Snoring & Sleep Apnoea

A recent study by asked a clinical trial group some simple questions; (Pancer et al)

  1. Does your husband/wife/child snore loudly?
  2. Does your husband/wife/child snore in any position
  3. How often were you kept awake by snoring?
  4. How often were you forced to sleep in another room?

Can You Relate To Any Of These Questions?

Can You Guess What The Research Programme Was Targeting?

Snoring is a common affliction, affecting persons of all ages, but particularly middle-aged and elderly men and women who are overweight.  In the 30-40 years age group at least 5 per cent of women and 10 per cent of men are habitual snorers.  There is an increase in prevalence to at least 15 per cent for women and 20 per cent of men in the 50-60 years age group. Unfortunately snoring and sleep apnoea also effects children, but can often be resolved by the removal of the tonsils and adenoids.

The occurrence of snoring has been regarded as an inconvenience or irritation by the bed partner and by the general public a source of humour.  The medical profession has identified snoring as a risk indicator of an upper airway abnormality associated with significant sleep disturbance and sleepiness and, although not all snorers have sleep apnoea, snoring is a cardinal symptom of Obstructive Sleep Apnoea (OSA).

OSA syndrome is a common, chronic disorder of sleep and breathing related to upper airway obstruction that develops during sleep. Obstruction of the airway results in many repeated involuntary breathing pauses during the sleep cycle. A study by Young et al. indicated that the incidence of OSA was 9 per cent for women and 24 per cent for men.

Snoring and OSA, disorders that result from upper-airway obstruction, have been associated with, hypertension (high blood pressure), ischaemic heart disease (reduced blood supply to the heart muscle), cardiac arrhythmia (abnormal heartbeat rhythm) and stroke.  Other more apparent symptoms include fatigue, irritability, depression, personality changes, difficulty concentrating, morning headaches, choking or gasping during sleep, sore, dry throat on waking, decreased sex drive or impotence, memory and judgement problems and falling asleep at work or while driving, which may cause life threatening accidents.

You may be wondering, “What is my dentist doing talking about snoring and this thing called OSA?”

Well the answer is simple. The Standards of Practice Committee of the American Sleep Disorders Association (ASDA) appointed a task force to review the current role of oral appliances in the treatment of snoring and OSA.  From this task force their recommendations are;

  1. Oral appliances are indicated for the use of patients with primary snoring or mild OSA.
  2. Patients with moderate to severe OSA should have an initial trial of nasal CPAP.
  3. Oral appliances are indicated for patients with moderate to severe OSA who are intolerant of or refuse treatment with nasal CPAP or surgery.

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It is our role as dental practitioners to help you understand these guidelines.  It is necessary to take a multidisciplinary approach to this very important issue.   We would send you to the appropriate specialists for adequate testing and to determine whether oral appliance therapy is the best treatment option for you.

Treatments for snoring and OSA

  1. Behavioural Therapy; This is extremely important to the overall plan.  It is important to identify and manage health or lifestyle conditions such as obesity, alcohol or benzodiazepine consumption, body position/sleep posture, and nasal congestion. Weight reduction is an important adjunct to treatment.
  2. Pharmacological Therapy; I only include this for completeness.  Articles reveal conflicting opinions.  Most authors believe there is no real effectiveness to pharmacological therapy without undue side effects.
  3. Nasal Continuous Positive Airway Pressure (nCPAP); the most effective treatment for moderate to severe OSA.  It employs a tight fitting mask that is attached to a blower that will blow room air under pressure through the nasal passage.
  4. Surgical Treatment; Designed to correct anatomical abnormalities that lead to airway obstruction.  There are a number of techniques available, depending on the site of obstruction.
  5. Oral Appliance Therapy; Based on the clinical research and clinical experience of the practitioners using oral appliances. It is clear that these devices have a positive effect on upper airway patency (open the airways)

Dental appliance therapy is useful for patients who suffer from snoring and or with mild sleep apnoea.  It may also prove useful in providing incremental improvement for patients with more severe apnoea who have failed treatment with nCPAP or surgery.  Oral appliances are also useful for patients who do not wish to have surgery or have poor compliance with the nCPAP treatment.  Patients have been shown to have a higher compliance and fewer side effects from treatment with an oral appliance than with nCPAP.

Remember the questions from the beginning of this article.  The results from Pancer et al stated that “Dramatic reduction in the attributes of snoring was achieved with the use of appliance in the entire group.  For example, loud snoring occurring “often” or “always” was present in 96% of patients at baseline, and in only 2% while wearing the appliance.  Moreover, 69% of the bed partners were “often” or “always” kept awake by loud snoring at baseline, but only 2% were kept awake when the appliance was used.” (Refer to Figure 1.)

Oral appliance therapy has been shown to be 50-80% effective in reducing OSA symptoms to normal in mild cases of the syndrome and having a significant reduction in a large proportion of the other patients studied.  There have been some reports of counterproductive outcomes in a small proportion of patients (approximately 2%). So guidance and follow up by your dentist and/or specialist is necessary for successful treatment. Currently within the practice we are trialing the Thornton appliance, which after our literature review, we feel will be the most appropriate appliance.(Refer to Figure 2.)

The number of patients complaining of any side effect (intensity greater than 0 is indicated. Intensity is rated as 0 = not at all, 1 = rarely and hardly disturbing, 2 = rare, but disturbing, 3 = often, but hardly disturbing, 4 = often and disturbing, and 5 = always, strongly disturbing.  Total number of patients surveyed was 24.

There are some side effects, in most cases these are very mild. According to Fritsch et al, “minor side effects, such as mucosal dryness or hypersalivation, transient tooth or jaw pain, or masticatory muscle stiffness, were quite common and occurred in 36% to 86% of patients.  However, according to the patients’ own judgements, the subjective benefits experienced from OA therapy outweighed these minor inconveniences by far and did not lead to discontinuation of treatment. (Refer to Figure 3.)

As has been discussed, a team approach facilitating the skills and knowledge of an Ear, Nose and Throat Surgeon and a Dental Professional is important in treating Snoring and OSA.  Please approach your Dental Practitioner about these issues if any of the above symptoms sound like you or you are interested for someone else.  OSA is a very important health issue.

The articles reviewed are available for your perusal.

Everybody needs a good night’s sleep, including our partners and friends.