CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

People with severe Obstructive Sleep Apnea (OSA) suffer from excessive daytime sleepiness. They fall asleep at the wheel of a car, in the bathtub, on the toilet, or at the dinner table.

"Collapsed or narrowed airways cause repetitive cessation of breathing for people with severe OSA. The best treatment for severe OSA is the Continuous Positive Airway Pressure or CPAP machine (pronounced Cee-pap), "says Dr. Awad, director of the Oakville Sleep Disorders Investigative Center and member of the American and Canadian Sleep Associations.

The CPAP machine looks like a miniature vacuum cleaner but works in reverse. A mask fits over the nose while a person sleeps. A hose connects the mask to the air unit - no tubes go into the throat. The CPAP blows room air gently through the hose and mask and into the sleeping person's nose and lungs.

A technician at the sleep lab increases the air pressure of the machine until the pressure is sufficient to keep the person's airway open and allow the person to breathe normally. An open airway improves sleep immediately.

Dr. Awad, who has treated 6000 patients since 1994, says, "People with untreated severe sleep apnea can die in their sleep from heart attacks and strokes. CPAP immediately opens the airway and people no longer have to labour to take a breath. Treatment with CPAP increases the amount of oxygen in the blood. An increase in the level of oxygen relieves strain on the heart, lessens risk of stroke, lessens hypertension, improves mood, and prevents fatal motor vehicle accidents."

People with severe sleep apnea who have excessive daytime sleepiness, who wake with morning headaches and feelings of fogginess and who rattle the doors in their house with their snores, tolerate and accept long-term treatment with CPAP.

People with moderate and mild symptoms of sleep apnea do not tolerate the CPAP well. Some CPAP users complain of facial irritation, headgear discomfort, nasal dryness, and gastric distention. CPAP users cannot always travel with the machine. They may use alternate treatment.

In a study that compared Oral Appliances and CPAP, researchers found that people with mild and moderate Sleep Apnea preferred Oral Appliances constructed by dentists and lab technicians.

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UVULOPALATOPHARYNGOPLASTY (UPPP)

Surgeons would perform more uvulopalatopharyngoplasties if they could explain the procedure to their prospective clients.

Maybe it's better that UPPPs are difficult to explain.

An obstructed airway leads to snoring and Sleep Apnea. Sleep Apnea or sleep disordered breathing can cause high blood pressure, heart attacks, car accidents and personality changes because a person does not receive enough oxygen to the brain. Snoring is a classical symptom of Sleep Apnea.

Fat deposits in the throat and mouth obstruct airways and cause snoring. Fat settles in the tissue surrounding the back of the throat, the pharynx. Fat collects in the roof of the mouth, the soft palate. The uvula blocks the airway space and reduces the size of the airway opening. Fat deposits around the neck for men and around the abdomen for women. This explains the statistic: 44% of men and 28% of women snore.

Obese people have a higher incidence of snoring and Sleep Apnea. Weight loss reduces Sleep Apnea and snoring in men, women and children.

Uvulopalatopharyngoplasty, or UPPP for short, also reduces Sleep Apnea and snoring.

UPPP is like liposuction, except the surgeon does not suck the fat off the abdomen. Instead, the surgeon uses scalpels and lasers to cut excess tissue from the back of the throat to enlarge the airway space. UPPP opens the airway so that a person with a partially obstructed airway can have a free flow of air coming into and out of the lungs.

As they do when they choose liposuction, where people choose surgery over diet and exercise, some people choose to have the fat at the back of their throat cut out. Weight loss and subsequent loss of fatty tissue can increase the size of the airway and alleviate snoring and Sleep Apnea.

Non-obese people can have soft tissue abnormalities that obstruct the airway. A large tongue can cause airway obstruction. Large tonsils and adenoids in children can cause airway obstruction. Surgeons can remove adenoids and tonsils and cut out excess tongue tissue.

For surgeons, until very recently, UPPP was a popular procedure. The surgeon shortens the soft plate, amputates or partially amputates the uvula and and cuts excess fatty tissue out of the walls of the pharynx.

At a recent conference for dentists I attended a full day Sleep Apnea seminar, where I listened to Dr. Kathleen Ferguson, a sleep disorder researcher in the Department of Medicine at University of Western Ontario.

"Advise your patients not to have the UPPP procedure. It is very painful and the fatty tissue comes back. The complications make it very dangerous. Scar tissue can further obstruct the airway. A person has to learn to swallow differently. Voice changes and the ability of making trilling sounds and rolling an 'R' alters because the surgery has altered the uvula," says Dr. Ferguson.

The December 2001 Journal of the Canadian Dental Association features Oral and Maxillofacial Surgery articles, and reports that UPPP "carries a risk of significant hemorrhage and post operative pain. " The article also reports that improvement occurs in less than 50% of patients and complete control occurs in 25% or less. Different studies show conflicting data, and definitions of success vary. But researchers seem to agree that improvement in less than 50% of patients does not constitute success.

Oral Surgeons now advocate a more effective method for opening the airway in selected patients. Maxillo-mandibular advancement changes the position of a person's lower and upper jaw. Surgeons move the lower jaw, the mandible, and the upper jaw, the maxilla, forward. The jaw advancement causes the airway to open. A study has shown the procedure reduces RDI reduction to 10 -65% of cases. ( RDI of 30 or more is severe, 10 and under is normal) 45% of patients stopped snoring and 45% reported a reduction in snoring severity. The people in the study had abnormal or less than ideal jaw positions. Surgery improved facial features.

Unlike treatment with CPAP and Oral Appliances where patient compliance determines the success of treatment, surgical jaw advancement permanently alters the position of the jaw.

"When all other treatment fails, a UPPP or upper and lower jaw advancement could save a person's life," says Dr. Barry Harnett an oral and maxillofacial surgeon, who has performed UPPP and jaw advancement operations.

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POLYSOMNOGRAPHY-MY NIGHT AT THE SLEEP LAB

I pack my pajamas, my favorite pillow, brush and floss my teeth, give my husband a goodnight peck, and drive to the Oakville sleep clinic.

I mutter along the way, "Okay. Okay. Maaaybe I snore. Okay. Maybe I have a sleep problem. Okay, I'll go if you go. (my husband did go to the sleep lab and does sleep with a CPAP) Okay, I'll check out this sleep lab procedure if I have to!"

On arrival I fill out forms, watch a testimonial video, give my health card to the technician and look at the computer screens, one monitor for each of the six sleep rooms.

Colleen, the sleep lab technician dressed in comfortable scrubs and slippers escorts me to Room 3 with a large bed, a fluffy comforter, rag rug on the floor, pale yellow walls, green wood trim, soft light from a lamp on the night table, framed picture of a home on the wall. A stuffed teddy bear perched on a dresser looks down at me.

"Put your PJ's on and come out and sit in this chair in the hall," says Colleen.

I do as I am told. I sit on the chair, outside my sleep room, in my pyjamas.

Colleen, picks up a measuring tape and measures my head. She rubs my scalp, applies a gooey jell-like conductor and tapes electrodes to my head to record my brain waves. Colleen attaches electrodes to my chest to record heart beats. She places electrodes above and below my eyes to measure eye movements.

Electrodes on my chin measure muscle tension. Electrodes on my lower legs measure leg movements. A sensor under my nose measures air flow. A strap around my chest and abdomen measures breathing movements. A sensor on my index finger measures blood oxygen levels. Twenty one electronic leads plug into a small square black box. The box plugs into a wall socket.

I try to breathe normally. I make an attempt at a normal conversation.

"So, you monitor the computers all night while we sleep?" I ask.

"Yes, two of us do."

"How do you go home and sleep in the daytime?"

"I have no trouble sleeping when I get home. I make sure my room is dark. I practice good sleep hygiene," says Colleen.

Colleen, checks to see the electrode leads do not get tangled and says, "OK, You are ready to sleep."

Colleen, holds the black box while I traipse back to the bedroom. Colleen lifts the covers. I lie down. She adjusts the room temperature to 65 degrees and tucks me in. She plugs the black box into electrical outlet on the wall.

"I just have to test the computer to see if everything works." Colleen leaves and gives me instructions via an intercom while a small camera above my head points down at me.

"Blink your eyes. Good. Move your legs. Good. Breathe in and out. Good. All the leads record on my computer. Good. If you need to go the bathroom at night, just wave at the camera and I will come and get you. You're wired. You can go to sleep now," Colleen says over the intercom.

Colleen returns to my room, rearranges my covers, switches off the light. Blackness envelopes me. I have learned that complete darkness makes the body produce melatonin. The sleep hormone. I lie rigid on my back and stare at the darkness, stare at the camera above my head. I hear Colleen's soothing soft voice over the intercom.

"Close your eyes now. Relax. You can move. You can make yourself comfortable."

I take deep breaths in and out, pretend that I'm in my own bed, turn on my side, cross and uncross my legs, arrange and rearrange my down pillow, turn on my back, pretend to sleep.

I hear a shower next. Room 4 must be getting ready to go to work. It must be morning. I must have fallen asleep. My sleep seemed light. I try to remember my dreams.

Colleen comes in cheerily and says, "Good morning," and detaches me.

"How did you sleep?"

"Uhhhhhh...sure." I mumble.

Colleen hands me a form. The form asks me how I think I slept. Terrible. I glance at the graphs on the computer screen.

"We have to prepare the report. You will have to return and get a consultation with the sleep physician. Here's your appointment card."

"Have a good day's sleep," I say to Colleen and leave.

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ORAL APPLIANCES

Silencer, Klearway, SnoreGuard sound like the names of Speedy Muffler King's new innovations for your car. In a way these oral appliances behave like mufflers as they diminish or eliminate snoring. But they have major health implications for people who have Obstructive Sleep Apnea (OSA).

In snoring and OSA the tongue falls back against the wall of the throat and blocks the airway. This obstruction causes people to snore and struggle to get air into their lungs while sleeping. Lack of oxygenated blood to the brain and heart can cause heart attacks, strokes, car accidents and high blood pressure.

An appliance called the Mandibular Anterior Positioner can pull the tongue forward and open the airway. A dentist takes molds of your teeth and the dental lab constructs athletic mouth guard- like thermoplastic arches that fit over your teeth.

The Mandibular Anterior Positioner, pulls the tongue forward by moving the lower jaw forward. Clear plastic arches on the top and bottom fit over the teeth and join together with a device that acts like a screw. Turning the screw moves the lower jaw forward . The forward movement of the jaw also moves the tongue forward. Forward movement of the jaw and tongue opens the airway.

Commercial dental labs construct over 50 different Mandibular Anterior Positioners. Dr. Alan Lowe of UBC's Sleep Disorders Clinic has developed and studied the Klearway Appliance. Because Health Canada has funded studies on the Kearway, we have more information about it than others. Commercial labs make similar appliances and claim their appliances work best.

Another appliance called the Tongue Retaining Device works for people who do not have teeth. The Tongue Retaining Device has a soft plastic bubble at the front. The bubble acts like a suction cup and keeps the tip of the tongue forward in the bubble. This appliance, although it works well in theory, feels uncomfortable to most people.

After my polysomnography interpretation appointment, my RDI reads 13 when I sleep on my side - gravity pulls the tongue forward away from the back of the throat when you sleep on your side or stomach - and my RDI reads 17 when I sleep on my back. 13 ranks as mild Sleep Apnea and 17 ranks as moderate Sleep Apnea.

I decide to try an Anterior Positioner Appliance. I choose an appliance called the Thorton Anterior Positioner(TAP).

The TAP works like the Klearway and the Silencer. I like the TAP because the device that moves the jaw forward sits at the front of the mouth instead of the roof of the mouth or at the side of the mouth. I can adjust the 'forward moving mechanism' myself, easily, while the appliance fits on my teeth. The TAP, like the other appliances, is made with a thermoplastic material.

I run hot water over the plastic. The plastic softens. I place the TAP over my top and bottom teeth. I turn the button until I feel comfortable. Turning the button advances my lower jaw gradually forward. I turn the button one turn every night.

"It works! You didn't snore at all," says my husband.

Dr Ferguson, a sleep research physician, shows in her study that 80% to 100% of people snore less when they use oral appliances. Oral appliances eliminate snoring for 15% to 64% of snorers.

Some people who could not tolerate CPAP showed an improved RDI using oral appliances. (RDI or Respiratory Distress Index measures the severity of Sleep Apnea- see keyword box) One study showed that in a group of people with mild to moderate Sleep Apnea, 70% who used appliances reduced their RDI by 50%. 13% showed an increase in their RDI.

A dentist knowledgeable in sleep disorder appliances and a sleep physician must monitor patients.

A polysomnography with an oral appliance in place shows how well oral appliances work.

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A RESTFUL SLEEP

Now, when my husband and I ask each other, "How was it for you?", we mean, "how did you sleep last night?"

Sometimes the answer is, "Like a stone".

Sometimes it's "So, so."

But mostly our sleeping has improved. He sleeps with a CPAP and looks like he is going SCUBA diving. I sleep with an Oral Appliance and look like I am ready to play hockey.

Our quality of sleep improves. Our quality of life improves.

As a dentist, I have focused mostly on oral hygiene. But I have learned the following about Sleep Hygiene.

1. Go to bed and wake up at the same time. This establishes a sleep/wake rhythm.

2. Exercise the same time everyday, preferably in the morning.

3. Keep your bedroom quiet, dark and a comfortable temperature: 18 C degrees or 65F.

4. Cut out alcohol, cigarettes, caffeine and sleeping pills.

5. Don't worry about tomorrow. If you worry, make 'To Do' lists.

6. Go to bed only when you feel sleepy. If you can't sleep, read or have a light snack.

7. Have a light snack before bed. Milk and cookies work. Remember to brush your teeth.

8. Avoid daytime naps.

9. Unwind, relax, bathe or shower before bedtime.

10. Sleep on your side or stomach, especially if you snore and have mild sleep apnea. Sew a tennis ball into the back of your PJ's. The tennis ball makes you roll over on your side or stomach.

SOURCE - Modified from brochure: Sleep Hygiene Habits. Oakville Sleep Clinic.

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TREATMENT PROTOCOL-Where To Start

If your bed partner says you snore, you probably snore.

If your kids have to close all the doors in the house to muffle the noise, you probably snore and have Sleep Apnea.

If you live alone, and nobody complains about you, but you answer yes to the following questions, you probably have Sleep Apnea.

Questions:

1. Do you have trouble with routine daily tasks due to poor attention span?

2. Do you feel like dozing off when you drive?

3. Do you have a headache when you awake in the morning?

4. Can you recall frequent nighttime arousals?

5. Do you still feel sleepy when you awake in the morning?

6. Do you use caffeine, tobacco, or over the counter medications?

7. Do you have any medical conditions that can cause sleep difficulties?

8. Have you gained weight recently?

9. Are you irritable and forgetful?

10. Do you have high blood pressure?

If you answer yes to these questions, a family physician or dentist can refer you to a sleep specialist for an overnight polysomnography.

Since Sleep Apnea is a medical disorder, a physician with advanced training in sleep disorder medicine must assess, and prescribe treatment.

Depending on the result of the sleep study, the sleep disorder doctor will prescribes treatment.

For Severe Sleep Apnea, CPAP works best.

For Moderate Sleep Apnea, CPAP or an oral appliance works for most people.

For Mild sleep apnea and simple snoring try sewing a tennis ball in the back of your pajamas. The ball makes you roll over and sleep on your side or stomach. Sleeping on your side and stomach makes the tongue fall away from the back of your throat. The airway opens. Snoring stops.

For Moderate and Mild Sleep Apnea the sleep doctor may refer you to a dentist trained to make an oral appliance. A follow up polysomnography is essential for people who wear oral appliances. For a small percentage of people, oral appliances make Sleep Apnea worse. A polysomnography will assess whether the oral appliance opens the airway or not.

Treatment guidelines stress a team approach in treating Sleep Apnea. The team consists of a family physician, a sleep disorder doctor, sleep lab technicians, a dentist, dental lab technicians.

Most people will experience sleep problems sometime in their lives. Sleep problems other than Sleep Apnea include: Narcolepsy, and Restless Leg syndrome. Other illnesses can cause people to sleep too much or too little.

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