Snoring is the sound that results from air rushing through a partially collapsed airway. Obstructive sleep apnea (OSA), which is due to a fully collapsed airway, is silent. When there is no airflow, there is no sound. Bed partners often tell stories about loud snoring punctuated by long silences. Often, they count the seconds of silence — “One … two … three …” — until, suddenly, the partner gasps, snorts and grabs a few deep recovery breaths. The silence begins again: “One … two … three …” This lasts all night long.

Snoring and sleep apnea are related conditions of the upper airway. Not all snorers have sleep apnea, but all obstructive sleep apnea patients snore. Snoring is associated with a group of disorders called sleep-disordered breathing, which is shown to affect up to 50% of adult Americans. The impact of snoring on quality of life is well documented: Disrupted sleep patterns lead to daytime sleepiness, while bed-partner disturbance causes stress and can lead to separate sleeping arrangements.

One study, which used in-laboratory polysomnography, found that the prevalence of sleep apnea in adults between 30 and 60 years of age was 9% for women and 24% for men. OSA is a condition that has been linked to heart disease, stroke, diabetes and early death.

Dentists have a highly effective treatment for partial airway collapse. The most common appliance used to treat sleep apnea, a mandibular advancement device (MAD), is a treatment that requires fabrication of upper and lower nightguards that are connected in a way that holds the lower jaw slightly forward during sleep. These devices also allow a trained dentist to adjust the jaw forward in 1 mm increments until symptoms resolve.

This forward jaw position puts tension on the muscles and ligaments of the upper airway, which helps to splint the airway open and prevent collapse. Improved cross-sectional area of the airway allows for quiet nasal breathing and a better night’s sleep.

The Silent Nite^® Sleep Appliance is a particularly successful device for the treatment of snoring in the dental office. Dentists have provided more than 400,000 Silent Nite appliances since its introduction in 1996. Key to the success of the Silent Nite device is that it can be delivered in any dental office without any special or expensive equipment. The device is designed with comfort in mind, helping patients sleep better throughout the night, which promotes patient satisfaction and adherence to therapy.

The Silent Nite Sleep Appliance is a simple, low-cost device that can be offered in the dental practice as an out-of-pocket snoring treatment for the price of a nightguard. Often, this treatment is provided provisionally to address the patient’s primary complaint: snoring.

It has been shown that snoring and sleep apnea are related conditions that require a trained physician to discern the difference and manage the ongoing care for the subset of patients who suffer from OSA. For a dentist to treat snoring and sleep apnea provisionally, an informed consent document should be a part of the patient’s record. This requires a discussion about the relationship between snoring and sleep apnea. It also requires a referral to a sleep physician for diagnosis and medical management. Many dental offices take the additional step of sending a letter to the patient’s primary care physician to document that snoring treatment has begun in the dental office.

Obstructive sleep apnea is a different condition with much higher stakes for the patient. From a physiological perspective, the complete obstruction of the airway sets in motion several physical and neurological mechanisms that impact long-term health and quality of life.

A specially trained physician is required for the diagnosis and medical management of OSA. In most cases, the physician will order a home or in-lab sleep study to establish the presence and severity of OSA.

When the patient’s airway is obstructed, no air is reaching the lungs. Oxygen levels in the bloodstream drop and carbon dioxide levels increase. This condition awakens the patient’s brain enough that the airway patency returns, and the patient takes a few breaths and falls asleep until the cycle starts again. The awakening that occurs to open the airway happens repeatedly throughout the night. In some cases, OSA is so severe that the patient appears to be unable to sleep and breathe at the same time.

The net result of this constant sleep disruption is that patients with OSA often complain of insomnia, daytime sleepiness and fatigue. Chronic sleep disruption is associated with quality-of-life issues, such as poor memory, disturbed concentration and mood changes.

The most dramatic physical consequences of OSA are the dramatic rise in systemic blood pressure and heart rate during an apnea episode. Prolonged and untreated OSA patients may be at a 42% increased risk of developing high blood pressure, even if all other symptoms appear normal.

The dental treatment for OSA is like the treatment for snoring: The device is essentially the same, while physical patient records are taken with either traditional impressions or a digital scan for the patient’s upper and lower dentition. Glidewell fabricates a Silent Nite sleep device using these patient-specific models, and the dentist delivers the appliance in the dental office.

Although patients often report that the appliance takes a little getting used to, many patients can wear the appliance all night from the first night of treatment. This is particularly true of OSA patients who have a profound sleep debt. These patients fall asleep very quickly and often report that they have never slept better. A follow-up sleep study is required to assess treatment success.

As patients habituate to the sleep appliance, muscles and ligaments often begin to relax. While they get accustomed to the new jaw position, snoring and sleep apnea can begin to return. Patients often begin to report returned symptoms like gasping while awakening or sleepiness. MAD appliances are adjustable for this reason. By changing the length of the connectors on the Silent Nite appliance, for example, it is possible to advance the jaw by up to 6 mm to open the airway.

There are very few therapies for snoring and sleep apnea. Positive pressure devices, weight loss and surgery are typically only considered for patients with severe disease due to low patient compliance, lifestyle impact and expense. Dental treatments for snoring and sleep apnea, on the other hand, are relatively inexpensive, comfortable and easily accessible.

The best treatment for snoring and sleep apnea is one that the patient will wear all night, every night. Sleep physicians and medical insurers use a measurement of hours of use when calculating treatment compliance. Dentist and educator Dr. John Viviano often makes the case in his lectures that measuring hours of use is the only efficient way to compare sleep therapies. He goes further when he demonstrates with his literature review that, given a choice, patients prefer dental devices over pressure devices by a significant margin. Indeed, Sutherland et al. state that “preference for oral appliance treatment may translate into significantly more hours of usage.”

The research I reviewed for this article was focused on obstructive sleep apnea. There are very few studies that look at the long-term effects of snoring treatment. This is possibly because of the more recognized health implications of OSA. It may also be because snoring is so much more prevalent, and patients don’t consider snoring to be anything more than a cosmetic issue.

It is clear then that the Silent Nite appliance and sleep treatment should be part of any dentist’s modern service offerings. The patient impact is great, and patients in general have come to expect expanded health and cosmetic services in the dental office.