Obstructive sleep apnea is defined as the restriction or inhibition of airflow and is due to obstruction of the upper respiratory tract during sleep. If repeated breathing breaks are accompanied by sleep disturbance and daytime fatigue, then we are talking about obstructive sleep apnea syndrome. At least 4% of men and 2% of women suffer from sleep apnea, but the number is likely to be higher and up to 17% of middle-aged men and 9% of women suffer from moderate to severe sleep apnea according to new epidemiological studies.
Untreated sleep apnea increases the activity of the sympathetic nervous system, the incidence of hypertension, type 2 diabetes, ischemic heart disease and stroke, the risk of premature death, the risk of traffic accidents and the use of health services. Cognitive and memory disorders are common in untreated sleep apnea. The diagnosis of sleep apnea is based on anamnesis, clinical examination, and sleep or night-time polysomnography.
Lifestyle changes to manage sleep apnea
Treatment of overweight sleep apnea patient always includes weight management and lifestyle counseling. Weight loss and smoking cessation may be sufficient to correct mild sleep apnea. In addition, regular exercise has been shown to reduce the symptoms of sleep apnea, even if the person doesn’t lose weight. In mild positional-dependent sleep apnea, positional therapy may be sufficient in treating mild sleep apnea. The use of compression stockings reduces fluid transfer from the lower limbs to the neck area in a supine position and thus alleviates the severity of sleep apnea.
CPAP therapy and its side effects
Moderate to severe sleep apnea syndrome is treated primarily with a night-time continuous positive airway pressure (CPAP) device that produces a continuous overpressure into the airways through a mask and keeps the upper airway open during sleep.
CPAP therapy reduces the sleepiness of sleep apnea patients and thereby improves quality of life, corrects memory and attention problems, improves endothelial function, reduces sympathicotonia, lowers blood pressure, may prevent recurrence of cardiovascular events, reduces pulmonary artery pressure, improves glucose balance and insulin resistance, may improve morning headache and relieves depression.
CPAP therapy can be performed using either constant pressure or self-regulating device. Some new studies have provided evidence that the self-adjusting CPAP device may have adverse cardiovascular effects.
CPAP therapy has a exposure-response relationship, that is, the more CPAP you use during sleep, the better is your response. The traditional recommendation is to have an average overnight use of at least 4 hours, based on studies of commitment to CPAP treatment in the 1990s.
Poor commitment to CPAP therapy results in poor treatment outcomes.
Commitment to CPAP has been found to be similar to commitment to antihypertensive drugs, with commitment ranging from 50% to 84%. Attempts to improve CPAP adherence can be achieved through careful guidance. Patient education based on behavioral therapy can also improve commitment to treatment.
Serious side effects are rarely associated with CPAP therapy
The most common side effects are mask-related problems, such as discomfort caused by air leakage, noise and dry eyes and redness, skin problems, air leak from the mouth and dry mouth, and nasal congestion.
Upper respiratory symptoms are common in patients with sleep apnea before and during CPAP treatment. Symptoms of dryness of the mucous membranes, especially dry mouth, appear to decrease with CPAP treatment. Adding a humidifier to CPAP treatment does not affect adherence to treatment or tolerability, but it alleviates upper respiratory symptoms during CPAP treatment. Topical nasal care products (nasal steroids, saline drops and rinses, vitamin A drops, nasal oils and anticholinergic sprays) have been shown to reduce nasal symptoms according to clinical experience, but there is no research evidence.
Initiation of CPAP therapy
Initiation, guidance, and assessment of CPAP therapy is performed early in the treatment by a specialist. Treatment-related problems usually appear within the first few months and often require more support and follow-up. Implementation of long-term follow-up varies from hospital to hospital. Follow-up focuses on the resolution of sleep apnea symptoms, adherence to treatment, weight management, treatment issues that may arise and their resolution, and the condition of treatment equipment and accessories. If a sleep apnea patient is in a profession that requires special vigilance, the success and response of CPAP treatment will be monitored by a specialist or occupational health care.
Are there any side effects with sleep apnea mouthpieces and mouthguards?
As you sleep, the muscles supporting the upper respiratory tract relax and the tongue sinks down over the throat, blocking the airways. Particularly in structurally confined airways, it may result in complete or partial obstruction of the flow of respiratory air. Although two thirds of sleep apnea patients are overweight, one third of them are normal weight. In addition to constricted adipose tissue in the nose and upper respiratory tract, the respiratory tract may also be constricted due to congenital anomalies of the jaw structure, such as elongation of the mandible, as well as narrow upper arch and overbite or crossbite. The role of dentists in recognizing the structural risk factors of the face and mouth is obvious in the suspicion of possible obstructive sleep apnea.
Do sleep apnea dental devices work?
Dental devices (sleep apnea mouthpieces and mouthguards) are particularly suitable for the treatment of normal weight and obese (BMI 25-35) patients with mild to moderate sleep apnea and those who are unable to use CPAP therapy despite experimentation and treatment guidance.
With a sleep apnea mouthpiece, the lower jaw and tongue muscles are moved forward, which widens the airspace of the throat at the level of the tongue. At the same time, the pharynx muscles are activated, which causes local tissue tension. There are many different types of sleep apnea mouthpieces based on dental arch reproductions that are individually made after dental evaluation; what they have in common, however, is that their effectiveness is based on moving the lower jaw forward. Prefabricated, so-called thermoformed rails are also available on the market, but their fit is often inferior and thus less effective than individually made rails.
Apnea mouthpieces reduce sleepiness and reduce AHI, but apparently less than CPAP treatment. In addition, sleep apnea mouthpiece therapy may have beneficial effects on arterial oxygen saturation, hypertension, depressive symptoms associated with sleep apnea, and quality of life. However, the mouthpiece should not be used in patients with severe dental adhesion disease.
All in all, bad teeth should be treated before making mouthpieces. The use of apnea mouthpieces and the outcome of treatment should be evaluated by a dental specialist. For moderate sleep apnea, the response to treatment should be objectively confirmed by sleep registration, and if the desired response is not achieved, the patient should be directed to other treatment.
Commitment to sleep apnea therapy with a mouthpiece has been good, at least in short-term follow-up studies. However, the use of apnea mouthpieces often has short- and long-term adverse effects, the amount of which depends on the characteristics of the mouthpiece and how much the lower jaw is brought forward. The most common short-term disadvantages are increased saliva secretion in the mouth and tenderness of the teeth and jaw joint mainly in the morning. Long-term use of a sleep apnea mouthpiece can alter bite, reduce over-bite, widen lower tooth arch, and reduce tooth contact in the lateral areas.
The initiation and evaluation of response to apnea mouthpiece care usually takes place in specialist care. The condition of the mouthpiece, its subjective efficacy, the patient’s bite and the function of the treatment should be monitored at least once a year or as needed.
Surgical treatment of sleep apnea
Surgical interventions may be considered if conservative therapies fail to respond adequately to the treatment of obstructive sleep apnea, or if the patient has significant structural abnormalities of the upper respiratory tract or face that predispose to sleep apnea.
Because the patient’s symptoms are caused specifically by partial or complete obstruction of the upper respiratory tract, it is natural that surgery is a viable option to attempt to open / widen the obstructed airways. Comprehensive examination of the upper respiratory tract is essential for targeting the right areas. This is best done by an ear, nose and throat doctor, who can examine the upper respiratory tract from the nose to the larynx, if necessary.
Drug-induced sleep endoscopy (DISE) examination may provide further indications of the obstruction. Generally speaking, soft tissue reduction can result in temporary upper respiratory tract enlargement, but hard tissue (= bones) modifications can result in permanent results. The upper respiratory tract can also be completely bypassed with a tracheal opening (tracheostomy), however, it is quite invasive and exceptional treatment. In most cases, surgical treatment may be considered if the BMI is <30 kg/m2. The exceptions are jaw surgery, obesity surgery and tracheostomy.
Nasal congestion may occur due to, for example, infections or allergies, whereby treatment is conservative. If the stenosis is caused by structural reasons (eg septal oblique, nasal polyps or tumors), surgery can unblock the nose. However, nasal care has been found to be of limited help with the symptoms of sleep apnea. In the treatment of snoring it works better. On the other hand, nasal surgery can increase compliance with nCPAP.
A tonsillectomy is surgery to remove the tonsils and sometimes this can be helpful. In obese patients, the tonsils often appear large due to the amount of parapharyngeal fat, and weight loss is the right treatment. The area of the oral cavity can be expanded by uvulopalatopharyngoplasty (UPPP) and its various modifications, for example with the aid of a laser (LAUP). With soft palate, submucosal tissue and tongue strain can be warmed by radio frequency vibration (RFA), resulting in scarring, shrinking and stiffening of the tissue. Pharynx and tongue treatments have achieved only temporary results. The best results have been obtained with multilevel surgery where different levels of the upper respiratory tract have been treated simultaneously.
With maxillofacial surgery, the upper and lower jaws can be moved separately or both at the same time forward, thereby increasing the airspace of the pharynx at the level of the tongue. Patients who have not responded to conservative treatment, may benefit from these surgeries with anatomical factors predisposing to sleep apnea on the face and jaw. Usually these surgeries have been done for bite problems and the relief of sleep apnea has been an added benefit. Depending on the need and extent of orthodontic treatment, orthodontic surgery with bite maintenance steps may take up to several years. Maxillofacial surgery is the most effective surgical treatment for sleep apnea and can in some cases be curative.
Obesity surgery has been shown to reduce the symptoms and signs of sleep apnea, but it is not a cure.
Surgery is not the primary treatment for obstructive sleep apnea in adults. However, its various methods may be helpful for patients who are unresponsive or intolerant to conservative treatments. For some patients, jaw orthopedics can be a curative treatment.
Summary on the treatment of obstructive sleep apnea in adults
The treatment of overweight sleep apnea patient always includes weight management and lifestyle counseling. In mild sleep apnea, weight loss may be an adequate treatment.
The primary treatment for moderate to severe sleep apnea syndrome is Continuous Positive Airway Pressure –machine (CPAP), which produces a continuous overpressure in the airways through a mask to keep the upper airways open during sleep.
Sleep apnea mouthpieces and mouthguards are particularly suitable for the treatment of patients with mild to moderate sleep apnea and those who for some reason cannot be treated with CPAP therapy.
If conservative therapies fail to respond adequately to the treatment of obstructive sleep apnea, or if a patient has significant structural abnormalities of the upper respiratory tract or face that predispose to sleep apnea, surgical interventions may be considered.