Sleep Medicine
DENTAL APPLIANCE TREATMENT FOR SNORING AND OBSTRUCTIVE SLEEP APNOEA
Throughout the western world, extensive studies have shown that up to 40% of male, and 30% of female adults have a significant level of snoring, increasing in frequency with age, weight gain, smoking, and alcohol consumption. This snoring can cause significant medical problems, and research has further shown that severe snoring may be a causative factor in the occurrence of strokes. Snoring can also often be a significant source of tension in personal relationships.
Snoring may also indicate the presence of a potentially serious medical condition called Obstructive Sleep Apnoea (OSA). The incidence of OSA in the population has been estimated at approximately 22% of males and 17% of females. Post menopause, the incidence of OSA increases in females to equal that seen in males.
Obstructive Sleep Apnoea leads to episodes of partial cessation of breathing (called hypopneas) or complete cessation of breathing (called apnoeas) throughout the night for periods of from 10 seconds to over one minute per episode. In severe cases of OSA, this can happen over 100 times per hour throughout the total sleep time. This allows oxygen levels in the blood to fall multiple times each night, and this can lead to serious medical conditions such as:
- Hypertension
- Heart disease
- Cardiac Arrhythmias
- Diabetes
- Decreasing neurocognitive function,
These episodes of interruption to breathing are terminated by the person coming out of a deep, refreshing sleep to a lighter sleep level where the muscles that control breathing and the airway can re-activate. Sometimes people may fully awaken to restart breathing, but mostly they only rise from deep sleep to very light levels of sleep where normal breathing is able to re-commence. These many episodes of arousals during the night lead to waking in the morning feeling unrefreshed, and also lead to the presence of excessive daytime sleepiness, which can be hazardous in the work place, or whilst driving.
The incidence and severity of OSA increases with increases in body weight, and the Body Mass Index (BMI). The world-wide increases currently being seen in body weight in developed countries are now showing up as a rapidly rising incidences of OSA, with studies showing up to 50% of the population in some areas of the western world now being effected.
People with OSA frequently, but not always, snore loudly, and may also have other symptoms:
- Unrefreshing sleep – tiredness on wakening in the morning
- Excessive daytime sleepiness
- Choking or gasping during sleep
- Nocturia
- Sore, dry throat on awakening
- Morning headaches
- Poor concentration and impaired vigilance
- Memory deterioration
- Decreased sex drive, or even impotence
- Personality changes that may include irritability
- Decrease in job performance
- Anxiety or depression.
Unrefreshing sleep and daytime sleepiness have also been shown to cause an increase of up to twelve times in the incidence of motor vehicle and workplace accidents.
Snoring and OSA may be treated using oral appliances, continuous positive airway pressure (CPAP), occasionally surgery, and where applicable – weight loss.
Oral appliances are now becoming more frequently recommended by many specialist medical sleep physicians – especially in cases where people are suffering with mild to moderate severity levels of OSA, or patients who have been recommended to use CPAP, but cannot manage or tolerate this form of treatment.
The treatment of snoring and/or OSA with an oral appliance is safe, painless and effective, and does not involve surgery.
These oral appliances are generally known as Mandibular Advancement Splints (MAS), and are custom made and adjustable to fully suit the requirements of each individual patient. They are easy to wear and comfortable to sleep with. It is possible to speak, yawn, or drink whilst wearing most oral appliances.
Dentists with specialised training in dental sleep medicine and oral appliances can treat OSA, and troublesome snoring, in co-operation with your sleep physician and local doctor.
Oral appliances have helped many people who snore or have OSA. These appliances are worn during sleep and help to keep the airway open by bringing the lower jaw and tongue slightly forward so as to hold your airway open whilst you sleep. (See also Causes of Snoring and Obstructive Sleep Apnoea)
Mandibular Advancement Splints work by gently holding the lower jaw slightly forward while you sleep, which brings the tongue forward and opens the airway.
Of every 100 snorers who use custom made and professionally fitted mandibular advancement splints, about 95 will have a significant decrease in their snoring, and to the noise levels that this snoring generates during sleep.
Of every 100 people with mild to moderate OSA who use custom made, professionally fitted mandibular advancement splints, about 80 will have either good or excellent results whilst using a dental appliance.
A dental appliance may be used alone or in conjunction with other treatments such as CPAP. They are also commonly recommended for people who do not like, or cannot tolerate CPAP.
Unlike CPAP, dental appliances are small and light, and require no power outlet – and they are easy to carry and to use when travelling.
As many as 25% of children have sleep difficulties or sleep disorders. Sleep disorders in children are linked to poor growth, adverse behaviour, poor learning, worsened mental health, and poor quality of life for both the child and the family.
Sleep plays an important role in learning by promoting the consolidation and integration of memory, and disruptions to sleep have significant effects on both learning and behaviour.
Children, like adults, also commonly suffer from snoring and OSA. Studies have shown the incidence of habitual snoring to be around 10% of pre-school and school aged children, and that this snoring is a cardinal symptom of childhood OSA. If your child snores, he/she almost certainly has OSA.
Obstructed breathing during sleep in children has a major influence on the developing cardiovascular system. Studies have also shown that children who snore tend to have higher resting blood pressure than those who do not regularly snore, even if they do not have OSA.
In children, OSA can lead to lack of normal physical and mental development due to their disturbed sleep, and the transient lowering of their blood oxygen levels during sleep. A child’s growth and development may also be affected by a lack of sufficient growth hormones, which are only released by the Pituitary Gland in the brain during deep sleep. Instead of feeling sleepy during the day as with adults, OSA in children is often manifested by hyperactivity and problems at school. Many children with OSA are mistakenly diagnosed as having attention-deficit/hyperactivity disorder (ADHD).
Snoring and OSA in children are most commonly due to enlarged tonsils and/or adenoids blocking, or partially blocking, the airway. Obesity is also often a significant factor in children developing OSA.
If your child is a mouth breather, or possibly snores or grinds his or her teeth, or has restless sleep patterns, it is important to have him/her fully investigated as early as possible.
During normal breathing, air is drawn in through the nose and past the soft tissues at the back of the throat. These tissues include the uvula, the soft palate, and the back of the tongue. During waking hours the airway is held open by the tone of the muscles surrounding it. During sleep, these muscles relax, and this can allow the tongue to fall back and obstruct the airway at the back of the throat. This is especially the case with people who sleep on their back (supine position).
Assessment of the degree of the OSA, and the presence of any comorbidities (co-existing, associated medical conditions), is crucial so that the most effective treatment can be instituted. This assessment may involve specialists with expertise in various areas, including respiratory medicine, dentistry, ear, nose, and throat surgery, and neurology.
Assessment begins with an initial diagnosis, and this usually needs to be followed by a formal sleep study, which may be done in a hospital, but now more frequently can be done with a simple overnight sleep study in your own home. In our dental clinic, this sleep study is set up for you by a fully trained sleep medicine professional, usually in your own home, and the results are then diagnosed by a specialist medical sleep physician, who then formulates a treatment plan individualised for each patient’s specific needs.
CPAP involves wearing a mask over the nose (sometimes over the nose and mouth) at night that delivers air under pressure via a small bedside pump. This gently forces the airway to stay open during sleep when the respiratory muscles are relaxed, and is a very effective treatment if used as prescribed. CPAP is generally used more for patients with severe levels of OSA, or with significant medical co-morbidities.
Unfortunately, although CPAP is widely accepted as excellent treatment for OSA, many people who would benefit from this form of treatment cannot tolerate CPAP.
People who do not like, or are intolerant of, CPAP may often be effectively treated with small, easy to wear, dental appliances. Under these circumstances, the approval of each patient’s specialist medical sleep physician is always sought before treatment with dental appliances is instituted for the treatment of OSA.
In adults, Surgery to treat OSA may occasionally be recommended, although this is much less common now than in the past.
In children, the most common cause of Sleep Disorders and Obstructive Sleep Apnoea is enlarged tonsils and adenoids, and their removal is often the preferred method of treatment.