Sleep Apnea

Sleep Disorder Breathing

If you snore loudly and often, you may be accustomed to middle of the night elbow thrusts and lots of bad jokes. But snoring is no laughing matter. That log-sawing noise that keeps everyone awake comes from efforts to force air through an airway that is not fully open.

Perhaps 10% of adults snore. Although for most people snoring has no serious medical consequences; however, for an estimated 80% of snorers, habitual snoring is the first indication of a potentially life threatening disorder called “Obstructive Sleep Apnea.”


It has been estimated that the indirect costs of sleep disorders are:

  • 41 billion dollars a year from lost productivity
  • 17 to 27 billion dollars a year from motor vehicle accidents
  • 2 to 4 billion dollars a year in home and public accidents.
Clearly, this is a major national problem that needs to be dealt with in an appropriate fashion. Dr. Stagg has extensive training in the recognition and treatment of Snoring and Obstructive Sleep Apnea.

DEFINITIONS:
“Apnea” is defined as the absence of breathing or the want of breath. When there is a cessation of airflow at the mouth and nose for more than 10 seconds an apnea episode has occurred. If a person experiences 30 or more apnea episodes during a seven hour period, then they are believed to be suffering from Sleep Apnea.
Apnea severity is usually categorized by the frequency of apnea episodes:
  • 5-15 episodes per hour is mild
  • 15-25 episodes per hour is moderate
  • More than 30 episodes per hour are considered severe.

These episodes can last anywhere between 10 to 20 seconds each, terminating with at least a partial wakening. Typically, a patient may have as many as 300 episodes per night. There are three basic classifications of sleep apnea: central, obstructive, and mixed.

Central Apnea – Airflow stops because inspiratory efforts temporarily cease. Although the airway remains open, the chest wall muscles make no effort to create airflow. The etiology frequently is encephalitis, brain stem neoplasm, brainstem infarction, poliomyelitis, spinal cord injury, and cervical cordotomy.


Obstructive Apnea – The cessation of airflow due to a total airway collapse, despite a persistent effort to breathe. An obstruction in the upper airway can occur in three areas. They are the nasopharyngeal, oropharyngeal, and hypopharyngeal regions.


Regardless of the level, an obstruction causes the breathing to become labored and noisy. As pressure to breathe builds, muscles of the diaphragm and chest work harder. The effort is akin to sipping a drink through a floppy straw, the more the collapse the greater the effort. Collapse of the airway walls will eventually block breathing entirely. When breathing stops, a listener hears the snoring broken by a pause until the sleeper gasps for air and awakens, but so briefly and incompletely that he/she usually does not remember doing it the next morning.


Mixed Apnea – A combination of central and obstructive apnea usually beginning with a central episode being immediately followed by an obstructive one.


What is Snoring?

Many people think that snoring and apnea is the same thing. This is not true -

Snoring, which is caused by a change in airflow through the nasal and pharyngeal tissues, is only a sign that a patient may be suffering from apnea. It’s basically like water running through a pipe. If the water runs abnormally through the pipe it will vibrate. The same thing happens with airflow when it is partially obstructed.

Snoring can be categorized by its severity -

  • On one side of the spectrum, you have the benign snorer, who snores but experiences no physical problems
  • On the other side of the spectrum, you have the snorer who suffers from apnea
  • In the middle you have the snorer who suffers from what we call Upper Airway Resistance Syndrome.

In these people, though they may not actually experience apnea episodes, their snoring is so loud and their breathing is so labored, that it still wakes them up numerous times throughout the night. This leaves them unrefreshed and tired in the morning.

THE ROLE OF THE DENTIST:

Pre -2006, the gold standard of care for treatment of Sleep Apnea was the C-Pap machine (Continuous - Positive Air Pressure). However, the compliance rate after one year with the C-Pap machine is so low (estimated to be less than 90%) that there have been some changes to help more apneic patients. As of January 2006, the American Academy of Dental Sleep Medicine has stated that mild to moderate Sleep Apnea can be treated with Oral Appliance therapy. Dr. Stagg has had extensive training in evaluating, screening and treating Sleep Breathing Disorders with Oral Appliance therapy.

Because the etiology of obstructive Sleep Apnea is multifactorial and the treatment options are varied, proper diagnosis and treatment are best handled by a team approach. Dr. Stagg may include in her team the patient’s primary care physician, a sleep specialist, an ENT or an Internist.

Dr. Stagg plays an active role in:

  • Screening the patients
  • Treating them in conjunction with other sleep specialists
  • Providing them with follow up treatment

SCREENING for ADULTS:
Patients will need to be evaluated for the presence of any physiologic and behavioral predisposing factors. A complete evaluation will reveal some of the physiologic factors. It should include the following:

  • Complete medical and dental histories
  • Soft tissue / Intra-oral assessment
  • Periodontal evaluation
  • Orthopedic / TMJ / Occlusal examination
  • Intraoral habit assessment
  • Examination of teeth and restorations
  • Initial dental radiographic survey (panoramic and/or full mouth Series and a baseline lateral cephalometric survey)
  • Diagnostic models

While doing the soft tissue / Intraoral assessment part of the examination, Dr. Stagg will evaluate all three regions of the upper airway.

An obstruction in the naso-pharyngeal area is usually caused by turbinate hypertrophy, a deviated septum, or an abnormal growth like a polyp. Although documenting a problem in this region is the job of an ENT, Dr. Stagg is qualified to access patients for patent nasal airway.


When evaluating the oropharyngeal region, Dr. Stagg first checks for hypertrophy in the tonsils. Then checks the size and position of the tongue as it relates to the soft palate. Finally she looks at the size and drape of the soft palate and the uvula. When the soft palate is excessive or drops down immediately, there is a good chance that this patient will suffer from an oropharyngeal blockage.


An obstruction in a hypopharyngeal airway space is a lot harder to detect through observation alone. We do know that when motor nerve activity stops during REM sleep, the tongue can drop back against the posterior pharyngeal wall and block the airway. Cephalometric films can give us some information on whether an airway is blocked. Although it is a two dimensional view of a three dimensional space, we can get an idea of the relative size of the airway, the posterior airway space, the length of the soft palate and the position of the mandible, maxilla and the hyoid bone.


Dr. Stagg has incorporated in her practice the Eccovision System by Health Technology Limited as a diagnostic tool to thoroughly and accurately assess the patient’s airway. Completely painless and non-invasive, the Eccovision emits sounds waves through a self-contained central processing unit comprised of two tools, 
the Rhinometer and Pharyngometer.  They map the patient’s nasal passages and pharyngeal airway, respectively, via a technique called “acoustic reflection”.  The results are onscreen graphics directly correlating to the physicality of the patient’s nasal passages and pharyngeal airway.  When used properly these tools do two things, identify the area of obstruction and graphically display the changes in the oral airway with lower jaw advancement and vertical changes so you can see the effect an oral appliance has on oral airway size.

SIGNS & SYMPTOMS:

The following are some of the signs and symptoms that are indicative of a person who is suffering from apnea:

Adults

  • Heavy snoring
  • Gasping or choking during the night
  • Excessive day time sleepiness 
  • Frequent arousals during sleep (fragmented sleep)
  • Non-refreshed sleep
  • Restless sleep
  • Morning headaches
  • Nausea
  • Personality changes such as becoming irritable or temperamental
  • Severe anxiety or depression
  • Poor job performance
  • Clouded memory
  • Intellectual deterioration
  • Occupational accidents 
  • Impotence
  • Decreased sex drive
  • Bruxing
  • Dry mouth when you awake
  • Scratchy throat

Children

  • Hyperactivity
  • Poor concentration
  • Developmental delay
  • Hyponasal quality to their voice
  • Noisy breathers
  • Obesity
  • Frequent upper airway infections
  • Ear aches
  • Bed wetting
  • Nocturnal mouth breathing
  • Snoring
  • Restless sleep
  • Nightmares
  • Night terrors
  • Headaches
  • Chronic nose running

Typically these children suffer from growth and development problems. A lot of them have under-developed maxillas, narrow upper arches, and retruded mandibles. Often they are highly allergic with their airway completely blocked due to tonsillar hypertrophy. If they are already having snoring and breathing problems, do not ignore them. For more information and the dangers of snoring please view this video.  

DIAGNOSIS:

After Dr. Stagg has done her thorough Dental Examination, the patient’s condition will need to be “diagnosed” and confirmed by a Medical Doctor.

An ENT, a sleep specialist, and Internist can work with you to make sure you get a complete medical work-up and sleep test.


A proper medical work-up by a physician can detect physiologic changes as well. Typically, these patients will:

  • exhibit a fragmented sleep pattern
  • experience excessive daytime sleepiness
  • have a change in their C02/02 ratio, causing acidosis

You will also find that these patients tend to have hypertension

  • Some will show signs of altered heart function like cardiac dysrhythmias and premature ventricular contractions
  • Someone suffering from apnea episodes can also end up having anoxic seizures, cardiopulmonary arrest and even experience sudden death

Even after a thorough evaluation by Dr. Stagg and your physician, a definitive diagnosis of OSA can only be accomplished by a sleep test. There are two types of studies:

  1. POLYSOMNOGRAM (PSG), an attended sleep study done in a hospital or sleep clinic. During sleep, the Polysomnogram measures ventilation, gas exchange, cardiac rhythm, the number and length of apneic episodes, assesses oxygen saturation, determines sleep stages, and detects arousals.
  2. Mobile sleep technology which allows you to take a similar test in the comfort of your own home also known as an unattended sleep study. Dr. Stagg uses the Watch-Pat 100 from Itamar, an ambulatory sleep study device. It uses a proprietary system to monitor the Sympathetic Nervous System. Studies have shown a relatively high correlation with a PGS test and the respective device.

Most major medical insurers will require patients to undergo a full blown PSG (Polysomnography) study in a sleep lab for primary diagnosis prior to paying for any treatment. However, in recent years, ambulatory sleep study devices have entered the dental market and are beginning to play an important role in proper treatment protocol. Patients with a high insurance may prefer the low cost of diagnosis with an ambulatory study as opposed to the relatively higher cost of a PSG. An ambulatory study, with a physician’s signature, is a legal diagnosis that Dr. Stagg can use to justify treatment.

TREATMENT PROCEDURES:

Once you understand some of the basics in sleep medicine, it becomes clear that Dr. Stagg, as a dentist, can play a significant role in both the prevention and treatment of snoring and OSA.

Early detection of structural abnormalities in the developing child affords us the opportunity to intervene with FUNCTIONAL THERAPY possibly preventing another eventual OSA casualty. For example, after a thorough orthopedic evaluation, Stagg may then decide to use orthopedic appliances to direct and control a child’s growth. Arch development, mandibular repositioning, and controlling vertical dimensions can create the intraoral volume needed to accommodate the tongue and prevent its compaction into the hypopharynx.


Many treatment methods have been tried over the years to treat snoring and obstructive sleep apnea. To date, three approaches seem to be most effective.

  • Continuous Positive Airway Pressure (C-PAP)
  • Surgical techniques
  • And the use of intra-oral appliances.

Regardless of the technique used, most people benefit by following a few general measures.

A. GENERAL MEASURES:

  • Lose weight – People with severe sleep apnea are almost always over weight
  • Sleep on your side
  • Avoid alcohol within two to three hours of bedtime
  • Avoid certain pharmacological agents.
B. SPECIFIC MEASURES:
Continuous Positive Airway Pressure (CPAP):
This technique involves wearing a mask tightly over the nose during sleep. Pressure from an air compressor is used to force air though the nasal passages into the airway. The forced air creates a pneumatic splint, keeping the airway open and allowing the person to sleep normally. When accepted by the patient, this treatment is highly effective and is considered the “Gold Standard” on which all other treatments are compared. To increase patient acceptance, many improvements have been made over the last few years. Even with all the improvements that have been made, this treatment modality is still not for everybody. In fact, daily compliance by patients using CPAP is less than 50%.

Besides being uncomfortable, the other negatives to this treatment are that it is inconvenient, and it dries out the airway mucosa.  There is also real concern of having reduced cardiac output and renal function.


C. SURGICAL APPROACHES:

NASAL RECONSTRUCTION: Surgical procedures to clear the nasal airway are done to correct turbinate hypertrophy, septal deformities, alar collapse and the removal of tumors or polyps.

UPPP: Uvulopalatopharyngoplasty was first introduced by Ikematsu in 1964 and later by Fujita in 1981. This surgical procedure enlarges the air space by excising redundant soft tissue of the palate, uvula, tonsils, posterior and lateral pharyngeal walls. Most clinical investigations indicate that the success rate of this surgical approach to correct OSA is less than 50%. This is due to the level and cause of the obstruction often being misdiagnosed. Removing some of the vibrating tissue may resolve snoring, but it does not prevent an obstruction by the base of the tongue. This is a serious surgery that is not without its complications.


LAUP: A laser Assisted Uvulectomy is a modification of UPPP surgery. It is accomplished using lasers and is considered a less invasive procedure. It is commonly being used to remove the redundant soft tissue of the palate believed to be causing snoring.


SOMNOPLASTY: This procedure uses a radio frequency to heat the tissue to a very precise temperature creating a finely controlled lesion of coagulation within the tissue. Over a period of four to six weeks, the injured tissue heals and in the process the tissue shrinks and tightens. This technique can be used to reduce the excess tissue in the soft palate, the nasal turbinates and the tongue. This procedure generally takes two to three treatments to shrink the tissue sufficiently to have a clinical effect.


ORTHOGNATHIC PROCEDURES:

Patients with a mandibular deficiency, surgical advancement to a normal occlusal relationship can bring the base of the tongue away from the posterior pharyngeal wall.

When both a maxillary and mandibular deficiency exists, a bimaxillary surgery will provide more physical room for the tongue as well as increase anterior tension on the tongue musculature. Waite et. al. has shown 96% improvement when bimaxillary advancement surgery was the primary surgical procedure.


In patients with a normal dental tongue space, a procedure called an anterior inferior genial osteotomy can be done.


DENTAL APPLIANCES:

Numerous appliances are available to treat snoring and obstructive sleep apnea. Research has shown that many appliances are quite effective and can now be considered an alternative when choosing a treatment modality. In fact, sleep appliances offer several advantages over other therapy choices. They are inexpensive, non-invasive, easy to fabricate, reversible, and quite well accepted by patients.

BASIC INDICATIONS for sleep appliances:
  • Are to treat primary snoring and mild to moderate obstructive sleep apnea.
  • Attempting to make an appliance is particularly appropriate for those patients who cannot handle CPAP.
  • When surgery is contraindicated or the patient is unwilling to go through a surgical procedure, then appliance therapy may be the way to go.

TREATMENT OBJECTIVES for appliance therapy:

  • To reduce snoring to an acceptable level
  • Resolve the patients’ OSA problems
  • Get a higher amount of oxygen into their systems
  • To eliminate excessive daytime sleepiness allowing them to function normally.

Sleep appliances seem to work in one or a combination of several ways.

  • Appliances can reposition the soft palate
  • Bring the tongue forward
  • Lift the hyoid bone
  • As they reposition, they also act to stabilize these tissues, preventing airway collapse
  • Lastly, appliances seem to increase muscle tone. Specifically, there seems to be an increase in pharyngeal and genioglossus muscle activity.
Variations in design range from the method of retention, the type of material being used, the method and ease of adjustability, the ability to control the vertical dimension, differences in mandibular movement and whether is it lab-fabricated or made in the office.

The appliance design that you choose will be dependent upon Dr.Stagg's knowledge of these variations and the oral conditions of the patient. In our office, when selecting an appliance, we will also evaluate the health of the TMJs, the periodontal structures and the number and health of teeth.

DIFFERENT EXAMPLES OF APPLIANCES:

  • Palate Lifters: The soft palatal lift appliance
  • Tongue retainers: - Tongue retaining device
  • Snor-X 
  • Non-adjustable Mandibular Repositioners
  • The clasp retained mandibular Repositioner
  • The mandibular inclined repositioning splint ( MIRS) 
  • The dorsal appliance
  • The snore free Appliance
  • Adjustable/ titratable appliances
  • The Herbst Appliance and variations
  • The Klearway appliance
  • The EMA: Elastic Mandibular Advancement Appliance
  • The TAP and variations
  • The Silencer
  • The Oasys Oral/Nasal Airway System ( has a nasal dilator too)

CHOOSING AN APPLIANCE:
Dr. Stagg can very effectively treat both snoring and sleep apnea with Oral appliances. It is important to determine if or when there are often multiple factors involved in causing the patient’s problem. In fact, there can be an obstruction in the nasopharyngeal, oropharyngeal and hypopharyngeal regions at the same time.
It is also important to work in a team approach to properly identify the causes of the obstruction or appliances may only work 50% of the time regardless of the appliance chosen. Sometimes, even under the best circumstances, we may need to utilize more than once appliance before finding the best one for the patient.

  1. Choose an appliance based upon your team’s clinical assessment of the level of the obstruction then evaluate its effectiveness.
  2. Your first appliance may act as a diagnostic tool or as a trial appliance.
  3. Your trail appliance can also be used to help determine whether a surgical approach could be effective. For example, if one of these appliances achieves some measurable level of success but the patient just can’t tolerate it on a daily basis, Orthognathic surgery, which repositions the chin or the mandible, may be an acceptable alternative.
  4. Dr. Stagg finds that a more conservative approach for a person who cannot get an appropriate “cure” with only appliance therapy and for whom surgery is not an option is to do a combined Oral Appliance/ C-Pap treatment.
  5. The C-PAP PRO: CPAP has a 50% failure rate because patients find most masks unbearable to wear. A new C-PAP interface called the C-PAP PRO: is the combination of a dental mouth piece attached to the C-Pap pro.

PROVIDING FOLLOW-UP THERAPY:
When we work as a team, oral surgeons, internists, ENTs and sleep labs, all have their roles. Ours is to be in charge of the appliance therapy. As the attending dentist, Dr. Stagg should do the selecting, fitting, and monitoring of appliances. Periodic evaluation of these appliances is a must. When they are kept clean and stored properly, we see them lasting a long time. However, patients will occasionally break them or wear through them. Our office needs to be notified ASAP so that we can immediately replace a lost or broken appliance.

Another valuable role ambulatory sleep studies such as the Watch-PAT 100 test performs is to verify efficacy of the appliance. Once an appliance is delivered it is important to have another sleep study done on the patient in order to have objective data showing the appliance has effectively treated the OSA. Patients widely prefer an in-home study option as opposed to having to return to the sleep lab for another test.


CONTRAINDICATIONS AND CONCERNS:

As a dentist, Dr. Stagg deems it essential that she work as part of a team of health care professionals. This is particularly important because many other medical conditions can be associated with OSA. Some of these are:

  • Increased hypertension
  • Elevated protein levels (Proteinuria)
  • Angina pectoris – more likely to develop
  • Initiation of gastroesophageal reflex
  • Frequent nocturnal voiding
  • Hypoxema
  • Hypercapnia (high blood level of CO2)
  • Cardiac changes – bradycardia, tachycardia, and right heart failure, possible leading to sudden death
  • Susceptibility to atherosclerosis
  • Hypothyroidism – causing polythycemia and bicarbonate retention
The treatment of snoring and OSA with dental appliances without first having a definitive diagnosis confirmed by your medical team could cause the patient to become worse, not better. For example, some appliances may alleviate snoring giving the patient and doctor false impression that the appliance is working, when in fact it is possible that the patient’s apnea episodes could be getting worse even though their snoring has decreased.

As with any other mandibular repositioning appliance, we will need to make sure that the patient’s occlusion stays stable. Even though most appliances cap the teeth, you can still get flaring and other occlusal changes.


Some of the COMMON SIDE EFFECTS that you see with the use of sleep appliances are excessive salivation, discomfort in the teeth, a dry mouth, tissue irritation from mouth breathing, temporary disharmonies in the bite and some pain in the joints. It is essential to respect the TMJs when considering the use of a repositioning appliance. A proper TMJ exam is recommended and if a patient is found to suffer from TMJ dysfunction, or their muscles are sore and painful while wearing a repositioning appliance, we may need to use another method.


PAYMENT may be obtained from medical insurance plans for the treatment of snoring and sleep apnea with appliances, but benefits differ dramatically from plan to plan. So payment through insurance is not always guaranteed. As we are a dental office, we will help our patients get reimbursed from their medical insurance, however we do expect payment for services as they are rendered.

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From Our Patients:

"I just wanted new dentures and didn't realize my bite was off. My bite is perfect now. I can chew everything much better. My ability to chew has improved 100% and I seem to be smiling more. I would recommend Dr. Stagg to my friends and family because Dr. Stagg thinks of your whole appearance when making your dentures while other dentists don't."
 
-Betty C

Dentures, 03/05/2007
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