Sleeping Together

What is Sleep Apnea?

The word apnea literally means “cessation of breath.”
 
Sleep apnea is a disorder characterized by the complete or partial cessation of breathing during sleep, despite attempts to breathe. Persons with sleep apnea typically make periodic gasping or snorting noises resulting in interrupted sleep. These interruptions in breathing, called apneas, are associated with:
• daytime sleepiness
• inability to stay alert and process information
• increased risk of heart attack
• mood changes and irritability
 
The most common symptom of sleep apnea is excessive sleepiness during the day which is caused by frequently interrupted nighttime sleep. Studies by the World Health Organization (WHO) have shown that insufficient sleep has been linked to the development and management of a number of chronic diseases and conditions including:
• diabetes
• cardiovascular disease,
• obesity
• depression
• sexual dysfunction
• accidents and even death
 
In Canada, from 2009 to 2016, Canadians reported a doubling of diagnose of sleep apnea from 3% – 6.4% of adults over 18 years of age. Older people are three times as likely to report sleep apnea and males are twice as likely to report sleep apnea/snoring symptoms. Females are more likely to report feeling tired, fatigue or insomnia.

 

Please see the following link for a more complete review of Sleep Basics from the Cleveland Clinic, Statistics Canada, the ASA and the American Association of Dental Sleep Medicine.

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American Sleep Association :   https://americansleepassociation.org

 

Who has Sleep Apnea?

OSA occurs as a result of certain physiological conditions such as:

 

• obesity

• facial disharmony (e.g. a retracted lower jaw)

• small mouth

• an enlarged tongue

• poor muscle tone

• orthodontics

• social factors such as excessive alcohol consumption 

 

As an example, a person who is older, overweight and has a large tongue may suffer from sleep apnea.  At night, during sleep, the back of the tongue compresses the airway in people with OSA, thereby causing a total or partial air blockage.  Apnea sufferers experience periods of silence because they aren’t breathing followed by a gasping noise when they try to start breathing again. This differs from snoring suffers who usually have a slow rhythmic constant noise. Think of a chain saw.

 

While the condition mainly occurs in adult males ages 49 and older, neck size, weight, ethnicity, family history and sleep position are also contributing factors. 

 

People with severe or moderate sleep apnea have more episodes when they sleep on their back By learning to sleep on their right or left side patients are able to reduce these episodes. Right side sleeping is preferable but either is better than sleeping on the back.

 

If you suffer from sleep apnea, your physician may initially recommend a change in lifestyle and diet. These changes may include: weight loss if you are overweight, adjusting your sleep position by sleeping on the side instead of the back, reducing your alcohol intake and use of sedatives.  If the condition persists despite these changes, your physician will recommend other treatment options.

 
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Diagnosing Sleep Apnea

Sleep apnea is a potentially life-threatening medical condition. If you suspect that you suffer from the
condition, our Qualified Dentist will conduct an examination and discuss the diagnostic screening process and options with you.
 
We will complete an initial consultation and in conjunction with your Doctor, a referral will be made to a sleep clinic for a sleep test. Upon recommendation by the sleep doctor of an oral appliance, we will review:
• your medical and dental history
• tooth, gum, jaw joint, hygiene, and radiographic examination
• a full disclosure of possible challenges and resolutions
 
A definitive diagnosis of sleep apnea can be made with a sleep study called Polysomnography (PSG). This is conducted during a visit to a sleep lab, where a sleep technician will monitor your sleep to determine snoring, breathing pauses, related oxygen levels and leg movements. The test is then read by the Physician and either an oral appliance or CPAP will be recommended.
 
Upon completion of the study and recommendation of a Health Canada approved appliance, the patient will be fitted with the appropriate device.  Once the appliance has been adjusted to the
patient’s optimum relief of symptoms, a home study can be performed to confirm an improvement.
 
With home testing monitors, we can confirm that the appliance is relieving the patient’s symptoms as best as possible.  Is the patient more alert? Are they snoring less? Do they feel more rested?
 
Once we have confirmed the effectiveness of the appliance, the patient is then referred back to the Sleep Clinic for a full laboratory sleep study.
 
Please use the following link to get more in-depth information from the American Academy of Dental
Sleep Medicine:

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Obstructive Sleep Apnea – symptoms :   www.aadsm.org/obstructive_sleep_apnea_snor.php

 

Treatment Options

At Dr. Richardson’s clinic, we offer a primary treatment option that includes the use of a custom dental appliance designed to open the area in the back of the throat. The dental appliance has proven effective in treating patients with mild to moderate obstructive sleep apnea as well as severe patients who are unable or unwilling to wear their CPAP mask. This option is a cost comparable solution that is easy to use and eliminates the discomfort experienced with the CPAP device.

 

There are many choices for the treatment of snoring and sleep apnea which include:

CPAP, nasal pharyngeal surgery, hypoglossal nerve stimulation, positional therapy, mandibular advancing appliances and tongue retaining devices. Upon examination of the nasal pharyngeal airway, there can be a restricted area which prevents air from travelling to your lungs.  Enlarged turbinate bones, deviated septum, overgrowth of nasal tissue and polyps all restrict air from entering from your nose to the back of your throat.  In these cases, a consultation with an ENT surgeon would be arranged for further investigation and treatment.

When we interpret your overnight sleep study ( PSG ), the number of times you stop breathing ( apneas ) are broken down by your sleep position.  If you snore or have more apneas when you are on your back, we have strategies to try and retrain you to be a side sleeper.

The Mandibular Advancing Device ( MAD ) consists of two appliances which moves the lower jaw forward.  The base of the tongue is pulled forward to open the airway.  The amount of movement is the important variable and must be done in small increments, slowly and uniformly.  After 3 years of use, 80% of patients with MAD are still wearing their devices nightly.  Conversely, after 3 years of use, 50% of patients with CPAP are still using them nightly.  CPAP defines success as only using the unit 5 out of 7 nights for 3.5 hours a night.  Studies show that you need 6 hours of Apnea reduction per night to get any cardiac benefit.

To make a MAD, the patient needs at least 8 firm healthy teeth per jaw.  This is not always possible due to tooth loss, gum disease or bony ‘bumps’ in the mouth.  Other treatments include, a tongue retaining device which pulls the tongue forward out of the mouth while you sleep, or a device that looks like 2 full dentures.  This is only possible when the patient has large firm ridges.
 

Hypoglossal Nerve Stimulation is a surgical procedure that implants a type of ‘Pacemaker” to stimulate the Hypoglossal nerve and allows you to keep your airway open in specific patients.

We will discuss any appropriate treatments at a consultation appointment.

 

Oral Appliance Advantages

Oral Appliance Advantages

 

Advantages of Mandibular Advancing Devices (MAD)

  • Easy to transport (no electric wires, tubing, or masks)

  • Small vs CPAP machine

  • No constant replacement of masks and tubing

  • No sore spots or dry patches, due to straps against your face 

  • Easy to turn over in bed 

  • Easy to get up to go to the bathroom and go back to sleep

  • No irritating noises from CPAP machine, mask, or tubing

  • Easy to clean appliance with Polident or similar products

Disadvantages

  • Not appropriate for severe sleep apnea unless the patient is unwilling or unable to tolerate CPAP

  • Can cause your teeth to move

  • Can cause bite changes

  • Possible short term muscle soreness

  • Possible breakage of previously treated teeth.

 

Please use the following links to get more in-depth information from the American Academy of Dental Sleep Medicine:

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Oral Appliance Therapy :   https://www.aadsm.org/oral_appliance_therapy.php

 

Managing Possible Side Effects :    www.aadsm.org/oat_patient_resources.php 

 
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What is Snoring?

Snoring can be defined as the rhythmic noise a patient makes when they inhale or exhale in the absence of any apnea, hypopneas, choking or waking.

 

Snoring occurs in 10 – 50 % of western populations. It has been suggested that this prevalence increases up to the age of 60 years of age and then decreases after that.  It is  more common in males than females, and increases with obesity, sinus issues, anatomical abnormalities and ethnicity.

 

If the patient exhibits a constant rhythmic sound, similar to sawing wood, this may indicate a snoring problem. Although not medically life threatening in itself, snoring is certainly life disturbing to the sleep partner as well other members of the family.

 

Types of Sleep Apnea

Sleep apnea occurs in three forms; Central Sleep Apnea (CSA), Obstructive Sleep Apnea (OSA) and Mixed Sleep Apnea.  Of the three, OSA is the most common.  

 

Central Sleep Apnea is rare but sometimes occurs in persons who have suffered a head injury or stroke. CSA takes place in a region of the brain where the nerves that regulate breathing no longer function normally and cause breathing to be impaired. It occurs because the brain fails to instruct the body to breath. The person can breathe, but doesn’t.

 

During an episode of Obstructive Sleep Apnea (OSA) the upper airway repeatedly collapses during sleep, preventing air from reaching the lungs. Breathing usually resumes with a loud gasp, snort, or body jerk. These episodes can occur many times during the night and the danger increases as the number of events escalate.

 

OSA episodes also interfere with a sound night’s rest which is essential for the body and mind to function efficiently. Loss of oxygen to certain vital organs can result in heart attack and stroke among other problems. A new research paper even suggests a link between hearing loss and sleep apnea.

 

The final form is Mixed Sleep Apnea which occurs when a person experiences both central and obstructive apnea. This is extremely rare.

 
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Symptoms of Sleep Apnea

Bed partners and other people in the household are a great source of information in identifying and reporting sleep apnea and snoring.  They are the ones who really notice someone’s loud and persistent snoring either accompanied by prolonged episodes of silence and gasping or just constant rhythmic snoring. Ask your household members what it sounds like when you are asleep. You may be surprised! 

 

Episodes may include restless legs syndrome where the patient feels an urge to move their legs accompanied by an unpleasant feeling in their legs.  The symptoms are worse during the evening and during periods of rest.

 

If you suffer from sleep apnea, common symptoms include:

 

• excessive tiredness during the waking hours, including immediately after waking up

•  irritability

• high blood pressure

• the tendency to doze off while at work, driving or even during conversations

• sexual dysfunction

• depression 

• high blood pressure

• heart attack

• stroke

 

Sleep apnea is a main predictor of coronary artery disease after smoking, severe obesity and 

diabetes.