Patient Information

Snoring

As a snorer, you may for the most part be blissfully unaware of the problem you cause those trying to sleep near you. If, however, your bed partner's sleep is disturbed on a regular basis, and you find yourself sleeping downstairs or in the spare room, there are options.

Once you are sure you want to address your snoring problem, read this information page and click on the Dentist Search link to find a BSDSM dentist, who can help determine the most appropriate treatment for you, as snoring can sometimes be a symptom of something more serious known as 'obstructive sleep apnoea'.

Snoring Treatment Options

Background

During sleep, the pharyngeal airway (throat) narrows, due to a reduction in muscle tone. Snoring is simply a vibratory noise generated by the back of the relaxed tongue, pharynx and soft palate. Further narrowing produces not only louder snoring, but also laboured inspiration (breathing in). Finally, yet further narrowing can cause complete obstruction known as obstructive sleep apnoea.

There comes a point where the increased inspiratory effort is sensed by the sleeping brain and a transient arousal is provoked (brief awakening to breathe before returning to sleep). A few of these arousals do not really matter. However, when there are many (sometimes hundreds) sleep becomes seriously fragmented resulting in daytime symptoms of excessive sleepiness. Snoring and sleep apnoea are part of a spectrum extending from 'benign' or 'simple' snoring with no sleep disturbance, through to obstructive sleep apnoea with severe daytime sleepiness symptoms and the physiological consequences of recurrent asphyxia (insufficient oxygen).

There are many claims made for snoring 'cures' or treatments and our understanding of snoring and sleep apnoea has increased enormously in the last ten years. Much can be done to help both these conditions. As a result, there has been an extraordinary rise in the number of hospital referrals for these conditions.

The purpose of this part of the BSocDSM website is to help the bed partner and snorer find non-commercially biased, objective information about the treatment options available to them. So, we need to explain what the Dental clinic, the ENT clinic, and the sleep clinic are best at doing and which patients are the most appropriate for each. We hope that this article will enable patients to decide from where they should seek the most appropriate treatment.

Is treatment really necessary?

'Benign' snoring can be far from benign. The social consequences can be extremely distressing: banishment from the bedroom, marital disharmony, no holidays because of enforced sleep disruption when sharing a hotel room, fear of travelling - falling asleep during long journeys on public transport and the consequent ridicule and embarrassment. Many of the stories we hear are very sad and not worthy of the all too common joking approach to snoring.

There is no doubt that treatment is essential for obstructive sleep apnoea and extremely appropriate for snorers. Obstructive sleep apnoea, resulting in serious sleep disruption, can produce greatly impaired performance at work, at home, and on the road. Car accidents are statistically much more common in this group. The response to appropriate therapy can be extraordinarily dramatic with commonly, a return to a state of alertness and vitality often not previously experienced for years or even decades.

Is the problem only severe snoring?

Are any of these features of Sleep Apnoea present?

• Daytime sleepiness (not tiredness) e.g. nodding off during less stimulating activities: reading, watching TV, meetings, etc.
• Bed partner has noticed episodes of breathing cessation (although any snorer will have occasional such events, especially supine [laying flat on your back]).
• Patient experiences waking with choking/obstructed episodes (although he will only recognise a tiny proportion of the number actually occurring).
• Regularly waking unrefreshed in the morning.
• Neck circumference over 17 1/2" (usually, but not always, indicates being overweight).
• Small pharynx (throat) on visual inspection.
• Waking hearing the 'end of your own snore'.
• Obesity, BMI >30.
• Having to sleep propped up.
• Making frequent trips to the bathroom during the night.

What causes snoring and sleep apnoea?

The most common causes are shown below:

• Overweight
• Nasal stuffiness
• Evening alcohol
• Residual tonsils
• Smoking
• Receding lower jaw
• Hypothyroidism
• Menopause

If one or more of these are present, you may find that you can successfully help yourself or your bed partner with simple lifestyle modification. However, sometimes none of the symptoms are present, or no difference is possible or permanently achieved.

What has the dentist to offer snorers?

There is good evidence that custom made intra-oral devices worn in the mouth at night can greatly help snoring. They work by holding the lower jaw forward during sleep, thus preventing the narrowing of the airway behind the tongue and greatly reducing or even stopping snoring. For some people they are useful for obstructive sleep apnoea ( although this has to be carefully determined). Increasingly around the world, oral appliances are being accepted as first line treatment for mild to moderate OSA when prescribed and monitored as part of a multidisciplinary team.

If you or your bedpartner has any of the features of obstructive sleep apnoea listed earlier then it would be wise for your sleep to be assessed before going ahead with a custom made anti-snoring device. In their simplest form, anti-snoring devices consist of two sports-type gum shields, one for the top teeth, and one for the bottom teeth. These are then welded together so that when worn at night the lower jaw is protruded about 75% of maximum.

Significant forces are imposed on the teeth and jaw joints so that the dentist has to be satisfied that these structures are sound. Side-effects may include excess salivation and some times a dry mouth initially, these usually disappear once you become accustomed to the appliance. Tooth sensitivity and a sensation that the jaw is not in the 'right' position is commonly reported post wear. Evidence of long term use producing minor tooth movement does exist and this has to balanced against the benefits. Most patients do not find these side-effects preclude use. Modern devices are more sophisticated these days and are much easier to live with than older style appliances and may exhibit less side-effects.

These devices (known variously as mandibular advancement/repositioning devices/appliances/splints) are only supplied through a dentist and are custom made for you by a dental laboratory. See pictures:

What has surgery to offer for snorers?

When all the above approaches have failed, the ENT department may be able to help. For example, nasal stuffiness can be helped by nasal surgery. Sometimes it is worth removing residual tonsils, although in adults this is not a trivial operation.

When all else has failed and the snorer is desperate for help (and a sleep study has been performed to confirm snoring and exclude sleep apnoea) then an operation on the throat and pharynx ( uvulopalatopharyngoplasty, or UPPP ) may be appropriate. This operation removes part of the soft palate, any residual tonsils, and tightens the pharyngeal walls: it is very painful postoperatively and may produce temporary difficulty swallowing (and rarely some subtle changes in the voice). However, if the above preconditions are met, thin patients can find this a successful operation and are generally pleased to have had the procedure. Other surgical operations on the palate, such as laser scarring, are only experimental and do not appear to be very successful.

Treatment of Sleep Apnoea

CPAP is considered the first line treatment for severe OSA, and is very effective in terms of overcoming daytime sleepiness symptoms. Severe sleep apnoeaics, do well with this therapy, despite the forbidding appearance. This is without doubt an arduous therapy, which involves wearing a mask over the nose at night connected to a quiet blower. It works by slightly pressurising the upper airway, blowing it open, thus preventing sleep apnoea (and snoring).

If your medical history or screening study suggests there may be significant obstructive sleep apnoea then you will probably be referred to a sleep unit for a sleep study. This may involve spending a night at a 'Sleep Laboratory' in hospital, at home with an electronic device to wear whilst sleeping. A hospital sleep laboratory is a bedroom with monitoring equipment, which may include measurements of heart and brain activity, respiratory effort and night movements whilst sleeping.

A sleep unit's main function is to diagnose obstructive sleep apnoea and offer treatment to those who are likely to benefit. If the symptoms are fairly disabling, and the diagnosis is confirmed by sleep study, then you may be offered nasal continuous positive airway pressure therapy (nCPAP) during sleep.

The hospital sleep unit may suggest that oral appliance therapy (a custom device supplied by a Dentist) is appropriate for you. This depends upon the severity of your sleep apnoea and the existence of other medical problems. Oral appliances can be used to treat all severities of sleep apnoea but effective results are less certain with increasing severity of apnoea. Severe sleep apnoea if treated with an oral appliance requires careful patient monitoring of effect, as small weight changes for instance, can negate effect.

Oral appliances may also be used as an alternative treatment for severe OSA, however the trained Dentist MUST be working as part of a multidisciplinary team, which would include a Consultant ENT surgeon or Respiratory Physician. Increasingly around the world, oral appliances are being accepted as first line treatment for mild to moderate OSA when prescribed and monitored as part of such a multidisciplinary team.

The technology of both oral appliances and nCPAP is fast developing with particular focus on improving the patient's ability to tolerate using them. CPAP technology development is focusing on better 'mask' design, inclusion of humidifiers and sensitive electronically controlled varying of air pressure as you breath 'in' and 'out'. Oral appliances are becoming smaller, thinner, and more adjustable.

Some useful terms

APNOEAIC EPISODE (ap-knee-ic) A period of not breathing whilst asleep usually lasting for more than 10 seconds.

HYPERCAPNIA (high-per-cap-nee-ah) A raised level of carbon dioxide in the blood. This is the gas normally breathed out. Its blood level rises if breathing is inadequate. Usually measured by taking an arterial blood sample.

HYPERSOMNOLENCE (high-per-som-no-lence) Technical expression for excessive daytime sleepiness.

HYPNOGRAM (hip-no-gram) The final print out of the all-night sleep stages after an overnight study. (REM and non-REM).

HYPOPNOEA (high-pop-nee-ah) A period of underbreathing: usually for more than 10 seconds.

HYPOTHYROIDISM (high-po-thy-royd-ism) Also known as myxoedema (mix-ee-dee-ma). When the thyroid gland fails to make enough thyroid hormone. Can present as obstructive sleep apnoea.

HYPOXIA (high-pox-ee-ar) When the body is short of oxygen and therefore the level in the blood falls.

HYPOXIC DIPS (high-pox-ic) The falls in oxygen levels, seen on the oximeter, that usually accompany apnoeas. Also known as desaturations, because, when not hypoxic, the blood is described as fully saturated with oxygen.

INSOMNIA (in-som-nee-ah) Being awake when you want to be asleep. Often thought of as a problem but may not be. Common if people try to spend too long in bed.

MANOMETER (man-om-eater) Device to measure the pressure being delivered by a CPAP machine (usually measured in centimetres of water [cm H20] - where a common CPAP pressure is about 10).

MICRO AROUSALS Very brief "awakenings", perhaps only seen when the brain waves (EEG) are being monitored.

MOVEMENT AROUSAL These are short awakenings with minor body movements, about which the sleeper is unaware.

MUFFLES™ Wax ear plugs. Less comfortable than the foam ones (EAR™) but more effective. From most chemists.

NARCOLEPSY (nar-co-lep-si) A cause of daytime sleepiness due to an inherited disorder of the control of dreaming sleep. Has to be differentiated from sleep apnoea, periodic leg movements and other rarer causes of daytime sleepiness.

NASAL CPAP (nasal see-pap) The process of delivering a continuously raised airway pressure mask worn on the nose, hence Continuous Positive (as opposed to negative) Airway Pressure.

OBSTRUCTIVE SLEEP APNOEA (ap-knee-ah) This syndrome is commonly referred to as OSA (obstructive sleep apnoea/apnea) or

OSAS (obstructive sleep apnoea/apnoea syndrome). Usually made up of 30 or more periods of not breathing when asleep. Each period lasting for more than 10 seconds.

BSDSM

The British Society of Dental Sleep Medicine is a society for all interested in the role they can play in enhancing the quality of life for those who suffer from sleep disordered breathing through recognising their symptoms of snoring and/or obstructive sleep apnoea, referring where necessary and providing oral appliances when appropriate.

This information is supplied in good faith and we hope that this guidance helps you learn more about treatment options and enables you to make an informed decision on what is the most appropriate treatment.

BSDSM policy is to provide up-to-date and accurate information about sleep related breathing disorders and its treatments, in line with accepted national and international guidelines. Where no such guidelines exist, our information is based on scientific evidence such as data from published clinical trials, or combined analyses of trials. Where such evidence is not available, our information is based on a consensus view of experts.

Each BSDSM publication is regularly reviewed and updated by specialists in the field, GDPs, and other relevant health professionals and patients. The medical information is approved by a member of BSDSM Clinical Advisory Board and the Medical Editor.

Please see our links page for related websites of interest.

The content of this publication is independent of sponsorship.

BSDSM Clinical Advisory Board Chair: Dr Roy Dookun BDS, MFGDP(UK), MGDSRCS(ENG), FFGDP(UK).

© British Society of Dental Sleep Medicine. All rights reserved. 2007

Produced 24 July 2007.