snoring & sleep apnea

Normal Breathing

When you breathe normally, air passes through the nose and past the flexible structures in the back of the throat such as the soft palate, uvula and tongue. While you are awake, muscles hold the airway open. When you fall asleep, these muscles relax but, normally, the airway stays open

Snoring

Snoring is the sound of obstructed breathing during sleep. While snoring can be harmless(benign snoring), it can also be the sign of a more serious medical condition which progresses from upper airway resistance syndrome (UARS) to obstructive sleep apnea (OSA).

What causes snoring?

Snoring occurs when the structures in the throat are large and when the muscles relax enough to cause the airway to narrow and partially obstruct the flow of air. As air tries to passes through these obstructions, the throat structures vibrate causing the sound we know as snoring. Large tonsils, a long soft palate and uvula and excess fat deposits contribute to soft tissue narrowing.

Obstructive Sleep Apnea

When obstructive sleep apnea occurs, the tongue is sucked against the back of the throat. This blocks the upper airway and air flow stops. When the oxygen level in the brain becomes low enough, the sleeper partially awakens, the obstruction in the throat clears and the flow of air starts again, usually with a loud gasp. People with obstructive sleep apnea (OSA) have disrupted sleep, and low blood oxygen levels. OSA has been associated with cardiovascular problems and excessive daytime sleepiness. The condition known as upper airway resistance syndrome (UARS) lies midway between benign snoring and true obstructive sleep apnea. People with UARS suffer many of the symptoms of OSA but normal sleep testing will be negative.

How do you know if you have OSA?

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy. If you score 10 or more on this test, you should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene and/or need to see a sleep specialist. These issues should be discussed with your personal physician.

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze or sleep.
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping

Print out this test, fill in your answers and see where you stand.

Questionnaire for Sleep Apnea Risk

Assess your risk for sleep apnea. The total score for all 5 sections is your Apnea Risk Score. Print out this questionnaire, write in your best answer for each question and see where you stand.

1. How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?

1. Never
2. Rarely (less than once a week)
3. Occasionally (1 - 3 times a week)
4. Frequently (More than 3 times a week)

Answer_____

2. How often have you been told that you have "pauses" in breathing or stop breathing during sleep?

1. Never
2. Rarely (less than once a week)
3. Occasionally (1 - 3 times a week)
4. Frequently (More than 3 times a week)

Answer_____

3. How much are you overweight?

1. Not at all
2. Slightly (10 - 20 pounds)
3. Moderately (20 - 40 pounds)
4. Severely (More than 40 pounds)

Answer______

4. What is your Epworth Sleepiness Score?

1. Less than 8
2. 9 -13
3. 14 - 18
4. 19 or greater

Answer ______

5. Does your medical history include:

1. High blood pressure
2. Stroke
3. Heart disease
4. More than 3 awakenings per night (on the average)
5. Excessive fatigue
6. Difficulty concentrating or staying awake during the day

Answer ______

If you answered 3) or 4) for questions A-D, especially if you have one or more of the conditions listed in question E, then you may be at risk for sleep apnea and should discuss this with your physician.

Note: You should always discuss sleep-related complaints with your physician before deciding on medical evaluation and treatment.

All About Fatigue: The Causes and Effects

(Reprinted with permission)

What is Fatigue:

• Fatigue is also known as sleepiness, tiredness, or exhaustion, and is a feeling of lack of energy or wanting to sleep.
• A number of medical conditions might cause fatigue but the most common cause is insufficient, high quality sleep (i.e., sleeping uninterrupted the entire time you’re in bed).
• When sufficiently fatigued, a person may experience very short, unremembered instances of sleep, called micro-sleeps, which can contribute to accidents.

Fatigue Impacts 40 million Americans with Sleep Disorders and Inadequate Sleep Causing:

• Increased health risks: high blood pressure, heart disease, stroke, and diabetes;
• Lack of energy to exercise and resulting weight gain;
• Sexual dysfunction;
• Mood swings, depression & irritability;
• Stresses on family & social life.

Consequences of Fatigue in the Workplace Includes:

• Impaired alertness & memory, inability to concentrate;
• Impaired judgment & poor decision making;
• Decreased motivation & productivity;
• Increased absenteeism;
• Increases by 3 to 5 time the likelihood of an accident.

Self-Management of Fatigue Is Important for Holders of Commercial Driver’s License (CDL):

• Being well rested is a requirement for being fit for duty.
• The hours-of-work requirement does not eliminate the driver’s responsibility for getting their needed hours of sleep or being treated so they are fully-rested while driving.
• If you drive while fatigued it is similar to having a blood alcohol content of .06 - .08. Nine out of 10 police officers have stopped a driver who they believed was drunk, but was later determined to be drowsy.
• Studies have shown that as many as 40% of commercial drivers have an undiagnosed sleep disorder that causes fatigue.
• It is the CDL holder’s responsibility to seek medical attention to ensure they do not have a sleep disorder or to obtain proper treatment.

Vulnerability to Fatigue:

• You are most vulnerable to fatigue when driving between 2 and 4 PM or 3 and 6 AM.
• The largest percentage of fatigue related accidents occur when a person is within 5 miles of their home or destination, when the brain’s drive to keep you awake begins to relax.
• The ability to perform adequately when fatigued is highly dependent on the individual. Some people need more hours of sleep to be fully rested. Others may become impaired sooner as a result of a lack of sleep.

Contributors to Poor Quality Sleep that Result in Fatigue:

• Having difficulty falling asleep can be influenced by factors that are difficult to control include:
  • Trying to sleep when the sun is up;
  • Falling asleep when you’re on a rotating schedule and the time that you go to bed keeps changing.
• Factors that make it difficult to fall asleep that you should try to avoid include:
  • Noise or interruptions;
  • Excessive stimulation prior to bed, such as an argument, physical exercise or eating;
  • Watching TV, using a computer, eating or reading/working while in bed. You want to avoid creating an association between activities that do not relate to sleeping while in bed.

Sleep Disorders that Contribute to Fatigue:

• Insomnia – can’t fall asleep, approximately 30 mm Americans affected, generally affects women more than men. Many of the environmental and behavioral/emotional conditions which affect high quality sleep contribute to the diagnosis of insomnia.
• Obstructive sleep apnea (OSA) – can’t breathe properly during sleep. Approximately 1 out of 5 men (20%( over age 40 have some degree of OSA, especially those who snore, are overweight or have large neck sizes. Among commercial drivers, the likelihood of having undiagnosed sleep apnea two times greater than the general male population. The severity of OSA ranges from 5 occurrences per hour to over 100. Each time an event occurs, the sleep is interrupted. OSA causes hypertension and if untreated reduces life expectancy by 10 years. 95% of those suffering from OSA are undiagnosed. Several treatment options exist. OSA is associated with lifelong diseases like diabetes or high blood pressure that should be diagnosed and treated for a driver to be “fit for duty”.
• Periodic limb movements in sleep (PLMS) – a less common disorder than OSA, often referred to as restless leg syndrome because the person needs to move their legs to be comfortable, but each time the legs move the sleep is interrupted. Not usually reported and diagnosed, a drug treatment is available.
• Narcolepsy – a rare disorder when a person will fall asleep in any place at any time. Is easily recognized and diagnosed, must be treated with a drug.

CDL Requirements for Diagnosis and Treatment of Obstructive Sleep Apnea (OSA):

• Department of Transportation guidelines require drivers with moderate to severe OSA to be treated in order to be fit for duty.
• You must disclose at the time of your DOT physical if you have been told that you snore loudly, or if you have awakened gasping for air or choking, or have been told you stop breathing, or are fatigued because these symptoms indicate you may have OSA. To avoid delays in being recertified, you should seek medical attention to determine if you have OSA and to receive treatment. Legal Implications of Driving while Fatigued:
• If you knowingly continue to drive when you’re fatigued or drowsy and have a collision, you will likely be liable for the injuries and damages caused to others.
• If you have a collision you could lose your CDL, and in the worst case be charged with vehicular manslaughter if you kill another person and it is shown that prior to the accident you:
  • Continued to drive while fatigued (even if there is a medical reason for the fatigue).
  • Did not seek medical attention to try and resolve the fatigue.
  • Did not report your fatigue at the time of your DOT physical.
  • Provided inaccurate or misleading responses to questions intended to determine if you have fatigue

© Advanced Brain Monitoring, Inc. 2007

Therapy (More about oral appliances)

There are several ways to treat snoring and sleep apnea. The most common is with a device called a CPAP machine. CPAP stands for continuous positive air pressure. It is usually applied through a tube to a mask that covers the nose. The air pressure that is generated splints the structures in the back of the throat holding the airway open during sleep.

Treatment can also be accomplished with surgery to the soft palate, uvula (that thing that hangs down from the roof of your mouth), and tongue to eliminate the tissue that collapses during sleep. More complex surgery can reposition the anatomic structure of your mouth and facial bones but this is done only in extreme cases.

Oral appliances that treat snoring and obstructive sleep apnea are small plastic devices, worn in the mouth, similar to orthodontic retainers or sports mouthguards. Oral appliance therapy involves the selection, design, fitting and use of a specially designed oral appliance that, when worn during sleep, maintains an opened, unobstructed airway in the throat.

Currently, there are over 40 different types of oral appliance available. Oral appliances may be used alone or in combination with other means of treating OSA, including general health and weight management, surgery or nasal continuous air pressure (CPAP).

Oral appliances work in several ways:

• By repositioning the lower jaw, tongue, soft palate and uvula
• By stabilizing the lower jaw and tongue
• By increasing the muscle tone of the tongue

Dentists with training in oral appliance therapy who are familiar with the various types and designs of appliances can determine which one is best suited for your specific dental and medical conditions. The dentist will work with your physician as part of the medical team in your diagnosis, treatment and on-going care. Oral appliance therapy can take from several weeks to several months to complete. Even after the intial phase of treatment is complete, your dentist will continue to follow you to be sure that treatment remains successful and to evaluate the response of your teeth and jaws.

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cpap and compliance...

CPAP – the “gold standard” 

While CPAP (continuous positive air pressure applied through a nasal mask) is considered the “gold standard” for treatment of obstructive sleep apnea (OSA), it is not without its problems. CPAP, when used, will control obstructive sleep apnea 100% of the time but there is a problem with patient compliance. Compliance simply means that a patient is following their doctor’s orders to keep their disease problem under control. In the case of sleep apnea, it means that the patient is using the CPAP machine every night as recommended life-long.
CPAP Compliance

But multiple research articles have shown that CPAP compliance can be as low as 50% because of discomfort and inconvenience. Obstructive sleep apnea sufferers who do not wear their CPAP machines increase their risk of heart failure, high blood pressure and stroke and are drowsy during the day and fall asleep while driving. OSA sufferers who stop wearing CPAP often snore, gasp and choke loudly disturbing their bed partners placing a strain on relationships and marriages.

Some of the common problems that people experience with CPAP are:

• The mask is uncomfortable
• The mask is taken off at night without knowing it
• The mask is taken off at night to use the bathroom and it’s too much bother to put it back on
• The mask irritates the skin and the nose
• Air in the stomach or sinuses
• The mask leaks air
• The pressure of the CPAP is bothersome
• The CPAP machine is too noisy to allow sleep
• The tubing gets in the way
• You just can’t get used to the mask
• The mask gives you a feeling of claustrophobia
• Your nose can be stuffy because of a cold or allergies
• The air is too hot, too cold or too dry

Whatever the reason, some people just cannot tolerate CPAP.

The alternative – oral appliances

Still there is hope. Oral appliance therapy, provided by dentists specifically trained in the use of these devices, can be an effective alternative to CPAP. A recent parameters paper published in the journal Sleep by the American Academy of Sleep Medicine stated that oral appliances can be used as first-line therapy in some patients for treating mild-to-moderate obstructive sleep apnea. The guidelines state

“Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep-position change.|”

Oral appliances, which resemble sports mouthguards are associated with better compliance than CPAP systems for many patients. Oral appliances can also be used as first-line treatment for primary snoring that is not associated with obstructive sleep apnea.

These appliances should be fitted by dentists specifically trained in oral appliance therapy and those experienced in treatment of temporomandibular joint and dental occlusion. Treatment with oral appliances should be followed on a regular basis and have follow up polysomnography.

******************

Advantages of Oral Appliance Therapy

Oral appliance therapy has several advantages over other forms of therapy:

• Oral appliances are comfortable and easy to wear. Most people find that it only takes a couple of weeks to become acclimated to wearing the appliance.
• Oral appliances are small and convenient making them easy to carry when traveling.
• Treatment with oral appliances is reversible and non-invasive

other options...

Sleep Position Training

In some patients, obstructive sleep apnea is related to sleeping on one's back. Positional therapy for the treatment of OSA has been studied. According to some researchers the prevalence of positional OSA is between 55 and 60%. Several devices, including the Snore-Ball and Dr. Parker's Snore Relief Cushion, have been developed to encourage the patient to sleep on his/her side rather than back.

Behavior Modification

• Weight reduction is occasionally the only treatment needed for the obese patient. Long term results require behavior modification to maintain reduced weight.(Neck size is a reliable index as a predictor of OSA. In men OSA is more prevalent in those with a neck size > 17 inches; in women, neck size > 15.5 inches.)
• Reduction in the intake of alcoholic beverages
• Limitations in the use of sedatives and muscle relaxants
• Cease smoking

Nasal Congestion

At times, nasal congestion or obstruction can lead to problems with snoring and apnea. In cases where the nasal passage is obstructed such as with enlarged turbinates or nasal polyps, surgical intervention is often needed.

In cases where nasal obstruction is transient BreatheRight strips and nasal sprays may be of value,

but their effectiveness is often significantly limited in most obstructive sleep apnea patients.

Adjustable Oral Appliance Options

Snoring isn’t just a noisy nuisance. As well as being loud enough to disturb both sufferers and their families, snoring can also interrupt sleep and place pressure on relationships.

Persistent loud snoring often disturbs the sleep of the snorer and anyone within hearing range. This disruption to sleep can contribute to fatigue and leave the sufferer feeling tired, drowsy, and inappropriately sleepy. The prolonged effects of lack of sleep can lead to slowed responses, memory problems, difficulty in paying attention and concentrating, and may also cause performance problems at work. More importantly, lack of sleep can increase the risk of automobile accidents and can adversely affect relationships. Surveys have shown that many snoring couples resort to sleeping in separate rooms.

When snoring is so loud that it disturbs the sleep of snorers and their family, it may be a sign of a related condition known as Obstructive Sleep Apnea (OSA).

Although OSA sufferers may experience hundreds of episodes of apnea per night, they are unlikely to remember any of them. If, as is often the case due to loud snoring and gasping, the sufferer sleeps separately or lives alone they may not be aware of their condition, even after many years.
SomnoMed MAS™

The SomnoMed MAS™ is a Mandibular Advancement Splint (MAS) that treats snoring and mild to moderate OSA by moving the lower jaw forward slightly. This forward movement tightens the soft tissue and muscles of the upper airway, which prevents obstruction of the airway while you sleep. The tightening created by the device also prevents the tissues of the upper airway from vibrating as air passes over them – the most common cause of loud snoring.

The SomnoMed MAS™ is a custom-made device, consisting of upper and lower dental plates with a unique patented fin-coupling component, which allows normal mouth opening and closing. The device is adjustable which improves the efficacy and comfort level of treatment, as the jaw is moved only as far as is required to alleviate the condition. The SomnoMed MAS™ design has a number of key features that are significant improvements on existing MAS oral appliances. These improvements make the device both comfortable and effective.

The SomnoMed MAS™ is a highly effective solution for the majority of patients with mild to moderate OSA who prefer oral Somnomedappliances to CPAP therapy, who do not respond to, are not appropriate candidates for, or fail CPAP treatment attempts. Our exceptional levels of patient acceptance, compliance, and treatment efficacy of the SomnoMed MAS™ are backed by a large body of clinical research. In clinical studies 91% of patients reported substantial improvement in sleep quality, 87.5% of patients reported nightly use, and 96% of patients stated they would like to continue to use the SomnoMed MAS™ . The SomnoMed MAS™ moves the lower jaw forward slightly which tightens the soft tissues and muscles of the upper airway, preventing obstruction during sleep. The tightening also prevents tissues of the upper airway vibrating as air passes over them. For more information, email or call, or visit the SomnoMed website.

Advantages of the SomnoMed MAS™

The device is comfortable and easy to wear, and most people find that it only takes one or two nights to get used to wearing it. TheSomnoMed MAS™ is small enough to fit in the palm of your hand, making it easy to carry when traveling. Durability The SomnoMed MAS™ is made from premium grade materials to ensure the durability of the device. Each device is hand-made to the Doctor’s specifications providing a comfortable fit. The SomnoMed MAS™ comes with a one year warranty against manufacturing defects and breakage. Patients must submit their Warranty Cards found in their User Instructions to activate the warranty.

SomnoMed MAS™

• Successful treatment of snoring and mild to moderate OSA
• Unrivaled patient acceptance and compliance
• Clinically validated for the treatment of snoring
• One year warranty

FAQ

When is it worn?

The SomnoMed MAS™ is only worn at night. The SomnoMed MAS™ is unique in that, unlike other oral appliances, it allows you to close your lips, so no one need know you are wearing it.

Is it comfortable?

You won’t find a more comfortable MAS.

Why?

Because it is custom-made to fit your mouth and it does not impinge on your tongue. You can open and close your mouth normally.

Is there a warranty?

Yes. The SomnoMed MAS™ offers a one year warranty against breakage and manufacturing defects, which means you can have full confidence in the product.

What if I have a bridge or denture?

Patients with crowns or bridges can be successfully fitted with the SomnoMed MAS™. Adjustments are made in the appliance to ensure that fragile crowns and bridges are not harmed. Patients with partial dentures may be successfully fitted with the SomnoMed MASTM as long as there are enough teeth to anchor the device. Ask your dentist if you are dentally appropriate for the SomnoMed MAS™.

What will the dentist do?

The dentist will thoroughly examine your teeth and mouth and may use X-rays to confirm your oral health status, as well as ensuring that you are dentally appropriate for the device. Dental impressions are required to fabricate a SomnoMed MAS™. They are taken, and sent to our laboratory where the appliance is made. Once custom made for you, the appliance will be inserted by a Dentist who will show you how to insert and remove it yourself, as well as how to clean and care for it.

'How effective is the SomnoMed MAS™?

One of the major advances offered by the SomnoMed MAS™ is improved patient compliance. The ability to freely open the mouth, speak, and drink with the device fitted, is a big step forward in this type of medical treatment.

• 96% of patients with proven OSA stated they would like to continue to use the SomnoMed MAS™
• 91% of patients reported substantial improvement in sleep quality with the SomnoMed MAS™
• 87.5% of patients reported nightly use of the SomnoMed MAS™

FDA

FDA Approval received July 2005

TAP...

HOW THE TAP WORKS

The Thornton Adjustable Positioner (TAP®) is a custom-made two piece adjustable appliance that is worn while sleeping. The trays of the appliance snap over the upper and lower teeth and hook together. The design is based on the same principle as cardiopulmonary resuscitation, CPR. The airway must be opened to allow air to pass through the throat. The TAP® holds the lower jaw in a forward position so that it does not shift nor fall open during the night. This prevents the airway from collapsing. The more you pull your jaw forward, the more your airway will open.

The TAP® is the only mandibular advancement device that can be adjusted easily by the patient or practitioner while in the mouth. This feature allows the patient to always be in control of their treatment. The unique design also allows the patient to fine-tune their treatment position at home to achieve maximum results.

Most patients experience relief the very first night they wear their TAP®. Although it may take up to a week to get used to wearing a TAP® appliance, this is a small hurdle for patients. Nine in ten patients wear the device all night, every night – making the TAP® a highly effective solution for both snoring and sleep apnea.

SNORING HEADS

Features

• *Patient-friendly
• Superior results
• Easy to fit
• Infinitely adjustable
• Precise control of advancement
• Interchangeable hooks
• Freedom for lateral movement
• More room for tongue
• Allows lips to close

The TAP® can help prevent conditions linked to sleep apnea:

• Chronic daytime sleepiness
• High blood pressure
• Heart attack
• Stroke
• Heartburn, reflux
• Morning headaches
• Depression

FDA Approval: Approved for both snoring and OSA
Date of FDA Approval: August 21, 1997

oral appliance approval...

Reprinted from http://www.medpagetoday.com

By Jeff Minerd, MedPage Today Staff Writer
Reviewed by Robert Jasmer, MD; Assistant Professor of Medicine, University of California, San Francisco
February 01, 2006

MedPage Today Action Points

* Consider oral appliances for patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to continuous positive airway pressure (CPAP) systems, who do not respond to CPAP, or who are not appropriate candidates for CPAP.

Review
WESTCHESTER, Ill., Feb. 1 - Oral appliances can be used as a first-line therapy in some patients for treating mild-to-moderate obstructive sleep apnea, according to updated guidelines from the American Academy of Sleep Medicine.

The updated guidelines, based on studies published since the original 1995 guidelines, appeared in the February issue of Sleep.

The previous guidelines recommended continuous positive airway pressure (CPAP) systems as first-line treatment for obstructive sleep apnea. But research suggests that in mild or moderate cases, usually defined as an apnea-hypopnea index from 10-30, oral appliances improve subjective and objective measures of sleepiness about as well, according to Clete A. Kushida, M.D., Ph.D., of Stanford, and colleagues.

CPAP systems are still superior in reducing measures of respiratory disturbances, and for this reason they should remain first-line therapy for patients with severe sleep apnea, the guidelines said.

"Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep-position change," according to the guidelines.

In various studies, the success rate of oral appliances hovered just above 50%, but in one study it reached as high as 81% for patients with mild obstructive sleep apnea, the guideline authors noted.

Oral appliances, which resemble athletic mouth guards, may be associated with better compliance than CPAP systems, which many patients find uncomfortable because they require a mask delivering positive pressure to be worn while sleeping, the authors said.

Oral appliances can also be used as a first-line treatment for primary snoring without features of obstructive sleep apnea, the guidelines noted.

Oral appliances should be fitted by a qualified dentist who has experience with the temporomandibular joint, dental occlusion, and associated oral structures, the guidelines said. To verify the efficacy of the device, patients should be followed with polysomnography or an attended cardiorespiratory sleep study.

Patients should have regular follow-up office visits with their dentist to monitor adherence and make sure the device is functioning correctly. Patients should also have regular follow-up with a primary physician or sleep specialist to make sure that symptoms are not worsening, the guidelines said.

The guidelines were issued in conjunction with the Academy of Dental Sleep Medicine.

Source reference:
Kushida CA et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006; 29(2).