By J. Todd Gray, DDS, D. ASBA, Koala Center for Sleep Disorders
The National Sleep Foundation (NSF) reports that more than 18 million adults have obstructive sleep apnea (OSA), a condition that causes interrupted breathing during sleep and that may lead to other health problems such as high blood pressure, heart disease, and depression, among others.
OSA occurs when the tongue and muscles relax during sleep. The lower jaw falls back toward the throat and the airway becomes compromised or completely blocked. Although not all patients with OSA snore, a typical sequence of OSA may begin when a person stops snoring and is silent for seconds or even minutes at a time. Lacking oxygen, the brain may cause the body to jerk in an attempt to wake the sleeper so that breathing will resume. The silence may end with a loud snort, cough, or gasp. This causes the sleeper to wake briefly and resume breathing. Once asleep again, the muscles relax, the tongue falls back, and the airway becomes blocked all over again. This cycle can occur hundreds of times per night. OSA may contribute to problems such as daytime sleepiness, morning headaches, and difficulty focusing on tasks, just to name a few. While sleep apnea can have a dramatically negative effect on quality of life, the good news is that treatment options are advancing every day!
According to the American Sleep Apnea Association, the gold standard of treatment for OSA has been continuous positive airway pressure therapy or CPAP. With CPAP, patients wear a breathing mask while they sleep. The mask, which fits snugly over the nose, or the nose and mouth, provides the patient with pressurized air that blows the relaxed soft tissues at the back of the throat apart so air can flow continuously. This increase in air pressure prevents the airway from collapsing. While CPAP is quite effective when used consistently, many patients are not compliant with using their devices. I have seen a number of patients who were unhappy with their CPAP. One patient, Kathy, had suffered from OSA for years. However, the CPAP wasn’t working for her because it was waking her up with mask leakage and discomfort. Kathy was looking for other options.
One alternative to CPAP that has been gaining ground in the OSA community is Oral Appliance Therapy (OAT). Oral appliances, which are similar to an athletic mouth guard or retainer, are designed to improve upper airway configuration and prevent airway collapse by holding the jaw and tongue in a correct position. The American Academy of Sleep Medicine (AASM) has approved OAT as a first-line treatment for those suffering from mild to moderate OSA. When a patient undergoes a sleep study to check for sleep apnea, doctors measure the number of apneas (complete cessation of breathing for ten seconds or longer) or hypopneas (shallow breathing or low respiratory rate) during each hour of sleep. Those with an Apnea-Hypopnea Index (AHI) of greater than 5 but less than 15 per hour are diagnosed with mild OSA. Moderate ranges from more than 15 to less than 30 per hour, and severe OSA presents with an AHI of greater than 30 per hour.
While oral appliance therapy is generally most effective for those with mild to moderate sleep apnea, the AASM also recommends it for those with severe OSA who are unable to tolerate CPAP devices or unwilling to wear them. While compliance rate is lower with CPAP, it is actually quite high with OAT. For those with severe OSA who have been unhappy with CPAP but are not candidates for oral appliance therapy alone, combination therapy may be a good alternative.
Combination therapy is exactly what it sounds like, the combination of CPAP and an oral appliance to treat more severe OSA. This approach has been gaining traction in the sleep apnea community because it allows effective treatment with greater compliance from patients. Recent research from the Journal of Clinical Sleep Medicine suggests that rather than thinking of CPAP and oral appliance therapy as “alternative treatment pathways,” patients and their doctors consider using the two together. Many people have been able to reduce the pressure on their CPAP devices significantly by using an oral appliance simultaneously, thus allowing them to be more compliant with their treatment plans. Another benefit of combination therapy is that the oral appliance prevents the sleeper’s mouth from falling open, so patients can eliminate the chin strap that may be required when using CPAP.
If you or a loved one have been diagnosed with OSA but are finding CPAP use difficult, you may want to consider oral appliance therapy. If your sleep apnea is mild to moderate, you may be able to replace your CPAP completely. If your sleep apnea is severe, you still may be able to use the oral appliance alone. However, if the oral appliance alone does not fully treat your severe sleep apnea, you may be able to sleep more comfortably by using combination therapy where the oral appliance holds the jaw in the proper position while the CPAP assists in keeping the airway open using a much lower pressure.
At the Koala Center for Sleep and TMJ Disorders in Bloomington, IL. Dr. Gray is trained to manage OSA with oral appliance therapy by conducting an oral and airway evaluation to see if you are a candidate for a comfortable and easy-to-wear custom fabricated oral sleep appliance. For more information, contact him at 309-319-6568 or bloomingtonsleep.com. Dr. Gray provides treatment for snoring, sleep apnea, and Temporomandibular Joint Disorder (TMD).