Snoring and Sleep Apnea

Snoring is a topic most people won’t expect to find on as dentist site. But the reason is simple. Some dental appliances have been proven to help reduce snoring, which is a symptom of sleep apnea and can be detrimental to one’s health.

Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause can last from a few seconds to minutes, and may occur up to 30 times or more an hour.

If you snore or have been told that you do, answer the following questions:

• Have you ever been diagnosed or treated for sleep apnea?
• Do you have allergies or problems breathing?
• Do you have any problems with breathing through your nose?
• Do you drink alcohol and or take sedatives six hours prior to going to sleep?
• Are their disorders of sleep apnea in your family?
• Have you sought treatment for snoring?
• Do you tend to be tired in the afternoon?
• Do you sleep but not wake up refreshed?

Email us if you answered “yes” to any of these questions. Feel free to print this and fill it out before coming in to our office. Might also be a good idea to give a copy to that spouse who snores!

Epworth Sleepiness Scale

In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number or each situation.

• 0 = WOULD NEVER DOZE
• 1 = SLIGHT CHANCE OF DOZING
• 2 = MODERATE CHANCE OF DOZING
• 3 = HIGH CHANCE OF DOZING

• ___ Sitting and Reading
• ___ Watching TV
• ___ Sitting inactive in a public place (i.e., in a theater)
• ___ As a car passenger for an hour without a break
• ___ Lying down to rest in the afternoon
• ___ Sitting and talking to someone
• ___ Sitting quietly after lunch (without alcohol)
• ___ In a car, while stopping for a few minutes in traffic
• ___ TOTAL SCORE

• Have you had a sleep study? ________
• Do you own a CPAP? ______
• If so, do you use it nightly? _________

Take a more detailed sleep test here and find out your score online.

Treatment for Snoring

1. Do nothing.
2. Sleep on your side rather than your back.
3. Exercise and weight loss reduction.
4. Use Continuous Positive Airway Pressure (CPAP).
5. Use the SnoreGuard, TheraSnore, The Silent Night, the O2 Oasys, or, the Silencer.

Dental Appliances For Snoring and Sleep Apnea

Snoring can be very annoying, and may disrupt or strain your relationships with your spouse, family members, or roommates. Snoring may also be a sign that you actually stop breathing at times during the night, and it can be very serious.

Sleep apnea is even a more serious condition because the throat becomes blocked during the night, stopping breathing for short periods of time. If you have sleep apnea, your partner may hear you alternate between snoring very loudly, and being very quiet.

You may even gasp or snort in your sleep. Some general symptoms of sleep apnea or snoring can be waking up tired, even after a full night’s sleep, or waking up with a headache. Additionally, some people feel very sleepy, or fall asleep at inappropriate times; for instance, at work or while driving your car.

(On the left is a picture of Dr. Bill Williams with Dr. John Remmer, inventor of the Remmer Sleep Recorder for Obstructive Sleep Apnea and Upper Airway Restriction at the Sleep Disorders Conference in Duluth, GA.)

There are many instances of irritability, with short temper and problems with concentration or memory. Because sleep is repeatedly interrupted many times during the night, you may never get a full night’s sleep with either snoring or sleep apnea.

There are also indications that high blood pressure, with the attendant risk of heart attack and stroke, particularly early morning or during the night, may be attributed to snoring and sleep apnea.

If you suspect that you have sleep apnea, or if your spouse notices that your stoppage of breathing, gasps, choking, snorting, and your attempts to start breathing again are very alarming, you should be in contact with the appropriate physician and/or sleep specialist.

For help in finding the correct sleep specialist to help with these sleeping disorders, you may contact our office for referrals.

The cause of snoring is usually a narrow airway. That is because air travels faster through a slender tube than through a broad one. This rapidly moving air causes the soft tissues of the throat, for instance the tonsils, soft palate and uvula, to vibrate very rapidly.

It is this vibration or swiftly moving air that is the sound of snoring. So the question is, “Why does snoring occur? There can be several areas involved such large tonsils, a long soft palate or uvula, and, in people who are overweight, excessively flabby tissue.

Also, age has an important effect in that tissues tend to be slightly less taut and tight as we age. The most common cause of a narrowed airway is a tongue that relaxes too much during sleep, and gets relaxed back into the airway with each breath taken.

In the case of complete airway obstruction, such as occurs in obstructive sleep apnea, the airway obstruction won’t clear until the brain’s oxygen level falls low enough to partially awaken the sleeper.

The tongue then returns to a normal position, and the airway seal is broken, usually with a loud gasp, which awakens the patient. We call this oxygen desaturation.

The treatment for both snoring and sleep apnea falls under generally three categories: (1) surgical; (2) medical; (3) dental. Measures such as weight loss, smoking cessation, and decreasing or eliminating drugs or alcohol should be undertaken.

(Here’s Dr. Mark Abramson, developer of the O2 Oasis Dental Snoring and Sleep Apnea Appliance with Dr. Bill Williams at the Sleep Disorders Conference in Duluth, GA.)

Usually, substantial lifestyle changes are unrealistic in many patients, so other forms of therapy must be considered. Many treatment options open to most people have been, at best, unattractive and undesirable and unobtainable.

Surgical procedures have had recent developments, such as laser surgical techniques for reduction and/or elimination of the uvula and other pharyngeal tissues. A surgical solution offers the patient a chance of relief, but with considerable discomfort, whatever the technique.

There also remains no guarantee of success when the anatomical changes are irreversible. The surgical approach usually involves removal of a lot of soft tissue, such as the soft palate, tonsils, uvula and some adjacent throat muscles so as to enlarge the opening of the airway.

The disadvantage of the surgical approach, of course, are the inherent risks of the surgical procedure itself. Sometimes the removed tissue grows back over time, and there is the possibility that one could get a nasal speech or a regurgitation of food into the nose.

The surgical approach has proven to be only about 40 to 50% effective, and there are other disadvantages in that it is an irreversible procedure.

The current gold standard of treatment is a respirator-like device known as a NCPAP (or nasal continuous positive air pressure). The patient wears a mask which fits over the nose, forming an airtight seal. A hose connects the mask to an air pump near the bedside.

A continuous flow of air holds the airway open and relieves the snoring and sleep apnea. Pump noise, voice changes, skin irritation from the mask, along with general throat dryness, reduce the patient compliance with this form of treatment.

Also, nighttime use of the CPAP appliance is difficult because a restless sleeper can get caught in the hose and perhaps loosen it, and also, the hose must be unhooked and reconnected during the nighttime if the patient needs to go to the bathroom or get up for any other reason.

Although the CPAP appliance is very effective in treating snoring and sleep apnea, the compliance rate is fairly low sometimes.

Another effective way of treating sleep apnea or snoring is sleeping position. The preferable sleep position is on one side, which makes it easier for the airway to remain open.

Some people even go to the length of sewing tennis balls in the back of their nighttime sleep wear so as to be reminded or prodded into not turning over and sleeping on their back. The adjacent airway diagrams are representative of sleeping position and the effect of the tongue on closing the airway.

A forward tongue and jaw position, which can be obtained with a dental sleep appliance, is an effective way to open up the airway and keep it open during the night.

Testing Instrumentation

The Remmers Sleep Recorder records signals that are commonly used in diagnosing patients who are suspected of having sleep apnea.

These signals are:

• Blood oxygen saturation
• Heart rate
• Pulse amplitude
• Nasal airflow (through nasal cannula pressure measurement)
• Respiratory airflow (through pneumotachograph when CPAP is used)
• Mask pressure (when CPAP is used)
• Snoring sound
• Body position
• Respiratory movements

This unit is used for pre- and post-titration evaluation of the airway when an oral appliance is being fabricated for the treatment of snoring and obstructive sleep apnea.

Dr. Williams does not diagnose sleep apnea. That must be completed by a board certified sleep specialist and typically involves in in-house polysomnogram.

Dental Sleep Appliances

Many studies over the past years have shown that advancing the mandible with dental sleep appliances may provide relief from snoring by physically pulling the tongue forward and out of the airway. As simple as this would appear, there are a number of significantly relevant ideas that enter into the picture.

An appliance needs to be fabricated that will be worn every night that will not compromise the TMJ, will not compromise the teeth, will not compromise the soft tissue, will not be bacterially invaded, and will not disturb the sleep partner while remaining comfortable to the wearer.

You can see that designing and use of a intra-oral sleep appliance for sleep apnea and snoring is very complex. In addition, the presence of bruxing on the part of most people who snore and who have sleep apnea is very important.

Newer research has shown that a very significant portion of patients, who have sleep apnea and snore, also brux very vigorously during the night.

The appliance that we use most often and meets all the criteria that has been mentioned for an ideal appliance is called The Silencer, of which some components are manufactured by Integrated Health Technologies.

Although we use many appliances from many different sleep appliance fabricators, we have found that The Silencer, from Integrated Health Technologies, is the most effective, and meets all the criteria for the most ideal appliance, and allows some bruxing.

The American Sleep Disorders Association, at their annual meeting, adopted a resolution, which accepted dental appliance therapy for the treatment, not only of snoring and mild sleep apnea, but also extended their recommendation to include treatment for moderate and severe cases of sleep apnea, when the snorer rejects or can’t comply with the Continuous Positive Air Pressure (CPAP) device.

Additionally, the American Medical Association unanimously passed a resolution to study the issue of sleep disorders, and this should, hopefully, address the correlation between sleep disorders. and motor vehicle accidents in addition to work place accidents due to excessive daytime sleepiness.

The Silencer, the O2 Oasis, and the Silent Night are all useful appliance in the field of dental appliances for snoring and sleep apnea, and each meets all the criteria for an ideal dental sleep appliance.

The Silencer has a two piece appliance that is adjustable in five different positions, which are forward and backward. Each position can be advanced some two millimeters from each other, giving a more adjustable range of forward positioning of the tongue and mandible.

With some other appliances, mainly the boil and bite type appliances, the position is usually fixed, and there is no freedom for the bruxer to move the jaw in any direction.

The advantage of having an adjustable appliance is, if the patient returns home and there is still some component of snoring or sleep apnea, which is noted by the sleeping partner, the patient can return to our office, and we can adjust the appliance in a more effective position, either forward or backward.

The repositioning can be repeated over several times until the optimal jaw and tongue position is reached, and it can be changed at any time in the future if there has been cessation of snoring in one position.

This appliance eliminates the problem with older types of appliances when they did not totally eliminate the snoring problem. In the past, the older appliances either had to be re-done, or the patient just gave up on them as being not effective.

If You Think You Have A Snoring Or Sleep Apnea Problem

In our office, we would either recommend you go directly to a sleep specialist, such as an ENT physician (Ear, Nose and Throat), or go to our sleep disorders center at Northside Hospital, and, with proper referral from your physician, undergo an overnight sleep study.

Through the use of various sophisticated physiological monitors, your heart rate, breathing, brain waves, muscle activity, bruxing activity can all be measured and recorded. They will be analyzed, and the sleep center will find out if your sleep apnea is mild, moderate, or severe, and advise you on the proper courses of treatment.

It also may be possible to undergo a trial treatment of either a dental appliance or a CPAP machine at the sleep clinic.

If you think that you have a snoring or sleep apnea problem, and desire treatment, either as a new patient or as a patient in which all other modalities have failed, and you wish to try a dental sleep appliance, please be in direct contact with our office.

We usually work with you, your physician, and the sleep center in fitting and fabricating any dental appliances. We also work very closely with insurance companies in getting payment for dental sleep appliances, and it is probable that you would be covered under medical insurance, provided you have the proper sleep studies and a referral from a physician.

At The First Visit In Our Office

The first visit for fitting of a dental appliance will include a thorough examination of teeth, mouth, TMJ, with the possible addition of needed x-rays of your jaw joints. It will also include dental molds, from which you may be fitted with a dental appliance.

There is a possibility that the first visit will include a temporary appliance, which you may take home and try out for a week to see if it’s effective before you invest in a more permanent and more expensive appliance.

At a succeeding visit, we will show you how to place the appliance in your mouth, how to care for it, how to use it, and we will check back with you in a few weeks to make sure you are comfortable with the appliance, wearing it regularly, and also make sure it is effective in treating either your snoring or sleep apnea.

It is also possible that we will be referring you back to your physician or sleep specialist to determine how effectively the appliance is in controlling your snoring and sleep apnea. We will also see you at regular intervals several months apart to maintain and to adjust the appliance that you are wearing so that it remains effective.

The material in this outline of snoring and sleep apnea has largely been obtained from Integrated Health Technologies, Wayne Halstrom, D.D.S., and from The Sleep Disorders Dental Society. If there are any questions or specific problems, you may be in contact with our office.

For information on the Silencer, click here.