If you have had a recent sleep study done (either at home or in a lab) and read by a board-certified sleep physician, then you now know what you are dealing with. The next question is “How do I treat this?” That depends on if you have obstructive sleep apnea, respiratory effort related arousals (RERA), or just primary snoring.
WHAT IS PRIMARY SNORING?
Primary Snoring: (If OSA has been ruled out, AHI is <4/hour)
- Over the counter or off the internet anti snoring devices. These tend to be “boil and bite”, are bulkier or do not fit as well. If the device cannot advance the jaw and keep it from falling back, it is just a mouth guard, and will not be effective. Beware of side effects to the teeth jaws and joints.
- We can custom fit you with an oral device in our office. This is not a custom-made, titratable device. Examples of these, less costly devices, might be the Silent Nite or the Snore guard. Each is FDA approved if done in office. These tend to be less durable.
- You may need a custom-made, titratable oral appliance, made in a lab. Sometimes the jaw has to be advanced to open the airway enough to stop the snoring. An example of this might be an EMA.
WHAT IS UPPER AIRWAY RESISTANCE SYNDROME?
UARS: (upper airway resistance syndrome). This is where the RERAs come in, and is measured on the Respiratory Disturbance Index (RDI). RERAs are apneic events that don’t meet the criteria measured by the AHI scale (less than 10 seconds, etc.). They show up as effort to breath by the diaphragm, spikes in heart rate and a change in brain waves picked up on an EEG. These RERAs cause a disturbance to the sleep staging, and thus result in poor, fragmented sleep.
- Might be as simple as getting you to stop breathing through your mouth at night and getting you to breathe through your nose. Treatment could range from a referral to an ENT or allergy specialist, using nose cones or Mute, to simple use of decongestants.
- You may need a custom-made, titratable oral appliance to open the airway.
WHAT IS OBSTRUCTIVE SLEEP APNEA?
Obstructive Sleep Apnea: (AHI >4/hour)
CPAP (continuous positive airway pressure). This is the first option a physician will offer because it is the most effective treatment. CPAP is considered the gold standard of treatment to control OSA. This can be used to treat the entire airway and is effective for both Central and Obstructive Sleep Apnea. It functions not to provide oxygen, but to provide pressure to keep the airway open. Options include various face masks and nose pillows. CPAP requires a monthly purchase of disposable supplies, ordered automatically. Additional options include:
- APAP (Automatic Positive Airway Pressure).
- BiPAP (Bilevel Positive Airway Pressure).
- ASV (Adaptive Servo-Ventilation).
MANDIBULAR ADVANCEMENT DEVICES
Mandibular Advancement Devices (custom-made, titratable oral appliances). As an AADSM “qualified” dentist, Good Night Dentistry is ideally suited to help with this treatment option. As of the 2015 AASM/AADSM guidelines update, oral appliances can be used to treat mild, moderate or severe obstructive sleep apnea, as the first alternative to CPAP for treatment.
They also can be used in combination with a CPAP machine, to help open the airway to reduce the air pressure, make compliance easier and to possibly improve the effectiveness. These oral devices work best on cases where there is an anatomic component, particularly if the constriction is at the back of the tongue or in the oropharynx. Because of this difference, studies have shown that oral appliance therapy is effective in just over 50% of severe cases of OSA, as compared with CPAP being effective 85 percent of the time. The offset here is in terms of patient compliance throughout any given night and also, after the first year of treatment.
There are currently over 100 appliances available on the market today. All work in a similar manner in that they slightly advance the jaw to open the airway, and prevent the jaw from falling back while you sleep. Categories include:
- Anterior Push/Pull. Examples would be the Tap3 or the Dream Tap devices.
- Posterior, Bilateral Pull. Examples would be the EMA or the Panthera devices
- Posterior, Bilateral Push. Examples might be the various Herbst designs.
- Examples of these are the Respire or other dorsal appliances.
- Mono Block. These are all one piece, both top and bottom.
- Temporary devices: Examples are My-Tap, Silent Sleep or Apnea Guard.
For more information, see the page on “About Oral Appliances.”
Surgery – Efficacy is about 30% as compared to CPAP or oral appliance therapy in the short term. Types available:
- UPPP (clears out tonsils, uvula, etc.)
- Septorhinoplasty ( to straighten the septum of the nose for better airflow)
- Tonsil and Adenoid removal (first-line treatment for children)
Advancement or expansion of the mandible and/or Maxilla
- Hyoid Suspension
- Genioglossus advancement
- Maxillomandibular advancement ( more common)
OTHER TREATMENT OPTIONS
Other adjunctive therapies to be used in combination with the above would include:
- Myofunctional Therapy
- Weight Loss
- Positional Therapy