Snoring occurs when the soft tissue structures of the upper airway collapse onto themselves and vibrate against each other as we attempt to move air through them. This produces the sound we know as snoring. Large tonsils, a long soft palate, a large tongue, the uvula, and excess fat deposits in the throat all contribute to airway narrowing and snoring. Usually, the more narrow the airway space, the louder or more habitual the snoring.
Obstructive Sleep Apnea
Obstructive Sleep Apnea (OSA) occurs when the tongue and soft palate collapse onto the back of the throat. This blocks the upper airway, causing air flow to stop. When the oxygen level drops low enough, the brain moves out of deep sleep and the individual partially awakens. The airway then contracts and opens, causing the obstruction in the throat to clear. The flow of air starts again, usually with a loud gasp. When the air flow starts again, you then move back into a deep sleep. The airway muscles collapse, as you awaken with a gasp. The airway clears once again as the process repeats itself. This scenario may occur many times during the night. The combination of low oxygen levels and fragmented sleep are the major contributors to most of the ill effects that the sleep apnea patient suffers. In addition to excessive daytime sleepiness, studies show that sleep apnea patients are much more likely to suffer from heart problems (heart attack, congestive heart failure, hypertension), strokes, as well as having a higher incidence of work related and driving related accidents.
How do you know if you have OSA?
Take a simple test but be sure to visit your physician if you think you have a problem.
Diagnosis of Obstructive Sleep Apnea
Since OSA is a serious medical condition, it must be diagnosed by a physician. Diagnosis is 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
Good sleep hygiene, weight loss, and exercise are some helpful OSA treatments a patient 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)
Continuous Positive Airway Pressure (CPAP) is pressurized air generated from a bedside machine. The air is delivered through a tube, connected to a mask, covering the nose. The force of the pressurized air splints the airway open. The CPAP opens the airway like air into a balloon; when air is blown into the balloon, it opens and gets wider. This is exactly how CPAP clears the airway.
Oral Appliance Therapy
Oral appliances are worn in the mouth to treat snoring and OSA. These devices are similar to orthodontic retainers or sports mouth guards. Oral Appliance Therapy involves the selection, design, fitting 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 many different oral appliances available. Approximately 40 appliances have been approved through the FDA for treatment of snoring and/or Sleep Apnea. Oral appliances may be used alone or in combination with other means of treating OSA. These means include general health, weight management, surgery, or CPAP. 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 training in Oral Appliance Therapy are familiar with the various designs of appliances. They can determine 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, and on-going care. Determination of proper therapy can only be 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 variety of methods to evaluate, diagnose and treat 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, mainly the removal of the excess tissues in the throat. It may be necessary to remove tonsils and adenoids (especially in children), the uvula, or even parts of the soft palate and the throat.
A Simple test if you think you have sleep apnea called the The Epworth Sleepiness Scale
The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations?
Choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Activity Score
Sitting and Reading _____
Watching TV _____
Sitting, inactive in a public place (theater, meeting, etc.) _____
As a passenger in a car for an hour without a break _____
Lying down to rest in the afternoon when circumstances permit _____
Sitting and talking to someone _____
Sitting quietly after lunch without alcohol _____
In a car, while stopped for a few minutes in traffic _____
Total _____
A score of 9 or above indicates you may be having a problem with daytime sleepiness but below 9 does not necessarily mean that you don’t have a problem. See your healthcare professional for advice if you snore, have been told that you awake gasping for breath or if you are sleepy during the day.
Two common oral appliances that can possibly alternatives to the CPAP
TAP3 Appliance
HOW THE TAP WORKS
The Thornton Adjustable Positioner (TAP®) is a custom-made two piece adjustable appliance that is worn while sleeping. The trays of the appliance snap over the upper and lower teeth and hook together. The design is based on the same principle as cardiopulmonary resuscitation, CPR. The airway must be opened to allow air to pass through the throat. The TAP® holds the lower jaw in a forward position so that it does not shift nor fall open during the night. This prevents the airway from collapsing. The more you pull your jaw forward, the more your airway will open.
The TAP® is the only mandibular advancement device that can be adjusted easily by the patient or practitioner while in the mouth. This feature allows the patient to always be in control of their treatment. The unique design also allows the patient to fine-tune their treatment position at home to achieve maximum results.
Most patients experience relief the very first night they wear their TAP®. Although it may take up to a week to get used to wearing a TAP® appliance, this is a small hurdle for patients. Nine in ten patients wear the device all night, every night – making the TAP® a highly effective solution for both snoring and sleep apnea.
SNORING HEADS
Features
*Patient-friendly
Superior results
Easy to fit
Infinitely adjustable
Precise control of advancement
Interchangeable hooks
Freedom for lateral movement
More room for tongue
Allows lips to close
The TAP® can help prevent conditions linked to sleep apnea:
Chronic daytime sleepiness
High blood pressure
Heart attack
Stroke
Heartburn, reflux
Morning headaches
Depression
FDA Approval: Approved for both snoring and OSA
Date of FDA Approval: August 21, 1997
FDA Registration Number: K972061
Oral Pressure Appliance (OPAP)
Description: Patients who are unable to be compliant with a nasal mask due to claustrophobia, head aches due to chinstraps or head gear and complaints of mask leaks leading to eye irritation, sinusitis may benefit by using oral mask ventilation with the OPAP. Oral positive air pressure delivered by a newly conceived proprietary dental appliance (OPA P) is a treatment alternative to nasally applied positive air pressure (CPAP or BiPAP). Mandibular advancement and modification of the upper airway structures is thought to enlarge the airway or reduce its collapsibility.
The OPAP® is an oral appliance which incorporates an airway and mandibular position in its design and function. Lt assures an airway to the retropharynx during sleep and allows delivery of positive air pressure (CPAP or BiPAP) through it if needed. The combination of mandibular positioning and the creation of an airway allows for an alternative mode of treatment for the collapsible airway found in O SA patients. This type of dental appliance may be used for mild to severe cases of OSA. Evaluation of the patient for the suitability of an oral appliance from a medical and dental standpoint is first determined.
A referral to a dental sleep specialist is then made. A complete dental exam including panorex, cephalometrics in addition to sonography of the TMJ joint was obtained prior to taking dental impressions may be considered. A bite registration is then obtained, allowing the OPAP® appliance to be custom made to the patients dental impressions.
Once a comfortable fit is obtained the OPAP® was connected to CPAP or BiPAP by the standard tubing. A titration polysomnogram test is then recommended with the O PAP and positive air pressure. Primary complaints with the OPAP® included oral drying, excessive salivation, discomfort with exhaling against CPAP.
Drying improves with the use of an inline humidifier. Excessive salivation improved with adaptation and continued use of the oral appliance. Discomfort with exhalation against orally delivered CPAP improved with the use of orally delivered BiPAP. The OPAP® has been designed for patients with and without teeth¬ Data presented to the FDA demonstrated the OPAP® appliance delivered oral air pressure capable of producing a reduction of the AHl in mild to severe cases of OSA to the same level of efficacy as nasal mask delivery.
This type of dental appliance may serve to be a therapeutic alterative to nasal CPAP and in certain mild cases this oral appliance is by itself capable of treating mild OSA. FDA Approval: Date of FDA Approval: Oct. 18,1999 Date of Canadian Approval: Feb. 25, 1999 FDA Registration Number: K991926 Canadian Approval Number: 18949
