Sleep apnea is a sleep disorder which is characterized by apneas (cessation of breathing events) during sleep.
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To determine the severity of sleep apnea, we consider the number of apneas (and hypopneas – partial cessations of breathing) which occur per hour of sleep as measured by polysomnography.
An AHI (Apneas and Hypopneas Index) of 5 per hour or above is regarded as mild sleep apnea as long as it is accompanied by clinical symptoms such as snoring, witnessed apneas, waking gasping/choking, excessive daytime sleepiness/fatigue, etc. or a minimum of 15 per hour in the absence of such symptoms (moderate sleep apnea).
An RDI of more than 30 awakenings per hour is considered severe sleep apnea.
Sleep apnea is also classified according to its cause into:
- Central sleep apnea – Breathing cessation events are caused by brain dysfunction.
- Obstructive sleep apnea – Breathing cessation events are caused by an obstruction.
- Mixed sleep apnea – Breathing cessation is caused by both central and obstructive factors.
It is possible to find central, obstructive, and mixed apneas in the same person. If at least 50% of apneas and hypopneas are central, then a CSA diagnosis is given.
Central sleep apnea
Central sleep apnea (CSA) is characterized by breathing cessation during sleep due to an instability of brain mechanisms controlling breath.
Chronically using some drugs may cause central sleep apnea, especially opioids such as methadone, morphine, and hydrocodone.
Central sleep apnea sufferers often experience/exhibit:
- excessive daytime sleepiness
- poor concentration
- morning headaches
- insomnia and nocturnal awakenings
When CSA sufferers finally sleep, their sleep tends to be lighter, restless, and may be disturbed by
- attacks of severe shortness of breath and coughing
- chest pain or discomfort
Treatment-emergent central sleep apnea
A condition which occurs after starting CPAP therapy for treatment of severe obstructive sleep apnea.
Risk factors include:
- More than 5 central apneas per hour or mixed apneas
- History of cardiac disease
- Being a male
- Opioid use
Obstructive sleep apnea
Obstructive sleep apnea (OSA) is a sleep disorder characterized by repetitive episodes of upper airway obstruction during sleep. Sufferers stop breathing many times per night, lowering blood oxygen saturation, and forcing them to briefly awaken in order to resume breathing.
The obstruction often occurs behind the palate and/or behind the tongue.
The correct question is not “what are the symptoms of sleep apnea,” since sleep apnea is a symptom, but one could ask:
- What causes obstructive sleep apnea? Of what condition is it a symptom?
- What are the consequences of sleep apnea?
The Causes of Obstructive Sleep Apnea
- Anatomic factors, for example:
- enlarged tonsils
- elongated soft palate/uvula
- inferiorly located hyoid bone leading to an elongated upper airway
- excess fat in the neck, tongue, throat – obesity and neck circumference above 17 inches (16 inches in males) are risk factors
- retrognathia – the lower jaw is set further back than the upper jaw
- micrognathia – the lower jaw is much shorter or smaller than the rest of the face.
- Neuromascular factors affecting muscles in the upper airway and the tongue, causing OSA especially during REM sleep.
- Neuroventilatory control factors – unstable respiratory control system along with anatomical features predisposing to upper airway collapse.
Other risk factors for developing obstructive sleep apnea (along with examples) include:
- Hormonal – postmenopause
- Endocrine – acromegaly, underactive thyroid
- Genetic – Down syndrome
- Ethnic factors – being Hispanic/Latino Americans
- Impact of alcohol, sedative hypnotics, and general anesthesia in predisposed individuals
The Consequences of OSA
Obstructive sleep apnea leads to sleep deprivation, which can have many disastrous consequences as well as to sudden death and mortality from all causes, specifically from heart failure and cancer. Documented consequences of OSA include:
- Cognitive impairment – excessive daytime sleepiness, fatigue, tiredness, lethargy, lack of energy, depression (and aggregation of preexisting depression), irritability, memory loss, poor concentration, etc.
- Cardiovascular/cerebrovascular – coronary heart disease, systemic hypertension (and pulmonary hypertension), diastolic dysfunction, arrhythmia, stroke, carotid artery abnormalities, increased volume percentage of red blood cells in the blood (hematocrit), etc.
- Endocrine – insulin resistance (type 2 diabetes), leptin resistance, dyslipidemia aggravation, etc.
- Chronic cough
- Alzheimer’s disease
- Societal/economic impact (less work days, reduced work performance, and increased medical expenses and divorce rates).
- Other possible consequences: osteoporosis, brain damage, and an increased risk for motor vehicle accidents.
Sleep Apnea, Dreaming, & Parasomnias
Here are some sleep disorders which are associated with/precipitated by sleep apnea:
- Sleep drunkenness, also known as confusional arousals, are episodes of waking up in a disoriented/confused state with sluggish speech/mentation. They can last from several minutes to hours. Sometimes they may be associated with inappropriate sexual behavior. These episodes are often not remembered and may be disturbing for parents/caregivers.
- Sleep walking (somnmbulism).
- Sleep terrors (night terrors) involve waking up with a scream and fear/panic as well as elevated heart rate, rapid breathing, and sweating.
- Sleep-related eating disorder – involuntary eating/drinking during nocturnal arousals.
- Sleep enuresis – involuntary voiding during sleep in adults.
- Nightmares (bad dreams) & vivid dreams
How Does Sleep Apnea Affect Dreams?
Sleep apnea may cause vivid dreams and nightmares.
Sleep Apnea Nightmares
Often, stimuli from the external world can influence our dreams. For example, needing to urinate during sleep, one may dream he is looking for a restroom. Or if one is hungry, one may dream of sitting in a restaurant, enjoying his favorite foods.
Sleep apnea are events of breath cessation. If one was awake, they would be experienced as not being able to breath, a sense of choking, and anxiety.
But since they occur during sleep, the experience may penetrate into the dream, generating a sensation of choking and anxiety and manifesting as a vivid nightmare (e.g., dreams of drowning, being strangulated, short of breath, buried alive, stuck in a constricted space, etc.).
Moreover, lower blood oxygen levels are known to induce bad dreams.
Usually, sleep apnea nightmares occur during cessation of breathing episodes in REM sleep.
Interestingly, sleep apnea nightmares are more common in mild cases than in severe cases of sleep apnea.
Nightmares are especially common in people suffering from sleep apnea in addition to PTSD.
Vivid Dreams / Increased Dream Recall
Sleep apnea sufferers wake up at least 5 times per hour, but in severe sleep apnea, they may wake up 30 times or more per hour.
This means that sleep is very fragmented and one is unable to reach the deeper stages of sleep. Sleep becomes shallow and one constantly drifts into light sleep, in which dreams may be experienced, following by an awakening making it likely to recall the dreams.
Vivid dreams are most likely to be experienced when sleep interruptions occur during REM sleep (for example in obstructive sleep apnea due to neuromascular factors).
Bad Dream Recall
Sleep apnea may also lead to an inability to recall dreams.
This may be due to disruption of REM sleep, leading to less dreaming.
Why might there be less REM sleep in sleep apnea?
Perhaps because frequent awakenings do not allow one to go through the different sleep stages. Normally, REM sleep, in which most of our dreams occur, comes after a full 90 minute cycle which includes deep sleep.
But in sleep apnea, one may remain constantly in light sleep, almost never reaching the deeper stages of sleep and REM.
How to Treat Sleep Apnea Dreams?
Suffering from such nightmares may cause daytime anxiety and depression. Luckily, there are ways to prevent and treat bad dreams, including sleep apnea dreams and nightmares.
The best treatment is to treat the underlying cause, whether it requires dental surgery, losing weight, or any other medical intervention required.
When that is not possible or temporarily, CPAP (continuous positive airway pressure) therapy can provide great relief to sleep apnea sufferers. CPAP machines employ air pressure to keep the airways open and their use results in a significant improvement in nightmare occurrence.
Other symptomatic treatments for sleep apnea dreams include herbal medications.
Is Snoring Bad? Snoring FAQ
Snoring is a condition affecting many people out there, and for the most part, it is indeed benign. It can give way to more serious sleep problems down the line though, and as such, it can be considered an early warning that not everything is right in dream-land.
Let us take a closer look at its causes and possible methods of control.
What can cause you to start snoring?
The cause of snoring is obviously mechanical: the muscles in the throat of the snorer relax so much during sleep, that the tissue collapses, partially blocking the airways.
When the air does rush through the thusly restricted passage, the loose, collapsed tissue begins vibrating, and thus snoring results. The more severely restricted the snorer’s airway is, the louder the snoring will become.
The intensity of snoring and with it, the depth of the problem, is defined by several factors.
The mouth anatomy of the snorer is one obvious such factor. Those who have long, thin, soft palates, are much more likely to develop snoring problems than those who don’t.
Sleep deprivation is always an issue with sleep disorders and snoring is not an exception either: it can lead to the “exaggerated” relaxation of throat tissue, and thus, indeed, to snoring.
Alcohol consumption is a major problem for proper, healthy sleep, for a myriad of reasons. It too relaxes throat muscles, leading to snoring, in addition to which, it also lowers the natural reflexes of the body that are meant to cope with the obstruction of the airways.
It is quite obvious to everyone that sleeping position is also a major issue snoring-wise. Those sleeping on their backs are much more frequent and loud snorers than those sleeping on their sides.
How I can stop my snoring?
As I already stated above, in and of itself, snoring is a relatively benign condition. It may be annoying to the people who sleep in the same room with the “perpetrator,” but the negative health impact of snoring is relatively limited.
Still, getting rid of even this minor inconvenience is something many are indeed rather keen on.
The good news is that there are a whole series of quick, and easy-to-implement measures one can take to curb snoring.
Here’s a quick look at them.
Sleeping position is perhaps the easiest variable to tinker with. Simply not sleeping on your back anymore should help a great deal with your snoring. In this regard, some people resort to solutions such as taping a tennis ball to the back of their pajamas, so sleeping flat on their backs is no longer an option for them.
Avoiding alcohol is a rather simple fix as well and it hardly needs to be detailed why it is generally a good idea as well.
Losing weight is another possible path to snoring-free nights. The problem with this approach is that it might not work for everyone. After all, thin people snore too, and there’s not much point in trying to lose still more weight for them.
Opening the nasal passages is always a good solution though, as is the practicing of good sleep hygiene.
Why do people all of a sudden start snoring?
Snoring – like most other sleep-related disorders – gets worse with age. There is simply no way around this truth.
If you are a man, you are more prone to snoring to begin with. As you get older (and presumably pack on weight), your snoring will indeed go from bad to worse. In the case of males, a lot of the age-related weight gain happens around the neck. Increasing the circumference of the neck will obviously expose one to snoring and other sleep disorders, such as sleep apnea.
With age, in addition to the problems listed above, muscle tone decreases as well, meaning that the tissue in one’s throat collapses easier and that snoring becomes louder, more frequent and it may indeed show up in people who never snored before.
While the actual treatment of snoring is always an option – as said above – I have mixed feelings in this regard.
Snoring is a sort of alarm bell for other – more serious – sleep problems (like sleep apnea). Simply turning this alarm bell off may therefore not be helpful in the long-run.
The best course of treatment for snoring is one that takes aim at underlying issues, and is therefore much more than a symptomatic treatment.
Is snoring bad for my health?
As already said, in and of itself, snoring is not bad for your health. It is at most extremely annoying to those who share a room with you while you sleep.
The problem with it is though that it is a sort of alarm, which heralds a wide range of other potential sleep disorders, some of which may indeed be rather dangerous.
Still, despite its relatively harmless nature, snoring does in fact carry a few health risks. The most important risk of snoring is linked to sleep apnea, and the multitude of health problems it entails.
Interruptions in breathing are obviously included in this dubious package, as is the oxygen deprivation of the brain. Waking up from the your sleep frequently will lead to poor overall sleep quality, and poor night’s sleep, which over the long-run can trigger other issues.
Getting frequently roused during a night will also interfere with one’s sleep patterns, resulting in a lot of light sleeping and little deep-sleep, of the kind that is needed for the proper replenishment of the body’s hormonal and energy resources.
All the above creates an overall strain on the heart too, upping the risk of heart disease, stroke and elevating one’s blood pressure.
Can you die from snoring?
The answer to that question can be very simple or more complex. While you will almost certainly not die from a snoring episode, snoring is in fact indicative of deeper sleep-related problems down the line and one of these problems is sleep apnea. Unlike a simple (but noisy) snoring episode, sleep apnea can indeed lead to death under certain circumstances.
The health risks associated with this snoring-related condition are numerous indeed. They include stroke, heart disease, daytime sleepiness, arythmias and even GERD (gastroesophageal reflux disease).
OSA (Obstructive Sleep Apnea) sufferers are more prone to physical injuries too, on account of their increased daytime sleepiness and the resulting inability to properly focus when needed. Indeed, OSA sufferers are much more likely to cause deadly vehicle accidents than their healthy peers.
Nocturia, headaches and mental health issues are also among the “blessings” that sleep apnea delivers, and it all starts with a little bit of snoring.
While snoring itself is no biggie, just remember that its mechanics are largely the same as those of sleep apnea. As a regular snorer, you are in essence a beginner sleep apnea sufferer.
If you decide to treat your snoring, make sure you treat the underlying causes that provoked it to begin with, rather than just its symptoms.
Do mouthpieces really work to stop snoring?
In addition to the snoring-control measures and solutions I detailed above, those truly bothered by the condition can resort to yet another anti-snoring aid: oral devices.
These oral devices usually take the form of mouth guards, designed by dentists and other specialists, with the express purpose of controlling the architecture of the wearer’s mouth during sleep. As such, devices like these can indeed effectively stop the collapse of the wearer’s throat tissue, thus eliminating snoring and the problems associated with it.
Also known as mandibular advancement devices, these mouth guard-like inserts effectively prevent the wearer’s tongue from slipping backward during sleep, while preventing the jaw from relaxing as well.
Certainly, most such devices are not the least bit comfortable, but many do indeed gain much-needed snoring (and what’s perhaps way more important: OSA) relief from them.
Such devices push the jaw forward a little, thus opening up the airways, they support soft palate tissue and they depress the tongue to keep it from sliding backward – as said above.
If you are considering such a device for snoring relief, please be aware of the fact that you will have to have it fitted by a dentist. Also know that there is quite a bit of controversy surrounding the FDA-status of most of these oral devices.
Can you get surgery to stop snoring?
Indeed, you can. The particular surgery that you’re looking for to secure relief from snoring, is called somnoplasty and it uses heat to induce changes in the tissues of the uvula and the soft palate. Through this procedure, the tissues of the above said organs are either strengthened, or they are removed. Despite its seemingly intrusive nature, somnoplasty is a procedure which is performed in-office, under local anesthesia (your doctor will not put you under for it, and as such, it is indeed a very safe procedure).
Unfortunately, despite somnoplasty’s efficiency in curbing snoring, it cannot be used for the treatment of sleep apnea. The heat generated through the somnoplasty procedure is obtained from low-level radiofrequency, rather than lasers (as with some of the other such surgeries). Its goal is to effectively generate localized burn areas right under the mucous layer, which are then reabsorbed by the body, stiffening the areas where this absorption occurs.
As any surgery, somnoplasty carries its own potential risks and complications. Sometimes it does not accomplish its goals (failing to eliminate snoring). It may also result in a change of voice in the patient, as well as nasal regurgitation, bleeding, pain and impaired healing.
Somnoplasty usually only takes about 30 minutes to perform.
How to Sleep Next to a Snorer
That’s easy. Use SleepPhones, headphones designed to be comfortable to sleep with.
While the the product does not have any external equipment to eliminate noise, SleepPhones can be used to block out snoring by listening to sound tracks such as ocean waves or white noise.
Dental Treatment of OSA and Snoring
This section addresses the use of oral appliances for the treatment of snoring and OSA (Obstructive Sleep Apnea). In that regard, it covers several angles. I take a close look at:
- Why OSA and snoring need to be treated.
- What treatment options exist, in addition to the oral devices that represent the focus of this piece.
- Why dentists are the medical professionals who are often the first to spot snoring/OSA problems.
- The advantages and disadvantages entailed by the various treatment options.
- Clinical trial-based evidence concerning the efficacy of oral appliances for OSA.
- How you should go about finding the proper form of dental treatment for your OSA.
What is OSA and why should you treat it?
…also: is snoring really something you should treat? Snoring is common and people seem to live with it fine.
The problem is that the root causes of Obstructive Sleep Apnea and snoring are the same. If you snore, you experience a restriction of your upper airway. More precisely, the obstruction occurs at one or several of three critical sites: the nose, the velopharynx, and the hypopharynx.
When you breathe in, you exert negative pressure on your upper airway. While you are awake, the pharyngeal dilator muscle counters this pressure. During sleep, this muscle relaxes and the airway collapses. As air is forced through the collapsed airway, it starts to vibrate. This is snoring.
If you fail to draw a breath for a set amount of time while snoring, OSA occurs. Being overweight and having a thick neck are OSA risk factors. Abundant pharyngeal tissue is always a problem.
Weight loss is, therefore, a natural first remedy. Some OSA risk factors are out of your control, however:
- Elongated palate
- Large tongue
- Facial bone structure peculiarities
- Thick lateral pharyngeal walls
- Longer pharynx (men usually have longer pharynxes than women)
Why you should not leave your snoring/OSA untreated
Sleep apnea, which is a consequence of snoring, results in blood oxygen desaturation. It also causes several micro-awakenings during the night. It thus deprives the sufferer of quality rest.
According to a 2015 study, by Melissa Knauert, Sreelatha Naik, M. Boyd Gillespie, and Meir Kryger, the health implications of OSA are enormous. If left undiagnosed and untreated, the condition can cause:
- Daytime sleepiness conducive to workplace- and vehicle accidents
- Myocardial infarction
- Morning headaches
- Frequent nocturnal urination (nocturia)
- Loss of libido
A substantial body of additional scientific evidence supports these findings.
Untreated snoring and OSA can result in death. The economic costs caused by untreated sleep apnea are also significant.
Snoring/OSA Treatment Options
Among an abundance of other scientific evidence, a 2016 study published at PubMed proves beyond doubt that Continuous Positive Airway Pressure (CPAP) treatment can increase the quality of life of OSA sufferers.
CPAP is widely regarded as the most efficient treatment solution for OSA. By forcing air into your collapsed upper airways, it eliminates the risk of choking. It also helps with snoring.
CPAP machines are somewhat cumbersome, however. They consist of a motor that generates air pressure, a face mask, and a tube connecting the two. Most CPAP machines are lightweight enough, so you can take them along when traveling.
Despite the apparent advantages of CPAP, you may find that you cannot get used to this type of treatment. People have reported scores of side effects. While some of these problems are tolerable, many pose real challenges to users.
According to WebMD, CPAP machines can cause:
- Discomfort and a sense of confinement from the mask.
- Dry mouth and sore throat.
- Chest muscle pain.
- Bloating and digestive discomfort.
- Sinusitis and even nose-bleeds.
- Sores on the bridge of the nose, where the edge of the mask rests.
Please note that if you happen to suffer from such side effects, you should contact your physician and have your device adjusted. Do not discontinue CPAP treatment in favor of an alternative solution on a whim.
Your care provider can recommend cushioned face masks or even heated humidifiers. Such solutions can alleviate many of the above-mentioned side effects.
Perhaps the biggest shortcoming of CPAP treatment is the fact that it does not lead to a permanent cure. To achieve that, a more radical approach is needed.
At first glance, surgery may not seem like an attractive option for many. It is more expensive than CPAP and dental appliance-based solutions. It is naturally intrusive as well.
On the other hand, unlike CPAP, surgery offers a permanent cure for OSA as well as snoring. It alters the airways, therefore it is a very effective treatment option. In addition to addressing the problem head-on, surgery also deals with maxillofacial and skeletal irregularities which also act as OSA triggers.
That said, you will likely require lifelong follow-up if you do go through such a surgical procedure.
If nasal obstruction is to blame for your snoring/OSA, surgery is a very effective option. It bears pointing out that in such cases, prosthetics are highly effective as well.
A 2012 study by Bettina Carvalho, Jennifer Hsia, and Robson Capasso provides a bevy of useful information on surgical procedures targeting OSA.
According to this study, OSA and snoring can be addressed through the following surgical procedures:
- Surgical procedures aimed at the nasal cavity can target soft tissue or skeletal structure. Polypectomy and ablation of turbinate are soft-tissue surgeries. Septoplasty is skeletal surgery.
- The procedure aimed at the Nasopharynx is called Adenoidectomy.
- Procedures targeting the Oropharynx can also be skeletal or soft-tissue surgeries. Tonsillectomy is one of the most popular such soft-tissue surgeries. Rapid Maxillary Expansion is the skeletal approach to Oropharynx surgery.
- The Hypopharynx can be targeted through Midline Glossectomy and tongue base reduction. Both are soft-tissue surgeries. Mandibular Advancement and Genioglossal Advancement are skeletal options.
- Maxillomandibular Advancement targets the Oropharynx and the Hypopharynx.
- Tracheotomy is the more radical solution of bypassing the airway.
It is up to the surgeon to decide exactly what type of surgery you require.
The main disadvantage of surgery is that having your airways rearranged in such an intrusive manner is problematic. It may provoke post-surgical complications.
There are OSA-sufferers for whom neither CPAP therapy nor surgery is a reasonable option.
For such patients, dental appliances represent an alternative treatment path.
Dentists and OSA/Snoring
It may be surprising that often, the earliest diagnosis of sleep apnea is delivered by dentists. It makes perfect sense, however.
Some dentists are trained to draw sleep-related conclusions from the dental condition of their patients. That said, only a qualified sleep specialist can set an official diagnosis in this regard.
Your dentist may still recommend a sleep study based on his/her observations.
Often, teeth-grinding (bruxism) is the first sign of OSA – according to WebMD. Bruxism leaves some telltale signs on people’s teeth. Dentists know exactly how to interpret the worn tooth surfaces that result from tooth grinding.
In addition to worn surfaces, tooth grinding also results in inflammation, receding gums, as well as an uptick in the number of cavities.
Once he/she has spotted these signs, your dentist can look for redness in your throat, caused by snoring. Other telltale oral signs of OSA are scalloped tongue-edges and a small jaw.
Why is bruxism often associated with Sleep Apnea? The act of clenching your jaw generates a wake-up signal for your brain. This signal allows you to awaken from an OSA choking episode, and to draw a breath.
If your OSA/snoring treatment does take the path of oral appliances, you will find yourself in the hands of a dentist again.
Oral Appliances for the Treatment of OSA/Snoring
Treating your snoring and sleep apnea through an oral appliance means much more than picking up a random mouthpiece online.
In a 2006 study, published in the Journal of Clinical Sleep Medicine, and updated in 2015, authors Kannan Ramar, Leslie C. Dort, Christopher J. Lettieri, and others, have defined a set of guidelines for oral appliance therapy.
According to this guide:
- If a sleep physician prescribes an oral appliance for OSA, the appliance should be custom-made by a specialist dentist. It should also be titratable.
- Sleep physicians should prescribe oral appliance treatment for non-OSA snoring. Leaving the condition untreated should not be an option.
- For OSA sufferers who do not tolerate CPAP therapy and are not willing to undergo surgery, sleep physicians should prescribe oral appliance therapy.
- Follow-up oversight for oral appliance therapy should be provided by a qualified dentist.
- Sleep physicians should follow up oral appliance treatment with sleep testing. This way, they can assess the efficacy of the treatment.
- Dentists, as well as sleep specialists, should invite oral appliance-treated patients for regular check-ups.
The problem with studies such as the mentioned one is that they provide no efficacy assessment for OSA of various degrees of severity.
How do oral appliances help with OSA? What about scientific evidence in this regard?
Dental appliances aim to keep your airways from collapsing through a handful of solutions. Some retain your tongue, others advance your mandible, and still others target your palate.
According to a 2014 study published in the European Respiratory Journal by M.M.M. Eisvogel, M.G.J. Brusse-Keizer, and L. Visscher, the efficacy of oral appliances is comparable to that of CPAP in regards to mild OSA.
The study draws this conclusion from the Dutch National OSAS guideline. It does not provide clinical evidence to support it.
For severe OSAs, the study still recommends the use of CPAP over dental devices.
Before I get to the advantages of dental appliances over other forms of OSA treatments, let me put forth that oral appliances should constitute a backup plan. These devices should not replace CPAP therapy for patients who tolerate/respond well to the latter.
- Cost efficiency has to be one of the top advantages of oral appliances. Most such devices are covered by medical insurance.
- Portability may not seem like a major asset but active people will likely not ignore it.
- Throughout this article, I pitted CPAP therapy against oral appliances. I did so intending to compare the two. CPAP can work extremely well with oral appliances, however. If you use your CPAP device at high pressures, an oral appliance may allow you to lower the pressure. Such a solution can greatly improve your comfort. By extension, it can also improve your CPAP adherence.
- Dental appliances are suitable for OSAs of varying degrees of severity.
- A 2018 study by AlRumaih, Baba, et al. concludes from relevant literature that OSA sufferers prefer oral appliances to CPAP due to convenience.
There are several conditions/features which impact the success rate of dental appliances.
- Retention or the accurate, comfortable, and lasting fit of the device is important. The appliance needs to stay in the required position all night. Rigid appliances can be a handful in this regard. Soft, heat-sensitive materials adhere and fit better.
- Adjustability refers to the possibility of adjusting mandibular position through the device.
- Adaptability defines the ability of the device to adapt to denture changes. Tooth fillings, crowns, etc. are some examples in this regard.
- Your weight. The more you weigh, the more severe your OSA symptoms tend to be.
- Your age. With age, muscles atrophy. Pharyngeal muscles included.
- Pharyngeal and nasal inflammation.
- Sleep hygiene.
- Sleeping position. The supine position is conducive to more severe OSA symptoms.
Unfortunately, the disadvantages of oral appliances are numerous. The most obvious shortcoming is the fact that these devices are not efficient at treating severe OSA. Other problems exist too.
- For some, oral appliances can be just as uncomfortable to wear as a CPAP mask.
- A qualified dentist has to custom-fit every device. The “self-adjusting” devices sold by various online operators are useless.
- Drooling can be a major problem with tongue-retaining devices.
- Oral appliances are hard on the temporomandibular joint. Once pain occurs at this potential point of failure, devices can become intolerable.
Medscape lists several other problems that may arise from the long-term use of oral appliances.
- Mouth sores and a host of dental problems can occur. These include, but are not limited to loose teeth, cracked/broken teeth, destroyed dental work, and root resorption.
- Muscle spasms.
- The permanent migration of the mandible, which can lead to a permanent change of bite.
- The accidental swallowing of broken pieces of the device.
- Soft palate implants can cause many other problems, such as ear and jaw pain, difficulty swallowing, possible extrusion, as well as difficulty swallowing.
The above points make it clear that you should accompany your oral appliance use with frequent follow-up trips to your doctor. One the one hand, you need to make sure you avoid the complications listed. On the other, you need a thorough progress assessment. Only through such a report can you establish the efficacy of the treatment you are following.
Progress analysis may consist of polysomnography and pulse oximetry sessions. Make sure you are well instructed in the proper use of the device. Have the integrity of your dentition and device checked regularly as well.
Types of Oral Appliances
While there are several options available in this regard, most oral appliances advance the mandible. Theoretically, such devices target three upper airway areas: the soft palate, the tongue, or the mandible.
- Soft palate advancement is likely to trigger the gag reflex. Such an approach is, therefore, less tolerable.
- Isolated tongue advancement is also a seldom taken route of treatment. It too may stimulate the gag reflex.
- Most devices either rotate the mandible downwards or advance it. Such devices also advance the tongue in addition to enlarging the upper airway.
- Fixed oral appliances come in the shape of implants. Palatal implants are embedded into the soft palate muscles, thus stiffening them. Such a solution is a permanent one. According to a 2008 study by Steward DL, Huntley TC et al. completed at the University Cincinnati College of Medicine, the efficiency of palatal implants for the treatment of OSA is limited at best.
Prefabricated, one-size-fits-all oral appliances have acquired a bad reputation. Some manufacturers have struck a compromise in this regard.
VitalSleep is a prefabricated mouthpiece. It comes in two sizes: medium for men and small for women.
It has a couple of tricks up its sleeve though. It comes with custom molded teeth impressions. This allows individual wearers to achieve a theoretically perfect fit, regardless of the peculiarities of their dentition.
Additionally, VitalSleep also features an Accu-Adjust System, which lets users fine-tune mandibular advancement. Accu-Adjust is a fancy name for a couple of screws that allow for adjustment.
The device has accrued an overwhelmingly positive score at TrustPilot. Most users seem to love it. Those who logged complaints decried bad fit and discomfort.
Unlike most prefabricated appliances, VitalSleep is not a mono-bloc solution. As such, it might be worth a shot. Costing ~$70, price-wise it is an interesting proposition.
Some anti-snoring device makers have turned to radically different solutions. PeaceSleeper uses electric impulses to stimulate pharyngeal muscles. Thus, the device is not a dental appliance.
Electric impulse-based muscle stimulation has been around for decades. People have used such devices to work out abdominal muscles etc. Now Peace Sleeper takes a similar approach to battle snoring.
The device needs to be applied to the throat, under the chin. It detects snoring. When snoring occurs, PeaceSleeper activates, sending electric impulses into the pharyngeal muscles.
The solution seems devilishly clever. If it does work as it is supposed to, it may even strengthen atrophied pharyngeal muscles over time, offering a permanent cure.
There are hardly any user reviews available on PeaceSleeper. The jury is still out on this one.
Clinical Trial Evidence
There is plenty of scientific literature available on the subject of the dental treatment of OSA. In addition to what I have covered in this article, there are quite a few clinical trial papers available.
A 1999 study by Jeffrey Pancer et al. has successfully demonstrated the effectiveness of the Thornton Anterior Positioner for snoring, as well as various degrees of OSA. Indeed, the appliance was deemed useful even in cases of severe OSA.
Some 86 percent of trial participants stuck with the program long-term. 32 percent of them reported experiencing discomfort. 60 percent of the participants were “very satisfied” with the results. Only 13 percent were moderately- or very dissatisfied.
A 2013 study by White DP and Shafazand S, at the Harvard Medical School, compared mandibular advancement devices to CPAP. The testing period was one month.
Surprisingly, the study found no difference between the impact of a MAD and CPAP, in adults treated for moderate to mild OSA. The variables tracked were daytime sleepiness, the general quality of life, and 24-hour mean ambulatory blood pressure.
Both treatments proved equally effective.
A 2016 literature review at the University Clinical Hospital in Valencia, Spain, by Serra-Torres, Bellot-Arcis et al., concluded that mandibular advancement alleviates the main symptoms of OSA.
The study found custom-made, adjustable devices superior to prefabricated, mono-bloc solutions.
Sleep Apnea: Frequently Asked Questions
Sleep apnea – unlike some of the sleep disorders I’ve covered here – is a very serious condition, one that may indeed result in the death of the sufferer.
What exactly causes sleep apnea though, how can it be treated, and ultimately: how can you get rid of it?
What qualifies as sleep apnea?
Sleep apnea is very clearly defined, and as such, it can be quite definitively identified by specialists. In theory, any in-sleep incident which sees the “victim” stop breathing for 10 seconds or more is a sleep apnea event.
During such an event, the amount of oxygen reaching the brain and organs of the sufferer is obviously reduced.
With sleep apnea, incidents of the above described nature occur several times per hour. Depending on the frequency and length of these apnea events, several levels of gravity have been defined.
Mild Sleep Apnea
Those who experience 5-14 episodes of breathing stoppage per hour, suffer from a mild version of the condition.
Those limits are indeed very broad, and the symptoms associated with the condition are quite generic and inconspicuous as well. They include drowsiness during activities which require a reduced amount of attention, such as watching television and reading.
Moderate Sleep Apnea
With moderate apnea, sufferers will run out of breath 15-29 times per hour, and if that seems like a lot, it’s because it certainly is. Such a frequency means having a sleep apnea event once every two minutes, on average.
The symptoms of a condition this severe include drowsiness during activities requiring a heightened state of alertness, such as concerts and meetings.
Severe Sleep Apnea
Severe sleep apnea is associated with breathing problems of a rather appalling frequency: those suffering from this kind of sleep apnea will experience breathing issues more than 30 times every hour.
Also, such victims will fall asleep during activities that require a massive amount of attention, such as eating, walking, and perhaps worst of all: driving.
In children, slightly different guidelines are used for the definition of sleep apnea.
What are the warning signs of sleep apnea?
While I’ve already covered some of the symptoms of sleep apnea above, that was just me scratching the surface ever so gently in this regard.
The symptoms of sleep apnea are numerous and they cover a wide range of issues, from snoring, to daytime exhaustion.
Indeed, while snoring can be a major sign of sleep apnea, not all snoring is indicative of the problem: snoring followed by choking and gasping noises, or lengthy pauses in breathing, most definitely is though.
Those suffering from sleep apnea will also find that their sleep is not refreshing and that they have headaches in the morning. These headaches are caused by the oxygen-deprivation of the brain.
Other sleep apnea symptoms are memory loss, irritability, decreased libido, having to hit the bathroom several times a night and insomnia – quite a foul collection of sleep-related pathologies.
If by warning signs, you mean risk factors, I can fill you in on these as well.
Being overweight always exposes you to sleep apnea. So does simply being a man, especially middle-aged at that…While women too get sleep apnea, the problem is much more prevalent in the male population.
Large neck-size is yet another risk factor, as is hypertension and a family history of sleep apnea.
Can you have sleep apnea at a young age?
Diagnosing sleep apnea in atypical sufferers such as teenagers and women is often more difficult than doctors will admit, and indeed those who fall outside the “middle aged, overweight man” category are often misdiagnosed with this condition.
Though most prevalent in the above mentioned category, sleep apnea can be present in just about any age group and that includes children.
While snoring is relatively widespread among the youth too, only a minute percentage of children actually have sleep apnea (some 2-3%). In most such cases, enlarged glands, such as adenoids and tonsils are the guilty party.
Making proper diagnosis even more challenging for doctors is the fact that while in adults, the correlation between obesity and sleep apnea is quite obvious, in children, no such correlation was found.
Apparently, the above said correlation begins showing at the age of 12, above which it becomes more and more pronounced as the years are added.
Childhood sleep apnea often does not even have to be treated. Some children will simply outgrow the condition, as the muscular structure of their throats changes and develops.
In the cases where infected tonsils or adenoids are to blame, tonsillectomy is considered an effective treatment, which has been found to solve some 80-90% of the cases.
Can you die if you have sleep apnea?
The death risks associated with sleep apnea are indeed rather numerous and unsettling.
While dying from an actual episode of in-sleep breath obstruction is not highly likely, the “reach” of this illness extends far above and beyond direct risks. It has been linked to diabetes, pregnancy complications and heart disease, not to mention driving events, which are indeed all potentially deadly.
Although one would think that proving the link between deadly car crashes and sleep apnea wouldn’t need an actual study, such studies were indeed conducted, and their findings are indisputable.
Not only are sleep apnea sufferers more likely to cause car crashes, their crashes are much more likely to be of the most deadly variety.
Exactly how much more prone is a sleep apnea sufferer to cause an accident?
Apparently, that number is threefold the risk of a non-suffering driver. Still more unsettling is the fact that the actual gravity of the condition plays no role in this regard. Even drivers with mild sleep apnea are three times more likely to cause car crashes than their healthy peers.
I can also tell you that sleep apnea is linked to diabetes, in a sort of directly proportional manner: the more severe one’s sleep apnea, the more likely he/she is to develop diabetes.
The pregnancy complications angle is quite self-explanatory, but it too extends beyond the direct problems caused by oxygen deprivation.
Can you get rid of sleep apnea?
Fortunately, the answer to that is yes.
As said above, in the case of the childhood version of the condition, sometimes not much has to be done about it: the sufferer will simply outgrow it.
With adults though, the problem calls for a different approach.
Putting forth a path to recovery is little more than common sense in this case too though.
Weight loss and lifestyle change is the obvious first step. The two go hand-in-hand, though obviously, this approach is only valid for those who are overweight/obese. The link between sleep apnea and being overweight has been clearly established, there are no questions at all in this regard. I can personally attest to the fact that weight loss will indeed “cure” sleep apnea, while delivering a host of other benefits to the overall health of the sufferer.
Despite being very effective indeed, weight loss can be difficult for most people to achieve. Therefore, CPAP (continuous positive airways pressure) should also be considered a front line treatment.
CPAP devices have to be worn over the face, and they can be quite clunky and uncomfortable. They blow air into the airways of the sleep apnea sufferer, to make sure that the oxygen supply is never cut short.
Because around half of those treated fail to stick to using the apparatus, alternative treatments, such as the use of an oral device, have been developed.
How serious is sleep apnea?
As I already stated several times above, sleep apnea is indeed a very serious condition.
It can trigger a number of other problems and health issues, some of which can in fact be fatal.
People suffering from OSA (Obstructive Sleep Apnea) are at a higher risk of developing high blood pressure and heart disease.
While this alone seems serious enough, there are other “blessings” included in the sleep apnea package too. Type 2 diabetes is another such issue, together with acid reflux and adult asthma.
Can removing tonsils cure sleep apnea?
In some cases: yes.
Tonsillectomy and adenoidectomy are considered as treatment options, especially with sufferers whose OSA is thought to be triggered by the inflammation of these glands. As such, removing the tonsils is mainly a treatment path for childhood sleep apnea, though in some cases, it may help in adults too.
What is important to know is that this treatment path involves surgery. As far as efficiency goes, OSA symptoms nearly always improve within 6 months following surgery.
What is the most effective treatment for sleep apnea?
Weight loss and a proper lifestyle change is the best way to treat OSA without intrusive intervention. Due to the nature of this approach though, this solution is obviously not feasible for all sufferers.
The currently accepted best course of OSA treatment leads through CPAP – there is no way around that. In addition to effectively treating sleep apnea, CPAP machines also eliminate snoring and the problems associated with it.
In addition to CPAP, oral appliances deserve a second look as well. They present a series of advantages over CPAP machines, which make them much easier to incorporate into the lifestyle of the sufferer.
In this respect, I have to caution against various over-the-counter appliances, which are not FDA-approved, and the effectiveness of which can therefore not be properly assessed.
UAS (Upper Airway Stimulation) therapy is yet another option to consider. It is a clinically proven therapy, which is aimed at people unable to resort to CPAP. The UAS system is a rather intricate one. It electronically monitors one’s breathing pattern during sleep, sending stimulating impulses to the right muscle groups when/if called for.
Nasal decongestives and positional therapy are also treatment options that can bring relief to some.