|Sleep Disorder Breathing:|
If you snore loudly and often, you may be accustomed to middle of the night elbow thrusts and lots of bad jokes. But snoring is no laughing matter. That log-sawing noise that keeps everyone awake comes from efforts to force air through an airway that is not fully open.
Perhaps 10% of adults snore. Although for most people snoring has no serious medical consequences; however, for an estimated 80% of snorers, habitual snoring is the first indication of a potentially life threatening disorder called “Obstructive Sleep Apnea.”
It has been estimated that the indirect costs of sleep disorders are:
“Apnea” is defined as the absence of breathing or the want of breath. When there is a cessation of airflow at the mouth and nose for more than 10 seconds an apnea episode has occurred. If a person experiences 30 or more apnea episodes during a seven hour period, then they are believed to be suffering from Sleep Apnea.
Apnea severity is usually categorized by the frequency of apnea episodes:
Central Apnea: Airflow stops because inspiratory efforts temporarily cease. Although the airway remains open, the chest wall muscles make no effort to create airflow. The etiology frequently is encephalitis, brain stem neoplasm, brainstem infarction, poliomyelitis, spinal cord injury, and cervical cordotomy.
Obstructive Apnea: The cessation of airflow due to a total airway collapse, despite a persistent effort to breathe. An obstruction in the upper airway can occur in three areas. They are the nasopharyngeal, oropharyngeal, and hypopharyngeal regions.
Regardless of the level, an obstruction causes the breathing to become labored and noisy. As pressure to breathe builds, muscles of the diaphragm and chest work harder. The effort is akin to sipping a drink through a floppy straw, the more the collapse the greater the effort. Collapse of the airway walls will eventually block breathing entirely. When breathing stops, a listener hears the snoring broken by a pause until the sleeper gasps for air and awakens, but so briefly and incompletely that he/she usually does not remember doing it the next morning.
Mixed Apnea: A combination of central and obstructive apnea usually beginning with a central episode being immediately followed by an obstructive one.
What is Snoring?
Many people think that snoring and apnea is the same thing. This is not true:
Snoring, which is caused by a change in airflow through the nasal and pharyngeal tissues, is only a sign that a patient may be suffering from apnea. It’s basically like water running through a pipe. If the water runs abnormally through the pipe it will vibrate. The same thing happens with airflow when it is partially obstructed.
Snoring can be categorized by its severity:
|THE ROLE OF THE DENTIST:|
Pre -2006, the gold standard of care for treatment of Sleep Apnea was the C-Pap machine (Continuous - Positive Air Pressure). However, the compliance rate after one year with the C-Pap machine is so low (estimated to be less than 90%) that there have been some changes to help more apneic patients. As of January 2006, the American Academy of Dental Sleep Medicine has stated that mild to moderate Sleep Apnea can be treated with Oral Appliance therapy. Dr. Stagg has had extensive training in evaluating, screening and treating Sleep Breathing Disorders with Oral Appliance therapy.
Because the etiology of obstructive Sleep Apnea is multifactorial and the treatment options are varied, proper diagnosis and treatment are best handled by a team approach. Dr. Stagg may include in her team the patient’s primary care physician, a sleep specialist, an ENT or an Internist.
Dr. Stagg plays an active role in:
|SCREENING for ADULTS:|
Patients will need to be evaluated for the presence of any physiologic and behavioral predisposing factors. A complete evaluation will reveal some of the physiologic factors. It should include the following:
An obstruction in the naso-pharyngeal area is usually caused by turbinate hypertrophy, a deviated septum, or an abnormal growth like a polyp. Although documenting a problem in this region is the job of an ENT, Dr. Stagg is qualified to access patients for patent nasal airway.
When evaluating the oropharyngeal region, Dr. Stagg first checks for hypertrophy in the tonsils. Then checks the size and position of the tongue as it relates to the soft palate. Finally she looks at the size and drape of the soft palate and the uvula. When the soft palate is excessive or drops down immediately, there is a good chance that this patient will suffer from an oropharyngeal blockage.
An obstruction in a hypopharyngeal airway space is a lot harder to detect through observation alone. We do know that when motor nerve activity stops during REM sleep, the tongue can drop back against the posterior pharyngeal wall and block the airway. Cephalometric films can give us some information on whether an airway is blocked. Although it is a two dimensional view of a three dimensional space, we can get an idea of the relative size of the airway, the posterior airway space, the length of the soft palate and the position of the mandible, maxilla and the hyoid bone.
Dr. Stagg has incorporated in her practice the Eccovision System by Health Technology Limited as a diagnostic tool to thoroughly and accurately assess the patient’s airway. Completely painless and non-invasive, the Eccovision emits sounds waves through a self-contained central processing unit comprised of two tools, the Rhinometer and Pharyngometer. They map the patient’s nasal passages and pharyngeal airway, respectively, via a technique called “acoustic reflection”. The results are onscreen graphics directly correlating to the physicality of the patient’s nasal passages and pharyngeal airway. When used properly these tools do two things, identify the area of obstruction and graphically display the changes in the oral airway with lower jaw advancement and vertical changes so you can see the effect an oral appliance has on oral airway size.
|SIGNS & SYMPTOMS:|
The following are some of the signs and symptoms that are indicative of a person who is suffering from apnea:
After Dr. Stagg has done her thorough Dental Examination, the patient’s condition will need to be “diagnosed” and confirmed by a Medical Doctor.
An ENT, a sleep specialist, and Internist can work with you to make sure you get a complete medical work-up and sleep test.
A proper medical work-up by a physician can detect physiologic changes as well. Typically, these patients will:
Once you understand some of the basics in sleep medicine, it becomes clear that Dr. Stagg, as a dentist, can play a significant role in both the prevention and treatment of snoring and OSA.
Early detection of structural abnormalities in the developing child affords us the opportunity to intervene with FUNCTIONAL THERAPY possibly preventing another eventual OSA casualty. For example, after a thorough orthopedic evaluation, Stagg may then decide to use orthopedic appliances to direct and control a child’s growth. Arch development, mandibular repositioning, and controlling vertical dimensions can create the intraoral volume needed to accommodate the tongue and prevent its compaction into the hypopharynx.
Many treatment methods have been tried over the years to treat snoring and obstructive sleep apnea. To date, three approaches seem to be most effective.
|A. GENERAL MEASURES:|
Continuous Positive Airway Pressure (CPAP):
This technique involves wearing a mask tightly over the nose during sleep. Pressure from an air compressor is used to force air though the nasal passages into the airway. The forced air creates a pneumatic splint, keeping the airway open and allowing the person to sleep normally. When accepted by the patient, this treatment is highly effective and is considered the “Gold Standard” on which all other treatments are compared. To increase patient acceptance, many improvements have been made over the last few years. Even with all the improvements that have been made, this treatment modality is still not for everybody. In fact, daily compliance by patients using CPAP is less than 50%.
Besides being uncomfortable, the other negatives to this treatment are that it is inconvenient, and it dries out the airway mucosa. There is also real concern of having reduced cardiac output and renal function.
C. SURGICAL APPROACHES:
NASAL RECONSTRUCTION: Surgical procedures to clear the nasal airway are done to correct turbinate hypertrophy, septal deformities, alar collapse and the removal of tumors or polyps.
UPPP: Uvulopalatopharyngoplasty was first introduced by Ikematsu in 1964 and later by Fujita in 1981. This surgical procedure enlarges the air space by excising redundant soft tissue of the palate, uvula, tonsils, posterior and lateral pharyngeal walls. Most clinical investigations indicate that the success rate of this surgical approach to correct OSA is less than 50%. This is due to the level and cause of the obstruction often being misdiagnosed. Removing some of the vibrating tissue may resolve snoring, but it does not prevent an obstruction by the base of the tongue. This is a serious surgery that is not without its complications.
LAUP: A laser Assisted Uvulectomy is a modification of UPPP surgery. It is accomplished using lasers and is considered a less invasive procedure. It is commonly being used to remove the redundant soft tissue of the palate believed to be causing snoring.
SOMNOPLASTY: This procedure uses a radio frequency to heat the tissue to a very precise temperature creating a finely controlled lesion of coagulation within the tissue. Over a period of four to six weeks, the injured tissue heals and in the process the tissue shrinks and tightens. This technique can be used to reduce the excess tissue in the soft palate, the nasal turbinates and the tongue. This procedure generally takes two to three treatments to shrink the tissue sufficiently to have a clinical effect.
Patients with a mandibular deficiency, surgical advancement to a normal occlusal relationship can bring the base of the tongue away from the posterior pharyngeal wall.
When both a maxillary and mandibular deficiency exists, a bimaxillary surgery will provide more physical room for the tongue as well as increase anterior tension on the tongue musculature. Waite et. al. has shown 96% improvement when bimaxillary advancement surgery was the primary surgical procedure.
In patients with a normal dental tongue space, a procedure called an anterior inferior genial osteotomy can be done.
Numerous appliances are available to treat snoring and obstructive sleep apnea. Research has shown that many appliances are quite effective and can now be considered an alternative when choosing a treatment modality. In fact, sleep appliances offer several advantages over other therapy choices. They are inexpensive, non-invasive, easy to fabricate, reversible, and quite well accepted by patients.
BASIC INDICATIONS for sleep appliances:
The appliance design that you choose will be dependent upon Dr.Stagg's knowledge of these variations and the oral conditions of the patient. In our office, when selecting an appliance, we will also evaluate the health of the TMJs, the periodontal structures and the number and health of teeth.
DIFFERENT EXAMPLES OF APPLIANCES:
CHOOSING AN APPLIANCE:
Dr. Stagg can very effectively treat both snoring and sleep apnea with Oral appliances. It is important to determine if or when there are often multiple factors involved in causing the patient’s problem. In fact, there can be an obstruction in the nasopharyngeal, oropharyngeal and hypopharyngeal regions at the same time.
It is also important to work in a team approach to properly identify the causes of the obstruction or appliances may only work 50% of the time regardless of the appliance chosen. Sometimes, even under the best circumstances, we may need to utilize more than once appliance before finding the best one for the patient.
|PROVIDING FOLLOW-UP THERAPY:|
When we work as a team, oral surgeons, internists, ENTs and sleep labs, all have their roles. Ours is to be in charge of the appliance therapy. As the attending dentist, Dr. Stagg should do the selecting, fitting, and monitoring of appliances. Periodic evaluation of these appliances is a must. When they are kept clean and stored properly, we see them lasting a long time. However, patients will occasionally break them or wear through them. Our office needs to be notified ASAP so that we can immediately replace a lost or broken appliance.
Another valuable role ambulatory sleep studies such as the Watch-PAT 100 test performs is to verify efficacy of the appliance. Once an appliance is delivered it is important to have another sleep study done on the patient in order to have objective data showing the appliance has effectively treated the OSA. Patients widely prefer an in-home study option as opposed to having to return to the sleep lab for another test.
|CONTRAINDICATIONS AND CONCERNS:|
As a dentist, Dr. Stagg deems it essential that she work as part of a team of health care professionals. This is particularly important because many other medical conditions can be associated with OSA. Some of these are:
As with any other mandibular repositioning appliance, we will need to make sure that the patient’s occlusion stays stable. Even though most appliances cap the teeth, you can still get flaring and other occlusal changes.
|Some of the COMMON SIDE EFFECTS that you see with the use of sleep appliances are excessive salivation, discomfort in the teeth, a dry mouth, tissue irritation from mouth breathing, temporary disharmonies in the bite and some pain in the joints. It is essential to respect the TMJs when considering the use of a repositioning appliance. A proper TMJ exam is recommended and if a patient is found to suffer from TMJ dysfunction, or their muscles are sore and painful while wearing a repositioning appliance, we may need to use another method.|
PAYMENT may be obtained from medical insurance plans for the treatment of snoring and sleep apnea with appliances, but benefits differ dramatically from plan to plan. So payment through insurance is not always guaranteed. As we are a dental office, we will help our patients get reimbursed from their medical insurance, however we do expect payment for services as they are rendered.