When air ceases to flow through a person’s upper airway with continued diaphragmatic efforts during sleep, he or she may be experiencing a pathologic condition called sleep apnea syndrome. Obstructive sleep apnea is now widely recognized as a common clinical disorder with potentially life threatening consequences. Snoring (considered by some to be the prelude to OSA) is present in 20% of men and 5% of woman among the 30-35 year-olds. By age 60, 60% of the men and 40% of the woman snore. The incidence of significant respiratory disturbance during sleep in males who habitually snore is 17%-34%. Among the obese, 60% of overweight men snore, I with the loudness increasing proportional to the weight gain. It is this loudness and disruptive snoring that usually leads to the patient seeking help. Between 5 and 10 million men may be affected.

During sleep, the muscles and tissue that line the air passage at the back of the mouth and nose normally relax and flutter. As a result, the opening of the airway shrinks and breathing becomes more labored. If the tissues crowd the airway excessively as occurs in: the presence of excess tissue (in an over-weight person for example), poor muscle tone, a large tongue (macroglossia), a small and or retruded lower jaw, tumors both benign and malignant, or blocked nasal airways (septal deviation), excess adenoidal tissue, a long and soft palate, a large uvula, this may lead to a pathologic obstruction of the flow of air. In addition to the structural abnormalities, excess body weight often typifies the patient with OSA. The most prevalent explanation of OSAS is that the tongue drops back against the posterior pharyngeal wall and obstructs airflow. This can result in the tissues vibrating (snoring), Increasing the blockage of the upper airway, can result in partial or complete obstruction of the airway.

This temporary blockage results in APNEA, which is defined as the cessation of airflow for more than 10 seconds, despite the person's persistent effort in trying to ventilate. The effort continues until the person abruptly self-awakens by gasping or a loud snort, or even choking for air. The patient resumes sleep in short order and most often awakens with no memory of the events. An apneic person may experience 50 –150 of these events every night. Such episodes can be particularly frightening/alarming to a caring mate or parent who typically describes the spouse who is excessively loud or frightening, with episodes of snorting or choking sounds (waking up to breathe) broken by periods of silence (not breathing at all).

Whether the airway remains patent or collapses depends on the amount of negative pressure in the airway and the counterbalancing muscle tonus of dilating muscles of the back of the mouth and throat. (More negative pressure and tonus keep the airway open). The genioglossus muscles are particularly important oro-pharynx dilators.

The similarities in upper airway anatomy and mechanical properties in patients with OSA suggest that there is a disease continuum, i.e. snoring is an earlier manifestation of OSA. Snoring is present in 90%-95% of patients with OSA and usually precedes other signs and symptoms of OSA, which typically develop over a period of years. Both snoring and OSA events contribute to sleep disruption as the patient arouses either from the snore, or in response to upper airway closure. Thus, both conditions contribute to the sense of poor or restless sleep and subsequent daytime sleepiness

OSA is classified as a severe, moderate and mild according to polysomnogram test analysis and the level of oxygen saturation in the blood associated with the apnea. The polysomnogram is analyzed for the number type, type, duration and frequency of apneic episodes. (The polysomnogram is a recording of the activity of particular parts of your body during four hours of sleep. The device used to analyze the activity of your body’s parts is remarkably similar to the device used when taking a lie-detecting test.) Its purpose is to accurately measure the patient’s ability to maintain an open airway during deep sleep. In "severe" apnea the number of apneas /hr is greater than 20.

OSA can be life threatening for a number of reasons: OSA has been seen to be associated with excessive daytime sleepiness, systemic and pulmonary hypertension (high blood pressure), ischemic heart disease, cerebrovascular disease (stroke) and sudden death. Systemic hypertension has been reported in up to 50% of patients with sleep apnea. Heart rates may be irregular or fast or arrhythmical. Perhaps most importantly at routine level sleep fragmentation can lead to daytime sleepiness, chronic fatigue, morning headache, irritability, memory and judgement impairment, mood disturbance, decreased sex drive and social withdrawal.

Patients with OSA are more likely to fall asleep at inappropriate times and have a higher rate of automobile and work related accidents. The quality of life is affected and the problem may cause marital discord and even contribute to separation and divorce.

OSA in children (most often related to enlarge tonsils and adenoids) has some unique features:

Body weight may be below normal and swallowing difficult. They may be slow eaters and dislike food that requires chewing. Daytime tiredness, morning crankiness, and mouth breathing may be present.

Chronic mouth breathing can lead to serious orthodontic problems and craniofacial development including the so-called adenoid facies or the long-face syndrome. For example, during November 1999 I examined an 11 year-old whose upper and lower teeth did not meet in the front (anterior open bite). Her examination revealed a rather large tongue, very large tonsils (right and left tonsils almost touching each other in the middle) and a long palate and large uvula (the dangling piece of flesh attached to the back of your palate). She was referred to the ear nose and throat specialist for analysis of soft tissue blockage of her airway. Her open bite was being caused by the excessively forward posture of her tongue and head to allow her airway to stay sufficiently open to allow easy breathing.

OSA is diagnosed by the history, clinical signs and symptoms, and the physical examination. The head and neck examination has two purposes 1. To ascertain the likely anatomic source of obstruction and to determine the presence of any inflammation, congenital, or neoplastic (tumors) of the obstructed airway. Such examination takes note of facial proportions, structures in the mouth and neck. Findings sometimes include an elongated palate whose uvulal end is rather long and enlarged itself. The tongue may be relatively in either an absolute way or a relative way. The oropharyngeal airway may b partly closed because of excess tissue.

The Promise of Sleep is a fascinating book and well written for the lay public by Dr. William Dement. Those of you among the sleep hungry/deprived will be forever wary of driving when sleep deprived. Dr. Dement is known worldwide for his research on sleep. He has a problem sleeping when he dwells on the accidents caused by lack of sleep.

There are two major treatment approaches to snoring/sleep apnea: 1. Surgical, 2. Non surgical. I will elaborate on the non-surgical approaches and suggest keywords: treatment OSA (obstructive sleep apnea) to those interested in knowing more about the surgical approach.

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea. Physicians, dentists, psychologists, and respiratory therapists all poll their knowledge to treat each patient appropriately and effectively.

Mild to moderate sleep apnea can be approached by A. behavioral changes, such as: losing weight, avoiding the evening use of alcohol and sedatives, eating earlier in the evening and avoiding the supine (on your back) sleeping position; B. medication to keep the nasal airway open and other agents to keep the patient in lighter stages of sleep. C. CPAP (continuous positive airway pressure). In CPAP air is delivered under a light pressure through a facemask into the nasal passages. This stream of air forces the tissues of the mouth and throat to remain apart as does the neck of a balloon when it is being inflated.

JAW REPOSITIONING TO ENLARGE THE AIRWAY USING A "DENTAL ORTHOSIS"

The only modality I provide is the "Dental Orthosis" an "appliance" that works by positioning the lower jaw downward and forward, advancing the tongue or altering the palate and mandibular position. It may be the primary treatment for those who cannot tolerate nasal CPAP or who are poor surgical risks. The most often reported side effects include excessive salivation and jaw joint (TMJ) discomfort. Learn more about this kind of appliance

In a study (Nowara and Meade) on 68 patients with mild to moderate obstructive sleep apnea accompanied by snoring, an appliance (the first version of the present day Therasnore) was designed to move and hold the lower jaw during sleep in more forward and downward position and thus increase the size of the air way. The authors concluded that "clinical problems with snoring can be improved with this dental orthosis in the majority of cases. For patients with troublesome snoring without significant sleep apnea. This treatment offers a solution with tolerably few side effects. For the patients with relatively mild sleep apnea, the dental orthosis may also improve upper airway function sufficiently to produce a clinically satisfactory result. Patient with more severe sleep apnea are less likely to have a satisfactory response, but these are the patients more likely to accept nasal CPAP."

WHAT SURGICAL APPROACHES  ARE AVAILABLE FOR SNORING?

Readers should take note of the following website to learn about one of the least invasive surgical approaches for the relief of snoring:
http://www.somnoplasty.net/home.html At this site you can see a video showing how the procedure is done in the doctor's office and read
medical abstracts about the efficacy of the procedure which takes about 30 minutes. I for one have decided to have this procedure done on myself in the near future since my wife  tells me that my snoring is becoming increasingly worse.  What makes this procedure more
appealing to me now is knowing  that it has been shown to as effective as devices worn in the mouth and that  the pain reported to follow the procedure lasts 1-3 days and is largely relievable by over-the-counter analgesics.  Briefly, local anesthesia is give to numb the back
of the mouth.  A probe is inserted to the flapping  part of the soft palate and sometimes the back of the tongue. Controlled radio energy
is delivered to the tissues inside these parts which causes them to coagulate (like an egg does when you cook it).  Over a period of 6-8 weeks the coagulated tissues are carried away by the bodies immune system causing the operated-on parts of shrink thereby causing the airway
to become large.  In Brooklyn (450 Clinton St.) you may contact Dr. Dan Arick (Ear, Nose and Throat Specialist) at 718 624 0222
His Manhattan office telephone number is 212 737 5511 (755 Park Avenue). E email: darick6217@aol.com.  He is a certified provider for the "Somnoplasty" procedure.  [Note: On May 24, 00  I had the Somnoplasty procedure done and have documented my complete experiences
 with it. If you want to read about it go to:  Somnoplasty for elimination and prevention of snoring: Dr. Ted's experience]. 

Osseiran, S. H., Treating Obstructive Sleep Apnea: Can an intraoral prosthesis help?
Journal of the American Dental Association, vol. 126, April 95, pp. 461-466,
American Association of Oral and Maxillofacial Surgeons: Sleep Apnea, vol. 14, No. 1.
Lanaido, N., et al., Addressing Snoring and Obstructive Sleep Apnea: A problem often overlooked in woman, Compendium of Continuing Education in Dentistry, vol. XIV, No. 12, pp. 1572-1583.
Schmidt-Nowara, W. and Meade, T, Treatment of Snoring and Obstructive Sleep Apnea with a Dental Orthosis, CHEST, vol. 99, pp. 1388-1385.