Sleep disorders affect a significant proportion of the population. Problems can vary from simple snoring to life-threatening obstructive sleep apnoea. Most sleep disorders affect both the patient who has the condition and the sleep partner. Most common effects of sleep disorders are daytime tiredness, irritability and difficulty concentrating. More serious problems caused can be high blood pressure with risk of heart attack or stroke, diabetes, extreme daytime tiredness, including falling asleep while driving and anti-social daytime sleeping.
If a person drives for a living and has been diagnosed with untreated obstructive sleep apnoea, the DVLA must be informed and the person is banned from driving until the condition has been satisfactorily treated.
This is the noisy vibration caused the partial closing of the airway by the tongue contacting the back of the throat and the soft palate. It usually occurs when the patient is sleeping on the back. Snoring is made worse by overweight, alcohol and sleeping tablets. The patient very often is not aware of the condition, and does necessarily feel tired during the day. At least 30% of adults snore, rising to 60% depending on age and sex.
OBSTRUCTIVE SLEEP APNOEA
This is a much more serious condition and can be life-changing in its effect. Obstructive sleep apneoa is also produced by the closing off of the throat airway by the tongue and surrounding tissues. Loud snoring is usually present followed by cessation of breathing with periods of total quietness and lack of movement. The patient then moves about in bed, often kicking the legs and gasping or snorting when breathing is recommenced. These episodes can be frequent and might occur twenty times per hour. The result is a very poor quality of sleep and a lowering in the oxygenation of the blood. Raised blood pressure is often present. General fatigue and daytime tiredness is very common. Normal living is often impossible due to falling asleep in the day and lack of the ability to concentrate.
It is important to gauge the extent and severity of sleeping disorders to help make a provisional decision about what treatment is indicated. A questionnaire is completed by the patient with the sleep problem and also the sleep partner. This asks about medical conditions, the patient’s opinion about the problem and how it affects daytime tiredness. The sleep partner is also questioned about the nature of the patient’s sleep and what noise is produced.
Further dental investigations are carried out in the surgery and measurements, such as weight assessment, are made to finalise the diagnosis. In severe cases of sleep apnoea, a patient will be referred to the medical practitioner for possible referral to a consultant at a hospital sleep centre.
TREATMENT FOR SNORING
Simple snoring is treated with a custom made appliance inserted in the mouth before sleeping which holds the jaw forwards, this is called a Mandibular Advancement Appliance (MAA). One-piece appliances that carry out this function can be bought on-line. These are invariably uncomfortable to wear and are poorly fitting and almost never successfully worn. Appliances made in this clinic are two part and are connected in a way to posture the jaw forwards to allow an enhanced airway at the back of the throat. Appliances can be made relatively inexpensively in plastic acrylic, or in a much less bulky and more sophisticated way, in chrome-cobalt metal.
Surgery (uvulectomy and palatoplasty) involving re-shaping the soft palate is sometimes offered by ENT surgeons. Treatment of this type is very intrusive, can be very difficult to tolerate and has an unknown outcome. It is irreversible, and if the result is unsatisfactory, cannot be rectified.
DIAGNOSIS AND TREATMENT FOR OBSTRUCTIVE SLEEP APNOEA
The diagnosis of this condition is carried out by a specialist sleep consultant. Hereford is fortunate to have a sleep centre in our hospital. All referrals must be made through the patient’s medial practitioner. Investigations might involve a sleep study (polysomnograph) which might be carried out at home, or in the hospital’s sleep centre “sleep house”. Treatment could be by constructing a mandibular advancement appliance, and/or fitting the patient with a CPAP machine. This is a Continuous Positive Airway Pressure machine which has a mask and air pump, forcing air through the patient’s nose and, therefore, throat. This is considered to be the “gold standard” treatment for obstructive sleep apnoea.
Frequently Asked Questions
- It is necessary to have a well-cared for stable mouth preferably with teeth in both jaws. It is advisable to have a check-up before stating treatment to avoid foreseeable treatment changing the shape of the teeth and spoiling the fit of an appliance
- Scrupulous oral hygiene
- Always take the appliance with you to each visit to the dentist
- Be prepared to be referred to a sleep consultant if your condition needs this
- It takes a little time to learn to use any appliance. Patience and perseverance are sometimes necessary. Patients generally adapt very quickly. Some say that they find that they cannot sleep without wearing the appliance after a very short time. Any appliance, like a denture, is noticeable and occupies space. Skeleton chrome-cobalt metal appliances are minimally intrusive and extremely well tolerated.
- Due to slight pressure on the teeth, the bite sometimes feels slightly different in the morning. This rapidly disappears within minutes.
- Frequently, a change in sleep quality is notice almost immediately. Some patients take a little time to adapt. Some appliances are adjustable and function is gradually enhanced.
- The reported success rate for MAAs is approaching 90%, provided that the appliance is worn as directed, especially if accompanied by other measures, such as weight loss, regular exercise, alcohol avoidance, etc.
- The most common reasons for lack of success include non-compliance, i.e. not wearing the MAA due to bulk, excessive jaw opening, patient general intolerance.
- The treatment is simple, non-invasive, reversible, can be given in the dental surgery.
- No surgery is involved.
- Cost can be relatively inexpensive.
- Co-operation is necessary and appliances must be worn to work.
- Appliances sometimes break and need repair or replacement.
- Small adjustments might be necessary after time.
- The mouth must be well cared-for with a stable dentition.
- Some people find that over a period of time there are very minor changes in the way the teeth bite together.
- This depends on the type of MAA. The range is from a simple acrylic MAA to a more sophisticated chrome-cobalt minimal bulk appliance. There is a small charge for an initial consultation which is refunded if treatment is carried out.
- Some patients like to try the less expensive option and progress to other levels when they are confident of success and their appliance needs replacing.