Ultimate Guide To SNORING and SLEEP APNEA
Snoring and sleep apnea are perhaps the most common sleep disruptors. Snorers and patients with sleep apnea generaly seek care for one of two reasons bed partner disturbance and daytime sleepiness. It is very important to understand that snoring and sleep apena are related conditions, but they do not always occur together. It can be said that all sleep apnea patients snore but all snorers do not have sleep apnea.
It is a great feeling to suggest a solution to a patient and have them report immediate success. This is the ideal result, however these therapies must be used by the patient all night every night. adapting to sleep therapies takes coaching and a commited patient.
Sleep apnea is a chronic condition treatment requires the patient to have specific knowledge and understanding of the capabilities of each therapy. This helps frame expectations and helps the patient stay in a positive frame of mind while adapting to using an oral appliance, CPAP or even a new pillow.
The scale that we use to judge snoring devices includes compliance, access and affordability. These considerations are in addition to clinical outcome. Does it stop the snoring? Is the patient able to breathe all night long?
If the device is difficult to access because of a complicated or expensive diagnostic protocol or the patient cannot comfortably use the device all night long, then even the most effective treatment cannot be considered the best therapy.
What is snoring and sleep apnea?
Snoring and sleep apnea are related chronic conditions of the upper airway. Snoring is the sound of air rushing through a partially collapsed airway. The tissue vibrates causing the snoring sound and often inflammation of these tissues results causing further narrowing of the airway.
Sleep apnea is when no air gets to the lungs for 10 seconds or longer. It can be described as obstructive or central sleep apnea.
Obstructive sleep apnea (OSA) is when the airway collapses completely and the sleeping person tries to draw breath against the obstruction. These patients often gasp awake for a few seconds then fall back into the obstructive breathing pattern. This sleep…gasp, sleep… gasp pattern can happen over 30 times per hour in severe cases.
Central sleep apnea (CSA) is a condition of the nervous system where the patient does not breathe for ten seconds or longer. In this case the patient’s brain is not asking for a breath so there is no effort on the sleeping person’s part. In this case the breathing just stops then the breathing starts again. It is very scary to watch a patient with this condition sleeping because the silences can be so long.
If snoring is accompanied by any of the following issues, it may warrant consultation with a dentist or physician for OSA evaluation:
- Witnessed breathing pauses during sleep
- Excessive daytime sleepiness
- Difficulty concentrating
- Morning headaches
- Dry mouth upon awakening
- Restless sleep
- Gasping or choking at night
- High blood pressure
- Chest pain at night
- Loud snoring that disrupts a partner’s sleep
In children, symptoms may include a poor attention span, behavioral issues or poor performance in school.
OSA often is characterized by loud snoring followed by periods of silence when breathing stops or nearly stops. Eventually, this reduction or pause in breathing may signal the person to wake up, and the patient may awaken with a loud snort or gasping sound.
For this post, we will focus only on snoring, which is a primary complaint and the reason most patients seek treatment for sleep-disordered breathing.
Lifestyle changes are perhaps the most important and effective treatments for snoring. To treat snoring, doctors are likely to first recommend lifestyle changes, such as the following:
- Weight loss
Fatty tissue around the neck and throat can contribute to the airway narrowing and the snoring that results. Losing weight can sometimes be all it takes to resolve snoring.
- Alcohol avoidance close to bedtime
Alcohol is a depressant, and it works as a muscle relaxant. After alcohol consumption, muscles of the airway can relax, allowing tissues to collapse into the airway.
- Treatment for nasal congestion
Nasal congestion can act as a further obstruction of the airway, making the snoring sound even worse.
- Avoiding sleep deprivation
Sleep deprivation can lead to very deep sleep that results in further airway relaxation. The more relaxed the tissues of the airway, the higher the possibility of partial collapse and the snoring that goes with it.
- Sleep positioning
Sleeping on your back allows the tongue and soft tissues to collapse into the airway. Side sleeping is the preferred position for a healthy night’s sleep.
Oral appliances are custom-fit dental mouthpieces that are made by a dentist. The most popular design is called a mandibular advancement device (MAD). The MAD engages the upper and lower teeth and, using adjustment arms, positions the jaw slightly forward during sleep. This forward position serves to put tension on the muscles and ligaments of the airway to keep them from collapsing and causing the snoring sound.
See the example below. The adjustment arms of the Silent Nite® Sleep Appliance work like a hinge to improve patient comfort. This MAD allows the patient to talk, drink water and take medication if necessary. Other MAD that have some of the same characteristics are
EMA, Oasys,and the DreamTAP . When the patient is wearing the oral appliance, it is not visible to the bed partner. It makes no sound, and when titrated correctly, neither will the patient.
When measured against the above scale, oral appliances for snoring and sleep apnea rate as follows:
- Compliance: Patients who wear oral appliances for snoring and sleep apnea find them comfortable and have no problem wearing them every night. In fact, one study that followed 256 patients for over two years found that patients were able to sustain wearing the appliance all night long about 90% of the time.
- Access and affordability: There are over 200,000 dentists in the United States, and the ADA states that 52% of adults report seeing their dentist every six months. Dental care is readily available in the U.S.
While sleep apnea treatment is covered by medical insurance, snoring treatments are not. In the dental office, snoring treatments range from $500 to $1,000, depending on the practitioner and geographical location. The American Sleep Association says: “The average cost for a sleep apnea mouthguard is estimated at $1,800–$2,000. This includes the actual sleep apnea mouthpiece, dentist visits, adjustments, follow-ups, and modifications to the dental device. Most health insurance companies and Medicare cover oral devices for sleep apnea.”
Continuous Positive Airway Pressure (CPAP)
Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) therapeutic devices blow air at a consistent pressure into the airway, providing a pneumatic splint for the airway, sufficient that the airway does not collapse during sleep. A CPAP machine is placed on the bedside and blows air through a hose to a mask or nose piece to deliver air to the airway. CPAP, like oral appliances, must be used in order to provide an effect. Common problems with CPAP include mask leaks, as well as patients experiencing trouble falling asleep, stuffy nose and dry mouth.
- Compliance: CPAP is an excellent therapy for patients who can adapt to it. The tubing and mask designs have evolved a great deal in the past 30 years; however, a recent 20-year retrospective study of CPAP wearers has shown that CPAP compliance is a woeful 34.1%.
- Access and affordability: CPAP is universally covered by medical insurance and the medical community has excellent familiarity with CPAP. In fact, CPAP is considered the gold standard of care by the medical community in spite of the documented poor compliance rate.
When measured against the above scale, note the following:
The American Sleep Association suggests that the average price for a CPAP machine ranges from about $500 to $3,000, with an estimated average price around $850. Many insurance companies cover the cost of CPAP and BiPAP devices. This usually includes CPAP parts and supplies, such as the mask, hose, filters, and tubing.
There are various options available to treat patients for snoring and sleep apnea. Whether it involves lifestyle changes, sleep appliances, CPAP, BiPAP, or a combination of treatments, the ideal choice is a solution that provides your patient with high-quality sleep each and every night.
for dentists who want to learn more about snoring and sleep apnea and a straightforward protocol for screening and treating patients, visit glidewelldental.com/pmad.