsed oral appliance therapy as the third currently acceptable treatment method for snoring and sleep apnea, the vast majority of the medical doctors are not aware of the value of oral appliances.
As time goes on, the public is going to become more aware of the health risks associated with snoring and sleep apnea. It is the dental professionals responsibility to educate their members, the public and the medical profession about the important role that dentists and oral appliances play in the treatment of snoring and obstructive sleep apnea.
CPAP (Continuous Positive Airway Pressure)
Surgical removal of nasal or oral obstruction
Mild Sleep Apnea. Patient stops breathing 5-15 times per hour.
Moderate Sleep Apnea. Patients stop breating 16-30 times per hour.
Severe Sleep Apnea. Patient stops breating mroe than 30 times per hour.
In 2006 in the January issue of the Medical Journal Sleep, the sleep specialists in the American Academy of Sleep medicine confirmed that:
Oral appliances are the first treatment option for mild to moderate sleep apnea
CPAP was the first treatment option for severe sleep apnea
Oral appliances may be used for patients who cannot tolerate the CPAP device.
The largest number of patients with sleep apnea (obstructive sleep apnea) are in the mild to moderate categories and should be treated with oral appliances.
The CPAP device (Continuous Positive Airway Pressure) is primarily used to treat patients with severe sleep apnea. While the CPAP device is extremely successful in eliminating sleep apnea in patients with severe sleep apnea when the device is worn, unfortunately, the failure rate is high when the patient cannot tolerate the CPAP device. These patients are then candidates for the oral appliances.
Prior to Fabricating the Oral Appliance
Patients must have a valid sleep study at a hospital or private sleep clinic or a home sleep study. This sleep study must be evaluated by a medical sleep specialist who will then send the report to the dentist who can then proceed to make the oral appliance.
At our office we send the patient home to sleep in their own bed with the home sleep study device known as the Embletta 100. The results of their home sleep study are then sent to a sleep specialist who makes the diagnosis. The sleep specialist then sends a letter to Dr. Shodjaee’s office and recommends the oral appliance or the CPAP device depending on the severity of the sleep apnea.
HOME SLEEP STUDY EMBLETTA 100
How do Oral Appliances Help Prevent Sleep Apnea
Sleep apnea occurs when the tongue falls back and blocks the airway for ten seconds or more. Most patients have a more serious problem when they sleep on their back which makes it easier for the tongue to fall back and obstruct their ability to breathe.
Oral appliances are like upper and lower mouth guards which gently move the lower jaw and tongue forward to open the airway.
TONGUE BLOCKS THE AIRWAY
APPLIANCE HOLDS JAW FORWARD
OPENS THE AIRWAY
Upper and lower parts that fit comfortably over the teeth.
The lower jaw is held forward with two interlocking parts on the side
Allows for patients to move their lower jaw to the side.
Patient is able to move lower jaw forward to help reduce snoring and sleep apnea by turning two side screws. The patient will adjust the appliance slowly forward so they will not cause problems with their jaw joints. Each turn is very minimal, ¼ mm. We recommend the patient adjusts the side screws every 3 days until the snoring and sleep apnea is corrected.
The Dorsal is extremely durable and will last 10 years or more.
Adequate tongue space.
Large space at the front so patient can breathe through their mouth if they get a cold.
(Elastic Mandibular Advancement Appliance)
Clear plastic upper and lower parts.
Connected by two side straps. (Side straps can be adjusted to move lower jaw and tongue forward to prevent snoring and sleep apnea)
Adequate space for the tongue.
Extremely comfortable for the patient.
Side straps hold lower jaw forward.
Side straps move the lower jaw slowly and comfortably forward 1 mm at a time.
Large space at the front so the patient can breathe through their mouth at night if they get a cold.
Not bulky therefore more tongue space.
Extremely small and comfortable.
Not as strong as the Dorsal Appliance. Will need to be replaced every 4 years.
Possible Side Effects of Oral Appliances
Excessive salivation at the start of treatment
Slight tooth soreness
Teeth may not touch evenly first thing in the morning. Bite is back to normal in a short period of time.
Confirmation of Effectiveness of Oral Appliance Therapy
When the bed partner confirms that the snoring has stopped then the patient will be given a home sleep study device to check to see if the sleep apnea as well as the snoring has been eliminated. If there is no snoring or sleep apnea then the patient is reappointed for the following:
Six months later
Once per year
If there is still some evidence of sleep apnea the patient will be instructed to keep turning the screws (Dorsal Appliance) or advance the mandible further with the different side straps (EMA Appliance). Then in a few months the home sleep test will be repeated until the snoring and sleep apnea problem has been eliminated.
When treating with oral appliances it is critical to have home sleep studies to confirm the effectiveness of the oral appliance.
In the cases of severe sleep apnea treated with oral appliances the patients are suggested to return to the hospital or private sleep clinic for an overnight study with the oral appliance.
Patients that are diagnosed with severe sleep apnea (obstructive sleep apnea) should be encouraged by the dentist and sleep specialist to wear the CPAP device since this is considered to be the gold standard for the treatment of severe sleep apnea. This means that the patient stops breathing more than 30 times per hour for 10 seconds or more. The CPAP device delivers air to the patient’s lungs through a mask which fits over the nose or over the nose and mouth, via an air compressor and a humidifier. The CPAP device is effective in opening the airway as the air pressure from the machine is gradually increased during the follow-up sleep study. (Polysomnogram, Hospital Sleep Study) The air pressure successfully displaces the tongue, uvula and soft palate and allows an adequate amount of oxygen in the air to enter the lungs.
When the patient wears the CPAP device and the air pressure is tolerable by the patient it is often effective in eliminating the snoring and sleep apnea. Patients who have severe sleep apnea and who are happy with their CPAP devices should not be encouraged to replace them with oral appliance therapy. However, some patients have their results improved when they wear a combination of CPAP and oral appliances.
Oral appliances are mainly prescribed for the large number patients who cannot tolerate the CPAP device or who are diagnosed by the sleep specialist with mild to moderate sleep apnea.
Reasons Why Patients Cannot Wear CPAP
Noise due to the air compressor prevents ability to sleep.
Pressure is too high.
Skin irritations from the mask.
Eye irritations from air leakage.
Headaches from head straps.
Tinnitus. (Ringing in the ears)
Difficulty breathing out against the air being forced through the nose.
Air in stomach.
Dislike being attached to a machine.
Younger men will not wear CPAP.
Psychological reasons. Do not like the “Darth Vader” look.