Sleep Apnea and Medicine

• What is sleep apnea?
• What are the symptoms of Sleep Apnea?
• How serious is Sleep Apnea?
• How is Sleep Apnea treated?
• Physical and Mechanical Treatments for Sleep Apnea
• What are the advantages and disadvantages of the various types of treatment for sleep apnea?
• Dental Products for Sleep Apnea

What is sleep apnea?

Sleep apnea can be a serious sleep disorder. People who have sleep apnea stop breathing for 10 or more seconds at a time while they are sleeping (one apneic event). These short cessations in breathing can happen up to 800 times every night. If you have sleep apnea, the periods of stopped breathing may wake you from deep sleep. If you are waking from deep sleep to light sleep all night long, however briefly, you aren't getting enough rest from your sleep.

Of the two types of sleep apnea, obstructive apnea and central apnea, Obstructive Sleep Apnea (OSA) is the most common. Nine out of 10 people with sleep apnea have this type of apnea. If you have OSA, there is a blockage in your windpipe (or trachea), which brings air into your body. This may be caused by your tongue, tonsils or uvula. The airway might also be blocked by a large amount of fatty tissue in the throat or even by relaxed throat muscles. In most cases, this condition causes a decrease in air intake and ultimately, oxygen supply to your entire body.

On the other hand, central sleep apnea is rare and is related to the function of the central nervous system. Patients with this condition lack the “go ahead” signal from your brain to trigger the muscles you use to breathe. The brain may not transmit the signal or the signal may be interrupted.

What are the symptoms of sleep apnea?

Excessive daytime sleepiness Frequent episodes of obstructed breathing during sleep. (The patient may be unaware of this symptom, realizing it only after a bed partner has brought it to his or her attention.)

Associated symptoms may include:

• Loud snoring
• Clenched jaw
• Morning headaches
• Unrefreshing sleep
• Dry mouth upon awakening
• High blood pressure
• Overweight/obesity
• Irritability
• Change in personality
• Depression
• Difficulty concentrating
• Excessive perspiration during sleep
• Heartburn
• Reduced libido
• Chest retraction during sleep in young children (chest pulls in)
• Insomnia
• Frequent nocturnal urination
• Restless sleep
• Nocturnal snorting, gasping, choking (may wake self up)
• Rapid weight gain
• Confusion upon awakening

Snoring

What is snoring?

The noisy sounds of snoring occur when there is an obstruction to the flow of air through the back of the mouth and nose. This area is the collapsible part of the airway where the tongue and upper throat meet the soft palate and uvula. Snoring occurs when these structures get close to touching each other and vibrate during breathing. When they do touch each other, then that individual has one apneic event.

Is snoring serious?

Yes! While it is socially annoying to the bed partner and may sometimes wake the snorer, it could be a sign of a sleep apnea. Only a licensed professional medical provider can tell you for sure if you have sleep apnea.

The treatment of sleep apnea with a dental appliance will reduce and often ELIMINATE snoring for the person wearing the appliance.

How serious is sleep apnea?

Sleep apnea is a potentially life-threatening condition that requires immediate medical attention. The risks of undiagnosed OSA include heart attacks, strokes, impotence, irregular heartbeat, high blood pressure and heart disease. In addition, OSA can cause daytime sleepiness that can result in accidents, lost productivity and interpersonal relationship problems. The severity of the symptoms ranges from mild to severe. Sleep Apnea is a progressive condition, worsening with age, and should not be taken lightly.

Is sleep apnea common?

Doctors estimate that about 18 million Americans have sleep apnea. Men and people who are over 40 years old are more likely to have sleep apnea, but it can affect anyone at any age.

Will this problem change my life?

Sleep apnea may already have affected you more than you know. Your quality of sleep, and therefore quality of life, will improve with improved sleep patterns and increased oxygen supply to your brain and rest of your body. The benefits of quality sleep will be seen in improving the physical, emotional and psychological aspects of your life.

How is Sleep Apnea treated?

How does the doctor determine if I have OSA?

A sleep test, called polysomnography, is usually done to diagnose sleep apnea. There are two kinds of polysomnograms. An overnight polysomnography involves spending one night at a sleep laboratory to obtain a full report of movement, respiration, oxygen levels, etc. during sleep, which the doctor will review. The second kind of polysomnography is a home monitoring test. Dr. Bakhtiyarii will provide a small device to take home with you, which will record your sleep with a computerized polysomnograph. These are painless tests and are covered by most insurance plans.

Mild to moderate sleep apnea is usually treated by some behavioral changes. Weight loss and sleeping on your side are often recommended. There are oral mouth devices, which keep the airway open, that may help to reduce snoring in three different ways. Some devices (1) bring the jaw forward or (2) elevate the soft palate or (3) retain the tongue (from falling back in the airway and blocking breathing).

Severe Sleep Apnea is usually treated with a C-PAP (continuous positive airway pressure). C-PAP is a machine that blows air into your nose via a nose mask, keeping the airway open and unobstructed. For more severe apnea, there is a Bi-level (Bi-PAP) machine. The Bi-level machine is different in that it blows air at two different pressures. When a person inhales, the pressure is higher and in exhaling, the pressure is lower. Your sleep doctor will "prescribe" your pressure and a home healthcare company will set it up and provide training in its use and maintenance.

Some people have facial deformities that may cause sleep apnea: a jaw too small for their airway or a smaller opening at the back of the throat. Some people have enlarged tonsils, a large tongue or some other tissues partially blocking the airway. Fixing a deviated septum may help to open the nasal passages. Removing the tonsils and adenoids or polyps may help as well. Children are much more likely to have their tonsils and adenoids removed.

Physical and Mechanical Treatments for Sleep Apnea

Continuous Positive Airway Pressure (CPAP)

To keep your airway open during sleep, a machine at your bedside blows pressurized air into a mask that you wear over your nose or face.

This is a very common long-term treatment for severe sleep apnea.

Dental appliances, oral devices, and lower jaw adjustment devices

These devices open your airway by bringing your lower jaw or your tongue forward during sleep. Most dental devices are acrylic and fit inside your mouth, much like an athletic mouth guard or orthodontic appliance. Two common oral devices are the OAYSIS (shown above, right) and the Tongue Retaining Device, also known as the “Full Breath” (shown at left).

Surgery

Surgery increases the size of your airway by surgically removing tissues. The surgeon may remove tonsils, adenoids, or excess tissue at the back of the throat or inside the nose; the surgeon may also reconstruct the jaw. This procedure can be done using a scalpel, a laser, or a microwaving probe (radio frequency energy).

Oxygen administration

A narrow tube runs from an oxygen source to your nose, where the tube ends in small plastic prongs that fit into your nose. Though rarely used, this procedure ensures that you get enough oxygen during sleep and may be used in conjunction with CPAP.

What are the advantages and disadvantages of the various types of treatment for sleep apnea?

Choosing the right treatment for your case of sleep apnea is an important decision. The following is a summary of the main advantages and disadvantages of each type of treatment for sleep apnea. Always consult a sleep specialist when making this decision.

Self-help/Reading Literature:

Advantages:

• Inexpensive
• Private, not embarrassing; unobtrusive to your bed partner
• The lifestyle changes you make can improve more than just your sleep

Disadvantages:

• Only works for mild sleep apnea
• You may have to make permanent lifestyle changes

CPAP (Continuous Positive Airway Pressure)

Advantages:

• Safe
• Very effective
• Immediate relief

Disadvantages:

• Difficult to use, so most people stop use within the first year
• Mask may be uncomfortable, claustrophobic, or embarrassing. Proper fit avoids discomfort.
• Many side-effects
• Machine may be noisy
• A lifelong treatment

Dental devices:

Advantages:

• Easier to use and maintain than CPAP, so people stay with this treatment longer and are therefore more likely to experience relief
• Small size, so more convenient for traveling than CPAP
• More effective than surgery for some airway obstructions

Disadvantages:

• Not as effective as CPAP
• Proper use is essential for treatment to be effective
• Used in conjunction with CPAP for severe sleep apnea and for some types of airway obstructions
• Many possible side-effects: soreness, saliva build-up; nausea, permanent change in the position of the jaw or teeth.

Surgery

Advantages:

• Can permanently cure your sleep apnea problem, and no more treatment is necessary

Disadvantages:

• Anesthesia and operations are inherently risky. May require a sequence of surgeries over time. The jaw may have to be wired shut for several weeks.
• Performing surgery on the wrong tissue can make no difference or even worsen the sleep apnea.
• If unsuccessful, can impede the success of other kinds of treatments
• Side-effects can be severe, such as pain and throat swelling

Oxygen Administration

Advantages:

• Life-saving treatment for people with heart-related breathing problems. Allows the person to sleep safely through the night.

Disadvantages:

• Only helps during the administration period
• Must be carefully adjusted, or it can increase apnea
• Waking episodes still occur during sleep
• Does not improve daytime sleepiness

Dental Products for Sleep Apnea:

Several different dental appliances or treatments are available and are proving to be very valuable treatments for mild to moderate obstructive sleep apnea. Dentists and orthodontists are slowly becoming more aware of obstructive sleep apnea and may become more involved with its diagnosis and treatment. Among the devices available are the following examples:

• The mandibular advancement device (MAD) is the most widely used dental device for sleep apnea. Similar in appearance to a sports mouth guard, MAD forces the lower jaw forward and down slightly, which keeps the airway open.
• Orthotics or appliances are sometimes used to hold the tongue in a specific position to keep the airway as open as possible.

Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.

Benefits of Mandibular Advancement Device

Studies generally indicate satisfaction with the dental devices. MAD and similar devices seem to offer the following benefits:

Reduce apneas significantly for those with mild to moderate apnea, particularly if patients sleep either on their backs or stomachs. (Though they are not as effective if the patient lies on his or her back.) They may also improve airflow, although less well, in those with severe apnea. Improve quality of sleep in many patents Improve and reduce the frequency of snoring and loudness of snoring in most (but not all) patients High compliance rates compared with CPAP

In one 2002 report, long-term use of a dental device achieved an 81% success rate, which was significantly higher than the 53% success rate noted for uvulopalatopharyngoplasty (UPPP), the standard surgical treatment. There were also fewer complications with the dental device.