Obstructive sleep apnea (OSA) solutions may be categorized into three general areas: surgical interventions, medical therapies and dental treatments. The level and intensity of each treatment may depend on the site and degree of the obstruction, and the discipline of the clinician who formed the diagnosis. Patients with sleep apnea often appear to be healthy and unaware of the health risks presented by untreated OSA. Lifestyle and ease of therapy are key decision drivers for these patients.

Although it is clear that untreated OSA is closely related to diabetes, heart disease, stroke, obesity and early death, patients often have a negative impression about treatment of this condition. For example, when Philips surveyed the general population in recognition of World Sleep Day 2021, it found that 30% of respondents believed that sleep apnea treatment is worse than the disease.

This article will describe sleep apnea from a physiologic perspective, and examine the role of surgical, medical and dental interventions in the management of this disease. With this information, dentists can better address patient concerns about therapy and explain how noninvasive dental treatment options can provide successful clinical outcomes.

It is impossible to discuss sleep apnea solutions without describing the physical condition that we know as obstructive sleep apnea. As a person falls asleep, the tissues of the upper airway begin to lose their tone. As they relax, the cross-sectional area of the airway begins to collapse. As each breath draws air through this narrow airway, the tissues vibrate and make the snoring sound. As the tissues further relax, the airway can collapse completely, obstructing airflow.

OSA sufferers experience repeated drops in oxygen saturation, which affects the heart and vascular system. During these periods of low oxygen, heart rate increases with a corresponding increase in blood pressure. The body responds by secretion of hormones related to stress and increasing the production of compounds that produce inflammation.

The physiologic response to the stress associated with OSA is to awaken to a lighter sleep state. This lighter sleep state allows tone to return to the tissues of the upper airway, restoring the larger airway cross-section to normalize breathing. This cycle can happen dozens of times per hour of sleep. The lack of deep restorative sleep will leave the patient feeling tired and unrefreshed in the morning.

As mentioned above, most patients are unaware that they suffer from OSA. When patients do seek sleep apnea treatment, it has been shown that their primary motivations are bed partner disturbance and excessive daytime sleepiness.

It is important to understand when considering OSA that not all patients with OSA snore, but all snorers experience some OSA. Excessive daytime sleepiness is diagnostic of OSA and is a key screening criterion for the condition.

Surgical treatment for obstructive sleep apnea may be an option for patients who have identifiable anatomical problems, such as enlarged tonsils, or for patients who are unable to adhere to less invasive measures. Surgical interventions generally fall into a few areas:

• Reduction or removal of turbinates and nasal polyps, and straightening a deviated septum to improve nasal breathing. These treatments do not completely resolve OSA. However, they will generally improve breathing and allow patients to be more adherent to continuous positive airway pressure (CPAP) or mandibular advancement device (MAD) therapy.
• Uvulopalatopharyngoplasty (UPPP), the most common upper airway surgery. UPPP surgery targets the airway behind the tongue, removing excess tissue as well as removing or trimming the soft palate and removing the uvula. This surgery has a number of side effects, including voice changes, difficulty swallowing and nasal regurgitation. Studies indicate that only about 50% of people undergoing UPPP experience satisfactory long-term treatment success.
• Maxillomandibular advancement (MMA), the surgical repositioning of the upper and lower jaw into an anterior alignment sufficient to enlarge the airway. This surgery requires the fracturing of the maxilla and the mandible. The procedure is very complex, but results are better than for UPPP. The comprehensive nature of this procedure carries with it risk to the patient and a much longer recovery period.
• Hypoglossal nerve stimulation, a recent surgical treatment that requires an electrode placed on branches of the hypoglossal nerve and a sensing electrode placed in the chest wall. Both are connected to a neurostimulator, similar to a pacemaker, located in a surgically created pocket under the clavicle. When the chest wall sensor detects an apnea, the neurostimulator sends a signal to activate the hypoglossal nerve, which controls the movement of the tongue. Upon activation, the tongue is enervated and restores tone to the airway. This procedure has been shown to be successful in treating some OSA patients.
• Tracheostomy, which was at one time considered to be the gold standard of care for OSA before the advent of CPAP. This surgery involves the creation of an opening in the airway below the larynx, bypassing the area of obstruction in OSA. The patient plugs the opening during the day in order to speak, but removes the plug at night in order to sleep. While not a common sleep apnea treatment in modern times, it is still used for very severe cases that cannot be treated in any other way.

The medical treatment for OSA is to manage the collapse of the airway with a column of pressurized air delivered by a continuous positive airway pressure machine. The air is delivered through the nose or mouth, usually at a pressure of around 10 cm H₂O. The air is delivered through a length of 6-foot tubing to a mask that patients attach to their face with headgear.

There are many common problems that could make CPAP uncomfortable and a challenge for patients to wear. In fact, many patients refuse to pursue diagnostic testing of sleep apnea because they have a negative attitude toward the condition and would not want to use a CPAP machine. In addition, they may believe CPAP is the only way to treat OSA.

CPAP is a very important sleep apnea solution, particularly as the severity of the condition increases. Adherence also improves as the patient feels therapy benefits, such as reduced daytime sleepiness and improved ability to manage comorbid conditions.

Often, CPAP-compliant patients will not allow themselves to even nap without the device. It is important to remember, however, that the CPAP machine is useless when electrical power is unavailable due to bad weather or when the patient is engaged in an activity like camping.

It is widely understood that the key elements in CPAP treatment are the mask as well as the headgear that holds the mask in place. If the mask is ill-fitting or improperly adjusted, air can be redirected into the eyes, or the hard plastic part of the mask can make contact with the face or forehead, which can lead to painful sores and marks on the skin.

Dental treatment of mild to moderate obstructive sleep apnea is based on a fundamental physiological principle. The tissues, muscles and ligaments of the oropharynx are attached to or affected by the position of the jaw. In very simple terms, moving the jaw forward with a mandibular advancement device and holding it there during sleep puts lateral tension on these structures, which splints the airway open so that it is less prone to collapse.

When the airway is splinted open in this way, the obstructive sleep apnea is treated and most, if not all, of the symptoms are resolved. Patients respond well to this therapy. The dental device is very comfortable; it just feels like wearing two nightguards to bed. Treatment can be delivered in any dental office with common materials that are used in the practice of general dentistry.

MADs like the Silent Nite^® Sleep Appliance, EMA^® appliance, OASYS Hinge Appliance^™, dreamTAP^™ and TAP^® 3 TL all achieve this effect, but in different ways:

• Silent Nite and EMA devices use traction to pull the jaw forward.
• The OASYS Hinge Appliance uses compression to push the mandible forward.
• TAP appliances are anterior mid-point devices that use traction to pull the jaw forward without impeding the free lateral movement of the mandible for patients with parafunctional jaw disorders.

All of these sleep apnea solutions can be adjusted after delivery, so it is very uncommon to require a remake for fit or clinical reasons.

The best sleep apnea solution is generally considered to be the one the patient will use all night, every night. Surgery is by far the easiest solution to be compliant with because once the procedure is complete, the anatomical structures are changed forever. The medical literature suggests that the net effect on sleep apnea for these surgical treatments is very low, except for MMA, which is the most invasive surgical procedure.

CPAP is an excellent therapy for patients once they get used to wearing the mask and headgear. It is important to know that sleep physicians use CPAP in their diagnostic procedures, so the titration and efficacy are known before the patient starts therapy at home. Unfortunately, adherence to CPAP is a challenge frequently encountered in clinicians’ offices, with adherence rates generally ranging from 30% to 60%.

Oral appliances prescribed and delivered by a dentist have been found to be very effective, with a high compliance rate. One study found that patients were able to sustain wearing their appliance all night long about 90% of the time. Most patients adapt to a sleep appliance within a few nights of sleep. Treatment can be inexpensive and outcomes are excellent for patients suffering from mild to moderate OSA.

As mentioned above, sleep apnea sufferers often present as healthy individuals and are unaware of their condition. It is critical that the wide array of sleep apnea solutions be presented because they can be used individually or together to achieve an effective OSA treatment.

Looking for a hands-on tool to enhance your communication with patients? Available for dental practices, the Sleep Appliance Sample Kit helps patients learn about various sleep devices during consultation. For more information or to order the kit, call 888-303-3975.