Dental sleep medicine for snoring and sleep apnoea
The impact of the facial anatomy, soft tissues and teeth are significant on having Sleep/breathing disorders. The prevention and management of this modern disease is important and starts in a very early age.
However, we are also able to treat older patients with sleep disorder breathing.
Oral Appliance Therapy for Snoring and Obstructive Sleep Apnoea
For every 10 Australian adults, two will experience snoring during their lifetime. Snoring is usually not considered to be a significant medical problem. However, for some people, snoring may indicate a more serious condition called obstructive sleep apnoea (pronounced ap-nee-ah). Snoring also indicates mouth breathing that leads to a dry mouth and an increased risk of gum problems and decay.
Obstructive sleep apnoea can be harmful to health and may ultimately lead to life threatening conditions such as stroke, heart disease or an increase in blood pressure.
The use of specialised mouthpieces or oral appliances can be an effective method of treating both mild to moderate snoring and obstructive sleep apnoea.
Oral appliances are fitted by a dentist whom is experienced in their use, usually in consultation with a respiratory or sleep-disorder physician or ENT.
The Causes of Snoring and Obstructive Sleep Apnoea
During normal breathing, air is drawn through the nose and past soft tissues at the back of the throat. During waking hours, the airways are held open by the muscles around the airway. In some cases, due to habitual mouth breathing the lower jaw grows down and further back and results in a smaller airway. During sleep the muscles in the neck and face relax and in, the already narrower airways, can cause obstruction of the airways.
In an attempt to overcome the obstruction, the person breathes harder, using the chest wall muscles and diaphragm. But the harder we try to breathe, the more the walls of the airway collapse. This is similar to trying to suck through a straw which collapses as the effort to withdraw liquid is increased. In cases where extra tissue is carried around the face and neck area the extra weight may also have an effect on the falling-in of the airways.
The obstruction may be partial (hypopnea) or complete (apnoea). If breathing is absent for more than 10 seconds, the condition is known as apnoea.
Oral appliance therapy uses a dental device, fitted inside the mouth to prevent the airways from collapsing during sleep. This is usually achieved by holding the jaw forward and therefore positioning the tongue more forward out of the back of the throat.
The Symptoms and Signs of Obstructive Sleep Apnoea
People who have obstructive sleep apnoea almost always snore loudly and usually have a number of other symptoms, including:
- Choking or gasping during sleep
- Tiredness on waking
- Sore or dry throat on waking
- Morning headache
- Excessive daytime sleepiness
- Poor concentration
- Memory deterioration
- Decreased sex drive or impotence
- Personality changes that may include irritability
- Decrease in job performance
- Signs of grinding and clenching in-between snoring episodes
Diagnosis and Assessment of Obstructive Sleep Apnoea
Proper diagnosis of the cause of sleep apnoea is essential, so that the most appropriate treatment can be offered. People with symptomatic snoring should be assessed by ENT specialist before any treatment starts.
Obstructive sleep apnoea can cause interruptions to breathing many times during the night, each episode lasting from 10 seconds to two minutes. A person is considered to have sleep apnoea if there are more than five partial or complete obstructions per hour of sleep.
Typically, the apnoea episode ends when the person wakes up briefly. Usually, the person has no awareness of these brief episodes at the time, but finds that sleep is not refreshing.
Treatment of Snoring and Obstructive Sleep Apnoea
Snoring and obstructive sleep apnoea may be treated using oral appliances, nasal continuous positive airway pressure (nasal CPAP), myofunctional orthopaedic appliances with braces or surgery. The consultation of dieticians or you GP may also be necessary in cases with too much weight around the neck area.
Oral Appliance Therapy
Dentist with training in oral appliance therapy are part of the team involved in the management of obstructive sleep apnoea and troublesome snoring. They have expertise in the types of oral appliances that will best suit your needs.
Following a thorough assessment of your mouth and teeth, which may include X-ray examination or the use of dental moulds, your dentist may fit an appliance.
Oral appliances are also called mandibular advancement splints (MAS) or mandibular advancement devices (MAD) and there are many types, not all of which are equally effective. The usual oral appliance consists of a “mouth guard” fitted to both the top teeth and the bottom teeth and then joined together in such a way that the bottom teeth end up in front of the top teeth. Pushing the bottom jaw forward in most people opens up the airway and supports it so that it is less likely to collapse. In this way helping to reduce either the number or severity of the apnoea events. For most people, advancing the jaw by about 8 to 10mm is enough to make a difference but this amount may need to be adjusted if it is not effective or if you find it too uncomfortable. There are other types of oral appliances including tongue retaining devices but mandibular advancement splints are the most commonly used.
Different appliances suit different people, depending on their specific dental or medical condition, so it may take more than one visit for the right appliance to be fitted.
This fitting and assessment may take some weeks to complete and we may advise the use of a chin strap to aid in mouth closing and nose breathing.
In every 100 snorers, about 95 will have a decrease in the noise levels they are making during sleep.
Of every 100 people with mild to moderate obstructive sleep apnoea, about 80 will have either good or excellent results while using these appliances.
The appliances may be used alone or in conjunction with other treatments such as surgery or nasal CPAP.
Advantages of Oral Appliance Therapy
The treatment of snoring or obstructive sleep apnoea with oral appliance therapy is safe, painless and effective. Treatment is usually reversible and does not involve surgery. The appliances are relatively inexpensive and easy to wear.
It is often possible to speak, yawn or even drink while wearing the oral appliance.
As the appliances are small and light, they are easy to carry during travel. If an oral appliance is cleaned and stored correctly, it should last for years.
Side Effects of Oral Appliance Therapy
Side effects of oral appliance therapy may include:
- Temporary discomfort around the teeth or jaw joint.
- Dry mouth.
- Excessive salivation.
- Irritation to the soft tissues of the mouth.
- Minor irregularities to the bite (this is usually temporary).
More severe side effects are rare. These may include significant discomfort to the jaw joint or permanent changes to the bite.
Nasal Continuous Positive Airway Pressure (CPAP)
This involves wearing a mask over the nose at night that delivers continuous pressure via a quiet pump. This gently forces the airways open during sleep. This is generally used for patients with moderate to severe apnoea or for patients with heart or lung disease.
Myofunctional orthopaedic oral appliances
Orthopaedic appliances aim to permanently change the shape, size and position of the upper jaw in order to have a better functional more forward position for the lower jaw. This more forward natural position aids in placing the tongue in a more forward natural position and more from out of the back of the throat, leading to less collapse. Most of these cases involve some form of orthodontic treatment after the orthopaedic device. This can form part of the total treatment regime in combination with other options and is a more long-term effect for mild to moderate cases and can even help to reduce the symptoms in severe cases.
Three Types of Apnoea
This is due to an obstruction of the upper airways. Obstructive apnoea is commonly caused by the collapse of the muscles around the throat and tongue. While associated with snoring, it is a more advanced, serious condition.
This occurs when the part of the brain that controls breathing “forgets” to send messages down to the breathing muscles, so breathing stops. This is usually not associated with snoring. Oral devices are not affective for this type of apnoea.
This is a combination of central apnoea and obstructive apnoea. Snoring usually occurs when you have mixed apnoea.
Several different surgical procedures can be used, including surgery:
- To open the breathing passages in the nose
- To remove tonsils
- To remove some of the excess tissue at the back of the throat
- To reduce tongue size
- To bring the upper or lower jaw forward
- To pull the tongue muscles forward
As discomfort or complications may occur, careful discussion with a surgeon is necessary.
Other Methods of Relief
Symptoms may also be improved by:
- Loss of excess body weight
- Taking regular exercise
- Avoiding alcohol or medications that may increase drowsiness
- Sleeping on your side rather than your back
- Learning the didgeridoo
For more information please refer to the Australian Sleep Association
DISCLAIMER – INFORMATION PROVIDED IN THIS BROCHURE IS GENERAL IN CONTENT AND SHOULD NOT BE SEEN AS A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. CONCERNS OVER SLEEP OR OTHER MEDICAL CONDITIONS SHOULD BE DISCUSSED WITH YOUR FAMILY DOCTOR.
Dr Ian Odendaal is a member of the ASA – AUSTRALASIAN SLEEP ASSOCIATION
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