Treatment of Sleep Disorders

Although CPAP and Oral Appliance therapy are the most commonly used, and best known treatments for Snoring and OSA, neither of them alone is ideal.  Best results can be attained by using a suitable combination of treatments.  Some of the treatment options available include –

Treating Symptoms –

The following approaches relieve the symptoms of Obstructive Sleep Apnoea (OSA), and Mixed Sleep Apnoea (MSA), and have a limited affect on Central Sleep Apnoea (CSA), but do not address the anatomical or physiological causes of these conditions.

1. PAP Therapy (including CPAP, AutoPAP and BiPAP).  These apply Positive Airway Pressure to the nasal and pharyngeal airway to hold it open (the airway is effectively blown up like a balloon), allowing continued breathing without obstruction.  PAP Therapy is the choice of the majority of Sleep Physicians, and is regarded as the “Gold Standard” treatment for OSA.
   
   
2. Oral Appliance Therapy (OAT) – is the preferred approach commonly used by dentists treating OSA.  Studies by Cistulli and others show that the medical benefit of OATs is the same as for PAP Therapies.
   
   
3. CPAP combined with OAT – In some cases, OAT does not achieve the desired result, even though it may reduce the obstruction of the pharyngeal airway.  PAP Therapy may be too difficult for the patient to cope with because of excessive pressures.
   
   By combining the two approaches, the OAT will open the airway enough that the pressure required for the PAP therapy will be reduced enough for patient comfort.
   
   
4. Tongue Surgery – In most cases of SRBDs, the tongue appears to be large, compared with the size of the mouth. In reality, it is extremely rare to see an actual large tongue. The case is that the jaws have not fully developed, due to problems with tongue posture and mouth breathing in the early childhood developing years – this is discussed in more detail elsewhere.
   
   Some surgeons will cut a section out of the tongue to make it smaller. This works in the short term, however the tongue has a habit of regrowing to its original size, and ends up being too large for the small mouth again, and the snoring and sleep apnoea return to their original condition. For this reason, such surgery is regarded as a temporary, symptomatic treatment, as it does not deal with the underlying causes.
   
   

Treating Some of the Causes –

The following treatments each aim to treat one or more of the anatomical or physiological causes of Sleep Apnoea.  Most are suitable for OSA and have little if any affect on CSA.  However there is medication to help treat the neurological background of CSA.

Surgical Treatments –

• ENT Surgery – Neither CPAP, nor OATs are effective if the nasal airway is severely obstructed.  For best and most thorough diagnosis, an ENT assessment is advised before commencing any form of treatment.
  
  The ENT can –
  • Stabilise the nasal valve with cartilage transplants,
  • Reduce turbinate hypertrophy,
  • Straighten deviated Septums,
  • Remove enlarged tonsils and adenoids
  • Reduce the length of the soft palate
  • Reduce flaccidity of soft palate
  • Reduce tongue volume at the tongue base
    
    …thus ensuring that this part of the upper airway provides minimum resistance or obstruction to airflow.
    
    ENT surgery can also affect the stability of the soft palate with implants or laser surgery which produces scar tissue which reduces the tissue collapsibility.  This reduces the vibration of the soft palate to treat snoring, and assist with OSA.

• Bariatric Surgery for Weight Loss – Research shows that for overweight patients (on average) a loss of 10% of their weight will bring about a 25% reduction in AHI.  This is because weight gain is accompanied by a significant enlargement of the tongue, and in men (more than women) there is also an increase in neck size which constricts the airway from outside.
  
  
• Pacemaker-style muscle stimulant implants – Inspire® Upper Airway Stimulation (UAS) is the only FDA-approved implantable device to combat obstructive sleep apnoea. Implanted in the body as an outpatient procedure, the small device is activated following a 30-day healing period. Working inside the body with a patient’s natural breathing process, Inspire can combat certain types of obstructive sleep apnoea, particularly in cases where a loss of muscle tone causes the tongue to fall back in the mouth.
  
  Based on a patient’s unique breathing patterns, Inspire delivers a mild stimulation to the hypoglossal nerve, which controls tongue movement and prevents the tongue from blocking the airway. By stimulating these muscles, the airway remains open during sleep.
  
  
• Maxillo-Mandibular Advancement Surgery (MMA) – In most cases, this provides an actual cure for OSA such that the patient will not need any further treatment.
  
  This is used for those cases which have significant underdevelopment of the Maxillofacial structures as the major cause of obstruction.  The surgery is done in conjunction with orthodontic treatment.  The surgical side of treatment involves a LeForte 1 approach to the maxilla, with maxillary expansion and advancement.  There is also a sagittal split surgical approach to the mandible for mandibular advancement.
  
  This increases the airway size in the nasal airway (with expansion), behind soft palate (due to Maxillary advancement), and in the pharynx posterior to the tongue (due to Mandibular advancement).
  
  

Non-Surgical Treatments –

• Weight Loss – advice on weight management should always be part of the overall treatment plan.  Working with a Nutritionist is very valuable for this process. (See also Point 5 above)
  
  
• Sleep hygiene – This is an assignment question in itself…  Sleep Hygiene should be discussed with all patients.
  
  Sleep Hygiene relates to preparation of the bedroom (dark, quiet, cool but not too cold, no electronic devices in the bedroom, and much more) and preparation of the person (avoid TV and device screens for one hour before bed, warm bath one hour before bed, avoid caffeine for 10+ hours before bed, avoid alcohol for 6+ hours before bed, dim lighting and relax before bed and much more). 
  
  This is also significantly affected by any medications used.
  
  Although sleep hygiene does not directly address OSA, it sets up a healthier sleep in general and thus, assists the other measures taken.
  
  
• Positional devices – Some patients have body position as a significant factor in OSA.  Most commonly with positional OSA, the supine sleeping position causes the majority of apnoeas.  Positional devices are designed to encourage the patient to stay on their side (or one particular side in some cases).  The classic simple approach is to sew a tennis ball into the back of the pyjama top – in extreme cases something similar to a back-pack is used. 
  
  There are also electronic biofeedback devices which sense body position and use vibration or electronic stimulus to encourage moving back to a healthier sleep position
  
  
• Non-surgical Nasal Valve treatment – nasal cones and breathe right strips.
  
  In cases of Nasal Valve Collapse, if a surgical approach is not viable or rejected by the patient, the nasal valve can be held open with nasal cones inserted into the nares, or the use of “Breathe Right” nasal strips externally to lift the nares.
  
  
• Non-Surgical ENT Therapy – In cases where there is mucosal inflammation in the nasal airway, with minimal hypertrophy, the inflammation can often be reduced with steroid nasal sprays like Nasonex.
  
  In cases of Allergic Rhinitis, allergy reduction strategies, including allergen desensitisation are recommended.  This is usually managed by the ENT Specialist or and Allergist.
  
  
• Nasal breathing retraining – see “The Oxygen Advantage” by Patrick McKeown –  This involves Buteyko style breathing techniques including full-time nasal breathing, which, among other advantages, increases the availability and absorption of Nitric oxide, with al of its respiratory and cardiovascular advantages.
  
  
• MFT (Myo-Functional Therapy) – Tongue posture therapy and improving pharyngeal tone – including “Mewing” – This improves the muscle and tissue tone of the pharyngeal airway, as well as improving the tongue posture and function, which opens the airway for healthier breathing and resistance to obstruction.
  
  
• Lip Taping – For those who have difficulty keeping their lips together at night, Micropore tape to close the lips over night can help develop he habit over time, thus assisting in developing nasal breathing.
  
  
• Medication – In recent years, there has been a growing interest in the use of medication to treat OSA.  Many medications have a deleterious affect on sleep staging, and particularly on deep slow-wave sleep, so caution is needed.  Cannabinoids show some promise in that they help sleep as well as helping with OSA
  
  
• Orthopaedic Maxillo-Mandibular Advancement – including orthodontic treatment – Using Dentofacial orthopaedic technologies (both fixed and removable appliances) this approach aims to achieve similar goals to those of the surgical approach, only without surgery.
  
  
  

What we do at Mountains Dental Sleep Medicine

Every patient is provided with the options of –

• Weight loss advice where warranted
• Sleep hygiene advice
• ENT Referral whenever there is any indication of nasal airway obstruction or tonsli enlargement
• Nasonex or other nasal sprays prescribed where appropriate
• Nasal breathing therapy – the book “The Oxygen Advantage, by Patrick McKeown” is recommended, and breathing coaching provided
• MFT – Tongue posture therapy – a referral to an Oral Myologist and/or “Mewing” videos are recommended for all patients and exercises to improve pharyngeal tone.
• Lip Taping – where nasal breathing is possible and practiced during the day, but developing the habit during sleep is troublesome.
• Nasal valve therapy – nasal cones or breathe right strips where nasal valve collapse is noted and a surgical approach is not desired
• OAT (Oral Appliance Therapy) is recommended for snoring and Mild–Moderate OSA and for those who either do not want or can not tolerate CPAP.  This is preferred for those who do not choose Orthopaedic treatment.
• Orthopaedic Maxillo-Mandibular Advancement – including orthodontic treatment – This is my preferred approach and recommended to all who have the appropriate anatomical underdevelopment.  This approach (in conjunction with the others listed above) has provided a cure for many of Dr Baret’s patients, and has dramatically improved the condition of all others treated this way.
• Referral for propper fitting of CPAP where appropriate
• CPAP combined with OAT for those who can gain from this approach
• Positional devices advice – where SDB is significantly influenced by sleeping posture

Referral for Maxillo-Mandibular Advancement Surgery – only for the most extreme cases of improper anatomical development. (I have never yet needed to refer for this.)