Obstructive sleep apnoea (OSA) can have potentially serious effects on your physical health and subsequently, impede on your ability to carry out day-to-day tasks. S4S Dental's expert, Professor Ama Johal answers Anetha at Celebrity Angels questions about treating obstructive sleep apnoea, risk factors for OSA and the benefits of dental appliances in the treatment of OSA.
What is obstructive sleep apnoea (OSA)?
Obstructive sleep apnoea is a serious sleep-related breathing disorder in which the upper airway repeatedly collapses, impairing the passage of oxygen, with significant co-morbidity, excessive daytime sleepiness and impaired quality of life for both the patient and their family.
How big a problem is OSA?
OSA predominately affects males, but with increasing age and post-menopause, the prevalence in general and in females particularly increases. Based on a recent UK wide survey, it is estimated that approximately 12 percent of middle-aged adults are affected, with a significant proportion remaining undiagnosed.
What is the common experience of obstructive sleep apnoea?
Patients suffering from OSA typically demonstrate a combination of nocturnal and daytime symptoms. Of the night-time symptoms, loud frequent snoring is a key disruptive factor to the sleeping partner and family, but the interrupted sleep and consequent excessive daytime sleepiness is the principle matter of concern to the patient.
If left neglected, what are the short and long-term consequences of sleep apnoea on an individual’s health?
Both the short- and long-term consequences of untreated obstructive sleep apnoea can have a very detrimental health effect for both the patient and their partner. Due to the impaired levels of oxygen and build-up of carbon dioxide, which result from the repeated collapse of the upper airway, significant negative cardiovascular effects have been reported. Association to hypertension, stroke, weight gain, impaired brain functioning and type II diabetes all been reported in the literature. Of equal importance are the effects of excessive daytime sleepiness on the patient’s ability to concentrate and associated risk of a road traffic accident.
Are there any risk factors that can increase an individual’s likelihood of experiencing obstructive sleep apnoea?
This is an interesting question and one that has attracted a lot of research. The precise cause of the collapse of the upper airway in OSA remains complex and multifactorial - we are aware of a number of aggravating factors which can exacerbate the condition. These include: sleeping on your back [promotes the tongue to fall back], obesity [with consequent further narrowing of the airway through fat deposition]; alcohol & central nervous system depressants e.g. antidepressants & sleeping tablets [natural muscle relaxant which impairs the airway's ability to remain patent], and smoking [causes oedematous change in the upper airway].
What are the most common treatment methods used to relieve symptoms of OSA?
The approach to managing OSA tends initially to focus on behaviour management, which is primarily directed at eliminating the aggravating factors. This can be challenging for patients, in particular weight loss, given that they are suffering from excessive tiredness already, so this approach is better integrated with active treatment, which essentially can be non-surgical or surgical therapy. The evidence in relation to surgery directed at the soft tissues of the upper airway or skeletal surgery remains relatively inconclusive, with impressive short-term results being seen but questionable long-term outcomes. Therefore, International guidelines advocate the use of continuous positive airways pressure [CPAP], delivered by means of a facemask, for severe OSA and symptomatic patients, or a custom-made mandibular advancement appliance [MAA] for patients with mild-moderate OSA, if they express preference towards this. Unfortunately, whilst CPAP remains the ‘gold standard’ for treating OSA, its acceptance by patients is low, with poor long-term compliance being demonstrated. Patients have been shown to prefer MAA therapy over CPAP.
How can dental appliances help treat obstructive sleep apnoea?
Custom-made mandibular advancement appliance [MAA] have been shown to be effective in the management of OSA both in the short- and long-term and as the alternative therapy for those patients unable to tolerate CPAP. Their principle mode of action appears to be anatomical, by drawing the tongue forwards and thus acting to increase the size of the airway in a three-dimensional capacity. Furthermore, there is evidence to support a potential physiological role, with stimulation of upper airway dilatory muscles. Equally, advancing the mandible places the soft tissues of the upper airway under a degree of stretch and therefore potentially acts to limit their ability to collapse.
How comfortable and convenient are dental appliances designed to treat sleep apnoea?
Custom-made mandibular advancement appliance [MAA] require professional dental input to ensure the patient’s dental and periodontal health are optimal to resist the unwanted negative forces placed on these tissues through MAA use. Their use is contra-indicated in epileptic patients or those with unstable dentitions, and clinicians need to ensure the patient is not suffering from TMJ dysfunction. The current 3rd generation MAA designs permit not only maximum retention but importantly, their ability to permit the patient to incrementally self-adjust in a slow and progressive manner which in turn allows maximum adaption and comfort to the appliance. As a consequence, such appliances are now able to be titrated [advanced] to the specific needs of the patient to maximise their therapeutic benefit. This has meant that many of the previously observed short-term side-effects, such as discomfort in the muscles of mastication, are now negated by this design of MAA.
Can individuals with severe obstructive sleep apnoea benefit from using a dental appliance?
Patients diagnosed with severe OSA are always offered CPAP as the first line choice of treatment due to its proven effectiveness. However, we know that unfortunately patient acceptance and tolerance due to their reported side-effects significantly compromises their use. MAA are acknowledged internationally as the alternative therapy in this group of patients, with research data demonstrating significant favourable effects. Whilst potentially being sub-optimal in their ability to reduce the number of obstructive events taking place, they have been shown to be used for longer periods of time and as such have a very beneficial effect.
As obstructive sleep apnoea is a chronic condition, are dental appliances a suitable long-term treatment method?
The principle challenge for any sleep physician, be they medical or dental, is that both evidence-based CPAP and MAA treatment modalities are life-long and entirely patient dependent for compliance. As such, they require long-term commitment from both the patient and clinician and so the patient’s involvement in the choice of treatment becomes increasingly important. The risk of unwanted tooth movement as a consequence of long-term use of the MAA remains a consideration but repeatedly patients with OSA, and particularly those unable to cope with CPAP, report they are unable to manage without the MAA and are prepared to accept this long-term complication.
How do S4S Dental’s oral appliances for obstructive sleep apnoea differ from other oral methods of treating OSA?
Given the long-term nature of the treatment, it is crucially important that we ensure the appliance is custom-made in such a manner that not only is it well fitting and permits incremental advancement of the mandible but that in an evidence-based world, we are able to support our choice of MAA with sound scientific research demonstrating their effectiveness. S4S is a dedicated laboratory specialising in the manufacture of these appliances, and as such has the necessary breadth of experience to offer this specialist treatment. In addition, they occupy a novel position in the UK, in that they further offer clinicians the training and support to help them navigate this relatively new but exciting branch of dentistry, in which we as a profession have the exciting opportunity to significantly contribute to the welfare of patients, beyond the oral cavity itself.
S4S (UK) Limited is a multi award-winning Dental Laboratory, providing a range of dental appliances for the treatment of Snoring, Sleep Apnoea, Bruxism and Orthodontics. Working with partner companies, S4S Dental aims to deliver a viable solution for the analysis and treatment of these dental disorders, through educating dentists on the efficiency of their products, building partnerships with key industry players, championing the individuals impacted by snoring, sleep apnoea and bruxism, alongside supplying products that are clinically effective, comfortable and generate value for money.