Sleep apnea is a type of breathing disorder which is a serious, potentially life-threatening condition characterized by brief interruptions of breathing during sleep. There are basically three types of apnea:

1. Central Apnea
The upper airway is open, but no oxygen is getting into the system. This occurs because the patient is not getting a chemical response from the brain to stimulate the lungs and the diaphragm to assist with breathing.

2. Obstructive Sleep Apnea
The lungs and the diaphragm are functioning normally, but no oxygen is entering the system because there is an obstruction in the upper airway.

3. Mixed Apnea
This is a combination of central and obstructive sleep apnea.

Oral appliances are only indicated for use in patients suffering from obstructive sleep apnea (OSA). The signs and symptoms of OSA include snoring, excessive daytime sleepiness, gasping or choking during the night, non-refreshed sleep, fragmented sleep, clouded memory, irritability, personality changes, decreased sex drive, impotence, and morning headaches.

Factors that affect obstructive sleep apnea are as follows:

1. Age
2. Obesity
3. Alcohol
4. Sedative Hypnotics (sleeping pills)

Children can also snore and suffer from obstructive sleep apnea. Often they are highly allergic and their airway is blocked due to enlarged adenoids, tonsils or swollen nasal mucosa. Clinical signs would indicate a turned up nose, allergic shiners under the eyes, mucous draining out of the nose, mouth breathing, and a nasal sound to the voice. Other signs are bed wetting, irritability, difficulty in concentrating at school and hyperactivity

At the present time, obstructive sleep apnea is defined as a medical problem and the diagnosis must be made by a medical doctor or sleep physician (pulmonologist) who is specially trained in the area of sleep medicine.

The dental profession has an important role to play in the treatment of patients with snoring and sleep apnea. If 60% of men and 40% of women between forty and sixty years of age snore, this is a huge problem. Snoring is a serious social problem for the spouse, but obstructive sleep apnea can be a life threatening situation for the patient in that it can lead to irregular heartbeat, high blood pressure and strokes.

At the present time, obstructive sleep apnea is a medical condition that is being controlled and treated mainly by the medical profession. Despite the fact that in September 1995, the American Sleep Disorder Association finally endorsed oral appliance therapy as the third currently acceptable treatment method for snoring and sleep apnea, the vast majority of the medical doctors are not aware of the value of oral appliances

As time goes on, the public is going to become more aware of the health risks associated with snoring and sleep apnea. It is the dental professionals responsibility to educate their members, the public and the medical profession about the important role that dentists and oral appliances play in the treatment of snoring and obstructive sleep apnea.

Diagnosis

SLEEP DIAGNOSTIC CENTER

Most hospitals have sleep diagnostic centers which are being run by sleep technicians working with physicians. Sleep centers have sophisticated equipment in an adjoining room where an intercom and video camera allow communication between the technician and the patient. The patient comes in at night and is hooked up to a number of machines which are used to monitor the activities of the brain, the eyes and the muscles. The recordings are done in a private room and there is no discomfort to the patient. The patient is not confined to a fixed position and can turn freely. Recordings are done during the night in a seven hour sleep period and the patient is discharged in the morning.

POLYSOMNOGRAM

The purpose of a polysomnogram is to evaluate the individual sleep architecture including the stages and cycles of sleep as well as to record the electrical activity of the brain, the eyes, muscles and heart.

1. Electroencephalogram (EEG)
   Records the activity of the brain. This verifies and records the different stages of sleep.
2. Electro-occulogram (EOG)
   Records the movement of the eyes and measures the periods of rapid eye movement (REM).
3. Electromyogram (EMG)
   Records muscle activity throughout the body.
4. Electrocardiogram (EKG)
   Measures cardiovascular abnormalities during sleep.

It also uses a finger or ear oximeter to measure the amount of oxyhemoglobin (oxygen saturation) in the blood. Patients suffering from OSA have a decreased amount of oxygen in the system.

Treatments

1. Oral Appliance Therapy
2. Continuous Positive Air pressure (CPAP)
3. Surgical Removal of Excess Palatal Tissue (UPPP) or the Laser Assisted Removal of the Uvula (LUAP)

Clearly, the largest number of patients suffering from obstructive sleep apnea are in the mild to moderate categories and should be treated with oral appliances. Despite the fact that treatment with the CPAP unit is extremely successful, there are a number of patients who cannot or choose not to wear the face mask with the attached air compressor. These patients are excellent candidates for oral appliances. Some patients either do not want surgery or have had surgery and the procedure has been unsuccessful in solving the problem of OSA. These patients prefer a non-surgical, non-invasive plastic intra-oral appliance that can be worn at night only to help solve their problem.

Today there are basically three types of appliances:

1. Soft Palatal Life Appliance
2. Tongue Retraining Device
3. Mandibular Repositioner

It should be noted that since 1987 all medical devices, including oral appliances for the treatment of snoring and obstructive sleep apnea, are required to have marketing clearance from the FDA.

Types of Appliances

1. Snore Free
   A prefabricated appliance constructed by the clinician at the chair. It is a relatively inexpensive, good diagnostic, temporary appliance and is used if the patient breaks or loses the permanent snoring appliance.
2. Silent Nite
   This two piece appliance is consists of two plastic parts which cover the upper and lower teeth and are joined together with a plastic plunger. The advantage of this appliance is that it is extremely comfortable
3. Modified Herbst
   This removable appliance is highly effective. The upper and lower acrylic components are held together by a plunger mechanism which holds the mandible forward in both the open and closed positions. The Modified Herbst has the advantage of allowing the patient to open and close as well as providing some limited side to side jaw movement
4. Nocturnal Airway Patency Appliance (NAPA)
   This is a rigid appliance which stabilizes the jaw in the horizontal and vertical dimension.
5. Klearway Appliance
   This is a one-piece appliance attached to the upper and lower teeth with a screw capable of advancing the jaw.
6. Silencer Appliance
   This is a two piece appliance held together with a special titanium hinge. This is one of the most comfortable appliances since it allows for jaw movements.After the oral appliance has been used for a few months and the treatment appears to be working, then a second polysomnogram must be taken to confirm that the snoring and obstructive sleep apnea have been corrected. If the polysomnogram reveals that there is still a problem, then it is advantageous to have an adjustable appliance.

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

The current gold standard utilized by the medical profession for the sleep apnea treatments RI of OSA is continuous positive airway pressure (CPAP). The patient wears a tightly fitting nose mask which is strapped to the head and connected by a hose to an air compressor pump. The air is forced into the airway through the nasal passages in order to open up the airway.

Complaints about the use of this air blower include pump noise, voice changes, skin irritations from the mask, nose and throat dryness, headaches from the strap around the head, tinnitus, difficulty getting to sleep, sinus infections, and difficulty breathing out against the air being forced through the nose.

The patients who should use CPAP are the severe cases of obstructive sleep apnea as the device may indeed be a life saver. In cases of mild to moderate OSA, or in cases where patients refuse to wear the CPAP, perhaps oral appliances may be the treatment of choice.

MOST COMMON SURGICAL TECHNIQUES

1. Laser Assisted Uvulaplasty (LAUP)
   This is a very popular form of surgery now being performed. The purpose is to surgically remove the uvula when it is excessive and deemed to be causing the problem.
2. Uvulopalatopharyngoplasty (UPPP)
   This is the surgical removal of excess palatal tissue which is thought to be causing the problem.

The disadvantage is that these surgeries can be quite painful during the healing period. Following the surgery, patients report voice changes and difficulty in swallowing their food.

Patients should be informed of all their options prior to any treatment whether surgical or non-surgical..