Do you or does someone you sleep with snore? Snoring is a common problem affecting about 40% of men and 20% of women in Canada. Snoring can be a nuisance to others within earshot but it also can be a sign that you may have a condition known as Obstructive Sleep Apnea (OSA), a health condition that can have serious consequences if untreated.
I am writing this article as a dentist because there is a device that you can get through your dentist can be an effective treatment for snoring and OSA.
In this article, I will discuss causes of snoring, indications when snoring could be a sign of obstructive sleep apnea and solutions for both.
What is snoring?
When we inhale, air passes in through our mouth and/or nose, into the back of our throat and down into our lungs. If anywhere along this path the airway becomes partially closed, the air will vibrate through the narrowed space and the resulting noise is what we call snoring.
Causes of snoring:
If the strip of tissue hanging down at the back of your throat (called the uvula) is longer than normal, this can vibrate and cause snoring.
If you are overweight or obese, fat can be deposited in your airway, narrowing it and resulting in snoring.
In many people, snoring is caused by the tongue falling to the back of the throat during sleep. The tongue can block the airway for a variety of reasons:
When we sleep, our muscles relax and the tongue being a muscle is no different. If you have a large, broad tongue, it is more likely to cause blockage of the airway than a smaller tongue would.
If the roof of your mouth is narrow and high, your tongue may have nowhere else to go during sleep other than the back of the throat; so this type of anatomy can make you more prone to snoring.
If you have a receded lower jaw or if your upper jaw is small in size, your tongue may crowd the back of your throat as it has nowhere else to go while you sleep, again leading to snoring.
Alcohol use before bedtime or sedatives (i.e sleeping pills) can make the tissues that line our airway relax more than they otherwise would during sleep causing them to collapse, narrowing the airway and leading to snoring.
Tobacco/smoking can cause inflammation of tissue in the airway which can also lead to airway narrowing, hence snoring.
Sleeping on your back can make you more likely to snore, with gravity causing the tongue and other tissues in the airway to sag and partial closure of the airway.
When is snoring a sign of a more serious sleep disorder: Obstructive Sleep Apnea?
In people who snore, we already know that there is partial airway closure. However in some cases, the closure can temporarily become great enough that the airway is significantly or completely closed.
If you are already prone to airway closure, due to any of the reasons listed above that cause snoring, as you inhale during sleep, the pressure from your lungs trying to bring in air can draw loose tissues that line the airway together and create a stop at the top of your airway. It’s like putting a cork in the top of a bottle.
If the airway closes, your chest is attempting to breath air in but nothing is getting through into the lungs.
If this blockage continues for 10 seconds or longer, it is called an apnea.
If the airway is not completely closed and some air is getting into the lungs but only 20 - 50% of the normal amount, and this lasts 10 seconds or longer it is called a hypopnea.
In our lungs, blood picks up oxygen which then gets pumped throughout our body. If there is a complete or partial blockage of air entering our lungs, the amount of oxygen in our bloodstream will decrease. Our brain eventually senses the lowered amount of oxygen in our bloodstream and awakens us from a deeper level of sleep to a lighter level of sleep so that we can take a breath.
As we take in air, we may snort, gasp or appear to be choking, all which can be alarming if witnessed by a sleeping partner. We don’t remember these partial awakenings as we are still in a light state of sleep when they occur, however if they occur many times our sleep is said to be “fragmented,” and we will not be spending enough time in restful deeper stages of sleep.
Some people who snore do not suffer from airway blockage great enough to reduce their blood oxygen levels, that is, they do not experience apneas or hypopneas. But for people who do, the number of times they may have reduced airflow and awakenings can number from just a few times and hour to over 30 times an hour.
If you count the number of apneas and hypopneas that occur each hour during sleep you arrive at a score which is also called the Apnea-Hypopnea Index (AHI).
If you have fewer than 5 sleep interruptions per hour, this is considered insignificant, however, if you have 5 or more, you are considered to have Obstructive Sleep Apnea (OSA)
Note: A sleep event is a partial or complete airway obstruction lasting 10 seconds or longer followed by a partial awakening to take a breath.
Obstructive Sleep Apnea is categorized the following way: Sleep events per hour 0-4........................................... snoring only 5-14 ........................................ mild obstructive sleep apnea 15-29 ...................................... moderate obstructive sleep apnea 30 or more ............................. severe obstructive sleep apnea
Symptoms of OSA
People who have many episodes of airway closures and awakenings during a night of sleep may wake up feeling tired, feel sleepy during the day, can be at greater risk for car and work related accidents, have morning headaches, have trouble concentrating and also can be irritable and depressed.
Who is Prone to OSA?
If you have the following physical features, you may be more prone to developing OSA:
If your neck circumference measures more than 40cm (15.75 in)
This is an indication that you may have excess fat in your neck and likely also lining your airway. 2. If your lower jaw is receded. 3. If you are obese. 4. If you are a man. 5. As well, many of the items listed in causes of snoring above can make you more prone to OSA, such as alcohol use before bed, taking sleeping pills, or having anatomy such as a broad flat tongue or high narrow palate (roof of your mouth).
How does Obstructive Sleep Apnea affect your health?
OSA affects the health of your heart and other parts of your cardiovascular system.
If you have OSA, your breathing is interrupted during sleep and your blood oxygen levels drop. Each time this occurs, this stresses your body and as a result your body releases adrenaline. If this occurs many times throughout the night, the high levels of adrenaline in your body can lead to high blood pressure.
Low blood oxygen levels caused by OSA during sleep stresses your body and heart. People with untreated OSA are more likely to have heart failure, atrial fibrillation, heart attack and stroke.
According to Harvard Health Publishing (Harvard Medical School) OSA is found in 47% to 83% of people with cardiovascular disease, 35% of people with high blood pressure and 12% to 53% of people who have had heart failure, atrial fibrillation and stroke. If you have untreated OSA, your risk of dying from heart disease increases by five times.
How do you know if you have OSA?
There are two simple questionnaires that can be taken to help answer this question.
1. The STOP-BANG questionnaire and
2. The Epworth Sleepiness Scale.
THE STOP-BANG QUESTIONNAIRE (developed by Dr. Francis Chung, University of Toronto, 2008)
Answer "Yes" or "No" to the following questions. A total of "yes" to 3 or more items on this questionnaire is considered high risk for OSA.
S Do you Snore loudly? T Do you often feel Tired, fatigued or sleepy during the daytime? O Has anyone Observed you stop breathing during your sleep? P Do you have high blood Pressure?
B Is your Body Mass Index (BMI) above 30? (Are you obese)? A Age: are you over 50? N Neck circumference over 40 centimetres? G Is your Gender Male?
Stop-Bang Score = ______ ***************************************************************************************** THE EPWORTH SLEEPINESS SCALE (developed by Dr. Murray John of Epworth Hospital, Melbourne, Australia, 1991) A score of 10 or more is considered sleepy. If you score 10 or more on this test, you may not be obtaining adequate sleep. These issues should be discussed with your physician.
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze or sleep 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping
Situation Chance of dozing/sleeping (0,1,2,3) Sitting and reading............................................................................... ___ Watching TV......................................................................................... ___ Sitting inactive in a public place........................................................... ___ Being a passenger in a motor vehicle for an hour or more.................. ___ Lying down in the afternoon ................................................................ ___ Sitting and talking to someone ........................................................... ___ Sitting quietly after lunch (no alcohol).................................................. ___ Stopped for a few minutes in traffic while driving................................. ___
TOTAL SCORE.. (add up all your answers) ___
(lowest score = 0, highest score = 24) Depending on your score to each test you may be more or less likely to have OSA.
The way to properly diagnose whether you simply snore or indeed have OSA is to see your family doctor and discuss snoring or daytime sleepiness issues you may have. Your family physician may refer you to a sleep clinic that will often conduct a sleep study. That often involves having you attend the sleep clinic for one night while they can observe you while you sleep. They will measure your breathing, blood pressure and determine whether your sleep is interrupted by airway closure and if so, for how long, how many times an hour and so on. They will also determine if breathing interruptions occur while you sleep on your side or only when you sleep on your back.
If you do have OSA, they will let you know whether it is mild, moderate or severe, as discussed above.
The CPAP Machine with full face mask.
Treatment of Snoring and OSA
If you have been diagnosed with mild, moderate or severe OSA, one treatment that is usually very effective is use of a CPAP machine.
CPAP stands for Continuous Positive Airway Pressure. The machine blows air through a mask that you wear on either your nose only, or nose and mouth together.
The pressure of the air flowing down your airway opens up collapsed tissues in the airway allowing air to pass into your lungs.
This eliminates snoring and also the other symptoms of OSA such as daytime sleepiness, lowers blood pressure and improves the health of your heart.
There are some problems that patients new to using a CPAP experience such as: finding the mask uncomfortable, feeling claustrophobic with the mask on, difficulty falling asleep with CPAP machine on, noise from the machine, dry mouth, removing the mask during sleep, finding the machine cumbersome to travel with or just not wanting to be connected to a machine during sleep.
There are usually solutions for all of these problems if you work with your CPAP provider, however despite this, 30 to 50% of patients that are prescribed CPAP quit using it.
The SUAD Appliance: One of many types of dental sleep appliances that bring the lower jaw forward to open up the airway.
Another treatment that can be used for people who snore or for those with mild to moderate OSA is a dental sleep appliance.
I mentioned earlier that one cause of snoring and OSA is the closure of the airway by the tongue as it falls to the back of the throat when we fall asleep.
Dental appliances are a recognized treatment for both snoring and mild to moderate obstructive sleep apnea, according to the American Academy of Sleep Medicine.
The most studied and accepted type of dental appliance used to treat these conditions is one that is worn in the mouth, bringing the lower jaw into a more forward position.
A technical name for this type of appliance is a “mandibular advancement appliance,” as “mandible” is the anatomical name for the lower jaw.
Professionally made dental sleep appliances work on the principle that if your lower jaw is brought forward, the base of your tongue (where your tongue attaches to your lower jaw) will also be brought forward, opening your airway during sleep and eliminating or reducing snoring and lessening or eliminating obstructive sleep apnea.
Dental sleep appliances can be very effective at eliminating or reducing snoring and in the treatment of mild to moderate obstructive sleep apnea. There are several different designs of sleep appliances available to patients, and made by dentists trained in delivering this form of treatment. One such appliance pictured here is the SUAD appliance, a popular sleep appliance I make for my patients.
Research has shown that the most effective dental sleep appliances have the following characteristics:
1. Those that are custom made by a dentist. Custom made dental appliances are found to be better tolerated and more effective in reducing snoring and obstructive sleep apnea symptoms than simple appliances you can buy over the counter. Unfortunately you get what you pay for in this case.
2. Are adjustable: i.e ideally, the distance that the lower jaw is brought forward can be increased or decreased in the appliance. Some patients can tolerate their jaw being brought more forward than others and it is nice to have the ability and flexibility to fine tune the distance rather than being confined to one setting.
3. Are composed of a separate upper and lower piece that fits over the teeth
4. The appliance opens the mouth minimally (you can open and close your mouth while wearing the appliance but the upper and lower piece will be closed together when your mouth is at rest).
The appliance design that I prefer has a soft inner material that contacts your teeth and a harder outer surface for durability.
Side effects of Dental Sleep Appliances for Snoring and/or OSA
Dental sleep appliances have very few side effects. They have been shown to be safe and effective and have been used for many years for patients who either snore or have OSA.
They do bring the lower jaw forward during sleep so in the morning your bite may feel different as your jaw settles back into its normal position over several minutes after waking.
Dental sleep appliances have been found to be safe for the jaw joint (TMJ) and have not been shown to causes changes in the joint.
Who is not a good candidate for a dental sleep appliance?
Research has shown that patients who snore or who have mild to moderate obstructive sleep apnea can be considered for these appliances.
If you have been diagnosed with severe OSA, research has shown that CPAP is the most effective treatment, however if you can not tolerate CPAP, wearing a dental sleep appliance (MAP), in some cases, is better than no treatment at all.
If your teeth and gums are not in good health, this will ideally need to be addressed prior to making a dental sleep appliance, as the dental sleep appliance needs firm support from the teeth and or gums. Loose teeth and a dental sleep appliance are not a good mix.
Patients who are missing all of their teeth in one or both jaws can still be candidates for these appliances but may have to consider dental implants to help hold the appliance in place if they are missing all of their lower teeth.
If a person is morbidly obese, dental sleep appliances have been found to be ineffective, as the airway cannot be sufficiently reopened merely by repositioning the tongue, as there is too much excess tissue in the collapsed airway during sleep.
Should I try a CPAP or Dental Sleep Appliance?
If you snore but do not have OSA you may wish to try a dental sleep appliance. It is portable (fits in your pocket) and is not as cumbersome as CPAP. Dental sleep appliances can eliminate snoring or at least reduce the amount or volume of snoring.
If you have mild or moderate OSA, research has shown that patients do better overall if they are given a choice as to what type of treatment they prefer. Once they have been given all the pros and cons of CPAP and dental sleep appliances and they make an informed decision they are more likely to continue with the treatment. For example, they are more likely not to give up on CPAP if that is their preferred choice versus a patient who is only given the choice of using CPAP or no treatment at all, which does occur at some sleep clinics.
Although CPAP has been shown to be the most effective way to treat OSA, studies have shown that it has to be worn for at least 4 hours a night to be more effective than a dental sleep appliance.
Research has shown that many patients with CPAP do not wear it through the entire night whereas patients with dental sleep appliances are more likely to.
So even though CPAP is more effective while it is worn, the fact is that patients who use dental sleep appliances get about the same amount of improvement in their symptoms of mild to moderate OSA. They wake up as rested as the average CPAP user, have the same cardiac and health benefits and also rate their overall quality of life the same as patients who use CPAP.
Some CPAP users do not bring their CPAP machines while they travel as they find the machine too large to lug around or they may be somewhere without a reliable power supply (e.g. when camping or on an overnight flight). Research has shown that if a regular CPAP user has a dental sleep appliance as a backup for times they can’t wear their CPAP, they offer good relief of their apnea symptoms especially compared to wearing no appliance at all.
Research has also shown that sleep partners prefer dental appliances rather than CPAP for their sleep mates who snore or who have mild to moderate sleep apnea. However, I don’t think this should be the overriding reason why someone should choose one mode of treatment over the other.
In a separate article, I will discuss other ways that some people who have OSA or who snore can be further helped through surgery and also by using devices that prevent you from sleeping on your back, which in some people worsens snoring and apneas. If you would like further information on the dental sleep appliances or if you would like to book a consultation with me, you can call our office at 416-691-2886 or email our office at BeechDental@gmail.com.
No one should have to live with a snoring sleep partner or obstructive sleep apnea. You owe it to yourself, your sleep partner and your family to get treatment, whether it is a CPAP or a dental appliance. Dr. Jeff Shnall