Treatment of Sleep Apnea and Snoring through the use of Oral Appliances
Dr. James Kramer, a Diplomate of The American Academy of Dental Sleep Medicine, works with referring physicians to evaluate and treat sleep disordered breathing, such as Snoring and Obstructive Sleep Apnea, with the use of oral appliances.
Diplomates of the American Board of Dental Sleep Medicine (ABDSM) have received the highest credential a dentist can earn in dental sleep medicine. To earn this qualification, dentists are required to demonstrate competency in dental sleep medicine and must pass a rigorous written examination. It signifies a professional commitment to education, knowledge and experience in dental sleep medicine.
Why do people snore?
Snoring occurs because a narrowing of the airway causes an increase in the speed air travels through the airway and this causes vibration of the soft tissues which creates the snoring sound. Factors that affect snoring are larger soft tissue in the airway, increased resistance in the airway and an increase in the relaxation of these soft tissues.
What are the consequences of untreated snoring?
Disrupted sleep of the affected individual and bed partner can occur. This can lead to daytime fatigue, drowsiness and marital discord.
What are some factors that affect snoring?
- Sleeping on your back
- Nasal obstruction
- Enlarged soft tissues in the throat
What is Obstructive Sleep Apnea?
Obstructive Sleep Apnea is a condition where the soft tissues in the throat completely close off the airway so that air cannot flow to the lungs. This can lead to a decrease in oxygen in the blood, which the brain senses, and alerts the muscles of the airway to tighten up and unblock the airway. As the breathing process begins again, a disruption of sleep occurs that can lead to a decrease in the body reaching the deep stages of sleep. This sleep disruption causes daytime sleepiness and fatigue that can have serious consequences on an individual's quality of life.
How is Obstructive Sleep Apnea diagnosed?
An overnight sleep study called a polysomnogram (PSG) is used to confirm a diagnosis of Obstructive Sleep Apnea. A PSG measures many body functions during sleep: sleep position, sleep stages, blood oxygen saturation, heart rate, snoring, apneas (airway closure) and hypopneas (airway narrowing). Patients are then given a diagnosis based on the number of arousals per hour of apneas and hypopneas. This is called the Apnea-Hypopnea Index or AHI.
- Mild - 5-15 events per hour
- Moderate- 15-30 events per hour
- Severe- 30 events per hour or greater
Three important variables are used to determine a patient's severity:
- The AHI, discussed above
- The amount of time the patient is having an apnea or hypopnea event
- The drop in blood oxygen levels as a result of the event
Is Sleep Apnea a serious health risk?
Systemic health effects of sleep apnea can be life threatening: cardiovascular disease from a lack of oxygen in the blood, high blood pressure, stroke, depression/anxiety, type 2 diabetes and a risk of motor vehicle accidents 3 times greater than the normal population.
How does an Oral Appliance prevent Snoring and Obstructive Sleep Apnea?
Oral appliances are custom made acrylic devices that cover the upper and lower teeth that position the lower jaw forward and open, which helps improve muscle tone and move the base of the tongue forward. This improves the size of the airway, allowing air to pass with less resistance. Oral appliances are very effective in preventing snoring and up to 70% effective in Obstructive Sleep Apnea depending on the severity of the disorder.
What do I do next if I think I would benefit from an oral appliance?
A medical evaluation and diagnosis is important to treating all illnesses, including sleep disordered breathing. A dentist is not licensed to diagnose Snoring or Obstructive Sleep Apnea. It is paramount to begin the process with a diagnosis made by a Board Certified Sleep Physician. Dr. Kramer works closely with patients' sleep physicians in a coordinated effort to give patients the best treatment possible.
What are the treatment options for Obstructive Sleep Apnea?
- Positional Therapy: Sleeping on one's side can significantly improve a person's sleep apnea or snoring.
- Continuous Positive Airway Pressure (CPAP): This device is the standard of care in severe sleep apnea patients. It has a mask that fits tightly over the nose or the nose and the mouth which is attached to an air blower. This air blower administers an air pressure which prevents collapse of the airway.
- Oral Appliance Therapy.: Discussed above.
- Surgery of the tongue, throat or jaw. An Ear, Nose and Throat specialist may perform soft tissue surgeries of the throat or tongue to clear the airway of patients who cannot tolerate CPAP or oral appliances. An Oral Surgeon may perform jaw surgeries that advance the upper and lower jaw which bring the soft tissues out of the airway. These surgeries are quite invasive and should be considered when non-surgical therapies have failed.
- Weight loss: Excessive weight can be the main reason for someone's OSA. Weight loss is unique in that it can be an option to eliminate someone's OSA instead of just treating it with therapy.
What is the best option for my condition?
There is no single best option. Many patients may benefit from a combination of the therapies listed above and this is the reason that a team approach is critical in deciding which therapy is best for the individual patient. Dr. Kramer has networked with area medical specialists in treating these patients. A patient is best served when all of the factors are considered before deciding on a course of treatment.
Indications for Oral Appliance Therapy
- Mild to moderate Obstructive Sleep Apnea
- Severe Obstructive Sleep Apnea patients who cannot tolerate CPAP therapy
- Combination therapy, where CPAP or surgery has not been completely effective
Contraindications for Oral Appliance Therapy
- Limited range of motion of lower jaw
- Active TMJ disorder
- Insufficient number of teeth (minimum 10 teeth on upper and lower)
- Active periodontal disease or excessive tooth mobility
Minor side effects of Oral Appliance therapy
- Excessive salivation
- Loosening of dental restorations
- Dry mouth
- Loosening of teeth
- Discomfort of teeth or jaw
Significant side effects of Oral Appliance Therapy
- Jaw pain
- Permanent bite changes
- TMJ noise or pain
Oral Appliances used in our office
5 FDA approved appliances are used in our office. No single appliance has been shown to be the most effective in clinical trials. Choosing the appropriate appliance is an important step in the success of oral appliance therapy. Listed below are the 5 appliances used and a brief description.
UltraAPM™: Made with a heat sensitive inner lining for maximum comfort and retention, the Ultra APM™ is an appliance for many indications. It has ample space for the tongue, allows for some movement and can be adjusted in .25 mm increments.
SUAD™: Made from a heat sensitive inner lining for maximum comfort and retention, the SUAD™ is an excellent appliance for those who grind their teeth. It has a metal framework for strength and allows for freedom of movement. It is advanced by adding small rings to the tube mechanism and the upper and lower parts are held together by elastics (rubber bands). It can be advanced in .25 mm increments.
TAP 3™: Made from a heat sensitive inner lining for maximum comfort and retention, the TAP 3™ is a unique appliance because it is very durable and small. The major drawback is that it restricts the space of the tongue and therefore is limited in use. It is easily advanced in .25 mm increments. There is limited range of motion and therefore not great for those who grind their teeth.
EMA™: Made from a thin, hard lining, the EMA™ is an appliance to use for patients who cannot tolerate a lot of material in their mouth. The upper and lower parts are attached with elastic straps that come in 5 different lengths and 3 tensions that comprise the adjustment mechanism. Finding the ideal length and tension is the important factor for maximum effectiveness of this appliance. It allows for excellent freedom of movement so it is an ideal choice for those with a history of TMJ disorders. The adjustment mechanism is not as exact as the other appliances, so it is not a good choice for more severe cases.
Somnomed MAS™: Made from a softer inner lining for comfort, the Somnomed MAS™ is a good appliance for those who need freedom of movement. Its upper and lower parts are held together by elastics (rubber bands) or the units are completely separate. It can be adjusted in increments of .1 mm.