Obstructive sleep apnea (OSA) is a condition where there are periodic stoppages of breathing (apneas) during sleep. Certain stages of deeper sleep induce muscle relaxation, which in turn allows pharyngeal structures to vibrate causing the snoring. If taken to an extreme, the airway can get sucked shut, closing it completely.
When there is a breathing stop (apnea) with a commensurate drop in blood oxygenation, an immediate response is triggered by the brain to wake up! This arousal response activates the sympathetic nervous system causing an increase in heart rate and blood pressure to rouse the patient from their sleep. These arousals can disrupt sleep but restore normal muscle tone to the pharyngeal dilator muscles, opening the airway, allowing breathing to resume. In moderate to severe cases these respiratory disturbances can happen hundreds of times through the course of the night and the arousals are so brief the person may be unaware that they are not sleeping soundly.
These patients will wake up feeling like they didn’t sleep and un-refreshed. This will result in excessive daytime sleepiness, a clinical symptom that may lead to increased accident rates, depression and sexual dysfunction. Poorly managed OSA can place the patient at risk for other co-morbid cardiovascular problems such as hypertension, heart attack and stroke.

Management of the Dental Patient with Obstructive Sleep Apnea

• Consider asking these screening questions as a part of your dental examination:
• Has anyone ever told you that you snore?
• Do you ever awaken in the morning sweaty?
• Do you wake in the middle of the night gasping for air?
• Does your sleeping partner ever tell you that you appear to stop breathing or choke in your sleep?
• Do you have heartburn or G.E.R.D. (Gastro esophageal Reflux Disease)?
• Is your blood pressure high or increasing and you don’t know why?
• Are you tired all of the time no matter how many hours you sleep?
• Do you suffer from Depression?

What should you do if your patient snores and answers yes to most of these questions?

If your patient answered yes to most of these questions and is a habitual snorer, they may be developing a life-threatening problem called Obstructive Sleep Apnea or OSA. This is a widespread problem that affects upwards of 24 million people in the United States and millions worldwide. Unfortunately, most unaware of their condition or are only treated for the symptoms. Often, snoring is the only “red flag” that a problem exists. If there is sufficient reason the patient is often invited back for a screening appointment with a trained auxiliary.

During this screening appointment the patient will fill out a brief questionnaire called an Epworth Sleepiness Scale Test that helps separate simple snorers from those snores who may be developing OSA. Next, a laryngeal study using an instrument called a Pharyngometer is done to check out the dimensions of the soft tissue airway and determine the airway response to jaw position changes. This test helps determine if the patient is a candidate for oral appliance therapy. If simple snoring is the problem, we will begin treatment using oral appliance therapy. If our tests indicate that we may be treating more that just a snoring problem, the patient will be referred back to their primary care physician or a sleep center for complete testing. The testing usually includes an overnight study (a polysomnogram or PSG) in a hospital setting to diagnose the severity of the patient’s disease.

Once there is a medical diagnosis, a variety of options are available to manage the airway. These options will range from using a medical device called a CPAP (Continuous Positive Airway Pressure), an oral appliance or even surgical intervention. In mild to moderate cases an oral appliance may be considered the treatment of choice to maintain the airway during sleep. Frequently, patients who cannot tolerate CPAP therapy are not given the option of using oral appliances because their doctor may not be aware of their effectiveness in managing OSA. All options should be discussed so that the patient can make an informed choice.

There are many types of appliances that can be worn to manage the airway during sleep. Most are mandibular repositioners that act to maintain the airway by pulling the tongue forward and stiffening the pharyngeal tissues of the upper airway. These small, plastic mouthpieces, similar to retainers or sports mouth guards, are custom fitted to the patient’s teeth and can be used up to 5 years, if properly maintained Unlike a CPAP, they’re portable and easy to maintain.

Properly titrated, oral appliances will dilate the airway and effectively reduce or eliminate the snoring immediately. Appliances fitted to treat UARS or OSA needs more titration and adjustment to obtain optimal efficacy to manage the patient’s condition. Home electronic testing units are used to ensure that these appliances are effectively managing their problem. Once stabilized patients should be seen every 6 months to a year for follow-up.

If diagnosed with sleep apnea, patients shouldn’t expect a cure, but the disorder can be effectively managed. Once treated, patients have more energy, fewer headaches, can concentrate longer, and be more alert. Appliances can be very effective, and the results are often dramatic and life changing.