Positive Airway Pressure Devices
Positive airway pressure machines, used with a variety of breathing masks, are the most widely used treatment for moderate and severe sleep apnea.
The mask, worn snugly over the nose, or sometimes nose and mouth, during sleep, supplies pressurized air that flows continuously or intermittently into the sleeper’s throat. The increased air pressure prevents the sleeper’s airway from collapsing.
The pressurized air is supplied through a flexible tube from one of several types of machines: CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), VPAP (variable positive airway pressure), and so on. Studies of the effect of PAP therapy show that people with sleep apnea who consistently use their machines feel better and, as a result of the reduction of apnea and hypopnea episodes during sleep, encounter fewer complications of the disease. There’s more information about PAP therapy here.
Although PAP devices are not used to treat snoring alone, they do eliminate snoring in addition to treating obstructive sleep apnea.
Oral appliances for the treatment of sleep apnea continue to increase in popularity as awareness grows amongst the public that oral appliances are an effective first line treatment for many sleep apnea sufferers. Over 100 different oral appliances are FDA approved for the treatment of snoring and obstructive sleep apnea. These appliances are worn in the mouth, just like a sports mouth guard or an orthodontic appliance, while you sleep. Oral appliances hold the lower jaw forward just enough to keep the airway open and prevent the tongue and muscles in the upper airway from collapsing and blocking the airway.
The American Academy of Sleep Medicine (AASM) has approved oral appliance therapy (OAT) as a first line treatment for patients diagnosed with mild to moderate OSA. The AASM also recommends oral appliances for patients with severe OSA, who are unable to tolerate or cannot wear CPAP devices. Another option for people with severe OSA is combination therapy (wearing CPAP and an oral appliance together) to help reduce the pressure on a CPAP machine, making it more comfortable to use.
Advantages of Oral Appliance Therapy
Oral appliance therapy is an effective, non-invasive treatment that fits easily into your lifestyle. Patients like oral appliance therapy because it is:
- Easy to wear
- Convenient for travel
- Easy to care for
Custom Made Oral Appliance vs. Boil and Bites
Although there are a few over-the-counter appliances you can purchase at drug stores or even online, remember that these oral appliances are not FDA approved for sleep apnea. When not fitted properly over-the-counter appliances can cause unwanted side effects, such as jaw problems or tooth movement or can even have the opposite effect and inadvertently worsen sleep apnea.
If you snore or believe you have sleep apnea, contact your primary care physician (PCP) to help schedule a sleep study to determine if you do have OSA. If it’s determined that an oral appliance is an option for you, it should be fitted by a dentist specially trained in Dental Sleep Medicine.
Finding a Dentist
Trained dental professionals will conduct a full evaluation of your teeth, mouth, and temporomandibular joint to ensure that your teeth and jaw structure are healthy enough to wear an oral appliance. Following the examination, you will have models of your teeth made and a follow-up appointment is scheduled to fit your custom oral appliance. The American Academy of Dental Sleep Medicine can help you find a trained dentist here
Adjusting to Oral Appliance Therapy
Since custom made oral appliances are adjustable, your dentist will work with you to maintain your jaw position by continuously monitoring your progress. It is important to maintain a prescribed follow-up schedule with your dentist to ensure the device is working, fitting properly and that you see an improvement in your symptoms. It usually takes only a few days to adjust to wearing the oral appliance all night while sleeping. Your dentist will review the details with you as well as the best way to maintain your oral appliance at home.
Types of Oral Appliances
Below are just a few examples of custom made oral appliances (also known as mandibular advancement devices or MADs) that are available.
Sleep Review’s oral appliance comparison guide (up to date as of August 2015) compares 21 oral appliances side-by-side. It compares features such as fitting description, adjustment description, materials, and recommended cleaning for the different devices. Click the image to view the full 4-page comparison guide.
Medical Insurance for Oral Appliance Therapy
Although a dentist will be placing your customoral appliance, the great news is that oral appliances are generally covered under your health insurance plan, not your dental plan. Prior to treatment, you or your dentist may want to contact your health insurance, directly, for an estimate of insurance coverage. Due to variations in medical insurance plans, coverages do vary.
Medicare provides reimbursement for oral appliances for those 65 or older under the durable medical equipment (DME) benefit. In order to help Medicare patients with a portion of the reimbursement for oral appliances, many dentists around the country have enrolled as Medicare DME Suppliers for oral appliance therapy for obstructive sleep apnea.
Some people with obstructive sleep apnea, or OSA, are unable to use continuous positive airway pressure (CPAP) therapy, the most commonly prescribed OSA treatment, despite best efforts. Now there are new, clinically tested therapies for some people with moderate to severe OSA. These new types of therapy work inside your body.
Hypoglossal Neuro-stimulation Therapy – Obstructive Sleep Apnea
Hypoglossal neuro-stimulation therapy was designed for the treatment of patients with moderate to severe OSA who have been unable or unwilling to use continuous positive airway pressure (CPAP) therapy. Implant therapy was specifically designed to deliver muscle tone to key tongue muscles, effectively controlling upper airway flow and significantly reducing or eliminating sleep apnea.
Neuro-stimulation Therapy – Central Sleep Apnea
Implantable systems that stimulates a nerve in the chest (phrenic nerve) to send signals to the large muscle that controls breathing (the diaphragm). These signals stimulate breathing in the same way that the brain signals breathing. The systems are placed during a minimally invasive outpatient procedure by a cardiologist.The systems are battery powered devices placed under the skin in the upper chest area with two small thin wires (leads), one to deliver the therapy (stimulation lead) and one to sense breathing (sensing lead).
Continued Excessive Daytime Sleepiness
Sometimes individuals with treated sleep apnea still experience excessive daytime sleepiness (EDS), a chronic condition, and need help with improving wakefulness. We know this sleep deficit is contributing to worsening co-existing medical conditions and impacts human performance as well as cognitive abilities.
For this reason, physicians may prescribe medications, after diagnosing EDS, to improve daytime functioning for those who suffer from this chronic condition.
Treatment of EDS relies on identifying and treating the underlying disorder which may alleviate the symptoms from EDS. The medications used to treat EDS work in the brain to help keep an individual alert and awake during the day. There is declining usage of older, previously prescribed medications to treat EDS due to several adverse effects risk of dependency, especially when illicitly misused. A new generation of medications, more specifically targeted to treat EDS cases is becoming the standard of care.
About 70 percent of people with obstructive sleep apnea are overweight or obese. Their health care professionals usually encourage them to lose weight.
Surprisingly, there have been few formal studies of how effectively weight loss leads to lesser snoring and diminished incidents of apnea and hypopnea during sleep. Despite this, anecdotally practitioners report striking improvements in both OSA and snoring among patients who lose weight.
In some situations a physician may wish to prescribe weight loss medications to an overweight or obese patient with OSA.1
Nasal decongestants are more likely to be effective in cases of snoring or mild sleep apnea. In some cases, surgery is an effective way to improve airflow through thenose.
Some people snore or have sleep apnea only when sleeping on their back. Such people can eliminate or reduce airway blockage simply by learning to sleep on their side.
The traditional technique to induce side-sleeping is dropping a tennis ball in a sock and then pinning the sock to the back of the pajama top. There are also a couple of companies that make a products designed to discourage supine sleeping.
Positional therapy generally works only in mild cases of OSA. In more severe cases, the airway collapses no matter what position the patient assumes.
Surgery is often effective in treating snoring. It is less effective in treating obstructive sleep apnea.
The challenge that confronts the surgeon is determining what part of the upper airway is causing the obstruction to airflow. There are many possible sites, and conventional sleep testing does not identify the area the surgeon should modify. If the surgeon does not treat that site in the airway, or if there are multiple sites of obstruction, it is unlikely that the sleep apnea will diminish to a degree that eliminates the need for other treatment.
Given the several sites where airway obstruction may exist, there are several types of operations currently used to treat sleep apnea. The most common is uvulopalatopharyngoplasty, or UPPP. The success rate of this operation is about 50 percent. Some surgeons have achieved very high success rates using multiple, staged operations.2 Nonetheless, most authorities recommend routine re-assessment for sleep apnea after surgery. See the caution below. There’s more about surgery here.
Most children with snoring or sleep apnea have enlarged tonsils, or adenoids, or both. In 75 percent of those cases, surgical removal of these tissues cures sleep breathing problems.
The American Academy of Pediatrics has endorsed removal of the tonsils and adenoids as the initial treatment of choice for sleep breathing problems in children. There is more information children’s sleep apnea and its treatment here.
Abstinence from alcohol before bedtime is an important part of treating sleep apnea.
In one study, several persons who received cardiac pacemakers were reported to have shown an improvement in their sleep apnea. No major organizations have endorsed this type of treatment, however. Further studies are underway.
Alternative healing methods are also in use. There is some evidence that playing the didgeridoo or other wind instruments may help in managing OSA. In Brazil, acupuncture researchers who are physicians report positive results in treating OSA with acupuncture.
Snoring, and certain details of snoring, can be a valuable early-warning alarm that sleep apnea is present. Treating snoring can remove this warning system. Just as seeing smoke is a warning that a fire may be burning, hearing snoring is a warning that sleep apnea may be present. And just as smokeless fires may be discovered late, with unfortunate consequences, so too may snore-free sleep apnea. Thus, when surgery or oral appliances are used to treat snoring, it is important to check for sleep apnea on a regular basis afterwards.
Anesthesia and Pain Medicine
The presence of sleep apnea presents special challenges to the administration of anesthesia and pain medications that may affect respiration or relax muscles. Since most people who have sleep apnea don’t know it, the anesthesiologist or pain clinician is well advised to screen the patient for OSA before proceeding. Should it be determined there is a likelihood that OSA is present, the next move is to order a sleep study to make sure or, at a minimum, to take the precautionary steps that should be taken with a patient whose sleep apnea has been diagnosed. These procedures are laid out in greater detail here. See also this article from two Mayo Clinic physicians
This summary of obstructive sleep apnea treatments is adapted from an article written by John Sotos, M.D., a member of the American Sleep Apnea Association‘s board of directors, and appears here by permission. The original may be viewed at http://apneos.com/treatable.html. Obstructive sleep apnea and snoring respond to several types of treatment.
- Find a Sleep Doctor
- Find a Sleep Dentist
- Find a Sleep Lab
- Find a Behavioral Sleep Specialist
- Find Home Sleep Testing
2 Riley, R.W., et al., “Surgical therapy for obstructive sleep apnea-hypopnea syndrome.” Chapter 77 in: Principles and Practice of Sleep Medicine. 3rd ed. Kryger, M.H., et al. (eds.) Philadelphia: WB Saunders, 2000.