Obstructive Sleep Apnea And The Role Of The Dentist
Obstructive sleep apnea is a common disorder in which an individual stops breathing multiple times each night. Let’s take a look at sleep apnea in more detail and explore a dental treatment called oral appliance (OA) therapy.
Has anyone ever told you that you snore like an old steam train or that you grunt or stop breathing during sleep? If so, you may have obstructive sleep apnea (sleep apnea or OSA for short). Sleep apnea is a common sleep disorder in which breathing ceases or airflow is significantly decreased, despite the effort to breath. It is caused by episodes of upper airway collapse, which recur during sleep and lead to a drop in oxygenation of the blood and frequent arousals from sleep. It causes a variety of symptoms from vague daytime drowsiness through to heart disease and accidents. The traditional treatment for OSA is CPAP but in this article, we discuss an alternative to CPAP known as oral appliance therapy (“sleep apnea mouthguard”).
What is sleep apnea?
Sleep apnea lies at the severe end of a continuum of sleep-related disorders of breathing, with simple snoring at the mildest end and upper airway resistance syndrome (UARS) in the middle. There is considerable overlap between the conditions.
The continuum of sleep-related breathing disorders, from snorers to UARS, to OSA.
What’s The Difference Between Central Sleep Apnea and Obstructive Sleep Apnea?
There is another, uncommon form of sleep apnea called central sleep apnea, characterized by periods of diminished or absent respiratory effort, rather than by airway obstruction (in OSA).
What Causes Sleep Apnea?
Sleep apnea is caused by collapse of the upper airway, specifically the soft tissue in the pharynx, the passageway that leads from the nose and mouth, to the esophagus and voice-box (larynx).
Many factors contribute to the development of sleep apnea including:
- Structural abnormalities of the pharynx, nose, tonsils, adenoids, tongue, soft palate, mouth or jaw, which cause the airway to narrow during sleep.
- Obesity, particularly if there is fat deposition in the neck and/or abdomen
- Gender: sleep apnea is more common in men, but increases in women after menopause
- Increasing age
- Race: people of African American, Asian, Mexican and Pacific Island descent are at higher risk than those of Caucasian descent
- Inflammation and allergies in the upper airway
- Alcohol and sedative consumption
- Smoking
- Habitual snoring with daytime sleepiness
- Sleeping on the back
- Hypothyroidism and acromegaly (excess growth hormone)
- Neurologic syndromes like stroke, post-polio syndrome and muscular dystrophy
- Heart or kidney failure
- Environmental toxins such as smoke, chemicals and allergens
- Family history of sleep apnea, in part due to a collection of gene abnormalities.
How common is sleep apnea?
Sleep related breathing disorders (SDB) affect approximately 2% of women and 4% of men in the USA, and the incidence increases with age. In the US alone 7-18 million people have SBD (1 in 4 are severe). An alarming 92% of affected women and 80% of affected men go undiagnosed.
Do I have sleep apnea?
So you may be wondering, “what are signs and symptoms of sleep apnea?” It is possible you may have had OSA for years without knowing it because symptoms often start off vague and mild and increase slowly. They include:
- Snoring, often loud, frequent, and a nuisance to others
- Witnessed apneas, in which a period of snoring is interrupted by a period of not breathing, followed by a snort or grunt
- Sensations of gasping or choking
- Needing to pass urine during the night (nocturia)
- Restless sleep, with frequent arousals and tossing and turning during the night
- Insomnia
- Waking tired (non-restorative sleep) or confused
- A headache in the morning, plus a dry or sore throat
- Daytime sleepiness and/ or tiredness during quiet times of the day
- Problems with memory, concentration and intellect (cognitive deficits), which can lead to decreased vigilance
- Changes in personality and mood changes, including depression and anxiety
- Impotence and decreased libido
- Gastroesophageal reflux
- Hypertension (high blood pressure)
Complications of Sleep Apnea
Not only are the symptoms of OSA unpleasant and disruptive, but research shows that there are also serious long-term consequences. A study published in the journal Sleep, concluded that the risk of premature mortality increased by more than three times for people with sleep breathing problems and by more than five times for those with severe OSA, compared to people with no sleep apnea.
According to the National Institutes for Health sleep apnea increases your risk of:
- Asthma
- Cancer
- Chronic kidney disease
- Cognitive and behavioral disorders, such as decreases in attention, vigilance, concentration, motor skills, and verbal and visuospatial memory, as well as dementia in older adults.
- Diseases of the heart and blood vessels, such as atrial fibrillation, atherosclerosis, heart attacks, heart failure, difficult-to-control high blood pressure, and stroke
- Eye disorders, such as glaucoma, dry eye, or keratoconus
- Metabolic disorders, including glucose intolerance and type 2 diabetes
- Pregnancy complications, including gestational diabetes and gestational high blood pressure.
In addition OSA increases the risk of motor vehicle accidents. One study found that the risk of motor vehicle crashes was 2-7 times higher in people with OSA, compared to those without. Clearly these risks are even more worrying for truck, train and bus drivers.
How is Sleep Apnea Diagnosed?
If you suspect you might have sleep apnea make an appointment to see your doctor. They will take a medical history and perform a physical examination, including blood pressure, weight and neck circumference, and examination of ears, nose, throat and mouth. They may go on to order some blood tests to rule our common problems like hypothyroidism, high cholesterol and diabetes. They may then refer you for an overnight sleep study (polysomnography), which is required to diagnose OSA and perhaps a specialized dentist.
What Are The Options For Sleep Apnea Treatment?
Treatment depends on the severity of sleep-disordered breathing. Those with mild apnea have more options, whereas those with moderate to severe apnea are likely to be offered nasal continuous positive airway pressure (CPAP). Your sleep physician may also refer you to a dentist who specializes in a new wave of obstructive sleep apnea therapies known as oral appliance therapy (OA). The options include: Conservative therapy, CPAP or BPAP, oral appliance therapy, surgery and medications.
Conservative therapy
This is an option for people with mild apnea, an includes:
- Avoid lying flat on your back
- Sleep upright, especially if overweight
- Quit smoking
- Avoid alcohol and sedatives (especially 4-6 hours before sleep)
- Avoid getting over tired
- Weight loss, if you’re overweight
Medications
A minority of people with OSA benefit from medications, but only to help overcome symptoms. For those with significant daytime sleepiness, central nervous system stimulants (such as modafinil) may be trialed.
Surgery
In people with very severe OSA surgical intervention may be considered. There are numerous options depending on the nature of the problem and these include the removal of tissue from the throat including tonsils and adenoids, craniofacial reconstruction with advancement of tongue or maxillomandibular bones (jaw and upper mouth), tracheostomy (insertion of a pipe into the trachea or windpipe). These surgeries come with significant risks and sometimes fail to improve outcome.
Sleep apnea devices
For people with significant OSA the options for sleep apnea devices include: CPAP, BPAP and oral appliance therapy.
What is CPAP?
A CPAP device consists of a blower unit that produces continuous positive-pressure airflow, via the nose and into the upper airway. The resulting improvement in airflow, oxygenation of the blood, reduction in snoring and arousals during sleep. In turn this improves symptoms and outcomes in many people. However there is a significant problem with CPAP that of compliance, in part because wearing a CPAP mask all night long is not very pleasant. It’s estimated that only 68% of people prescribed CPAP are still using it 5 years on, and that’s a problem because OSA recurs within a few days of CPAP cessation.
Problems with CPAP include:
- Discomfort, dryness and abrasions (skin, nose, sinuses, mouth, eyes)
- Sensation of suffocation or claustrophobia
- Difficulty breathing out
- Inability to sleep
- Chest discomfort
- Excessive burping (due to air swallowing “aerophagia”)
- Sinus discomfort.
- Severe complications such as pneumothorax are rarely reported.
- Noise: CPAP machines create noise (airflow and clicking) and this may disturb the patient and their sleeping partner.
What is BPAP?
In contrast to CPAP, which delivers a constant pressure, BPAP or BiPAP (Bilevel positive airway pressure) adjusts the pressures during inspiration and expiration. However compliance is still a significant problem.
What is Oral Appliance Therapy for sleep apnea? Dentists Treat Sleep Apnea Too
According to the American Academy of Dental Sleep Medicine “dentists pioneered the use of oral appliance therapy for the treatment of obstructive sleep apnea and snoring in adults. An oral appliance is a device worn in the mouth only during sleep”. A dentist specializing in sleep disorders provides a custom-fit appliance (rather like a sports mouth guard or orthodontic retainer) moves the tongue, jaw and/or soft palate forward, expanding the airway and preventing it from collapsing.
Sometimes known as a “sleep apnea mouthguard” there are over 40 different types of OA. These alternatives to CPAP fall into three main categories:
- Mandibular repositioners or Mandibular Advancement Devices (MAD)
- Tongue-retaining devices (TRDs)
- Palatal-lifting devices
OAs can also be used alongside CPAP or BPAP.
How Can Dr Kundel Help With Sleep Apnea?
If you are suffering from the symptoms of sleep apnea and are interested in exploring alternatives to CPAP or non-surgical approaches to treatment, please contact our office in Stamford, CT or New York City to schedule a comprehensive evaluation https://stamforddentist.com.