OBSTRUCTIVE SLEEP APNEA:
The International Classification of Sleep Disorders distinguishes more than 80 different disorders, which can be effectively managed.
In the case of Obstructive Sleep Apnea (OSA), treatment generally falls into two major categories: conservative (non-surgical) and surgical. All surgery carries risks and outcomes can vary greatly. As such, we strongly urge patients who have been diagnosed with a sleep-disordered breathing problem to explore conservative therapies as the first step in managing their disorders.
Non-Surgical Treatment Options
1. Oral Appliance Therapy - Oral appliance therapy is highly effective in managing mild-to-moderate Obstructive Sleep Apnea. It is also recommended by the American Academy of Sleep Medicine for patients who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidate for CPAP or who fail attempts with CPAP.
Briefly, there are two different types of sleep appliances that can be used to treat OSA:
- A mandibular advancement device works by moving your lower jaw forward slightly. This, in turn, tightens the soft tissue and muscles of your upper airway to prevent obstruction during sleep.
- A tongue retaining device prevents your tongue from falling against the back of your throat and blocking your airway. Although it can be effective, use of this type of device is far less commonly used than mandibular advancement devices.
An oral sleep appliance looks like an athletic mouth guard. Worn in the mouth during sleep, it prevents the soft tissue in your throat from collapsing and obstructing your airway.
There are many different oral appliances, each of which has benefits and limitations. Most oral sleep appliances can be adjusted quickly and easily, and offer decided advantages to patients in terms of cost, effectiveness, comfort and ease of use. Selecting the best oral appliance for each patient requires the skill and judgment of an experienced dentist. One appliance does not fit all.
To be effective, an oral sleep appliance must be precision-fit for each patient by an experienced dentist who is fully versed in dental sleep medicine practice parameters and protocols. Because an oral sleep appliance works by bringing your lower jaw forward, it is also important that the dentist who prescribes your oral sleep appliance have a complete understanding of the jaw joint and TMJ disorders.
Follow-up appointments during which your appliance will be inspected for wear and fit-checked, the health of your oral structures and integrity of your occlusion will be evaluated, and you will be reassessed for worsening signs of OSA, are also a vitally important part of treatment in our office.
2. Continuous Positive Air Pressure (CPAP) - CPAP therapy involves wearing a pressurized mask over your nose that is attached to a small pump that forces air through your airway to keep it open. CPAP eliminates snoring and is considered “the gold standard” for treatment of OSA.
CPAP equipment has undergone many improvements since the first one was invented in 1980 Collin Sullivan, MBBS, PhD, FRACP, using a vacuum cleaner and a length of hose. There are always improvements being made to CPAP masks, too. Despite this, the rate of patient compliance is very low. (For information about CPAP intolerance, click here.)
A CPAP machine acts like an “air splint” to maintain airway patency during sleep.
3. Combination Therapy - Using a CPAP machine and an oral sleep appliance at the same time can be very effective and it can also help you better tolerate the CPAP. In brief, the oral sleep appliance reduces the amount of pressure needed for your CPAP to be effective.
In combination therapy, the role of the intra-oral mouthpiece is to create an oral seal that connects to the positive airway pressure generated by your of your CPAP machine. In essence, the oral appliance acts as an interface between you and your CPAP, eliminating the need for a nasal mask and straps. It can also be detached from our CPAP machine and used separately if needed.
In combination therapy, an oral appliance serves as the interface between you and your CPAP machine.
We work with physicians who have prescribed combination therapy for their patients on a regular basis; the results have been excellent. In particular, we have found that patients who are diagnosed with severe OSA benefit more from combination therapy than they do by using CPAP therapy alone. Research studies on the efficacy of combination therapy also support this finding.
Complementary Health & Wellness Strategies
Additional strategies Dr. Bailey may recommend in conjunction with oral appliance therapy or combination therapy to manage OSA includes, but is not limited to, the following:
- Weight Loss - Studies show that losing as few as 10 pounds may be enough to make a difference.
- Sleep Position Change - People tend to snore more when they sleep on their backs; sleeping on your side may be helpful.
- Dietary Changes - Avoid consumption of alcohol, caffeine and heavy meals, especially within two hours of bedtime.
- Tobacco Cessation Program - Tobacco use causes inflammation to the throat and, therefore, should be eliminated. (We have recommended tobacco cessation programs and other stop-smoking strategies to patients with great success.)
- Daily Mouth Exercises - Daily exercises for your tongue and upper airway can help improve snoring and sleep apnea when done faithfully each night, approximately 20 minutes before bedtime.
Surgical Treatment Options
Generally speaking, OSA is best managed conservatively and without surgery, which inherently carries risks. To be sure that you are well informed about all of your options, we have included some of the more common OSA surgical procedures here.
1. Tonsillectomy - Enlarged tonsils and adenoids can cause snoring and sleep apnea in children. As such, the one exception to our caution against surgery for the treatment of snoring and Obstructive Sleep Apnea is tonsillectomy, which has proven very successful in eliminating sleep-disordered breathing in children. We urge you to consult Dr. Bailey for an opinion as to whether removal of your child’s tonsils would be beneficial.
2. Laser-Assisted Uvuloplasty (LAUP) - This is a surgical procedure that opens the airway behind the soft palate by removing the uvula and surrounding tissue. It is typically performed by an oral & maxillofacial surgeon with local or general anesthesia.
Note: LAUP surgery is painful and the true success rate appears to be in the range of 30-50%. In most cases, snoring is reduced but not eliminated. In addition, the results are not permanent and some studies show that LAUP surgery can cause or worsen sleep apnea. We, therefore, urge patients to seek a second opinion before undergoing LAUP.
3. Uvulopalatopharyngoplasty (UPPP) - UPPP surgery involves surgically removing all or part of the uvula (the soft flat of tissue that hangs down in the back of your mouth), parts of your soft palate and throat tissue behind it, plus your tonsils and adenoids. The goal of UPPP surgery is to increase the width of the airway at the throat’s opening, block some muscle action to improve the ability of the airway to remain open and improve the movement and closure of the soft palate. Note: Studies suggest that the UPPP surgery success rate is 50% or less over the long term. It is also very painful and has been associated with a number of very serious complications. The American Association of Sleep Medicine recommends that patients try non-surgical treatment options, such as the oral appliance therapy we provide in our office, before undergoing UPPP.
4. Palatal Implants (aka: “Pillar Procedure”) - This procedure involves having a doctor inject braided strands of polyester filament into your soft palate to stiff it and reduce snoring.
Note: Although palatal implants have not been shown to result in any serious side effects, the benefits and safety of this procedure are still being studied.
5. Radio Frequency (RF) Tissue Ablation (somnoplasty) - This treatment for snoring and OSA uses radio waves to shrink the tissue in the throat or tongue, thereby increasing the space in the throat and making airway obstruction less likely. Over the course of several treatments, the inner tissue shrinks while the outer tissue remains unharmed.
Note: Several treatments may be required and the long-term efficacy of this procedure has not been determined. Additionally, since all surgery has inherent risks, we urge patients to seek a second opinion before deciding upon somnoplasty as a treatment option.