Snoring & Obstructive Sleep Apnoea

If you  suffer from excessive daytime sleepiness (hypersomnia) and this is not related to a temporary change in work hours (shift working) or exceptional temporary conditions then you should consult your doctor to have a general medical assessment with a view to also assessing snoring and obstructive sleep apnoea.

If you want to undertake a provisional assessment of your sleep status, you can download a sleep app onto your phone and this will give you an indication of your sleep pattern.

1. Snore Lab
2. Sleep Talk
3. Sleepzy

If you are not getting approximately 7-8 hours of quality sleep per day then it is important that you obtain medical advice, initially with your doctor.

Dentists do receive training in sleep disordered breathing and whereas it is not within the scope of practice to diagnose and treat obstructive sleep apnoea, we can screen for this condition and will advise you of your next steps if we believe that you have sleep disordered breathing.

Snoring and Sleep Apnoea are part of a spectrum of sleep disordered breathing conditions. It is vital for mental and physical welfare to have full refreshing reparative sleep.

The condition of snoring itself results in a frequent loud rattling noise that arises from partial obstruction of your airway. This is due to a physical obstruction of the airway due to:

• obesity and fattening of the circumference of the neck
• enlarged pharyngeal tissues (the tissues that surround your wind-pipe)
• an enlarged uvula (pendulous soft tissue at the back of your throat)
• an excessively large, broad tongue
• collapse and construction  of the tissues at the back of your mouth during certain sleep positions particularly when you sleep on your back
• enlarged nasal ‘turbinates’

This obstruction may occur every time you breathe in and out which may be approximately 12 times per minute. The air turbulence during breathing results in loud snoring noises which may stop you and your partner enjoy full reparative sleep. The loudness may wake you or your partner up and this will result in interruption of  sleep. This will make you or your partner irritable. Chronic sleep deprivation will  result in physical and mental illness.

Snoring can progress to a much more serious condition known as obstructive sleep apnoea (OSA). In this condition the subject not only snores, but also suffers from oxygen deprivation because there is complete occlusion of the airways by collapse of tissues, and breathing actually stops for periods of up to 10 seconds. This can occur several times every hour. Those with serious apnoea will cease breathing every 1-2 minutes for approximately 10 seconds.

This periodic cessation of breathing results in frequent gasping and arousals from sleep which disrupt the normal sleep cycle. The frequency of cessation of breathing will reduce blood oxygen saturation and disrupt your sleep cycle.

The effects of sleep deprivation are manifold:

• initial effects of sleep deprivation start with excessive daytime sleepiness, irritability and difficulty in concentration. This can cause accidents at work and this makes driving hazardous
• chronic sleep deprivation will eventually result in emotional instability and mental illness such as chronic anxiety and depression
• you will eventually lose your libido and sexual desire will be supressed
• the combination of the items above will affect the quality of your relationships with your nearest and dearest
• physically, you will eventually suffer from high blood pressure and will become more prone to heart disease and stroke
• a reduced tolerance to stress will make your anxious, and this heightened emotional response will make you nauseous and more prone to oesophageal reflux
• the bodies regulatory systems (called homeostasis) become unreliable and you may become more prone to high cholesterol, high blood sugar and a weakened immune system

Please do not leave it too late before you suffer medically. You should have your condition diagnosed and managed as soon as possible. Your dentist can provide you with initial advice.

Sleep Apnoea in itself is not life threatening if you are fit and well. In the longer term a frequent reduction in oxygen supply to the heart during sleep is detrimental to cardiovascular and mental health and will be life threatening. The condition  can increase your chance of stroke and heart attack. The reduction in quality of sleep will also lead to insomnia and metal health disorders such as chronic anxiety, obsessional traits and depression.

Obstructive Sleep Apnoea (OSA) must be considered to be a serious condition and you should consider immediate full investigation and treatment.

It is inevitable that sleep deprivation will lead to insomnia and if this is not corrected you will start to feel irritable, cranky and you will struggle to remain emotionally stable. This will cause disharmony in relationships at home and outside of home.

Many patients approach us for the provision of a mandibular advancement device (MAD) which holds your jaw forwards while you sleep and can reduce and control snoring and mild obstructive sleep apnoea. For many of our clients, the motivation is that they need to sleep in a separate room to their partner due to the intensity of snoring that is too difficult to cope with by their bed partner.

If after reading this information you feel that you have sleep disordered breathing then you must certainly approach your doctor. He may seek further information by asking you to log a diary of events just before you go to sleep with view  to identify any pattern of behaviour that may be causing sleep disordered breathing. Your dentist, while not diagnosing sleep disordered breathing can conduct an examination and undertake a screening test known as the ‘Epworth Sleepiness Score’. From this, we may be able to ascertain if you are suffering from snoring or mild sleep apnoea as you may be amenable to support with a mandibular advancement device. This is no replacement for full diagnosis and investigation with an overnight sleep study which is conducted by your local hospital respiratory support and sleep centre (RSSC). The sleep study results in the production of a graph known as a ‘polysomnogram’. From this, your respiratory physician will determine how many breathing cessations for 10 seconds or ‘apnoeas’ you suffer per hour. If you suffer from more than 15 apnoeas per hour, your respiratory physician will not recommend a mandibular advancement device but recommend CPAP (continuous positive airway pressure). This is delivered by a machine that forces airflow into your lungs at night and helps you attain a more regular oxygen saturation and therefore uninterrupted restful sleep.

It is not within the scope of practice of a dentist to manage obstructive sleep apnoea. A dentist can however screen for sleep apnoea through a score known as the Epworth Sleepiness Score, and take a history, and advise on the liklihood of needing more in depth assessment with your doctor or respiratory physician. A dentist may recommend the use of a mandibular advancement device (MAD) to open up the airway while you sleep in the hope that this helps management of your condition. Such a device will only be sensible for mild obstructive sleep apnoea and cannot replace professional assessment by your doctor and the possible referral to a respiratory support and sleep centre (RSSC) which is usually part of a hospital unit.

A sleep study, known as a “polysomnogram” is usually undertaken by a specialised centre, usually a hospital where a  respiratory consultant will oversee the monitoring and analysis of results. You will usually have an overnight stay (or during the day for shift workers who work at night) and will be connected to various monitoring devices to measure the following activity within the brain and body:

• EEG (electro encephalogram). This study measures brain waves and this is useful in determining your stages of sleep, particularly your transition between 3 important phases of sleep known as REM sleep, or NREM (rapid eye movement sleep, and non-rapid eye movement sleep).
• A pulse oximeter. This measures the oxygen saturation of your blood throughout the night and a real-time chart is constructed over the duration of sleep on your oxygen saturation levels. The pulse oximeter also measures your heart rate
• A capnograph. This measures

There are other conditions that a sleep study can pick up that may  influence sleep apnoea, or atleast certainly be relevant for further management:

• Periodic limb movement disorder
• Narcolepsy
• Restless legs syndrome
• Insomnia
• Sleep walking
• REM sleep behaviour disorder

Your dentist will provide you with additional information on the above, or may refer you to Dr.Raj Wadhwani our Clinical Director, who has a special interest in sleep medicine.

Snoring is caused by:

1. Obstruction of the oral airway, typically due to collapse of the soft palate against a broad tall tongue vase
2. Obstruction of the nasal airway
3. Combination of the above

Correction of snoring relies on accurate diagnosis of what the cause is and determining if you suffer from “oral snoring” or “nasal snoring” or a combination of both. The oral airways can collapse due to loss of muscle tone as you get older or due to obesity, use of alcohol, and sleeping pills.

Some of our dentists have received additional training in the management of snoring and can help you tackle the condition, even if this means referral to the appropriate practitioner. Dentist are particularly skilled in the fabrication of oral devices such as a vestibular shield or a mandibular advancement device.

There are a variety of treatments that may be used to help you with this condition. This ranges from wearing a device that dilates tissues or undertaking non-invasive surgical procedures using radiofrequency devices and lasers. As a last resort surgical procedures can be employed.

Summary of Treatments

• Wearing a mandibular advancement device (MAD) prosthesis to hold the jaw forwards and open the air-way
• Wearing of a chin strap to stop the mouth falling down and backwards while the jaw is relaxed during sleep
• Wearing a ‘vestibular sheild’ to block oral breathing and force breathing through the nose
• Use of a CPAP (continuous positive airway pressure) machine
• Use of nasal dilaters
• Laser assisted uvuloplasty (LAUP)
• Somnoplasty – use of low levels of radiofrequency heat to remove tissues of the uvula and soft palate
• Surgical trimming of a pendulous soft palate – “palatuvuloplasty”
• Surgical excision of nasal turbinates (soft tissue thickenings) by a procedure known as radio-ablation
• Alternative surgical procedures such as tonsillectomy, adenectomy, uvulopalatalpharyngoplasty (UPPP), Thermal ablation palatoplasty (TAP)
• Combination procedures

Obstructive Sleep Apnoea (OSA) is a distinctly different condition from snoring although those who suffer from OSA usually also snore. OSA sufferers experience  a periodic reduction in blood oxygen saturation. Obstructive sleep apnea can be mild to severe depending on the frequency of reduction in oxygen saturation.

• If you suffer from mild apnoea, this can be controlled by devices that dilate the oral airways such as a nasal dilator, or a mandibular advancement device or both.
• If you suffer from moderate to severe obstructive sleep apnoea, this requires use of a CPAP (continuous positive airway pressure) device. This device is a machine with a mask that is worn throughout the night which forces air into the airways and prevents the airways from closing

A mandibular advancement device (MAD) is a prosthesis that holds the lower jaw forwards during sleep and assists in maintaining positive airflow into the lungs. There are many economical devices that can be bought online  which are generic and loosely fit around the jaw to hold it forwards to improve the patency of the airway. Some of these generic devices need to be softened in boiling water and be moulded to the mouth.

A more bespoke and precisioned device is made by the dentist. This is much more comfortable and healthy for the oral tissues and this can provide tremendous relief for snoring and sleep apnoea.

Some of our dentists have significant additional training in the area of snoring and sleep apnea and can facilitate onward referral to the correct clinician to help you manage your condition.

Most people who use CPAP have been diagnosed with obstructive sleep apnoea by means of a sleep study. Many individuals dislike use of the CPAP machine due to the drying effect on the mouth or resent use of the unwieldy mask throughout the night, and possibly find this an undignified experience. If you have moderate to severe sleep apnoea then CPAP is highly recommended to prevent sleep deprivation, insomnia and the associated effects which can include medical disorder such as mental health issues and cardiovascular disease.  If you have mild sleep apnea this can be managed by a mandibular advancement device (MAD), or alternative devices such as nasal dilaters, chin straps and such like.

Your dentist will advise you on the liklihood of your condition being mild by reference to your Epworth Sleepiness Score (ESS). Please take the test yourself on the tab below.