Sleep apnea is a potentially life-threatening sleep disorder characterized by repeated pauses in breathing during sleep. The term sleep apnea is derived from the Greek etymology meaning “without breath”. Breathing pauses can last anywhere from several seconds to minutes, and happen as often as 30 times or more per hour. Ongoing disrupted breathing causes an imbalance between the carbon dioxide and oxygen levels in the bloodstream, as not enough carbon dioxide is exiting and not enough oxygen is entering the body.
Sensing this imbalance, the brain sends a message to the body, telling it to wake up to restart breathing the process. People with sleep apnea will partially awake as they struggle to breathe, and this is often accompanied by loud snoring or choking sensations. Because people with sleep apnea don’t always completely awake during the episodes, they are often unaware they have a sleeping disorder and it can remain undiagnosed.
There are two main types of this disorder; central sleep apnea which occurs when the brain fails to send important signals to the breathing muscles, and obstructive sleep apnea which occurs when air cannot flow through the nose or mouth even though the body is still trying to breathe. Obstructive sleep apnea is far more prevalent and easily treatable by the dentist.
Common signs of obstructive sleep apnea can include severe early morning headaches, sleepiness in the daytime, and insomnia. Fortunately, the dentist is equipped with the necessary technology and expertise to treat sleep apnea in several different ways.
Reasons for treating sleep apnea
It is very important to seek medical attention if sleep apnea is suspected. A sufferer can completely stop numerous times per hour, and this can quickly turn into a deadly situation. Obstructive sleep apnea occurs when the soft tissue lying at the back of the patient’s throat collapses into the airway. The tongue then falls towards the back of the throat which tightens the blockage and prevents oxygen from entering the lungs.
The problem worsens when the chest region, diaphragm, and abdomen fight for air. The efforts they make to obtain vital oxygen only cause a further tightening of the blockage. The patient must arouse from deep sleep to tense the tongue and remove the soft tissue from the airway.
Because sleep apnea causes carbon dioxide levels to skyrocket in the blood and oxygen levels to decrease, the heart has to pump harder and faster to compensate for the lack of oxygen. Sleep apnea patients can technically “die” many times each night. Sleep apnea has been linked to a series of serious heart-related conditions, and should be investigated by the dentist at the earliest opportunity.
What does sleep apnea treatment involve?
Initially, the dentist will want to conduct tests in order to investigate, diagnose, and pinpoint a suitable treatment. The dentist can offer many different treatment options which depend largely on the exact diagnosis and the health of the patient. The dentist may advise the patient to halt some habits that aggravate sleep apnea such as smoking, alcohol consumption, and tranquilizer use.
Sleeping masks were traditionally used to keep the patient’s airways open while they slept, but nowadays there are some less intrusive options. Dental devices that gently tease the lower jaw forward are very effective in preventing the tongue from blocking the main air passage. These dental devices are gentle, easy to wear, and often help patients avoid unwanted surgeries.
A more permanent solution is to have surgery that sections the lower jaw and helps pull the bone holding the tongue forward slightly. This surgery has an impressive success rate and is simple for the dentist or oral surgeon to perform. The dentist needs to formally make a diagnosis of each individual case before recommending the best course of action.
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Diagnosis of Sleep Apnea
Central sleep apnea, obstructive sleep apnea, and mixed sleep apnea are the variations of apnea that occur in the syndrome. In central sleep apnea, respiratory muscle activity ceases simultaneously with airflow at the mouth and nostrils. This disorder is found in patients with central nervous system (CNS) insufficiency that affects the outflow of neural output from the respiratory center to the diaphragm and other muscles of respiration.
The most common type of sleep apnea by far is obstructive. This is characterized by sleep-induced obstruction of the upper airway.
Mixed sleep apnea is a combination of central and obstructive apnea. This pattern begins with an episode of central apnea with no airflow detectable at the mouth and nostrils and no respiratory muscle activity. The pattern ends with an episode of obstructive apnea with only cessation of airflow at the mouth and nostrils.
A diagnostic evaluation includes a thorough history and physical examination, radiologic evaluation, and polysomnography. Little additional information can be gained from routine laboratory tests.
After a complete history is obtained from the patient and his or her bed partner, a complete clinical examination of the mouth, nasal, pharyngeal, and laryngeal areas is performed. The emphasis of the clinical examination should be the identification of anatomic abnormalities that may contribute to or produce obstruction during sleep. The nose is examined for a deviated nasal septum and enlargement of the turbinates. Micrognathia, retrognathia, and macroglossia may be noted in examination of the oral cavity. Occasionally masses or tumors in the nasopharynx or hypopharynx may be noted. In the pharynx, adenotonsillary hypertrophy, a long soft palate, a large base of the tongue, and excess pharyngeal mucosa are potential causes of obstruction.
The appearance and position of the soft palate, base of tongue, and lateral pharyngeal walls are evaluated. Changes in the position of the base of the tongue such as forward movement with protrusion of the mandible are noted.
A lateral cephalogram is routinely obtained in the radiologic evaluation of sleep apnea patients. Cephalometric analysis is performed to identify any skeletal and soft tissue abnormalities that may exist. The advantages of cephalometry are its easy access, low cost, and minimal radiation exposure. Patients with skeletal deficiencies are more likely to have obstruction at the base of the tongue or at the level of the soft palate. Riley and colleagues determined that obstructive sleepapnea patients had an inferiorly positioned hyoid bone, a longer-than-normal soft palate, and a narrowing at the base of the tongue.
Computed tomography (CT) is an alternative to cephalometry and has been used to provide a quantitative assessment of the upper airway at various levels. Some authorities feel that the airway can only be assessed by a CT scan. A cephalogram and a CT scan are static evaluations at a fixed time of a dynamic system and they should be viewed as only part of the overall evaluation of the patient.
Nocturnal polysomnography remains the gold standard for establishing the diagnosis of sleep apnea, quantitating its severity, and determining the success of treatment modalities. The study is performed in a sleep laboratory and the patient’s sleep is monitored overnight. At least 4 hours of total sleeptime must be recorded for a diagnostic study.
The sound of snoring is caused by the uvula, tongue and other pharyngeal tissues of the throat flapping as air passes over them when you breathe during sleep. When you fall asleep, the muscles in the throat, soft palate and uvula relax and the tissues can create such vibration noises when air passes in and out.
Airway blockage is the root of all snoring problems. When you snore, your airway is partially blocked by the soft tissues in the back of the throat, back of the tongue, soft palate and uvula. This causes a decrease of air flow to the lungs, which ultimately causes a lack of oxygen to the brain. Snoring may be a recognizable symptom of Obstructive Sleep Apnea (OSA) and it is important that your physician and dentist to take note of this indicator.
At the very minimum, at least 30% of adults snore on a regular basis and up to 50% snore occasionally. Men snore more than women at a ratio of 2:1 but women do snore. Snoring increases with increasing age and increasing weight. Allergies, asthma, colds and sinus infections increase the risk of snoring.
Drinking an alcoholic beverage before you go to sleep, being overweight, smoking or overeating all can make the problem worse as can some medications like muscle relaxants In some people simply sleeping on their back can cause snoring.
Snoring can ruin your sex life, and more…
Medical problems associated with snoring
Repeated deprivation of oxygen to the brain can cause high blood pressure which can damage the carotid arteries on each side of the neck. The carotid arteries carry oxygen to the brain. The damage can lead to the development of cholesterol and calcium containing plaque which further restricts blood flow to the brain and can lead to stroke.
So what can you do about snoring…
- Avoid sleeping on your back. Sewing a tennis ball into the back of a T-shirt and wearing that as pajama tops will help to prevent rolling over on your back
- Raise the head of the bed 4 inches or so
- Lose weight
- Avoid drinking alcohol within 3 hours of bedtime. Do not take a drink to help you fall asleep.
- Stop smoking
- Avoid medications that relax the muscles (if possible)
- Don’t eat a heavy meal within three hours of bedtime
- Ask your bed partner to wake you if you snore
- Exercise to improve your physical condition
- Try nasal strips or nasal dilators to keep the nostrils open
- Ask your dentist about your snore problem and a stop snoring mouthpiece called an oral appliance to help stop snoring and control sleep apnea
If the problem is really severe and/or if you stop breathing during sleep get checked by a sleep physician. He or she may recommend a CPAP machine or surgery.
CPAP uses certain amount of air pressure to hold the airway open. Air-pressure is not constant to every individual and may vary from person to person. This may take several adjustments before the right setup can be optimized. Studies have shown it to be a gold standard for treatment of sleep apnea, however, compliance is an issue due to lack of portability of the appliance. CPAP is also intolerable to many people because of its claustrophobic mask and compressor and may cause irritation/infections.
Surgical procedures are performed on OSA patients daily. They range from simple outpatient types to more complex procedure. Some may involve nasal and soft palate surgeries along with jaw repositioning surgeries in order to widen the airway. Dental oral appliances may be an alternative to those who cannot stand CPAP but want to avoid surgery.