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Sleep Apnea From a Dentist’s Perspective

Posted Jul 01 2009 6:40pm

Dentists play a very important role in the team approach to the treatment of obstructive sleep apnea. Physicians, dentists, psychologists, and respiratory therapists all combine their collective knowledge to treat each patient properly and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of immense help to physicians in treating sufferers with sleep disordered breathing problems.

Snoring

Nearly one-half of all adults snore. The problem is exaggerated with overweight persons.
Snoring occurs when there is a partial obstruction to the free flow of air through the mouth and nose. The sound occurs when loose structures in the throat, like the uvula and soft palate, vibrate as air passes over them. Snoring can get worse when the muscles in the back of the throat are too relaxed either from drugs taken to help induce sleep or alcohol intake. Snoring can also be caused by an overly large uvula and soft palate, nasal congestion, a deviated septum or other obstructions in the nasal and pharyngeal airways. In children, large tonsils and adenoids can be the cause of snoring. Pregnant women often snore because of a narrowing of the airway and increased weight due to the pregnancy.

Is Snoring Serious?

Yes, snoring can be serious both socially and medically. Snoring can bring great disharmony to marriages and cause sleepless nights for our bed partners.

Medically, snoring can be the forerunner of obstructive sleep apnea that has been associated with heart failure, high blood pressure and stroke. On its own, snoring has been connected to Type II Diabetes. Sleep apnea typically interrupts loud snoring with an episode of silence in which no air passes into the lungs. Eventually the lack of oxygen and the increase of carbon dioxide will awaken you forcing the airway to open, usually with a loud gasp.

The CPAP

The most frequently prescribed medical treatment for OSA is the “Continuous positive airway pressure” unit, or CPAP (pronounced “C-Pap”) and a newer variation called BiPap. These apparatuses have a high flow fan, a hose and a sealed nasal mask to which the patient is attached to while sleeping. Clinical studies have shown that CPAP is highly effective in relieving most apnic episodes. In addition to the CPAP unit, physicians usually prescribe a weight loss regimen, and abstinence from tobacco and alcohol. Unfortunately, patient compliance is generally a problem due to the noise of the air compressor, the constriction of movement caused by the hose attachment, stuffy nose and skin irritation caused by the nosepiece, and complaints of being able to have less intimacy with a bed partner.

Due to these and many other complaints from users of the CPAP units, OSA research teams carried out extensive trials on mandibular advancement appliances (airway dilators, or “snore guards”). These projects and trials resulted in a 1995 review by the American Sleep Disorders Association. The review determined that oral appliances are a good alternative to CPAP in cases of mild to moderate obstructive sleep apnea.

The dental treatments for obstructive sleep apnea are superior to the CPAP unit from the point of view of patient compliance. Dentally oriented treatments for this problem fall into two groups; detachable appliances that advance the lower jaw while the patient is asleep, (airway dilators, more commonly known as snore guards) and surgical solutions, some of which advance the lower jaw permanently.

If an actual case of obstructive sleep apnea is assumed, the dentist normally uses his skills in conjunction with the help of a qualified physician specialist who can assess the need for, and ultimately the success or failure of the treatment. This makes sense since it is the physician who can order and construe the medical tests involved in the institution of the foundational diagnosis.

The Detachable OSA Appliances (Snore guards)

Anything that advances the lower jaw forward (bringing it into protrusion) will cause to lift the tongue and epiglottis away from the back of the throat relieving some of the limitation caused by the relaxation of the muscles during sleep. In order to wear such an appliance, it is crucial that the patient have adequate numbers of healthy teeth in both upper and lower arches for the appliance to attach to. If the patient lacks healthy teeth, dental implants may still make it possible to wear a detachable snore guard.

Note that detachable snore guards separate the upper and lower teeth and therefore perform the functions of a bruxing guard in addition to those of the snore guard. Consequently, a snore guard may not only treat snoring and obstructive sleep apnea, but it may well treat the symptoms of TMJ disorder as well. However, in very severe cases of organic joint dysfunction due to TMJ, the forward repositioning of the lower jaw may aggravate the damage to the jaw joint and thus a snore guard may not be appropriate for those sufferers.

To create a detachable snore guard, an impression will be taken of both the top and bottom teeth, and models are poured in plaster. Then the patient may be instructed to bite into a slab of wax with his lower jaw protruded as much as possible without actually straining. This is called a protrusive bite registration. Both the models and the protrusive bite registration are then sent to the lab. The laboratory returns the finished appliance, which can take a number of different forms depending on what your dentist orders.

Different Types of Snore Guards

There do exist different types and brands of snore guards, and many orthodontic laboratories have their own brand of appliance that they use. You, together with your dentist, must decide on the correct type of snore guard for you, based on specific needs. Some snore guards are very effective at relieving the obstructions causing OSA, but they are limited by the ability of the TMJ to move forward. As a general rule, the maximum advancement of the lower jaw that can comfortably be achieved with a fixed-jaw-relation snore guard is in the range of 3 to 5 millimeters. This is normally enough to relieve the airway, and will work quite well for most people. The drawback to a fixed relation guard is that the appliance cannot be adjusted to bring the lower jaw further forward as the joints (TMJ) relax over time. Adjustability is very desirable since obstructive apnea is a progressive disease and further jaw protrusion often becomes possible as the joint ligaments stretch further.

Oral appliances (OA) that treat snoring, UARS, and OSA are devices worn in the mouth similar to sports mouth guards or orthodontic retainers. They are made of plastic and fit partially or completely within the mouth. Currently there are over 40 different types of oral appliances available. OA’s may be used alone or in combination with other means of treating sleep apnea, such as weight management, surgery and CPAP. There is no one particular appliance that will work for every patient. Any dentist supplying oral appliances will be familiar with several different types.

Categories of Appliances:
There are currently two categories of appliances in general use.

1. MRD - Mandibular Repositioning Device

  • A more commonly prescribed appliance.
  • It repositions and stabilizes the lower jaw, tongue, soft palate, and uvula.
  • It also helps to increase the muscle tone of the tongue.

2. TRD - Tongue Retaining Device

  • This device advances the tongue and actively holds the tongue forward to open the airway, thus preventing it from falling backward and blocking the airway.
  • These devices are most useful in patients with large tongues, poor dental health, no teeth, and chronic joint pain.

Indications for Use of an OA:

  • Primary snoring
  • Mild OSA
  • Moderate / Severe OSA sufferers who are intolerant or refuse the CPAP unit ( as set forth by the American Sleep Disorders Association)
  • Poor tolerance of nasal CPAP
  • Poor surgical risks
  • Non-successful UPPP surgery
  • Use of appliance during travel


Advantages of using an Oral Appliance:

  • Oral appliances are much small and convenient making them easy to carry when traveling
  • Treatment with oral appliances is reversible and non-invasive
  • After becoming acclimated to wearing the appliance, most people find them easy to wear and more comfortable than the CPAP unit.
  • Quiet
  • Easily adjustable
  • More comfortable than the CPAP unit, generally resulting in increased compliance

Are There any Side Effects From Using Oral Appliance Therapy?
Patients using oral appliance therapy may experience the following side effects:

  • Excessive salivation or dryness.
  • Morning soreness in the teeth or jaw muscles.
  • Tooth movements (generally minor)

Most of these side effects improve within just a few weeks of regular use and some adjustments of the appliance. Patients with arthritis and chronic jaw joint dysfunction may experience more difficulty tolerating an OAT.

Top 3 Dentists is a resource for anyone looking for the optimum in dental practice. Being at the top doesn’t mean being the most expensive, but it does mean being the most qualified.

Search for the Top 3 Dentists in your area who practice in that specialty. Please note that some of our Periodontists (or other specialists) may require a direct referral from a General Dentist. In such cases, you would simply choose one of the general Top 3 Dentists to perform a comprehensive examination on you — and then ask for a referral to the specialist of your choice.

Check out this website for referrals of highly qualified dentists: http://www.top3dentists.com/pages/sleep_apnea

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