Sleep Apnoea & Snoring

shutterstock_238829449Snoring and SLEEP APNoEA

Quality of life can be drastically compromised by sleep disorders, and at Boston House we can offer expert help in the screening and treatment of these conditions.

Obstructive sleep apnoea, resulting in serious sleep disruption, can produce greatly impaired performance at work, at home, and on the road. Car accidents are statistically much more common in this group.

Snoring is a major symptom of a serious medical condition called ‘obstructive sleep apnoea’ (OSA), so careful screening to preclude the presence of this condition will be carried out prior to any treatment being started.

Snoring can occur during sleep when the pharyngeal airway (throat) narrows, due to a reduction in muscle tone. Snoring is simply a vibratory noise generated by the back of the relaxed tongue, pharynx and soft palate.

‘Benign’ snoring can be far from benign. The social consequences can be extremely distressing: banishment from the bedroom, marital disharmony, no holidays because of enforced sleep disruption when sharing a hotel room, fear of travelling – falling asleep during long journeys on public transport and the consequent ridicule and embarrassment.

Our sleep expert is Dr Aditi Desai whose background in restorative dentistry led her to develop an interest in sleep medicine over the past ten years ago. Dr Desai is currently the president of the British Society of Dental Sleep Medicine.

Dr Desai treats patients that suffer from snoring and obstructive sleep apnoea with dental appliances that can modify and enlarge the patient’s airways.

The treatment of sleep disorders is tailored to the individual patient and referral to a sleep specialist or ENT specialist is possible if treatments fail to deliver the required results.

Snoring Treatment Options

Background

During sleep, the pharyngeal airway (throat) narrows, due to a reduction in muscle tone. Snoring is simply a vibratory noise generated by the back of the relaxed tongue, pharynx and soft palate. Further narrowing produces not only louder snoring, but also laboured inspiration (breathing in). Finally, further narrowing may cause complete airflow obstruction known as obstructive sleep apnoea.

There comes a point where the increased inspiratory effort is sensed by the sleeping brain and a transient arousal is provoked (brief awakening to breathe before returning to sleep). A few of these arousals do not really matter.

However, when there are many (sometimes hundreds), sleep becomes seriously fragmented, resulting in daytime symptoms of excessive sleepiness. Snoring and sleep apnoea are part of a spectrum extending from ‘benign’ or ‘simple’ snoring with no sleep disturbance, through to obstructive sleep apnoea with severe daytime sleepiness symptoms and the physiological consequences of recurrent asphyxia (insufficient oxygen).

There are many claims made for snoring ‘cures’ or treatments and our understanding of snoring and sleep apnoea has increased enormously in the last ten years. Much can be done to help both these conditions. As a result, there has been an extraordinary rise in the number of hospital referrals for these conditions.

Is treatment really necessary?

‘Benign’ snoring can be far from benign. The social consequences can be extremely distressing: banishment from the bedroom, marital disharmony, no holidays because of enforced sleep disruption when sharing a hotel room, fear of travelling – falling asleep during long journeys on public transport and the consequent ridicule and embarrassment. Many of the stories we hear are very sad and not worthy of the all too common joking approach to snoring.

There is no doubt that treatment is essential for obstructive sleep apnoea and extremely appropriate for snorers. Obstructive sleep apnoea, resulting in serious sleep disruption, can produce greatly impaired performance at work, at home, and on the road. Car accidents are statistically much more common in this group. The response to appropriate therapy can be extraordinarily dramatic with commonly, a return to a state of alertness and vitality often not previously experienced for years or even decades.

Is the problem only severe snoring?

‘Benign’ snoring can be far from benign. The social consequences can be extremely distressing: banishment from the bedroom, marital disharmony, no holidays because of enforced sleep disruption when sharing a hotel room, fear of travelling – falling asleep during long journeys on public transport and consequent ridicule and embarrassment.

Many of the stories we hear are very sad and not worthy of the all too common joking approach to snoring.
There is no doubt that effective treatment is essential for obstructive sleep apnoea and extremely appropriate for snorers.

Obstructive sleep apnoea, resulting in serious sleep disruption, can produce greatly impaired performance at work, at home, and on the road. Car accidents are statistically much more common in this group. The response to appropriate therapy can be extraordinarily dramatic with, commonly, a return to a state of alertness and vitality often not previously experienced for years or even decades.

There is evidence that so called ‘simple snoring’ is also linked with persistent daytime hypertension, insulin resistant diabetes and carotid artery atherosclerosis. Many now believe that ‘simple snoring’ may be a precursor to OSA.

Are any of these features of Sleep Apnoea present?

  • Daytime sleepiness (not tiredness) e.g. nodding off during less stimulating activities: reading, watching TV, meetings, etc.
  • Bed partner reports episodes of breathing cessation (although any snorer will have occasional such events, especially when sleeping supine – ‘on your back’).
  • Patient experiences waking with choking/obstructed episodes.
  • Regularly waking un-refreshed in the morning.
  • Neck circumference over 17″ (usually, but not always, indicates being overweight).
  • Small pharynx (throat) on visual inspection.
  • Waking hearing the ‘end of your own snore’.
  • Obesity, BMI >30 (weight in kilograms divided by height in meters squared)
  • Having to sleep propped up.
  • Making frequent trips to the bathroom during the night.

What causes snoring and sleep apnoea?

The most common OSA predisposing factors are shown below:

  • Overweight
  • Nasal stuffiness
  • Late evening alcohol
  • Use of night time sedatives
  • Residual tonsils
  • Smoking
  • Receding lower jaw
  • Hypothyroidism
  • Menopause
  • Sleeping on your back

If one or more of these factors are present, you may find that you can successfully help yourself or your bed partner with simple lifestyle modifications. However, sometimes none of the potential causes can be identified and/or no beneficial effect is seen after the OSA predisposing factors have been addressed.

What has the dentist to offer snorers?

There is good evidence that custom made intra-oral appliances – mandibular repositioning appliances (MRAs) [variously known as MRDs – D for device] worn in the mouth at night can greatly help reduce snoring. They work by holding the lower jaw and tongue forward during sleep. The narrowing of the airway behind the tongue is prevented thus reducing the likelihood of snoring and even apnoea episodes.

MRDs are primarily indicated for the treatment of simple, non apnoea snoring as well as for mild – moderate OSA when prescribed and monitored as part of a multidisciplinary team.

MRDs consist of close fitting, custom made ‘rims’ that fit around the upper and lower teeth. These rims are connected in various ways to allow the lower jaw to be postured and held in a forward position. Many of these appliances will allow some horizontal and vertical lower jaw movement.

MRDs impose significant forces to the teeth and jaw joints and the dentist has to be satisfied that these structures are sound and able to withstand these forces. Side effects of treatment may include excess salivation (sometimes a dry mouth), jaw joint ache and tooth sensitivity. These are short-term side effects and usually disappear once you become accustomed to the appliance. Evidence of long-term side effects include minor tooth movements and bite changes. These side effects must be balanced against the benefits of treatment. Most patients do not find these side effects sufficiently intrusive to discontinue treatment.

Examples:

BHDDC

ResMed Narval CC® anti-snoring appliance

 

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Thornton Adjustable Positioner (TAP) anti-snoring appliance

 

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OrthoApnea anti-snoring appliance

 

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Somnodent anti-snoring appliance

 

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Herbst anti-snoring appliance

 

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Silensor anti-snoring appliance

 

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Somnowell anti-snoring appliance

 

 

Treatment of Sleep Apnoea

CPAP (continuous positive airway pressure) is considered the first line of treatment for severe OSA and is very effective in terms of overcoming the symptoms of excessive daytime sleepiness. Patients with severe sleep apnoea respond well to this therapy. However, it is without doubt an arduous therapy, which involves wearing a mask during sleep (over the nose or nose and mouth), which is connected to a small air pump. The treatment works by blowing air into and pneumatically inflating the collapsible part of the upper airway, thus preventing vibration and blockage of the flexible upper airway breathing tube. Subsequently, sleep apnoea and snoring are prevented.

If your medical history and screening suggests there is a likelihood that you are suffering from OSA then you will be referred to a Respiratory Physician for a sleep study and diagnosis. This may involve spending a night at a hospital ‘Sleep Laboratory’ or more usually, you will be given a portable monitor so that a simpler study can be carried out in the comfort of your own home. Such monitors can record your heart rate, your blood oxygen carriage, your breathing (including any apnoeic events), snoring events and body position.

Once diagnosed by the Consultant Respiratory Physician, custom MRD therapy may be prescribed. The exact therapy depends upon the severity of your sleep apnoea and the existence of other medical problems. Oral appliances can be used to treat all severities of sleep apnoea but effective results are less certain with increasing severity of apnoea. Severe sleep apnoea, if treated with an oral appliance, requires careful patient monitoring.

Such custom made oral appliances can only be made, fitted and monitored by trained dentists.
When MRDs are used as an alternative treatment for severe OSA the trained dentist MUST be working as part of a multidisciplinary team, which would include either a Consultant ENT surgeon or Respiratory Physician.

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Continuous Positive Airway Pressure (CPAP)

Some useful terms

APNOEAIC EPISODE (ap-knee-ic) A period of not breathing whilst asleep usually lasting for more than 10 seconds.

HYPERCAPNIA (high-per-cap-nee-ah) A raised level of carbon dioxide in the blood. This is the gas normally breathed out. Its blood level rises if breathing is inadequate. Usually measured by taking an arterial blood sample.

HYPERSOMNOLENCE (high-per-som-no-lence) Technical expression for excessive daytime sleepiness.

HYPNOGRAM (hip-no-gram) The final print out of the all-night sleep stages after an overnight study. (REM and non-REM).

HYPOPNOEA (high-pop-nee-ah) A period of underbreathing: usually for more than 10 seconds.

HYPOTHYROIDISM (high-po-thy-royd-ism) Also known as myxoedema (mix-ee-dee-ma). When the thyroid gland fails to make enough thyroid hormone. Can present as obstructive sleep apnoea.

HYPOXIA (high-pox-ee-ar) When the body is short of oxygen and therefore the level in the blood falls.

HYPOXIC DIPS (high-pox-ic) The falls in oxygen levels, seen on the oximeter, that usually accompany apnoeas. Also known as desaturations, because, when not hypoxic, the blood is described as fully saturated with oxygen.

INSOMNIA (in-som-nee-ah) Being awake when you want to be asleep. Often thought of as a problem but may not be. Common if people try to spend too long in bed.

MANOMETER (man-om-eater) Device to measure the pressure being delivered by a CPAP machine (usually measured in centimetres of water [cm H20] – where a common CPAP pressure is about 10).

MICRO AROUSALS Very brief “awakenings”, perhaps only seen when the brain waves (EEG) are being monitored.

MOVEMENT AROUSAL These are short awakenings with minor body movements, about which the sleeper is unaware.

MUFFLES™ Wax ear plugs. Less comfortable than the foam ones (EAR™) but more effective. From most chemists.

NARCOLEPSY (nar-co-lep-si) A cause of daytime sleepiness due to an inherited disorder of the control of dreaming sleep. Has to be differentiated from sleep apnoea, periodic leg movements and other rarer causes of daytime sleepiness.

NASAL CPAP (nasal see-pap) The process of delivering a continuously raised airway pressure mask worn on the nose, hence Continuous Positive (as opposed to negative) Airway Pressure.

OBSTRUCTIVE SLEEP APNOEA (ap-knee-ah) This syndrome is commonly referred to as OSA (obstructive sleep apnoea/apnea) or

OSAS (obstructive sleep apnoea/apnoea syndrome). Usually made up of 30 or more periods of not breathing when asleep. Each period lasting for more than 10 seconds.