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Treatments
If an internet search is performed using the string ‘snoring’ or ‘OSA’ you will be swamped with treatment options for these two conditions that range from pillows, nasal sprays, breathing exercises, weight-loss pills, over the counter nose strips, and meditation tapes, to the more scientifically and researched evidence based treatments such as Continuous Positive Airway Pressure (CPAP), mandibular advancement appliances, and surgery.
Dr. Tony Eldridge B.D.S
The treatment of snoring and Obstructive Sleep Apnoea (OSA) is not performed in a ‘One Stop Shop’ or by purchasing a product off the Internet. It is often a condition that occurs from a multifactorial cause i.e. from a combination of weight gain, genetics, throat tissue architecture, nasal obstructions, diet, allergies, medical conditions, and so forth. Therefore, in many cases, only addressing one of the causes is not enough to treat the snoring or OSA. Often, a combination of treatments is required to achieve maximum medical improvement of a person suffering from a sleep disorder.
Oral Appliances
The use of oral appliances in the treatment of snoring and mild to moderate sleep apnoea is a scientifically proven and effective method. The American Academy of Sleep Medicine (AASM) recently reviewed its 1995 practice parameter guidelines on the use of Oral Appliance Therapy (OAT) recommending it as a first line treatment in specific circumstances of Snoring and Obstructive Sleep Apnoea. These updated guidelines by Kushida et. al. appeared in the February 2006 issue of the journal Sleep.
Although not as efficacious as CPAP, according to these guidelines, for patients with snoring or mild to moderate sleep apnoea, who cannot tolerate CPAP, fail treatment attempts with it, are unwilling to use it, or do not respond to CPAP, and those that fail treatment attempts at weight loss and changes in sleeping position, oral appliances are indicated.
In more severe cases of sleep apnoea when CPAP cannot be tolerated or very high pressures are required, OAT may be used as a replacement of or in conjunction with CPAP. The decision to cease using CPAP however, and the benefits of its use against the adverse health effects of severe sleep apnoea should always be considered very carefully.
How Do Oral Appliances Work?
Oral appliances (or Mandibular Advancement Splints) are worn on the upper and lower teeth during sleep and help prevent the tongue and the soft tissues of the mouth and throat from collapsing by holding the lower jaw forward.
By wearing the appliance during sleep, adequate air intake occurs and helps provide normal regular sleep free from snoring, obstructions, and respiratory related arousals. Appliances can be used by themselves or in conjunction with other treatments such as surgery or Continuous Positive Airway Pressure (CPAP) systems. Designed properly for each individual patient and their specific circumstance, oral appliances are safe, effective, comfortable, and have very few side effects.
There are basically two types of oral appliances on the market.
1. Non-adjustable: These are essentially two mouthguards joined together that fit over the upper and lower teeth and hold the jaw forward in one position only. Many variations of one-piece oral appliances are available on the market and these are most often sold over the Internet.
Boil & Bite non-adjustable.
“Boil and Bite” appliances, and one-piece appliances are cheap and often the optimal position of the lower jaw is a pure guess for patients and dentists. It is these types of appliances most of the problems with jaw joints, muscle pain, and poor efficacy result from as fitting and function is not professionally and expertly carried out.
2. Adjustable: Current research has proven that adjustable appliances are far more superior, effective, and comfortable in the treatment of snoring and OSA. The most comfortable appliances are constructed by taking impressions of the patients teeth and positioning the jaw forward slowly in increments until the ideal position is achieved. Often movements of only 1mm are required to bring the patient from “I am still snoring with this appliance” to “I feel great in the morning and my wife is very happy”
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Somnomed MAS fully-adjustable.
Adjustable appliances also have the added benefit of protecting the teeth from bruxing and being customisable to include additional components and design for retention, tongue positioning, lip seal, and jaw joint problems.
Tongue Retaining Devices: These appliances are designed to allow the tongue to remain in a forward position between the anterior teeth by holding the tongue in an anterior bulb with negative pressure, during sleep. This pulls the tongue forward to enlarge the volume of the upper airway and to reduce upper airway resistance.
Tongue Retainer device.
Tongue retaining devices are used mainly for people with no natural teeth. Results vary greatly between different people due to comfort factors.
Treatment with Oral Appliances
Oral appliance therapy for the treatment of Snoring and Sleep Apnoea is very reliable and efficacious mode of therapy when carried out professionally and with expert knowledge. It is not however an isolated treatment, or a ‘magic plastic cure’ using a one size fits all approach such as ‘off the shelf boil and bite’ appliances.
Sleep disorders must always be considered and assessed intimately with lifestyle issues, soft-tissue architecture, the Temporomandibular Joints, oral health, the occlusion, and general health including any existing medical conditions and medications. A working relationship therefore between Respiratory Physician’s, Ear Nose and Throat surgeons, General Medical Practitioners, and a Dentist who has specific knowledge, training, and experience in treating sleep disorders is essential to successful team management of patients with snoring and sleep apnoea.
Patients treated with oral appliances should return at strict regular scheduled recalls to monitor patient adherence, allow adjustment of and evaluate deterioration of the appliance, and to evaluate the oral tissues, joint structures, and occlusion. Regular follow up is also needed to assess the patient for signs and symptoms of worsening OSA.
Sleep breathing disorders can contribute to severe life threatening medical complications and so it is our priority to provide you with a ‘Long-term Treatment Plan’, and not just a treatment.
CPAP
Positive airway pressure systems maintain the upper airway patency during sleep by forming a pneumatic ‘splint’. This pressure prevents the airway from collapsing by pumping air via a mask attached to the machine by a hose.
The constant air pressure, usually around 5-20 cmH20 (centimetres of water) is delivered throughout the breathing cycle. Most patients do well with 8-10 cmH20 air pressure. The exact pressure required for each individual patient is normally assessed in the first instance during an overnight Polysomnography (sleep study). Newer machines are also available in auto-titrating models that allow computer-controlled pressures to be delivered that are automatically adjusted as required during sleep.
Recent advances in masks, humidification, pressure delivery systems, and patient education have greatly improved comfort and adherence to CPAP machines and they are still rated as the most effective medical treatment for severe Sleep Apnoea.
Surgery
The strategy behind surgical intervention for the treatment of snoring and obstructive sleep apnoea is to open the site of blockage. The actual blockage site however, may be in more than one place and are typically found at the nose, soft palate, or base of the tongue. Therefore, some of the more well know procedures such as removal of tonsils, straightening a crooked septum, and trimming of the soft palate (removal of the fleshy bit of the roof of the mouth – UPPP) are routinely carried out. Other less well known techniques may also be employed such as enlargement of the breathing space behind the tongue, implants into the soft palate, surgical advancement of the mandible or maxilla (lower or upper jaw), or an operation directly on the tongue tendons.
Surgical techniques are:
- Rhinoplasty, Septoplasty, and Adenoidectomy
- Uvulopalatopharyngoplasty (UPPP) and Tonsillectomy
- Somnoplasty and Pillar-palato implants
- Genioglossus advancement
- Hyoid Suspension
- Maxillo-mandibular advancement
- Tracheotomy
Post operative healing of a UPPP.
The majority of these surgical techniques are carried out by an Ear, Nose, and Throat surgeon (ENT), whilst an Oral and Maxillofacial surgeon will perform the jaw advancement surgery. In many cases, surgery alone will not provide complete relief from snoring and OSA symptoms but it can often be required as a very important part of a comprehensive treatment plan
Site © 2007-2008 Dr. Tony Eldridge B.D.S. Last modified August 11, 2008.