Obstructive Sleep Apnea and Snoring Therapy

Snoring is extremely common and, in many cases, relatively harmless. Nearly everyone snores at one time or another. Occasional light snoring, at worst, is a minor annoyance. Loud and habitual snoring can disrupt your sleep and may be a sign of a much more serious sleep disorder – obstructive sleep apnea. 

Snoring is a sound that occurs in the upper airway as you breathe in air. The unmistakable sound is a sign that your airway is partially blocked, usually by soft tissue in your throat. The flow of air causes the soft tissue to vibrate, generating the noise, which comes out of your nose, mouth or both. 

The volume of snoring depends on the person. You may snore so loudly you wake yourself up. Snoring may also cause you to have a dry mouth or to wake up with a dry mouth and a sore throat.

Snoring Facts

• Snoring can affect almost anyone.
• Habitual snoring has been found in an estimated 24 percent of adult women and 40 percent of adult men.
• Both men and women are more likely to snore as they age. Men become less likely to snore after the age of 70.
• Alcohol, drugs, muscle relaxers and tobacco products contribute to snoring for both men and women.
• Obese or overweight people tend to snore because there is more fat tissue in the back of their throats.
• Pregnancy can increase a woman’s change of snoring.
• An estimated 10 to 12 percent of children snore.
• Snoring appears to run in families

Is it Snoring or Obstructive Sleep Apnea?

Obstructive sleep apnea frequently goes undiagnosed because people often mistaken the serious sleep disorder for snoring. About half of loud snorers have some form of sleep apnea.

Snoring and obstructive sleep apnea have similar causes. Sleep apnea happens when the tissue in the upper-airway blocks the entire airway, causing a pause in your breathing. The blockage keeps oxygen from reaching your organs including your heart and brain. When the blood-oxygen level drops low enough, the body momentarily wakes up. It can happen so fast that you may not be aware you woke up.

Snorers who suffer from sleep apnea may make gasping, choking or snorting sounds as they try to breathe and feel drained of energy during the day. 

If you think you may have obstructive sleep apnea, get diagnosed by a board certified sleep physician at an AASM accredited sleep center. 

Snoring Treatments

There are several behavioral and medical treatments for snoring. Medical factors may affect treatment, so it is important to speak with a physician.

Dental Treatment Options

• Oral appliance therapy
• Upper airway surgery

Behavioral Techniques

Losing weight can decrease the severity of snoring, because excess fat tissue in the back of the neck worsens snoring. Weight loss alone may not help stop snoring for everyone.

Avoiding alcohol, drugs, muscle relaxers and tobacco products can also help reduce or eliminate the presence of snoring. 

Positional Therapy

You may be able to reduce snoring by sleeping on your side instead of your back. Shifting your sleeping position keeps the weight of your neck from collapsing on your airway. This approach may not help everyone.

Obstructive Sleep Apnea

Obstructive sleep apnea is very common and potentially life-threatening medical disorder that prevents airflow during sleep. More than 18 million Americans have sleep apnea, and many are not receiving treatment.

Sleep apnea occurs when tissue in the back of the throat collapses and blocks the airway, reducing the amount of oxygen delivered to all of your organs including your heart and brain. People with sleep apnea may snore loudly and stop breathing for short periods of time. When the blood-oxygen level drops low enough, the body momentarily wakes up. It can happen so fast that you may not be aware you woke up. This can happen hundreds of times a night, and you may wake up in the morning feeling unrefreshed.

In addition to snoring and excessive daytime sleepiness, sleep apnea can cause memory loss, morning headaches, irritability, depression, decreased sex drive and impaired concentration. Sleep apnea patients have a much higher risk of stroke and heart problems, such as heart attack, congestive heart failure and hypertension (high blood pressure). Sleep apnea patients are also more likely to be involved in an accident at the workplace or while driving.

Signs of Sleep Apnea

Typical sleep apnea patients are often older, obese and have thick necks, but men and women of any age or body type can have sleep apnea. The sleep disorder progressively worsens with age and weight gain. Listed below are some common signs of sleep apnea:

• Unintentionally falling asleep during the day
• General daytime sleepiness
• Unrefreshed sleep
• Fatigue
• Insomnia
• Waking from sleep with a choking sound or gasping for breath
• Loud snoring

If you have these symptoms, you might have sleep apnea. Schedule an appointment at an AASM Accredited Sleep Center for an overnight sleep study.

Diagnosing Sleep Apnea

A physician is required to perform an overnight sleep study to properly diagnose obstructive sleep apnea. The test, also known as a Polysomnogram, will chart your brain waves, heart beat and breathing during sleep. It also records arm and leg movement.

A sleep specialist will look for other conditions that may mimic or worsen the symptoms of OSA, such as:

• Another sleep disorder
• A medical condition
• Medication use
• A mental health disorder
• Substance abuse

A sleep specialist will take your symptoms into consideration during diagnosis. Prior to the appointment, ask your partner if you snore loudly, stop breathing or gasp for breath during the night. The sleep specialist will also want to know if you gained weight or stopped exercising before your symptoms began.

Treatment Options

Once you are diagnosed with obstructive sleep apnea, a multitude of treatment techniques can be employed including:

• CPAP (continuous positive airway pressure)
• Oral appliance therapy
• Upper airway surgery

These techniques may be used alone or in combination with other treatments for sleep apnea. Behavioral therapies include weight loss, avoidance of alcohol and tobacco and sleeping on your side, and may reduce the severity of sleep apnea.

Oral Appliances

Oral appliances (OA) are a first-line treatment for patients with mild to moderate Obstructive Sleep Apnea (OSA) who cannot tolerate or do not respond to CPAP therapy, or do not respond to behavioral measures such as weight loss or sleep position change. This small plastic device fits in the mouth during sleep like a sports mouth guard or orthodontic retainer. Oral appliances help prevent the collapse of the tongue and soft tissues in the back of the throat, keeping the airway open during sleep and promoting adequate air intake. Oral appliances may be used alone or in combination with other treatments for sleep-related breathing disorders, such as weight management, surgery or CPAP.

Standards of Care

• Patients with primary snoring or mild OSA who do not respond to, or are not appropriate candidates for treatment with behavioral measures such as weight loss or sleep-position change.
• Patients with moderate to severe OSA should have an initial trial of nasal CPAP, due to greater effectiveness with the use of oral appliances.
• Patients with moderate to severe OSA who are intolerant of or refuse treatment with nasal CPAP. Oral appliances are also indicated for patients who refuse treatment, or are not candidates for tonsillectomy and adenoidectomy, upper airway surgery, or tracheostomy.

Oral Appliance Therapy

Oral appliance therapy involves the selection, fitting and use of a specially designed oral appliance that maintains an open, unobstructed airway in the throat when worn during sleep. Custom-made oral appliances are proven to be more effective than over-the-counter devices, which are not recommended as a screening tool nor as a therapeutic option.

Dentists with training in oral appliance therapy are familiar with the various designs of appliances and can help determine which is best suited for your specific needs. A board certified sleep medicine physician must first provide a diagnosis and recommend the most effective treatment approach. A dental sleep medicine specialist may then provide treatment and follow-up.

The initial evaluation phase of oral appliance therapy can take several weeks or months to complete. This includes examination, evaluation to determine the most appropriate oral appliance, fitting, maximizing adaptation of the appliance, and the function.

Ongoing care, including short- and long-term follow-up is an essential step in the treatment of snoring and Obstructive Sleep Apnea with Oral Appliance Therapy. Follow-up care serves to assess the treatment of your sleep disorder, the condition of your appliance, your physical response to your appliance, and to ensure that it is comfortable and effective.

Advantages of Oral Appliance Therapy

• Oral appliances are comfortable and easy to wear. Most people find that it only takes a couple of weeks to become acclimated to wearing the appliance.
• Oral appliances are small and convenient making them easy to carry when traveling.
• Treatment with oral appliances is reversible and non-invasive

How Oral Appliances Work

• Repositioning the lower jaw, tongue, soft palate and uvula
• Stabilizing the lower jaw and tongue
• Increasing the muscle tone of the tongue

Types of Oral Appliances

With so many different oral appliances available, selection of a specific appliance may appear somewhat overwhelming. Nearly all appliances fall into one of two categories. The diverse variety is simply a variation of a few major themes. Oral appliances can be classified by mode of action or design variation.

Tongue Retaining Appliances

Tongue retaining appliances hold the tongue in a forward position using a suction bulb. When the tongue is in a forward position, it serves to keep the back of the tongue from collapsing during sleep and obstructing the airway in the throat.

Mandibular Repositioning Appliances

Mandibular repositioning appliances reposition and maintain the lower jaw in a protruded position during sleep. The device serves to open the airway by indirectly pulling the tongue forward, stimulating activity of the muscles in the tongue and making it more rigid. The device also holds the lower jaw and other structures in a stable position to prevent the mouth from opening.

Upper Airway Surgery

Upper airway surgery is a potential treatment when other options are unsuccessful in eliminating the symptoms of sleep apnea or are not tolerated by patients. Surgery is site-specific, meaning it requires the identification of specific anatomic areas contributing to airway obstruction. Depending on the location and nature of the airway obstruction, the procedure may be minimally invasive or more complex. It may be necessary to remove the tonsils or other parts of the soft palate or throat. A detailed examination of the entire upper airway is necessary before your surgeon can decide which surgical procedures are most effective.

Maxillomandibular Advancement

MMA is the most effective and acceptable surgical treatment of sleep apnea, with success rates ranging from 94 to 100 percent. The surgical procedure involves osteotomies (bony cuts performed by intraoral incisions) to advance the upper and lower jaws to pull forward and tighten the soft palate, tongue and other attached soft tissues. The process enlarges and stabilizes the entire upper airway. MMA requires an overnight hospital stay. Your jaw may be wired shut for several weeks, which may result in weight loss.

Anterior Inferior Mandibular Osteotomy With Hyoid Suspension

AIMO involves a chin bone osteotomy to pull forward the tongue and anterior neck muscles to enlarge and stabilized the airway behind the tongue base. The procedure is not as effective as MMA, but it will not change your bite and your jaw will not have to be wired shut. AIMO may be performed as an outpatient procedure or in combination with MMA and other procedures.

Surgery of the Soft Palate

There are various operations of the soft palate that can treat snoring, upper airway resistance syndrome and sleep apnea. The most commonly performed procedure is an Uvulopalatopharyngoplasty (UPPP), which involves the trimming of a bulky soft palate. The UPPP is often performed in combination with removal of enlarged tonsils or adenoids. A Laser-Assisted Uvuloplasty is a modified version of the surgery that involves scarring cuts to tighten the soft palate and sequential trimming of the uvula over several appointments. While LAUP is less painful and has fewer side effects, it is less effective than UPPP in treating sleep apnea. Radiofrequency Volumetric Tissue Reduction, sometimes called Somnoplasty, shrinks the soft palate and tongue base using energy waves similar to microwaves. Each surgical procedure of the soft palate comes with potential for adverse side effects including throat swelling, nasal reflux of air during speech and fluid during drinking. Throat swelling usually occurs immediately after surgery. 

Nasal Surgery

Nasal obstruction may be treated by several nasal surgical procedures. Septoplasty straightens a deviated septum. Turbinate Reduction removes or reduces large turbinates and polyps. While these procedures may be performed independently as outpatient procedures, they are often used in combination with other procedures to treat snoring and sleep apnea.

Weight Reduction Surgery

Bariatric surgery, such as gastric bypass, may be indicated as a last resort treatment of morbidly obese patients with sleep apnea. Cervicofacial liposuction is a relatively safe procedure that selectively removes excessive fatty tissue below the chin and anterior neck to reduce the weight against underlying soft tissues. Liposuction also helps minimize airway collapse behind the tongue base. It is usually in combination with other surgical procedures.

Tracheostomy

The operation bypasses the entire upper airway by creating an opening in the larynx or windpipe. Although tracheostomy has the highest therapeutic efficacy for sleep apnea, it has many psychosocial problems and is typically reserved as a last resort for the treatment of severe sleep apnea. Tracheostomy is particularly beneficial for patients with complicated medical conditions that prevent other above-listed surgical procedures.