Host: This video is designed to give the dentist or medical professional. A sorted foundation and understanding of snoring and related sleep disorders. We will examine the role of the dentist, physician and patient in the treatment of these disorders. We will begin by discussing the history of snoring and then move on to the causes of snoring and sleep apnea, patient screening and diagnosis finally we will cover a variety of treatments including medical, dental and over the counter or home remedies.
Snoring undoubtedly has affected human begins from earliest man; references to snoring appear throughout latterly from Roman times to the present. It was in fact that Charles Dickens character Joe from the Pickwick Papers that inspired the term pickwickian syndrome. This term was first used in 1956 to define the classic individual with a sleep disorder accessibly sleepy and frequently obese. In 1965 a French researcher Gaston made the connection between excessive sleepiness, obesity and snoring. As you might expect in general men snore more than women by a margin of about 2 to 1.
Snoring also increases with age and weight gain approximately 30% of all man age 30 snore. This figure will increase by approximately one percentage point per year until age 60. The use of drugs or alcohol before bed time are also factors that can contribute to snoring, finally upper airway abnormalities can be key factors and causing snoring. The social consequences of snoring often are the reason patients request treatment. It is not uncommon to see a spouse wearing ear plugs, sleeping in a separate room or even considering divorce but the occurrence of sleep disorders associated with snoring is also a strong motivation for medical intervention.
The specific reason for snoring varies from person to person but snoring is generally caused by a partial blockage or narrowing of the upper airway. The snoring sound occurs, when the base of the tongue falls against the soft palate and causes associated tissues to vibrate. These tissues include the soft palate, tonsils, tonsillar pillars and the back and the side walls of the throat.
The sleep disorder most frequently associated with snoring is a condition known as sleep apnea. The term apnea a Greek word means for want of breath some estimates indicate that sleep apnea is present in as many as 3% to 4% of the population. Sleep apnea usually versions with age and weight gain. As with snoring sleep apnea is more prevalent in men than women. Sleep apnea syndrome has become the accepted medical term for those patients suffering from obstructed breathing and episodes of frequent arousals during sleep, resulting in excessive day time sleepiness. There are three types of sleep apnea the most common type is obstructive sleep apnea or OSA.
In OSA the patient experiences intermediate upper airway obstructions that cause a sensation of breathing. Another form of sleep apnea is known as central sleep apnea because it is associated with the transient reduction of the central raspatory drive that controls breathing. This causes the diaphragm muscles to stop working and prevents the lungs from receiving oxygen. It is not uncommon to find patience with OSA, who have some central sleep apnea mixed in. This brings us to the third type of apnea known as mixed sleep apnea this type of apnea begins as a central type with reduced central raspatory drive and concludes with obstruction of the upper airway.
Sleep apnea is generally arbitrarily classified as mild, moderate and severe; this classification is based among other things on the apnea hypopnea index or AHI, which is the frequency of apneas and hypopneas for hour of sleep. Mild sleep apnea presents principally with snoring. This patient may or may not have day time sleepiness and will have an apnea hypopnea index or AHI of 20 or less. With moderate sleep apnea day time sleepiness is more of a problem, personality changes such as depression and irritability and lose of sexual Lobito in the patient may be present.
The snoring will be accompanied by very noticeable pauses in the breathing pattern. The AHI index will be between 20 and 40 and apnea, hypopnea index have more 40 is considered severe, severe sleep apnea's will have a considerable problem somnolence and lethargy. They will fall asleep at inappropriate or inconvenient times, such as while driving a car or even in public places. Snoring and apnea usually occur due to recurrent upper airway obstruction during sleep, relaxation of the upper airway dilator muscles the tongue relapsing back against the soft palate and mucous membrane congestion of the nasals passages all can contribute to some degree to the narrowing of the upper airway.
Following the onset of sleep muscle relaxation and gravity cause the tongue to drop back against the soft palate, which in turn pushes back against the posterior oropharyngeal area -- either partially or totally occluding the airway. If the airway is partially occluded the patient will suck air at a greater velocity through the mouth causing the uvula and or the soft palate to vibrate creating the snoring noise. If the air way is totally blocked the patient is unable to breathe and has an obstructing apnea.
During breathing a negative intra pharyngeal pressure develops, if the nasal passage is congested or blocked and the patient is breathing orally the negative pressure is increased because the skeletal muscles relaxed during sleep including the dilating muscles of the upper airway, this negative pressure can pull the soft tissues of the collapsible airway inward there by partially or completely occluding the airway. When a patient has OSA the sensation of breathing during sleep produces hypoxemia a lowering of the blood oxygen level as well as hypercapnia and increase in the carbon dioxide level of the blood the corresponding reaction by the autonomic nervous system is to arouse this snoring.
The patient arouses just enough to take a deep breathe of air. These micro arousal events can occur as frequently as one hundred times an hour in a severe sleep apnea. While snoring is generally caused by a partial obstruction of the upper airway the actual side of the obstruction can vary occurring anywhere from the nerves to the hypopharyngeal space, all though few people snore suddenly due to a nasal source. Nasal obstructions such as deviated septa, polyps and adenoids sometimes contribute to OSA and snoring.
Children who snore often can suffer from a nasopharyngeal obstruction, such as enlarged adenoids. Overall pharyngeal obstructions are generally caused by and elongated soft palate large uvula or tonsillar hypertrophy, macroglossia or an enlarged tongue retrognathia of the mandible and then inferiorly positioned hyoid bone can also be factors in oropharyngeal obstructions. Airway collapse at the level of the epiglottis and vocal cords is an occasional cause of OSA, hypersomnolence or excessive day time sleepiness or EDS and loud snoring are the two most common symptoms of sleep apnea syndrome.
Virtually everyone, who has OSA also has heavy snoring, the patience with central sleep apnea are less likely to be snorers, other clinical features of sleep apnea syndrome include a wakening or choking during the sleep and light unrefreshing sleep. We also sometimes seem nocturnal insomnia, nocturnal myoclonus, or abnormal motor activity such as leg jerks during sleep intellectual and personality changes, sexual impotence and morning headaches and dry mouth, any physical condition that reduces the size of the airway is an important factor in OSA.
Obesity is a common disorder associated with sleep apnea; the more obese patient will have a larger tongue and soft palate. Further more as a person gains weight the added mass around the neck constrict the airway, obese patience may have an increased amount of fat deposition in the upper airway. Micrognathia are a small lower jaw is another disorder that is commonly associated with sleep apnea as it can reduce the upper airway diameter. Macroglossia and retrognathia a posteriorly displaced mandible are also often present in snores.
But these conditions alone do not necessarily indicate a problem with snoring or sleep apnea, other disorders that are also sometimes associated with obstructive sleep apnea include adenotonsillar hypertrophy or enlargement of the adenoids and tonsils, adenotonsillar lymphoma tumor of the adenoids and tonsils and temporomandibular joint disease. The consequence of snoring and sleep apnea can range from a mild annoyance to such serious health risks as hyper tension and stroke, sleep apnea has also being link to cardiac arrest as well as other cardio pulmonary and cardio vascular problems.
Some of the most serious consequences of sleep apnea syndrome include the stomach hypertension, pulmonary hypertension, Cor-pulmonale, heart failure, polycythemia, cardiac dysrythmia and unexplained nocturnal death. Studies have shown that mortality is increased in untreated OSA patients. We have covered what sleep apnea is why it occurs and what its effects are, next we will discuss ways to diagnose sleep apnea including the polysomnogram the whole monitor and the Epworth sleepiness scale.
The most accurate way to assess sleep apnea is with the polysomnogram or sleep study, this will monitor the patients brain waves, heart rhythms, respiration, muscle tone, blood oxygen levels, snoring and body position to generate this information the patient has electrodes on the scalp, face, chest and legs, probes at the nose and mouth a microphone at the neck and the oximeter prob on the finger, many patience with severe sleep apnea still have no trouble falling asleep.
Another method of assessing sleep apnea is with the home monitor or ambulatory monitoring system such as the -- these systems vary in complexity and cost. They are useful for patience, who do not have access to a laboratory or for follow up study after treatment for snoring and sleep apnea. Patients receive instruction on the set up of the monitoring system at the physicians office home monitors record heart rate changes and a arrhythmias blood oxygen levels, nasal and oral air flow as well as thoracic and abdominal expansion body position and snoring, sleepiness a cardinal symptom of OSA can be evaluated with the questionnaire such as the Epworth sleepiness scale or ESS.
Well the questionnaire cannot diagnose sleep apnea it is an important tool that should be given to all patients. Developed at the Epworth University in Melbourne Australia the ESS has proven to be a useful tool for sleep apnea. These eight situations may be scored by the patient in just a few minutes based on how likely he or she is to fall asleep in each of the listed settings a score of the 11 or higher indicates the high potential for abnormal sleepiness and sleep apnea, obstructive sleep apnea may be treated in a variety of ways including surgery medical devices, and oral or dental appliances there are also life style changes that help to reduce or eliminates snoring. It is believed that obesity contributes to snoring and sleep apnea by parapharyngeal deposition of fat, weight loss has in fact the know two significantly reduced apneic episodes by reducing the tissue both neck and throat because smoking can contribute to snoring by causing irritation and swelling of the mucous membranes of the throat and the upper airway reducing or discontinuing smoking may help in the treatment of snoring.
Alcohol is a central nervous system depression that tends to depress the arousal response of the autonomic nervous system. It also increases muscle relaxation there by aggravating snoring and sleep apnea it is recommended that the snoring are apneic patient referring from drinking alcohol before bed and only drink in moderation at other times.
Surgical procedures to treat OSA include tonsillectomy, uvulopalatopharyngoplasty, maxillary and mandibular advancement, tracheostomy and laser assisted uvulopalatoplasty or LAUP. Tonsillectomy can be a surgical choice for the treatment of snoring and OSA especially in children that only if other anatomical conditions are not contributing to the narrowing of the throat or pharyngeal areas. The most common surgical procedure fro snoring and sleep apnea has been uvulopalatopharyngoplasty or the UPPP as it is known in UPPP the surgeon removes most of the loose tissue in the upper airway including part of the soft palate and the uvula. While this surgery enjoys a good initial success rate in the selected patients the effectiveness is often diminished over time, some patients may suffer a change in their voice and regurgitation of liquids through the nose when swallowing or even a loss of the gag reflex.
Finally the UPPP can be a painful and expensive process. In recent years laser surgery or LAUP has become a popular treatment for snoring though it is not generally considered to be a treatment for OSA. In this surgery a laser beam is used to trim the uvula and soft palate in this series of clinic sessions performed under local anesthesia the result in tightening up the tissue lifts the palate clearly airway as the scares heal. Whether it's little dated to date the drawbacks to the laser surgery are similar to those of UPPP including pain and cost.
Doctors at Standford University pioneered the maxillary and mandibular advancement to open the posterior airway. This surgery in addition to UPPP and genioglossus repositioning seems to have a high success rate especially for those patients with recession of both the maxillary and mandibular arches. This procedure requires specialized expertise and is not widely available. There are also numerous gadgets that have been developed to treat snoring these range from nose clips, pillows and chin straps the device is designed to give the snorer a shock these devices may work for a few people primarily those who snore in one position for example only on their backs.
But they are of little valued to the patient with OSA. For the snorer, who snores only on his back one of the simplest methods for treatment is to show a pocket on the back of a night shirt or pajama and put a tennis or golf ball in it, this prevents the snorer from sleeping on his or her back another type of treatment is the nasal dilator, this is a device which is placed on the nose to mechanically spread the nostrils and allow more air to pas through to the airway, for those people who snore because of a nasal obstruction nasal dilators may be useful, by for the best mechanical device for eliminating upper airway collapse is nasal continuous positive air way pressure or nasal CPAP, CPAP has proven effective for approximately 90 to 95% of all OSA sufferers. CPAP is essentially in air compressor that attaches to a mask, which is placed and secured over the patient's nose. The machine uses closely regulated positive air pressure to maintain an open airway.
A refinement to the CPAP is the biophysics nasal CPAP or BIO-PAP which functions similarly to the CPAP but allows for the reduction of the air pressure during the excalation face of breathing. This results in the lowering of the resistance against which the patient must exhale. These are proven to be very successful approaches to snoring and sleep apnea. Though patient comfort may be an issue and compliance has been reported as low as 50% some patients cannot tolerate sleeping with the mask attach to their face all night.
Well others complain about the noise of either the compressor the hissing air or both. Some patients have also reported that blowing air escaping from the edges of the mask rise up their eyes. Finally the device is relatively expensive and can be a burden to those patients who travel frequently. There are numerous oral or dental appliances available to treat snoring and OSA, these are considered to be a reasonable modality for treating simple snoring and mild sleep apnea especially for those patience who cannot or will not tolerate the CPAP.
Oral appliances generally are either mandibular repositioners or are they are tongue devices, in most cases the appliance is laboratory made, that is it is constructed in a dental lab from a model of the patients mouth. These oral appliances are not only non-invasive and comparatively inexpensive; They also have been shown to improve snoring. In a recent paper oral appliances for the treatment of snoring and obstructive sleep apnea Dr. Wolfgang Smith-Nowra at all, concludes the spite considerable variation and the designs of these appliances the clinical affects are remarkably consistent. Snoring is improved in almost all patients and it's often illuminated. Mean results of studies show that OSA improves in the majority of patients.
The following treatment protocol is suggested for the use of oral appliances in the treatment of snoring and mild OSA. Ideally -- medical evaluation by a physician specializing in sleep disorders should be the first step in determining the appropriate treatment; this examination will probably includes some type of sleep test. If the patient is determined to have simple snoring or mild OSA and an oral appliance is an acceptable option the dentist or physician would then evaluate the patient dentally fro oral appliance therapy.
The patient would not be faded with the mandibular advancement appliance if he has no teeth or has dentures that do not fit well. Patients, who are accessibly over weight, are also not good candidate for oral appliances. The most common side effect of oral appliances is excessive salivation but occasionally we see an opposite reaction dry mouth, both of these responses tend to clear up after a week or so temporomandibular joint or TMJ soreness and our repositioning can also occur especially with mandibular repositioning devices that lock the jaws in place, occasionally soft tissue irritation is seen particularly with hard equipped devices.
Finally sometimes the patient will experience sore teeth after wearing an oral appliance. The three most important aspects of oral appliances are first these mandible placement and adjustment. Second lateral freedom for the jaw and third full occlusal coverage, which provides posterior support fro the teeth.
Tom Meade: Hello I'm Tom Meade and graduated from - school of -- in 1966 since 1985 I've been involved in the development and research of oral appliances for the treatment of snoring and obstructive sleep apnea. The research has been conducted at the University Of New Mexico School Of Medicine, I hope the tape that you just viewed will be helpful and to your patients. Thank you.
In summary well the study of snoring and related sleep disorders is a relatively new field these problems have played a man through out history. Well there are both social and medical reasons to seek treatment this serious consequences of sleep apnea are merit medical attention. Treatments varied from there ridiculous nose clips and chin straps to the extreme tracheostomy. Less invasive and less costly options are available to the healthcare providers.
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