Snoring and Sleep Apnea….It’s a Family Affair !!!
If you suffer from sleep apnea or snoring, your quality of life may be reduced because you are unable to get a good night’s rest. The same can likely be said for your bed partner. In fact, a sleep companion is generally the first person to notice that a loved one has a sleeping disorder.
Are you tired during the day on a regular basis? Have you been told that you snore? You may have sleep apnea. Sleep apnea is a common sleep disorder in which a person’s sleep is disrupted because of issues with breathing. Obstructive sleep apnea (OSA) is the most common form of sleep apnea and is caused when the airway is blocked. Sleep apnea affects people of all ages and genders, but is more prevalent in men. Snoring is commonly associated with sleep apnea, and can be one of the first signs of the disorder. Dr.Bellorini has received advanced training and is available to provide sleep apnea therapy conservatively and effectively.
If left untreated, sleep apnea can be responsible for numerous health problems in addition to chronic tiredness. These health problems can include:
- high blood pressure
- heart failure and cardiovascular disease
- erectile dysfunction
- memory and concentration impairment
Sleep Apnea Causes
Obstructive sleep apnea is caused when the muscles in the back of your throat relax and cause the airway to collapse. When this occurs, this may lower the level of oxygen in your blood, causing your brain to force you to awaken. When you awaken you may not even be aware that your sleep was disrupted. Although many people with obstructive sleep apnea think they actually sleep well at night, these disruptions actually impair their ability to reach deep, restful phases of sleep. Sleep apnea, like high blood pressure, is difficult if not impossible to identify without proper testing. And like high blood pressure can have a significant impact on your long term health.
Many sufferers of sleep apnea are overweight, thus contributing to their disorder. Having excess weight in your neck or abdomen can compress the breathing muscles and cause cessation of breathing. Conservative treatments of sleep apnea include weight loss to prevent issues with excess neck weight from increasing symptoms.
Obstructive sleep apnea is a condition in
which the soft tissues at the back of the throat completely close off the
airway so that air cannot flow into the lungs. This airway blockage can reduce
the amount of oxygen reaching the brain and body. When that happens, the brain
alerts the muscles in the airway to tighten up and unblock the air passage.
This leads to a cycle of blocking and unblocking the airway and causes
significant disruption of sleep.
Symptoms of Sleep Apnea
Family members are usually the first ones to notice a person’s symptoms for sleep apnea. These generally include loud snoring or gasping for air during sleep. Other symptoms include:
- Headaches in the early morning
- Frequent visits to bathroom during night
- Waking frequently during the night
- Mood problems
- Poor memory
- Sore throat in the morning
- Heavy snoring
- Stop breathing when asleep and/or gasping for breath while asleep
- Jerking or kicking your legs at night (restless leg syndrome)
Causes of Snoring
Snoring occurs when there is an obstructed flow of air through the mouth and nose. This tends to happen in the following ways:
- Obstructed nasal airway– This can result in snoring when you have a sinus infection or during allergy season. This can also happen if you have a deformity of the nose such as a deviated septum or nasal polyps.
- Weak throat and tongue muscles– If your throat and tongue muscles are too relaxed, they may collapse and fall back into the airway. This can be caused by deep sleep, alcohol consumption, and the use of some sleeping pills.
- Bulky throat tissue– A bulky throat tissue is often the result of an overweight patient.
- Long soft palate and/or uvula– A long soft palate or a long uvula (the dangling tissue in back of the mouth) can narrow the opening from the nose to the throat. When these structures vibrate and bump against one another the airway becomes obstructed, causing snoring.
Snoring is a problem that affects 67% of adults. It is conservatively estimated over
120 million people in the United States snore every night. Snoring can cause
disrupted sleep for both snorers and their sleeping partners and it can lead to
Snoring is the harsh sound that occurs when the tissue at the back of the roof of the
mouth vibrates against the back of the throat. During sleep, throat tissues,
the tongue and the muscles that line the airway all relax, narrowing the
airway. Air passing through the narrower airway cause the tissues to vibrate
against each other and create the snoring sound that can grow louder during
sleep. Loud snoring may also be an indication of a bigger health problem; sleep apnea.
Risks of Snoring
The most common risk for habitual snorers is obstructive sleep apnea. Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. Sleep apnea can result in the partial or total obstruction of the airway during sleep. It may also cause the following:
- frequent awakening during sleep
- cause light sleep
- a strain on the heart which may lead to heart attack or stroke
- result in a poor night’s sleep that can effect your quality of life
Use these 4 Strategies to Minimize Snoring
These strategies may reduce or eliminate your snoring. No matter what treatment you pursue for snoring or obstructive sleep apnea, these recommendations will have a positive effect on its outcome.
- Sleep on your side to counteract the effects of gravity and reduce or eliminate snoring.
- Normalize your weight to reduce snoring and apnea symptoms.
- Relieve nasal congestion to help decrease snoring. Nasal sprays can be prescribed by your physician. (Note: Over-the-counter nasal sprays should not be used longer than a few days.) Nasal strips which increase nasal air flow may also be beneficial.
- Avoid alcohol or sleeping pills within four hours of bedtime. Both will cause relaxation of the soft tissues and muscles in the airway and will make sleep apnea or snoring worse.
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you, and its important to be truthful. Use the following scale to choose the most appropriate number for each situation:
To check your sleepiness score, total the points _____________________
How You Rate :
Score Points (1 –
6) Means you are getting enough sleep!
Score Points (7 – 8)
Your score is average
Score Points( 9 and up)
Very sleepy , and should seek medical advice
We believe our first responsibility is to inform and educate our patients.
We review the evaluation findings and explain the risks, benefits and reasonable expectations of the different treatment options with each patient. We guide patients in deciding which oral appliance will be most effective and comfortable for their situation. Then we work closely with the patients for a 3-4 month period to ensure the comfort and effectiveness of their treatment.
Thereafter, patients are seen at least once a year to assess their progress. This comprehensive approach is important to achieving a successful treatment outcome.
If you are not sure that you have sleep apnea or snoring problems but are experiencing difficulties, with daytime sleepiness or waking during the night, the following information may help.
Consult a physician
All snorers should be evaluated by a physician or sleep disorders specialist before pursuing treatment, especially if they:
- Wake unrefreshed in the morning,
- Fall asleep easily during the daytime at inappropriate times (while watching TV, reading, driving or in meetings), or
- Have periodic stoppages of snoring or breathing during sleep, as observed by their bed partner.
Your doctor’s evaluation will probably include:
- A complete medical history and a history of your snoring and related symptoms.
- A complete physical examination to assess the presence of obstructive sleep apnea or other sleep disorders or health problems.
If the doctor suspects that obstructive sleep apnea is present, additional testing of your sleep may be necessary.
Medical and Dental Treatment For Sleep Disorders
- Snoring – Positional device (anti-snoring cushion) , Breath-Right Strips , Prescription Nasal Sprays , Vicks Vapor Gel ….these items alone or in combination with other treatments for snoring or obstructive sleep apena can be successful
- Obstructive Sleep Apnea – Continuous Positive Airway Pressure (CPAP) Treatment, currently this is the primary treatment for people with obstructive sleep apena . The device has a small air blower connected to a flexible hose to a cushioned plastic mask that covers your nose . The blower forces air through the hose and mask into your nose and throat to keep the air passage open during sleep.
- Snoring and Obstructive Sleep Apnea – Oral Appliance Therapy uses a small acrylic device that fits over your upper and lower teeth or tongue (similar to a orthodontic retainer or mouth
guard). This device slightly advances the lower jaw or tongue moving the base of the tongue forward to open the airway . This improves breathing and reduces snoring and apnea . The appliance is customized for each patient by a dentist experienced in the treatment of snoring and obstructive sleep apnea . This therapy is effective for treating people with snoring and mild to moderate obstructive sleep apnea (and certain cases of severe OSA and is usually well-tolerated by patients).
- Snoring and Sleep Apnea – Types of Surgery Treatments Available :
a) Laser-Assisted Uvulopalatoplasty(LAUP) – a technique that removes a portion of the soft palate and most of the uvula and is often done in the office using local anesthetic . Less effective for treating people with moderate or severe OSA.
b) Uvulopaltopharyngioplasty (UPPP) – Done in the hospital , this procedure removes all of the uvula and about one-third of the soft palate . It requires a 2-week healing period and can be effective for treating people with snoring and mild OSA . It is not as effective for treating people with moderate – severe OSA.
c) Sommoplasty(radio frequency surgery) – this is a minor surgical procedure completed in the physician’s office using local anesthetic and a customized electrode that delivers radio frequency energy to the tongue and/or soft tissue of the palate . This treatment reduces snoring by creating scarring which decreases vibration of the tissues.
Sleep Apnea & Snoring Mouthpiece: A CPAP Alternative
Oral appliance therapy is an option for those patients that are unable to tolerate a CPAP machine. If you have tried to remedy your sleep apnea with a CPAP machine you may have objected to:
- Mask discomfort
- CPAP machine noise
- Dry mouth or nasal congestion
- Feelings of claustrophobia
Managing sleep apnea with a CPAP machine is simply not an option for many patients. This is why the American Academy of Sleep Medicine (AASM) has approved the use of custom-made oral appliances for the treatment of snoring and mild to moderate OSA. These oral appliances, designed by Dr. Bellorini and are custom-fitted to help our patients get a full night’s rest and minimize the effects of sleep apnea and snoring.
An oral appliance is a small acrylic device that fits over the upper and lower teeth or tongue . This device slightly advances the lower jaw or tongue , moving the base of the tongue forward and opening the airway . There are many types of oral appliances , depending on your specific needs and the final customization is completed by Dr. Bellorini.
The American Academy of Sleep Medicine has stated that an oral appliance is indicated as the frist treatment of choice for patients with primary snoring , mild obstructive sleep apnea or patients with moderate OSA who prefer the appliance to CPAP as a second treatment option for patients with severe sleep apnea who cannot tolerate CPAP.
Therefore , oral appliance therapy is indicated for:
- Primary /heavy snoring
- Mild or moderate sleep apnea and certain cases of severe OSA
- Poor tolerance of nasal CPAP
- Failure of corrective surgery
- Use during travel
- In combination with nasal CPAP
There are a number of temporary side effects that may be noticeable during the first few weeks or may require minor adjustment of the appliance by the dentist. These include:
- Tension in the jaw
- Sore teeth or gums
- Excessive salivation or a dry mouth
- Temporary change in the bite (when appliance is removed in the morning)
- Noises in the jaw joint
The potential side effects that can be more problematic include:
- Jaw muscle or joint pain
- Permanent changes in the bite
- Slight movement of teeth
- Loosening of dental restorations (crowns, bridges, etc.)
From the research evidence and our clinical experience , jaw muscle and joint pain occur in approximately 10% of the patients and the pain will disappear when the patient discontinues use of the appliance . Soreness or pain is not an issue for 90% of the patients . Changes in the bite can occur in about 30-40% of the patients . Although the changes may be slight it may still be difficult for the patient to close their back teeth together , which may have an effect on their ability to chew effectively . The slight movement of teeth and loosening of dental restorations occurs very infrequently (1 % of the patients) but is still worth doing.
Types Of Oral Appliances
- Mandibular Advancement Devices- Are custom made for each patient ,using a special hard acrylic material . They fit snugly , but comfortably over the upper and lower teeth . The appliance holds the lower jaw slightly forward to open the airway and restore normal breathing during sleep . They have a built-in adjustment mechanism that allows gradual advancement of the jaw to help achieve optimum effectiveness .
- Tongue Retaining Devices – Custom-made and pre-fabricated models are available . They are a soft , pliable material that has a compartment that fits around the tongue to hold it forward by means of suction . Used most often for patients with dentures or for those whose jaw cannot be adequately advanced .
- Types of Appliances Used in Our Office – We use several different oral appliances and is based on several patient factors . These include the severity of the apnea condition , patient’s bite and jaw structure , size of the tongue and soft palate , presence of tooth clenching or grinding , jaw range of motion , health of teeth and gums ,and many others .Currently Dr. Bellorini works with the following appliances :
The SomnoMed MAS™ is an oral appliance, which fits over the upper and lower teeth, much like a sports mouthguard. Unlike a sports mouthguard, however, it is a precision-made, clinically-tested medical device, which is highly effective (in most cases) in preventing snoring and mild to moderate obstructive sleep apnea.
The medical term for your lower jaw is ‘mandible’ and an oral appliance worn over the teeth is a ‘splint’, hence the name SomnoMed Mandibular Advancement Splint, or SomnoMed MAS™.
This is a thermoplastic appliance which must be heated in hot tap water every night (to make flexible) before it is placed in the mouth. It allows for some side-to-side movement of the bottom jaw and limited opening, so that water can be sipped without removal of the appliance. The adjustment hardware is on the roof of the mouth and it takes some time to get used to swallowing with material in that location. The patient is able to adjust the bottom jaw forwarded in very tiny 25 mm increments. The appliance is completely contained within the mouth, and though it makes the lips look a bit puffy, is completely hidden when in use.
This is a hard plastic appliance which has the adjustment hardware set on the cheek side of the molar teeth. It prevents side-to-side motion, but since the bottom jaw is held closed with small orthodontic rubber bands, opening the jaws is fairly easy. The modified Herbst is smaller than most appliances and has a long life span. It allows jaw movement in all directions but backwards. The patient can take medications, use an asthma inhaler or talk with this appliance in place. This appliance can be fabricated out of material that has no methylmethacrylate and is thus safe for patients who are allergic to this material.The modified Herbst is one of the ‘yardsticks’ used by other appliances seeking FDA acceptance. Patients who severely grind their teeth at night can crack this appliance.
The E.M.A. is the thinnest and least bulky of all the appliances. It is similar to clear acrylic orthodontic retainers, and the ‘hardware’ (located to the cheek side of the molar teeth) consists of specially designed, patented elastic bands. This appliance moves the jaw forward in fairly significant steps, which may be difficult to tolerate. Some care must be taken to avoid breaking the lower portion when replacing the custom elastics. The EMA is well tolerated by patients who grind their teeth. It has no metal and can be used by patients with a nickel metal allergy.
Adjustable PM Positioner
The is a custom-made appliance constructed of a heat-sensitive acrylic that fits over the upper and lower teeth. The appliance is comfortable on the teeth and leaves added space for the tongue compared to other devices. It allows a small amount of jaw movement (4mm) so that the patient does not feel “locked into position”. The adjustment mechanisms are on the cheek side of the appliance near the molars and allows for easy advancement of the jaw position to improve effectiveness of the device when it is indicated. This appliance is used most frequently in our office because of its ease of use, effectiveness and durability.
This is also a custom-made appliance that is made of a heat-sensitive acrylic that has a separate upper and lower portion that is connected in the front of the device by a hook and bar assembly. This device is comfortable on the teeth and allows good freedom of movement of the jaw. Therefore it is used frequently for patients who tend to grind their teeth heavily. Since the position of the jaw can be adjusted while the appliance is in place, it is also used for patients who have a certain jaw structure that would require that feature. As mentioned the front assembly is located near the tip of the tongue and it protrudes between the lips, so it may take a little bit more time to adapt to the device. However, most patients find it to be comfortable within the first 5-10 days.
Tongue Retaining Device (TRD)
This is a custom-made appliance made of a soft, pliable material that has a compartment in which the tongue is held in place by means of suction. This appliance is most frequently used for patients who have very few or no teeth. The TRD may require some time for the patient to adapt to having their tongue held in place, so a tongue exercise and adaptation program is started a few weeks prior to the date of insertion of the device. This appliance may be difficult to tolerate if the patient has trouble breathing through their nose.
Silent Nite, SnoreAid and Therasnore
These are other appliances currently used in the office. The Silent Nite is a smaller appliance that is very comfortable to wear and can be effective for patients who are primarily snorers or have very mild apnea. However it is less durable and has much less adjustability. The SnoreAid and Therasnore appliances can be fitted the day of the appointment, which is a great option for patients who need the appliance immediately (if they are leaving on vacation the next day, etc.). However these devices are much less durable and the Therasnore is bulky compare to other appliances. The Adjustable PM Positioner , TAP Plus and Tongue Retaining Device are all FDA accepted for snoring and sleep apnea. The Silent Nite, SnoreAid and the Therasnore are FDA accepted for snoring only.
Effectiveness of Oral Appliances
Research evidence shows that oral appliances are effective in treating snoring in 85-90% of the patients. The mandibular advancement devices are effective in normalizing the apnea levels in 75% of the patients with mild sleep apnea (5-20 events/hr.), 60% effective for patients with moderate sleep apnea (20-40- events/hr.) and 40% effective for patients with severe sleep apnea (more than 40 events/hr.). Patients with moderate or severe sleep apnea must have a follow-up sleep study, while using the oral appliance to confirm the effectiveness of the device and a consultation with the sleep medicine physician to discuss the results. It should be noted that in surveying patients who started with a CPAP machine only 50% were still using their machine while the other 50% was not . This is why Dr. Bellorini has been recommending these oral appliances to help patients and their family’s get a good nights sleep.
Getting a Diagnosis
If you suspect that you have sleep apnea, the usual first step is to discuss your suspicions with your primary care physician. If you don’t have a primary care physician, you can go directly to a clinician who is a sleep specialist. But check your health care insurance coverage first. Some policies require you to see a primary care physician first, and some policies limit the sleep centers and testing facilities whose services they will pay for. Unfortunately, you may discover that your policy offers limited or no coverage for the diagnosis and treatment of sleep apnea, in which case you may wish to switch insurers if and when you can.
Sleep specialists come from a variety of medical backgrounds. They may be pulmonologists (lung specialists), otolaryngologists (ears, nose, and throat), neurologists (brain and nerves), psychiatrists (mental health), or primary care physicians–internists and family practitioners. Some dentists also have special training in the treatment of sleep disordered breathing, which includes sleep apnea. A definitive diagnosis of sleep apnea can be made only with a sleep study conducted during a visit to a sleep lab, usually overnight, or a home study performed with special equipment. Your sleep specialist will be helpful in providing you with the information about getting a sleep study done . Once a diagnosis is made your sleep specialist will discuss with you the treatment options that would provide you and your family with a good night’s sleep.
A sleep study generates several records of activity during several hours of sleep, usually about six. Generally, these records include an electroencephalogram, or EEG, measuring brain waves; an electroculogram, or EOG, measuring eye and chin movements that signal the different stages of sleep; an electrocardiogram, EKG, measuring heart rate and rhythm; chest bands that measure respiration; and additional monitors that sense oxygen and carbon dioxide levels in the blood and record leg movement. None of the devices is painful and there are no needles involved. The testing procedure as a whole is known formally as “polysomnography,” and the technician who supervises it is usually a “registered polysomnographic technologist,” or RPT. Usually the bedroom where the test is conducted is more like a comfortable hotel room than a hospital room.
Your doctor might prescribe a “split-night study,” in which the first hours are devoted to diagnosis. If obstructive sleep apnea is found, the patient is awakened and fitted with a positive airway pressure device. The remainder of the patient’s slumber is then devoted to determining how well he or she responds to PAP therapy.
Home-based Sleep Monitoring Devices
There are a number of different home sleep testing devices on the market, but none of them record all of the data parameters that a full in-lab sleep study will. Also, the in-lab sleep studies are monitored by sleep technicians that are there to make sure that monitoring sensors stay in place for accurate data recording as well as your vital signs are within safe parameters. The good news for most people is that home sleep testing devices (HST) are effective in diagnosing obstructive sleep apnea.
WatchPAT is an FDA-approved diagnostic device that uses innovative technology to ensure the accurate detection of sleep apnea. Its ease of use is unparalleled and it is greatly complemented by the fact that WatchPAT testing is done in the comfort of your own bedroom, an environment that best reflects the pattern of your sleep habits. That fact alone may prove to be a lifeline for the millions of undiagnosed patients who are unwilling to spend the night away from home in a hospital sleep center. WatchPAT monitors changes in peripheral arterial tone and activity, as well as in blood oxygen saturation levels. It also identifies sleep apnea events just like the equipment used in polysomnography (PSG) sleep studies performed in hospital sleep labs.
The data and reporting that we use in our home sleep test kits detect the following parameters listed below.
- Detection of Airflow Patterns (Also records snoring events)
- Respiratory Effort
- Oxygen Saturation Levels
- Heart Rate
Am I Eligible for a Home Sleep Test?
- You are between 18 and 65 years of age. Home sleep tests are not recommended for children or older adults.
- You have a high risk of moderate-to-severe sleep apnea. Your risk for sleep apnea can only be determined by a complete sleep evaluation. Key risk factors include loud and frequent snoring, daytime sleepiness, obesity, and witnessed pauses in breathing during sleep.
- You have no other major medical problems. Other medical problems can affect the results of a home sleep test, including lung disease, neuromuscular disease, and congestive heart failure.
- You have no other sleep disorders. Other sleep disorders also can affect the results of a home sleep test. During your evaluation the sleep specialist will determine if you show signs of having another sleep disorder. Examples include central sleep apnea, periodic limb movements, insomnia, parasomnias, circadian rhythm sleep disorders, and narcolepsy.
Example Brands of Home Sleep Testing Devices
- ApneaLink Plus-Resmed
- ARES-WaterMark Medical
- Watch PAT-200
- Alice PDx-Respironics