Exploring the Connection between Sleep Apnea and Heart Disease

According to a study presented at the 2010 meeting of the Radiological Society of North America (RSNA), people with obstructive sleep apnea (OSA) tend to have more extensive and noncalcified coronary plaque. Recent studies have linked sleep apnea with coronary artery disease, and we have long known about the connection between sleep apnea and heart disease. To attempt to explore the mechanism for the connection between sleep apnea and heart disease, researchers looked at the coronary arteries of 49 people with sleep apnea and 46 people without. All patients had complained of atypical chest pain or had prior equivocal physiological testing. Here are the results of the imaging:

Extent of Coronary Artery Disease	OSA	No OSA
One-vessel CAD	6%	15%
Two-vessel CAD	27%	7%
Three-vessel CAD	22%	13%
Four-vessel CAD	33%	24%

 

The trend had a significance of p=0.0017. In addition, the imaging showed that OSA sufferers were more likely to have noncalcified and mixed plaque, or buildup in the arteries. These soft plaques are more likely to break loose to cause acute cardiac events, such as a heart attack or sudden cardiac death.

The results of this study are compelling, and another good reason why people should seek treatment for sleep apnea early, before they develop life-threatening coronary artery disease. The main weakness of this particular study is that the body mass index of the two populations may have been a significant confounder. The average BMI of the OSA population was 33 whereas that of the non-OSA population was only 30, a potentially significant difference that was not addressed in press releases about the study. Nonetheless, the connection between cardiac death and sleep apnea continues to strengthen.

If you think you may suffer from sleep apnea, you are encouraged to seek treatment that works. To learn more about the full range of treatment options, please contact a local sleep dentist today.

CPAP NOT WORKING? WHAT TO DO WHEN YOUR CPAP DOESN'T IMPROVE YOUR SYMPTOMS.

CPAP is extremely successful at treating sleep apnea. Why do 60% of patients abandon such a successful treatment?

There are many reasons given by patients, but a very common response is that their CPAP did not work? When patients report that their CPAP does not work they usually mean that the symptoms of sleep apnea were not relieved. They may still be tired or wake with morning headaches. Often they find that they cannot sleep with the CPAP or they actually had their sleep disturbed by CPAP.

It is not uncommon to see patients who no longer have sleep apnea but have as many arousals as they did before CPAP. Some patients display a higher arousal index with CPAP than with their apnea untreated.

Another common problem is complex sleep apnea where following treatment with CPAP there is breakthru central sleep apneas. These may be due to over-titration of the CPAP pressure blowing off the CO2 (carbon dioxide) which decreases the urge to breathe.

THE MOST COMMON REASONS TO ABANDON CPAP ARE ABOUT COMFORT NOT THAT CPAP IS INEFFECTIVE! I HATE CPAP! is a common complaint.

Many patients complain about mask comfort. Some patients have acne, facial irritation or rashes from the masks. Other patients have trouble being tethered to the hose while others complain about CPAP noise.

Whatever the complaint if CPAP is ineffective or the patient cannot tolerate it an alternative to CPAP is important. Oral Appliances are considered a first line treatment for mild to moderate sleep apnea that patients almost always prefer to CPAP. Oral Appliances are not a first line treatment for severe sleep apnea but are considered an alternative to CPAP when patients cannot tolerate CPAP.

The severity has little effect on how well patients tolerate CPAP and so it can be expected that 60% of severe apneics will also abandon CPAP use.

Medicare is now going to accept the use of oral appliances for treating severe sleep apnea after CPAP fails.

Women and Sleep Apnea

Although men are more likely to suffer from sleep apnea, women can also suffer from this deadly condition. In fact, sleep apnea is likely underdiagnosed in women. While some sleep centers report seeing 8 or 9 men for every one woman, the actual proportion of sleep apnea sufferers who are women is more likely 33-45%. One reason why women may be underdiagnosed with sleep apnea is that men are more sound sleepers and may not notice disturbances in their partner's sleep. Also, because some physicians think of sleep apnea as a man's disease, women who report common sleep apnea symptoms (fatigue, daytime sleepiness, mood changes, waking with headaches), are often misdiagnosed with:

• Anemia
  
• Depression
  
• Overwork or overstress
  
• Fibromyalgia
  
• Insomnia
  
• Hypothyroidism
  
• Menopausal changes or other hormonal conditions
  

Or they may be told they are hypochondriacs with nothing wrong. Overall, the main symptoms of sleep apnea were the same for men and women, but women were more likely to report morning headaches, while men were more likely to report dry mouth in the morning. Women with sleep apnea are more likely to have depression than men.

However, because sleep apnea is misdiagnosed or underdiagnosed in women, there is not enough data about the condition's different effects on men and women. However, what data there is suggests that the mortality rate for women for the dangers of sleep-apnea may actually be higher.

If you are a woman suffering from depression, daytime sleepiness, fatigue, or other conditions, you should consider the possibility that you have sleep apnea. To learn more, please contact a local sleep dentist today.

Chronic Cough? Sleep apnea evaluation is probably indicated according to new article in Journal Cough.

A new article in the Journal Cough suggests that patients with chronic cough should be evaluated for obstructive sleep apnea (OSA). The article "Chronic cough and obstructive sleep apnea in a community-based pulmonary practice." details evaluation of 75 chronic cough patients. 38 of these patients were evaluated for OSA and 33 were positve for OSA. That translates into 44% of all patients had OSA. That also translates into over 86% of patients with a chronic cough were positive for sleep apnea. The authors also reported "93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough" which is an incredible relief. This is especially true since CPAP causes cough in some patients. The patients who did not get relief from CPAP should be evaluated on an oral appliance. Oral Appliances are better tolerated than CPAP by the majority of patients with obstructive sleep apnea.

The article Quantifying chronic cough: objective versus subjective measurements." from Respirology. 2010 Nov 5 discusses counting coughs and this approach could be used in patients to see if there is a circadian pattern to the coughs in apnea vs non-apnea patients. The authors stated "Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity" .

A major fault of the authors, Sundar KM, Daly SE, Pearce MJ, Alward WT was that they did not go back and evaluate the other 37 patients for sleep apnea. I assume that the other patients were not "typical" sleep apnea patients but many patients with sleep apnea do not fit the typical pattern of obese, thick neck and older male patient. If the 86% OSA figure was consistent throughout the Chronic cough population than perhaps chronic cough would be an absolute indication for sleep apnea testing.

Another interesting correlation would be to GERD (gastroesophageal reflux) and OSA which is a known risk factor for GERD. GERD accounted for 37% of cough population as a single etiology but GERD was also involved in multiple etiologies cough in 31 of the 75 patients. Multiple etiologies for the chronic cough included: GERD-upper airway cough syndrome (UACS), 31%, GERD-cough variant asthma (CVA), 5%, and GERD-UACS-CVA 3%

There is a commonality between cough, breathing, TMJ disorders and oral and pharyngeal reflexes. These reflexes that control breathing and pharyngeal structures are well described by A J Miller in "ORAL AND PHARYNGEAL REFLEXES IN THE MAMMALIAN NERVOUS SYSTEM: THEIR DIVERSE RANGE IN COMPLEXITY AND THE PIVOTAL ROLE OF THE TONGUE"

I have frequent references to his work in the www.ihateheadaches.org site and the www.ihatecpap.com site. These reflexes have direct effects on swallowing and breathing two essential functions of the jaws, tongue and oral cavity. Chronic misuse of these structures leads to repetitive strain injuries to the muscles and joints. These are frequently lumped into a junk diagnosis of TMJ, TMD, MPD, myofascial pain, Myofacial pain and are associated with sleep disorders, chronic pain, fibromyalgia and other central sensitization disorders involving the trigeminal nerve.

Cough. 2010 Apr 15;6(1):2.
Chronic cough and obstructive sleep apnea in a community-based pulmonary practice.
Sundar KM, Daly SE, Pearce MJ, Alward WT.

Intermountain Utah Valley Pulmonary Clinic, 1055N, 300W, Provo, UT 84604, USA. krishna.sundar@imail.org
Abstract
BACKGROUND: Recent reports suggest an association between unexplained chronic cough and obstructive sleep apnea (OSA). Current guidelines provide an empiric integrative approach to the management of chronic cough, particularly for etiologies of gastroesophageal reflux (GERD), upper airway cough syndrome (UACS) and cough variant asthma (CVA) but do not provide any recommendations regarding testing for OSA. This study was done to evaluate the prevalence of OSA in patients referred for chronic cough and examine the impact of treating OSA in resolution of chronic cough.

METHODS: A retrospective review of chronic cough patients seen over a four-year period in a community-based pulmonary practice was done. Patients with abnormal chest radiographs, abnormal pulmonary function tests, history of known parenchymal lung disease, and inadequate followup were excluded. Clinical data, treatments provided and degree of resolution of cough was evaluated based on chart review. Specifically, diagnostic testing for OSA and impact of management of OSA on chronic cough was assessed.

RESULTS: 75 patients with isolated chronic cough were identified. 44/75 had single etiologies for cough (GERD 37%, UACS 12%, CVA 8%). 31/75 had multiple etiologies for their chronic cough (GERD-UACS 31%, GERD-CVA 5%, UACS-CVA 3%, GERD-UACS-CVA 3%). 31% patients underwent further diagnostic testing to evaluate for UACS, GERD and CVA. Specific testing for OSA was carried out in 38/75 (51%) patients and 33/75 (44%) were found to have obstructive sleep apnea. 93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough.

CONCLUSIONS: OSA is a common finding in patients with chronic cough, even when another cause of cough has been identified. CPAP therapy in combination with other specific therapy for cough leads to a reduction in cough severity. Sleep apnea evaluation and therapy needs to considered early during the management of chronic cough and as a part of the diagnostic workup for chronic cough.

PMID: 20398333 [PubMed]PMCID: PMC2861010Free PMC Article

Respirology. 2010 Nov 5. doi: 10.1111/j.1440-1843.2010.01893.x. [Epub ahead of print]
Quantifying chronic cough: objective versus subjective measurements.
Faruqi S, Thompson R, Wright C, Sheedy W, Morice AH.

Division of Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, United Kingdom. HU16 5JQ.
Abstract
Background and objective: The assessment of chronic cough has been improved by the development of objective ambulatory cough monitoring systems and subjective quality of life questionnaires. Experimental induction of cough is a useful tool in the assessment of the cough reflex. We wanted to assess the reproducibility of and association between these measurements. Methods: This was a prospective observational study in patients with chronic cough of greater than six months duration. All patients had an initial 24 hour cough recording. They also completed a Leicester Cough Questionnaire, a Symptom Assessment Score, a Visual Analogue Score for cough and had a capsaicin cough challenge performed. They were reviewed at 8 weeks when all assessments were repeated. Results: The study included 25 patients (15 females) with a mean age of 54 years. The median cough count at the second visit (302) was significantly lower compared to the first visit (381, p<0.01). However the cough counts at both the visits correlated well (r=0.9. p<0.01).All the other forms of assessment were found to be highly reproducible at 8 weeks (r= 0.6-0.9, p<0.01). Cough counts correlated well with the other forms of assessment (r= 0.4-0.6, p<0.01). There was good correlation between each of the subjective forms of assessment (r= 0.6, p<0.01). Conclusions: The various forms of assessment of cough are reproducible. Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity. It appears to lie between these latter two assessments of cough and may represent the best global objective synthesis of cough.

© 2010 The Authors. Respirology © 2010 Asian Pacific Society of Respirology.
PMID: 21054670 [PubMed - as supplied by publisher]

WHAT IS THE GOLD STANDARD OF TREATMENT FOR SLEEP APNEA?

THE QUESTION OF WHAT IS THE BEST SLEEP APNEA TREATMENT IS ACTUALLY A VERY POOR QUESTION. THE CORRECT QUESTION IS WHAT IS THE BEST SLEEP APNEA TREATMENT FOR A SPECIFIC PATIENT. Most patients prefer oral appliances to CPAP.

CPAP or Continuous Positive Air Pressure has long been considered the "Gold Standard" for treating sleep apnea. It is extremely effective when patients use it but patient compliance has always been a major problem It is interesting that the NHLBI lists oral appliances before CPAP. (See website info below) but also says that oral appliances are for mild apnea and snoring while it has now been shown that when properly titrated Oral Appliances are equally effective to CPAP for treating mild to moderate sleep apnea. Oral Appliances are also considered to be an alternative to CPAP when it is not tolerated.

The NHLBI website states
"The goals of treating sleep apnea are to:
Restore regular breathing during sleep
Relieve symptoms such as loud snoring and daytime sleepiness
Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes."

Approximately one in four CPAP users actually meet those goals. Those patients generally adapt easily to CPAP and rarely go without using it. 60% of patients abandon CPAP entirely and 15% struggle with it and use it in less that effective manner. It is the 75% that are not adequately treated with CPAP that usually utilize oral appliances or surgery. Oral Appliances are also not tolerated by everyone and patients need significant numbers of teeth or implants to use many types of appliances. While most patients prefer oral appliances to CPAP there are some patients who do not tolerate appliances and must seek alternative treatments.

This Goal statement is a very interesting statement. Is use of CPAP a restoration of "Normal Breathing" or "Regular Breathing" ? I would propose that an effectively titrated oral appliance actually restores both regular and normal breathing. CPAP breathing is not "normal" trhough it may be regular. BiPAP breathing is probably closer to "normal" breathing.

Secondly treatment should relieve snoring and daytime sleepiness. Daytime sleepiness is an interesting aspect as it can be measured subjectively (patient opinion) or objectively by MSLT (multiple sleep latency test) or MWT (Maintenance of Wakefulness Test)

Patients utilizing oral appliances frequently report being more rested with an oral appliance than when treated with CPAP even when the CPAP machine gave more complete resolution of AHI. This may be a difference between regular and normal breathing.

The statement "Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes" is extremely important. Treatment of sleep apnea has numerous health benefits. These benefits are achieved with CPAP, Surgery and Oral Appliances.

The NHLBI site also discusses that some patients may benefit from surgery. It is important to note that the surgery must meet the goals stated. Soft palate surgery does not restore regular breathing and should be cosidered adjunctive surgery not curative surgery.


THE FOLLOWING INFORMATION IS TAKEN FROM THE NATIONAL HEART LUNG AND BLOOD INSTITUTE WEBSITE http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html

How Is Sleep Apnea Treated?

Lifestyle changes, mouthpieces, breathing devices, and surgery are used to treat sleep apnea. Medicines typically aren't used to treat the condition.

The goals of treating sleep apnea are to:

Restore regular breathing during sleep
Relieve symptoms such as loud snoring and daytime sleepiness
Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes.

If you have sleep apnea, talk with your doctor or sleep specialist about the treatment options that will work best for you.

Lifestyle changes and/or mouthpieces may be enough to relieve mild sleep apnea. People who have moderate or severe sleep apnea may need breathing devices or surgery.

If you continue to have daytime sleepiness despite treatment, your doctor may ask whether you're getting enough sleep. (Adults should get at least 7 to 8 hours of sleep; children and adolescents need more.)

If treatment and enough sleep don't relieve your daytime sleepiness, your doctor will consider other treatment options.

Lifestyle Changes

If you have mild sleep apnea, some changes in daily activities or habits may be all the treatment you need.

Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep.
Lose weight if you're overweight or obese. Even a little weight loss can improve your symptoms.
Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
Keep your nasal passages open at night with nasal sprays or allergy medicines, if needed. Talk with your doctor about whether these treatments might help you.
If you smoke, quit. Talk with your doctor about programs and products that can help you quit smoking.
Mouthpieces

A mouthpiece, sometimes called an oral appliance, may help some people who have mild sleep apnea. Your doctor also may recommend a mouthpiece if you snore loudly but don't have sleep apnea.

A dentist or orthodontist can make a custom-fit plastic mouthpiece for treating sleep apnea. (An orthodontist specializes in correcting teeth or jaw problems.) The mouthpiece will adjust your lower jaw and your tongue to help keep your airways open while you sleep.

If you use a mouthpiece, tell your doctor if you have discomfort or pain while using the device. You may need periodic office visits so your doctor can adjust your mouthpiece to fit better.

Breathing Devices

CPAP (continuous positive airway pressure) is the most common treatment for moderate to severe sleep apnea in adults. A CPAP machine uses a mask that fits over your mouth and nose, or just over your nose. The machine gently blows air into your throat.

The air presses on the wall of your airway. The air pressure is adjusted so that it's just enough to stop the airways from becoming narrowed or blocked during sleep.

Treating sleep apnea may help you stop snoring. But not snoring doesn't mean that you no longer have sleep apnea or can stop using CPAP. Sleep apnea will return if CPAP is stopped or not used correctly.

Usually, a technician will come to your home to bring the CPAP equipment. The technician will set up the CPAP machine and adjust it based on your doctor's prescription. After the initial setup, you may need to have the CPAP adjusted on occasion for the best results.

CPAP treatment may cause side effects in some people. These side effects include a dry or stuffy nose, irritated skin on your face, dry mouth, and headaches. If your CPAP isn't adjusted properly, you may get stomach bloating and discomfort while wearing the mask.

If you're having trouble with CPAP side effects, work with your sleep specialist, his or her nursing staff, and the CPAP technician. Together, you can take steps to reduce these side effects. These steps include adjusting the CPAP settings or the size/fit of the mask, or adding moisture to the air as it flows through the mask. A nasal spray may relieve a dry, stuffy, or runny nose.

There are many types of CPAP machines and masks. Tell your doctor if you're not happy with the type you're using. He or she may suggest switching to a different type that may work better for you.

People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP.

Surgery

Some people who have sleep apnea may benefit from surgery. The type of surgery and how well it works depend on the cause of the sleep apnea.

Surgery is done to widen breathing passages. It usually involves shrinking, stiffening, or removing excess tissue in the mouth and throat or resetting the lower jaw.

Surgery to shrink or stiffen excess tissue in the mouth or throat is done in a doctor's office or a hospital. Shrinking tissue may involve small shots or other treatments to the tissue. A series of such treatments may be needed to shrink the excess tissue. To stiffen excess tissue, the doctor makes a small cut in the tissue and inserts a small piece of stiff plastic.

Surgery to remove excess tissue is done in a hospital. You're given medicine that makes you sleep during the surgery. After surgery, you may have throat pain that lasts for 1 to 2 weeks.

Surgery to remove the tonsils, if they're blocking the airway, may be very helpful for some children. Your child's doctor may suggest waiting some time to see whether these tissues shrink on their own. This is common as small children grow.

Somnomed Appliance Caused Patient To Develop "TMJ"

JEFF: I have an oral device (sonomed) for sleep apnea. It gave me TMJ. I haven't been able to tolerate cpap.


Dr Shapira: YOU STATE THAT YOU HAVE A SOMNOMED TO TREAT SLEEP APNEA BECAUSE YOU CANNOT TOLERATE CPAP.
It is excellent that you have chosen to treat the sleep apnea which can cause heart attacks, strokes, memory loss and excessive daytime sleepiness.

YOU THEN STATE THAT YOU DEVELOPED TMJ BUT GAVE NO SPECIFICS AS TO SYMPTOMS. TMJ STANDS FOR TEMPOROMANDIBULAR JOINT, NOT A DISEASE. It is important to understand the SPECIFIC problems so they can be addressed. Patients wearing oral appliances for sleep apnea may experience bite changes or tooth movement but damage should not occur to the joints. It is essential to work with a dentist who has training in treating sleep apnea and TMJ disorders.

ACCORDING TO THE NHLBI SLEEP APNEA IS A TMJ DISORDER. SEE http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf You have actually developed a new symptom from the same disorder but because you didn't specify symptoms I can not specify what to do next.

The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances should be well trained in treating TMJ disorders.

IF YOU CAN GIVE ME SPECIFIC INFORMATION I MAY BE OF MORE HELP. Please review www.ihateheadaches.org to learn about Neuromuscular Treatment of TMJ Disorders, headaches and migraines.

The following is the result of a web form submission from:
comments: I have an oral device (sonomed) for sleep apnea. It gave me TMJ
I haven't been able to tolerate cpap

THIS IS A RECENT NEW POST; I also got tmj from sonomed sleep appliance / it was pulling my jaw forward too much. It clicks when i chew and my ear feels like watery.

DR SHAPIRA RESPONSE: THESE PROBLEMS ARE USUALLLY EASY TO PREVENT OR CORRECT BUT YOU MUST BE PROCACTIVE FROM THE START OF APPLIANCE USE

CPAP Machines Cause Facial Changes

According to research published in the October Issue of the journal Chest, wearing a CPAP mask can change the shape of your face. Researchers in Japan and Canada x-rayed 46 patients (41 men and 5 women, average age56) who were using CPAP machines for treatment of sleep apnea. X-rays were taken before patients started using the machine and after they had used the machine for at least two years (on average 35 months). Although previous research had shown that these changes occurred in children, this is the first time evidence of changes in facial physiognomy have been linked to CPAP use.

According to researchers, the people who used the CPAP machine experienced significant changes in the shape of their dental arches, as well as changes in the relationship between their upper and lower jaws. Several variables contributed to the overall shift of the jaw backward. Although the patients did not self-report the changes in their face shape, the researchers expressed concern at the trend in the changes.

The concern is that by pushing the jaw backward, CPAP may worsen obstructive sleep apnea in the long term. A recessed jaw reduces space for the tongue and may make the tissues of the airway more likely to collapse.

An alternative to CPAP is oral appliance therapy, which works by moving the jaw forward to help keep the airway open. Oral appliances have not been shown to alter the shape of the face or dental arches.

To learn more about sleep apnea treatment options, please talk to a local sleep dentist today.

Oral APPLIANCES AND NASAL CPAP ARE EQUAL IN EFFECTIVENESS ACCORDING TO NEW ARTICLE IN RESPIRATION.

A recent article " Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial" in Respiration compared oral appliance therapy and nasal CPAP therapy in treating mild to moderate sleep apnea. The article looked at carefully controlled studies in which both the CPAP and the oral appliances were carefully titrated. The article concluded that "There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively."

It is important to note that the article clearly states that treatment is equal when there is objective titration of the oral appliances. I have strongly been recommending titration on all oral appliance therapy for over ten years. This is trtuly a landmark study because while CPAP has always been considered "the gold standard for treatment of sleep apnea" that statement is no longer true for mild to moderate sleep apnea.

This study did not cover severe sleep apnea therefore CPAP is still considered the gold standard of treatment for severe sleep apnea and oral appliances are an alternative for patients who do not tolerate CPAP.

The major problem with CPAP has always been low compliance. A recent study showed 60% of patients do not tolerate CPAP treatment. If compliance is factored in then it is clear that oral appliances are now the "Gold Standard" of treatment for mild to moderate sleep apnea.



PubMed abstract:
Respiration. 2010 Oct 20. [Epub ahead of print]ral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial.
Aarab G, Lobbezoo F, Hamburger HL, Naeije M.

Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, Research Institute MOVE, University of Amsterdam and VU University Amsterdam, The Netherlands.
Abstract
Background: Previous randomized controlled trials have addressed the efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA). Their common control condition, nasal continuous positive airway pressure (nCPAP), was frequently found to be superior to MAD therapy. However, in most of these studies, only nCPAP was titrated objectively but not MAD. To enable an unbiased comparison between both treatment modalities, the MAD should be titrated objectively as well. Objective: The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device. Methods: Sixty-four mild/moderate patients with obstructive sleep apnea (OSA; 52.0 ± 9.6 years) were randomly assigned to three parallel groups: MAD, nCPAP and placebo device. From all patients, two polysomnographic recordings were obtained at the hospital: one before treatment and one after approximately 6 months of treatment. Results: The change in the apnea-hypopnea index (ΔAHI) between baseline and therapy evaluation differed significantly between the three therapy groups (ANCOVA; p = 0.000). No differences in the ΔAHI were found between the MAD and nCPAP therapy (p = 0.092), whereas the changes in AHI in these groups were significantly larger than those in the placebo group (p = 0.000 and 0.002, respectively). Conclusion: There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.

Copyright © 2010 S. Karger AG, Basel.
PMID: 20962502 [PubMed - as supplied by publisher]

Did Sleep Apnea Cause the Death of State Representative Donatucci?

 

In the debate about whether CPAP or oral appliances are a better treatment for sleep apnea, sometimes there comes along an opportunity that is too good to miss. Consider, for example, the recent story of the Pennsylvania state representative who died of sleep apnea because the CPAP mask was too uncomfortable to wear.

Or did he? According to reputable sources, the actual cause of Rep. Donatucci's death is currently unknown, but because of its association with sleep apnea and CPAP, the forces of oral appliances have taken up the cause to promote his death as evidence that sleep apnea, and by extension ineffective treatments like CPAP, kills. However, it is unclear that this is the story at all.

Rep. Robert C. Donatucci was a Philadelphia democrat who was overweight and, it seems, had been positively diagnosed with sleep apnea the week before his death. He had been encouraged to try sleep apnea treatment with CPAP, but found the mask too uncomfortable. Instead, he planned to lose weight and try other lifestyle changes to treat his condition. Unfortunately, he died before he was able to lose his weight.

This leads us to two questions: Does sleep apnea kill? And Did sleep apnea kill Rep. Donatucci?

The answer to the first question is yes, although not acutely. Sleep apnea causes physical and psychological problems that increase your risk of all-cause mortality sixfold, according to at least one study. Death could be caused by heart attack, stroke, or other cardiovascular damage related to sleep apnea. Or it could be caused by a car crash, whose risks are increased by the daytime sleepiness that sleep apnea causes.

The answer to the second question is a little harder to come by. We do not have access to the full amount of information we need to answer it. However, it is likely that sleep apnea contributed to the representative's death.

If a person dies only one week after being diagnosed with sleep apnea, it is unlikely that any treatment method could save his or her life. This stresses again the need to undergo a sleep study if you have any of the known risk factors for sleep apnea, including being overweight, snoring, or having daytime sleepiness.

To learn more about sleep apnea diagnosis, please contact a local sleep dentist and head off the dangers before they become irreversible.

Specific Areas of Brain Damage Associated with Sleep Apnea

Italian researchers have identified several regions in the brain that suffer damage as a result of obstructive sleep apnea. They also found that these regions responded to treatment with significant structural recovery.

The researchers matched 17 sleep apnea sufferers with 15 age-matched healthy individuals. All subjects underwent a sleep study, took cognitive tests, and underwent magnetic resonance imaging. Then the sleep apnea sufferers began treatment. Three months later, the tests were repeated.

Initially, the sleep apnea sufferers showed impairment in most cognitive areas, as well as their mood. Many reported sleepiness. They also showed focal reductions in brain matter in the enthorhinal cortex, the left posterior parietal cortex, and the right superior frontal gyrus. The Enthorhinal cortex plays an important role in memory, especially biographical memory. The posterior parietal cortex controls voluntary movements. The superior frontal gyrus has been shown to be involved in self-awareness, mood, laughter, spatial cognition, and working memory. Identifying these damaged regions provides important insight into the mechanisms of sleep apnea's dangers. It shows, too, that there are other potential risks that cannot objectively be measured. With sleep apnea, you may be at risk for losing important parts of your identity and self-awareness.

Fortunately, the researchers also found that treatment of sleep apnea could reverse the damage suffered in these specific regions of the brain. Although the researchers used CPAP as the treatment method, it is likely that other adequate treatment methods like oral appliance therapy could lead to similar reverses.

If you are a sleep apnea sufferer, don't put your life and your personality at risk, get treatment today. To learn more about sleep apnea treatment options, please contact a local sleep dentist today.

Did use of headgear cause sleep apnea problem?

Robert: As a kid, I had to wear head gear to pull my lower jaw back to help correct a slight under bite. Could this adjustment of my mouth/jaw be a factor in my sleep apena.

Dr Shapira response: It is quite possible that the headgear made you more likely to have sleep apnea. What is probably more important was the opportunity to increase your airway during ortho tx.

Orthodontics can ce a complete of partial sleep apnea cure or a major complicating factor.

When orthodontic widening is done at a young age it widens the palate and the floor of the nose. It is recommended that pediatric patients with sleep apnea should have obstructive tonsils and adenoids removed. It is also recommended that a followup sleep study always be done to evaluate residual disease. The majority of patients may benefit from maxillary widening as well.

Some top researchers are recommending that orthodontic widening precede T & A removal to lessen surgical complications and risks.

Treatment of sleep apnea with an oral appliance advances the mandible at night but those changes can become permenant. CPAP tend to act like a Headgear causing backward movement of the maxilla and upper teeth.

All parents contemplating orthodontics for their children should work with growth and development orthodontists who understandf airway and sleep apnea. The outmoded practice of removing permenant bicuspid can produce an orthopedic position more prone to sleep apnea.

Can Carbon Dioxide help treat central and mixed sleep apnea? Should CO2 be added to CPAP Flow to Treat Central Sleep Apnea & Cheyne-Stokes Breathing?

Patients with central and mixed sleep apnea are different than obstructive sleep apnea patients. There has been work done with increased dead space in CPAP units and addition or carbon dioxide to treat central sleep apnea and Cheye-Stokes breathing. It is actually a build-up in CO2 that cause awakening and breathing in all apnea patients.

If Carbon Dioxide can be judiciously supplied to these patients it could solve the problems of central sleep apnea and emerging central apnea in patients treated with CPAP or Oral Appliances.

It may also explain why appliances like the TAP that limit opening seem more effective in some patients than Herbsts, Suad,, or Somnomed appliances. Appliances that allow easier oral opening and breating are more likely to have decreased CO2 levels.

Remember, it is the rise in CO2 (carbon dioxide) that turns on the drive to breathe.

Sleep Apnea Treatment in Children improves Performance and Behavior. Treacher-Collins syndrome is discussed in Cleft Palate Journal

I recently came across an older article on sleep apnea and Treacher-Collins syndrome. The article describes improvements in Behavior and performance after correction of micrognathia. What is startling is that the article was published almost 30 years ago long before most physicians worried about pediatric sleep apnea. We now know that 80% of ADD and ADHD children have sleep apnea. Scalloped tongues are indicative (80% predictive) of sleep apnea.

We now know that all snoring and even the mildest sleep apnea can never be ignored in children. It is a shame how many years were wasted with children waiting to outgrow tonsils or adenoids. If you read the story of my son on the main website I had to fight to have his airway corrected. Even seeking a sleep study was considered for Billy was considered crazy. Now it appears the literature supported treating airway obstructions in children several years prior to my experiences.

I have to wonder what other advances are being ignored or just unknown despite published literature.

I know that headache and pain treatment is currently grossly undertreated by neuromuscular dentistry despite the research and case studies. See http://www.ihateheadaches.org


Cleft Palate J. 1981 Jan;18(1):39-44.
Obstructive sleep apnea in Treacher-Collins syndrome.
Johnston C, Taussig LM, Koopmann C, Smith P, Bjelland J.

Abstract
Studies of the Treacher-Collins syndrome have emphasized hearing and surgical considerations. Although craniofacial anomalies have been associated with respiratory disorders in infancy, the presence of such problems in older children has not been emphasized. An eight-year-old with Treacher-Collins syndrome presented a history of recent behavioral problems at home, poor attention span and performance in school, daytime somnolence, and sleep apnea with relatively long periods of chest movement but no airflow. He also had abnormal sleep behavior consisting of rocking to and fro on his hands and knees, often to such an extent that his nose became abraded. ICU monitoring with observation and recording of sleep patterns and sounds, and fluoroscopy of his upper airway utilizing cineradiography while asleep confirmed the diagnosis of obstructive sleep apnea. The patient subsequently underwent an orthognathic surgery consisting of insertion of rib bone grafts after anterior advancement of his mandible. This procedure resulted in disappearance of the obstructive sleep apnea and associated symptoms. Because of micrognathia, patients with Treacher-Collins syndrome are at high risk for developing obstructive sleep apnea. Surgical correction of their deformities can result in improvement in cosmetic appearance as well as in resolution of the obstructive episodes with improvement in performance and behavior.

CPAP USE CAUSES SIGNIFICANT CHANGES IN POSITION OF BONES OF FACE AND TEETH. THESE CHANGES MAY CAUSE TMJ DISORDERS OR SMASHED FACES.

A new study in Chest shows significant changes in bone and teeth positio secondary to CPAP use. The changes are retropositioning of the upper maxillary teeth and the bones of the face. Smashed Face Syndrome resulting from long term CPAP use could have negative consequences of a cosmetic and physiologic nature.

It is important to note that treatment of sleep apnea is essential and that CPAP and Oral Appliances the only First Line treatments can cause changes. These changes should not be considered a reason to discontinue life-saving treatment with either modality.

The changes that occur with Oral Appliance treatment are not the same as changes that occur with CPAP use. There are ominous problems that could be associated with the CPAP specific changes. These changes could cause worsening of Sleep Apnea if CPAP use is discontinued and even lead to an addiction to CPAP. I have discussed problems with "CPAP Addiction" with Dr Alex Golbin a prominent sleep physician and pioneer of the field of Sleep Medicine.

The change that occured with use of CPAP include "Significant retrusion of the anterior maxilla, a decrease in maxillary-mandibular discrepancy, a setback of the supramentale and chin positions, a retroclination of maxillary incisors, and a decrease of convexity" These findings were visible on cephalometric radiographs but were not reported by patients. All of these changes have the potential to cause TMJ problems, tension headaches and migraines. The changes CPAP cause will lead to retropositioning of the mandible. The changes caused by oral appliances are anterior positioning of the mandible. Studies have shown that these changes do not adversly affect the TM Joints (TMJ). In fact these are the same changes that take place when treating TMJ disorders with a neuromuscular orthotic. Part of the effect of neuromuscular treatment of headaches and migraines (see www.ihateheadaches.org) is thought to be do to improvements in airway and quality of sleep.

Dentists routinely explain to their patients that oral appliances can change bites and move teeth as part of their informed consent for treatment.

The responsibility for informing patients of negative orthopedic changes from CPAP falls on the prescribing physicians and on CPAP manufacturers. The FDA should make device manufcturers include information on this subject in their materials.

Chest. 2010 Oct;138(4):870-4. Epub 2010 Jul 8.
Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea.
Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA.

Department of Oral Health Sciences, The University of British Columbia, Vancouver, BC, Canada. htsuda@dent.kyushu-u.ac.jp
Abstract
BACKGROUND: Many patients with obstructive sleep apnea (OSA) use nasal continuous positive airway pressure (nCPAP) as a first-line therapy. Previous studies have reported midfacial hypoplasia in children using nCPAP. The aim of this study is to assess the craniofacial changes in adult subjects with OSA after nCPAP use.

METHODS: Forty-six Japanese subjects who used nCPAP for a minimum of 2 years had both a baseline and a follow-up cephalometric radiograph taken. These two radiographs were analyzed, and changes in craniofacial structures were assessed. The cephalometric measurements evaluated were related to face height, interarch relationship, and tooth position.

RESULTS: Most of the patients with OSA were men (89.1%), and the mean baseline values for age, BMI, and apnea-hypopnea index (AHI) were 56.3 ± 13.4 years, 26.8 ± 5.6 kg/m(2), and 42.0 ± 18.6/h. The average duration of nCPAP use was 35.0 ± 6.7 months. After nCPAP use, cephalometric variables demonstrated a significant retrusion of the anterior maxilla, a decrease in maxillary-mandibular discrepancy, a setback of the supramentale and chin positions, a retroclination of maxillary incisors, and a decrease of convexity. However, significant correlations between the craniofacial changes, demographic variables, or the duration of nCPAP use could not be identified. None of the patients self-reported any permanent change of occlusion or facial profile.

CONCLUSION: The use of an nCPAP machine for > 2 years may change craniofacial form by reducing maxillary and mandibular prominence and/or by altering the relationship between the dental arches.

PMID: 20616213 [PubMed - indexed for MEDLINE]

Sleep Apnea Elevated in Veterans with PTSD

We know that sleep apnea is commonly correlated with mental health disorders, but until now it was unknown just how strongly the disorder was correlated with post-traumatic stress disorder (PTSD). However, a recent study, conducted by researchers at the Walter Reed Army Medical Center, shows just how close the connection is.

According to the study, 54% of PTSD patients had obstructive sleep apnea, far above the normal population rate of approximately 20%. Furthermore, although the patients were on average slightly overweight (28.91 average BMI), the difference between PTSD patients and the general population was still statistically significant. Also statistically significant was the relative youth of the population compared to the typical age of sleep apnea sufferers. Sleep apnea has been known to be associated with traumatic brain injury, but surprisingly in this population the OSA sufferers were less likely to have traumatic brain injury than the non-sufferers.

One contributing factor was the use of painkillers and sedatives among the veterans with PTSD. But this was not statistically significant.

The study authors noted that one challenge for treating sleep apnea in this group was that compliance with CPAP therapy was potentially even lower than in the general population.

If you are suffering from mild to moderate sleep apnea, there is a more comfortable and easier treatment option. Oral appliance therapy is a treatment option for many obstructive sleep apnea patients. To learn more about sleep apnea and its treatment option, contact a local sleep dentist today.

Inland Empire Sleep Solutions offers alternatives to CPAP for Patients in Washington State and Idaho. Live a Better Life Through Sleep!

Reprinted information from 24/7 Press Release
Inland Empire Sleep Solutions: The Best Sleep Apnea Treatment: CPAP vs. Oral Appliances. A Question of Compliance and Effectiveness. Oral Appliances Win the Compliance Award. Snoring Can Be Cured!

CPAP is considered the gold standard for sleep apnea treatment but poor compliance issues with CPAP often make oral appliances the best sleep apnea treatment. For the morbidly obese patient, CPAP is the best first line treatment.

What is the best sleep apnea treatment? It is not CPAP, according to a recent study that showed 60% of patients abandon CPAP use. At least it is not the best treatment for the 60% of patients who abandoned it. This does not mean CPAP is not the most effective treatment, what it means is no matter how effective a treatment may be, it is a poor treatment if it is not used. Oral appliances are an extremely effective treatment for mild to moderate sleep apnea but less effective for morbidly obese patients and those with severe sleep apnea.

Oral appliances are the "Best Sleep Apnea Treatment" because patients actually use them. Compliance issues have always been the biggest problem with CPAP. Studies have shown most patients quit CPAP completely but even patients who use CPAP average only 4-5 hours/ night 4-5 nights a week. That is not the best treatment but it is better than no treatment. The best site for information on oral appliance therapy and dental sleep medicine is http://www.ihatecpap.com.

Dr Ira L Shapira is a Diplomate of the American Board of Dental Sleep Medicine. He is the president of I HATE CPAP LLC. He is proud to announce a new resource for Washington State and Idaho to help patients with sleep apnea and snoring find solutions. Inland Empire Sleep Solutions http://www.inlandempiresleepsolutions.com/ is bringing the best information on Sleep Apnea Treatment to the Inland Empire region.

Medicare recognized how poor CPAP compliance was and now has minimum usage schedules for CPAP that will save Medicare millions of dollars because such a small percentage of patients actually utilize their machines on a regular basis. Inland Sleep Solutions will feature dental offices where there has been training in Dental Sleep Medicine.

CPAP is the "best treatment" for the 25% of patients who love their CPAP, and use it all night, every night.

Oral appliances may be less effective across a range of all patients at eliminating sleep apnea but they are much more effective at achieving patient compliance. A treatment that is used will always be superior to a treatment that is not used.

Oral appliance success can be greatly improved by titration of appliances in the sleep lab. When an appliance eliminates sleep apnea based on a sleep study it is effectively equivalent to CPAP. The issue of compliance almost always favors oral appliances but objective monitors for oral appliance use are not yet available. They probably will be available in the very near future making oral appliances a leading choice of sleep medicine physicians who care about patients desires.

The best treatment is one that works and is used. For most patients with mild to moderate sleep apnea the best treatment is an oral appliance due to much higher compliance. If compliance is equal and CPAP or appliances are equally effective than both would qualify as the best treatment. The patient can chose their desired treatment. Studies have shown the majority of patients offered a choice prefer a comfortable oral appliance over CPAP.

Some severe sleep apnea patients refuse CPAP, for those patients an oral appliance is superior to "no treatment".

CPAP is almost always the best treatment for the morbidly obese patients but an oral appliance is still better than no treatment if CPAP is refused.

There are patients who are severe and/or morbidly obese and the "best treatment" is actually combination treatment of an oral appliance and CPAP combined. A mask retained by the teeth instead of straps may be considerably more comfortable for many patients and lower pressure from combined use makes CPAP easier to tolerate.

The best treatment may be CPAP but with a custom made nasal mask that is made from an impression of the patients face similar to how dentures are made. Custom masks combined with oral appliances are a new entry in the field coming from airway management.

Cleanliness is of major importance with both CPAP and oral appliance treatments. Dirty masks and hoses can lead to sinus infections, bronchitis and pneumonia while poor oral hygiene with an oral appliance can lead to periodontal disease. Dr Shapira advise all patients to keep their masks and hoses scrupulously clean. It is vital to be just as thorough in cleaning oral appliances and in maintaining oral hygiene care when wearing an oral appliance. They are not well suited for patients who do not regularly brush their teeth.

What is the best CPAP mask for patients who utilize CPAP? Studies have shown that different masks and machines usually do not increase patient compliance but they do increase comfort for patients who actually use CPAP. Other studies have shown that patients' usage of CPAP initially predicts long term compliance with CPAP. Patients who reject CPAP initially rarely embrace CPAP use in the long term. What is the best CPAP mask? A mask the patient actually uses. This will be very patient specific.

What is the best type of CPAP machine? There is standard CPAP machines that come in many styles and shapes. The industry has done a good job of making CPAP machines quieter and smaller. BiPAP machines have lower pressure during expiration that reduces claustrophobic feelings in some patients and often eliminates the sensation of drowning on air. Ramping is a gradual increase in pressure allowing patients to fall asleep prior to pressure increasing. Humidification and heated hoses are also increasing patient comfort. Unfortunately all of these advances have not been shown to increase overall patient compliance.

Servo-ventilation machines are more efficient and effective in treating central sleep apnea, which is a neurological condition where the brain "forgets" to breathe.

The best sleep apnea treatment is always patient specific. The 60% of patients who do not tolerate CPAP will likely find comfortable oral appliances are the best treatment.

A small minority of patients do not tolerate CPAP or oral appliances. The best treatment for these patients may be surgery.

What is the best sleep apnea surgery? The morbidly obese and extremely severe sleep apneics may find that a tracheotomy is the best treatment. Patients breathe through their throat bypassing the pharyngeal blockages. Most patients do not want a trach.

Soft palate surgery is almost never the best sleep apnea treatment. UP3 or Uvulopalatopharyngealplasty is painful and has very high morbidity but more importantly rarely eliminates sleep apnea and patients still require CPAP or oral appliance therapy. Pillars, somnoplasty, LAUP or laser-assisted uvuloplasty are less painful but still ineffective in treating most apnea patients completely.

Maxilo mandibular advancement is extremely effective but is major surgery where the upper jaw (maxilla) is cut loose from the skull and often split in pieces, the lower jaw (mandible) is sectioned into 3 pieces and the hyoid bone is sectioned in pieces and then the patient is wired shut for six weeks. This surgery is often very successful. A geniohyoid surgery is less invasive only splitting the lower jaw in pieces and advancing the chin and tongue. While it is effective in patients with severely recessed lower jaws (weak chin) in most patients it is the "Jay Leno" surgery creating his unique profile.

For severely obese patients with severe sleep apnea bariatric surgery may be the best sleep apnea treatment.

It is also possible to do several tongue reduction surgeries that vary in effectiveness. Dr Shapira suggests that patients attempt CPAP and/or Oral Appliances before considering surgery. Patients with blocked nasal airways frequently improve with partial turbinectomies and correction of deviated septums but while helpful this will usually not eliminate sleep apnea.

Dr Shapira reminds patients of the famous quote: "There is no disease or disorder known to man that can't be made worse by sticking a knife in it." This does not mean to avoid surgery cautions Dr Shapira but rather to approach any surgery with caution and consider the possible problems associated with surgery.

Information on the dangers of sleep apnea, sleep apnea treatment and comfortable oral appliances is available at http://www.ihatecpap.com.

We are currently looking for Dentists with training in Dental sleep Medicine in the following communities. Dentist wishing to become part of the program can contact Meg at meg@hamiltonsaunderson.com

Washington State
Clarkston
Colfax
Ellensburg
Ephrata
Kennewick
Moses Lake
Pasco
Pullman
Richland
Ritzville
Spokane
Spokane Valley
Walla Walla
Washougal
Wenatchee
Yakima
Idaho
Coeur d'Alene
Lewiston
Moscow
Priest Lake

Videoendoscopy for Locating Source of Obstructive Sleep Apnea

There are many potential treatments for obstructive sleep apnea, including oral appliances, CPAP, and surgery. These treatments all attack sleep apnea from a different angle, and all are slightly different in their effectiveness at targeting different types of obstructive sleep apnea. Obstructive sleep apnea is often categorized into three different types. Type I is when the airway collapses in the retropalatal region (the upper airway between the nose and mouth). Type II is when the airway collapses in both the retropalatal region and the retroglossal region(the part of the airway behind the tongue, sometimes called the retrolingual region), and type III is when the collapse occurs only in the retroglossal region.

Now a new study has proven the effectiveness of videoendoscopy for identifying the regions of the airway most likely to collapse during apneic events. In this technique, a flexible fiber optic camera is inserted into the airway with the patient at the seated erect position and then at the reclined position and the change in the width of the airway between these two positions. In the study, performed by researchers from the University Sains Malaysia, it was shown that nearly 85% of the patients had significant obstruction in the retropalatal region (i.e. were likely either type I or type II obstructive sleep apnea sufferers) .

The significance of this proportion is significant because oral appliance therapy is most effective at treating retrolingual OSA, although it has also been shown to improve retropalatal OSA. This means that many people may not get full benefit from this much more comfortable and convenient form of obstructive sleep apnea treatment and may be forced to use either CPAP or surgery.

If you would like to learn more about your sleep apnea and sleep apnea treatment options, please contact a local sleep dentist today.

Preventing Sleep Apnea-Related Postsurgical Complications

People with sleep apnea are more likely than other patient to suffer post-surgical complications related to anesthesia. In order to identify those people at an increased risk for sleep apnea, doctors are now considering using a simple 8-item questionnaire. The questionnaire, known as the STOP-BANG tool. This tool is a revised version of the earlier STOP sleep apnea screening tool, and has been shown to be more effective.

I n a recent study, people with high scores on the STOP-BANG test were more than 10 times more likely to have postsurgical complications than those with low scores (19.6% vs. 1.3%). People with high STOP-BANG scores also tended to have longer hospitals stays (mean of 3.6 days vs. 2.1 days). The questionnaire augments the original STOP questionnaire with elements from the Berlin Questionnaire, including body mass index, age, neck circumference, and gender, all of which have been strongly correlated with apnea risk. Overall, combining the STOP-BANG score with the American Society of Anesthesiologists score of 3 or higher had a 91.7% sensitivity in predicting postsurgical complications.

Identifying and treating your sleep apnea can be a matter of life or death, not just for postsurgical complications, but for cardiovascular disease and other serious illnesses. To learn more about diagnosing and treating sleep apnea, please contact IHATECPAP today to find a sleep dentist near you.

Sleep Apnea Can Masquerade as Dementia

As we age, many of us fear losing our mental faculties. Dementia can make us forget our loved ones, have paranoia, lose the ability to distinguish between present and past, or lose the ability to focus or concentrate. However, many people who experience pronounced dementia symptoms may find that their symptoms are due either in whole or in part to obstructive sleep apnea rather than dementia.

Seniors with cognitive problems often experience significantly increased quality of life once they start getting treatment for their sleep apnea. According to researchers in the field, nearly half of all older adults have sleep apnea, and the proportion is even higher among adults that manifest the symptoms of dementia.

The prevalence of sleep apnea in this population is due to a number of factors, including both an increasing tendency to be overweight as well as the weakening of muscles and tissues whose rigidity previously held open the airway at night. The condition is so common among older adults that it may be in large part responsible for the misconception that older adults are supposed to be sleepy during the day.

One of the problems with treating an apneic elderly population experiencing symptoms of dementia is that many do not comply with the typical treatment regimen of CPAP. Although many seniors were able to use CPAP, they did not use it for the recommended time overnight, and others simply cannot use it enough to get the full benefit. This makes it important that seniors consider all possible sleep apnea treatment options.

Furthermore, doctors recommend that "Any time there are symptoms of dementia, you should think about sleep apnea and discuss it with your doctor."

If you or a loved one suffers from dementia and you would like to talk to a local sleep dentist about sleep apnea diagnosis and treatment, please contact IHATECPAP today.

FMCSA Rules Present Challenges for Dental Appliance Therapy

At a September 28 meeting considering a 2009 fatal large truck accident in Oklahoma, the National Transportation Safety Board (NTSB) cited mild obstructive sleep apnea as a contributing factor to the driver's fatigue. The accident that killed ten people were killed and six people (including the truck driver) were injured. This tragic accident might have been prevented if the driver's sleep apnea had been treated, making him less susceptible to fatigue while driving.

Commercial drivers with sleep apnea are twice as likely to be involved in an accident, according to studies cited by the Federal Motor Carrier Safety Administration (FMCSA). Treatment of sleep apnea virtually eliminates this increased risk, but so far the only permissible treatment for commercial motor vehicle drivers is CPAP. Although surgery is considered a possible treatment for obstructive sleep apnea, many surgery patients still need CPAP after surgery.

Although FMCSA advisers considered dental appliance therapy, the alternative was rejected because:

• Randomized clinical studies did not show it reduced crash risk
  
• Compliance monitoring is a challenge
  

Therefore, in order to prove that dental appliances are an acceptable treatment option for truck drivers, advocates must overcome these two objections. Continued studies can probably overcome the first challenge, but the second is harder, although some appliances might be modifiable with pressure-sensors to monitor that they are being used.

Although dental appliances are not approved for use by commercial truck drivers, they have been shown to be an effective treatment for mild to moderate sleep apnea for most people. To learn more about this alternative to CPAP treatment, please contact a local sleep dentist today.

DEPRESSION AND SLEEP APNEA: RESEARCH SHOWS SLEEP APNEA TREATMENT MAY RESOLVE RESIDUAL DEPRESSIVE SYMPTOMS. CPAP and Oral Appliances are indicated

A new study "Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms." (see abstract below) suggests that treatment of sleep apnea will aid in resolution of symptoms. While this study used CPAP, Oral Appliances should have identical results.

The study concludes that "The results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.

Another study "Obstructive sleep apnea and depression." (see abstract below) reports 21-41% depression in sleep pne patients. It sites a previous study that lists sleep apnea as a risk factor for depression. It is not surprising that " Patients who have depression as well as OSA appear worse off than those with OSA only" ties together symptoms and treatments of sleep apnea, headaches and depression.

An opinion statement in Curr Treat Options Neurol. 2010 Jan;12(1):1-15 on on "SLEEP AND HEADACHES" ties together headaches, psychiatric problems and sleep apnea but stops short of what the NHLBI report that focuses on masticatory/trigeminal orgin of these problems.

The NHLBI published a report on the "CARDIOVASCULAR AND SLEEP RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" THAT LOOKS AT MASTICATORY SYSTEM AS A COMMON CAUSE OF SLEEP APNEA, HEADACHES AND MANY OTHER PROBLEMS. Shimshak et al published two articles in Cranio that showed a 200-300% increase in medical costs in every field of medicine in patients diagnosed with TMJ disorders. This would include headache, migraine, depression and other diverse conditions.

The National Heart Lung and Blood Institue report states:
"The term TMD refers to a collection of medical and dental conditions affecting the temporomandibular joint (TMJ) and/or muscles of mastication, as well as contiguous tissue components. Symptoms range from occasional discomfort to debilitating pain and severely compromised jaw function. The masticatory apparatus is not only involved in chewing and swallowing but also in other critical tasks, including breathing and talking. Specific etiologies such as trauma and degenerative arthritides underlie some forms of TMD but there is no common etiology or biological explanation. TMD is hence comprised of a heterogeneous group of health problems whose signs and symptoms are overlapping but not identical.
Although broad longitudinal and cross-sectional epidemiological studies have not been carried out, TMD is estimated to affect about 12% of the general population, representing more than 34 million Americans. The majority of those seeking treatment are women in their reproductive years. As for many other pain conditions, the clinical scenario of TMD also tends to be more severe in women than men. TM disorders are considered a serious health problem because many individuals lose their ability to hold regular jobs and to function productively even within the context of a household environment.

The report talks about symptoms including "TMD has been used to characterize a wide range of conditions diversely presented as pain in the face or jaw joint area, masticatory muscle pain, headaches, earaches, dizziness, limited mouth opening due to soft or hard tissue obstruction, TMJ clicking or popping sounds, excessive tooth wear and other complaints."

The report also discusses effects on swallowing and breating ease: "There appears to an associated increase in coughing in subjects with sleep apnea. Occlusion of the pharynx can force residual secretions into the glottis and trigger coughing reflexes, swallowing reflexes, and other reflexes that could contribute to the disorganization of breathing during sleep. In addition to the muscles of mastication, the tongue plays an important role in the coordinated events of swallowing and breathing. The integration of breathing and swallowing is tightly linked, and these events in turn are in some manner linked to blood pressure regulation. Each of these pathways has been studied by scientists in individual disciplines, but there is a need for interdisciplinary studies to determine the interactions of the peripheral and central neural pathways controlling breathing, chewing, swallowing, and cardiovascular events. The presence of pain in patients with TMD would be expected to seriously impact upon these reflex and motor pathways. Little is known about the role of tongue position and how this may be altered in subjects with altered jaw location and structure. Sleep state has been shown to alter the central modulation of the coordination of breathing, airway dynamics, swallowing, and associated cardiovascular events. Differences in central modulation of these events in subjects with sleep apnea and TMD need to be evaluated using sleep as a dynamic change in the state of the individual. Cardiovascular, neuroendocrine, respiratory and swallowing alterations in awake and sleeping subjects need to be studied in a systematic manner in both in animal models and human subjects."

There are common developmental aspects that have been well documented between sleep apnea and TMJ disorders. There is an enormous cross over of signs and symptoms as well. While all sleep apnea may not be entirely related to masticatory structures there is unquestionably a large amount of crossover. There is a solid base of evidence based studies showing how airway issues change growth and development. There is also solid evidence based studies on treatment of sleep apnea with appliances that anteriorly position the mandible. there are numerous clinical reports and studies showing treatment of headaches and TMJ disorders with anterior positiong.

Is it time to look at a large proportion of sleep apnea as being related to jaw development. This would make it a treatment that could be treated and corrected by early interventions such as tonsilectomy and maxillary expansion. Maxillary expansion allows the mandible to automatically anteriorly position and frequently grow a healthier airway. A recent study showed that most pediatric patients having tonsils removed should also have expansion. Expansion according to many experts should precede tonsilectomy to reduce post operative risks.

The early correction of airway and jaw disorders could possibly save massive dollars in lifetime medical expenses if we extrapolate from the work of Shimshak. Shimshak did not show a correlation not cause and effect of TMJ disorders to increased medical expenses.

My opinion is that there is a definite cause and effect of TMJ disorders to massive increases in medical expenses. I believe that for the majority of patients sleep apnea are due to masticatory conditions that should be defined as a TMJ disorder. If we define sleep apnea as a TMJ disorder that other problems like ADD and ADHD are secondary TMJ disorders. This would also apply to morning headaches, cardiovascular, neurological, and psychiatric disorders


Sleep Med. 2010 Jun;11(6):552-7. Epub 2010 May 21.
Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms.
Habukawa M, Uchimura N, Kakuma T, Yamamoto K, Ogi K, Hiejima H, Tomimatsu K, Matsuyama S.

Department of Neuropsychiatry, Kurume University School of Medicine, Kurume, Fukuoka, Japan. hmitsu@med.kurume-u.ac.jp
Abstract
BACKGROUND: Although extensive studies have indicated a relationship between obstructive sleep apnea (OSA) and depressive symptoms, the effect of continuous positive airway pressure (CPAP) treatment on residual depressive symptoms in patients with both major depressive disorder (MDD) and coexisting OSA has not been examined.

METHODS: Seventeen patients with continued MDD despite pharmacotherapy such as antidepressants and/or benzodiazepines, who also had comorbid OSA, were required to complete the Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), and Epworth sleepiness scale (ESS) at the commencement of the study and then again after 2 months of CPAP treatment.

RESULTS: BDI and HRSD scores decreased from 19.7 to 10.8 and 16.7 to 8.0 after 2 months of CPAP treatment (both p<0.01). We also found significant correlations among the improvement rates in BDI, HRSD and ESS scores (R=0.86 and 0.75, both p<0.01). The mixed effect model demonstrated a significant ESS effect on BDI and HRSD.

CONCLUSIONS: The results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.

PMID: 20488748 [PubMed - indexed for MEDLINE]

Sleep Med Rev. 2009 Dec;13(6):437-44. Epub 2009 Jul 10.
Obstructive sleep apnea and depression.
Harris M, Glozier N, Ratnavadivel R, Grunstein RR.

Australasian Sleep Trials Network, Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia. melanie.harris@flinders.edu.au
Abstract
There are high rates of depression in people with obstructive sleep apnea (OSA) in both community and clinical populations. A large community study reported a rate of 17% and reports for sleep clinic samples range between 21% and 41%. A large cohort study found OSA to be a risk factor for depression, but we are unaware of any longitudinal study of the reverse association. However correlations have not generally been found in smaller studies. Well-designed longitudinal studies are needed to examine temporal relationships between the two conditions and further research is needed to establish the role of confounders, and effect modifiers such as gender, in any apparent relationship. Symptoms common to OSA and depression, such as sleepiness and fatigue, are obstacles to determining the presence and severity of one condition in the presence of the other, in research and clinically. Sleep clinicians are advised to consider depression as a likely cause of sleepiness and fatigue. Several possible causal mechanisms linking OSA and depression have been proposed but not established. Patients who have depression as well as OSA appear worse off than those with OSA only, and depressive symptoms persist in at least some patients in short term studies of treatment for OSA. Direct treatment of depression in OSA might improve acceptance of therapy, reduce sleepiness and fatigue and improve quality of life, but intervention trials are required to answer this question.

PMID: 19596599 [PubMed - indexed for MEDLINE]

Curr Treat Options Neurol. 2010 Jan;12(1):1-15.
Sleep and headache.
Rains JC, Poceta JS.

Center for Sleep Evaluation, Elliot Hospital, One Elliot Way, Manchester, NH, 03103, USA, jrains@elliot-hs.org.
Abstract
OPINION STATEMENT: Headache has been linked to a wide range of sleep disorders that may impact headache management. There are no evidence-based guidelines, but the authors believe that literature supports the following clinical recommendations: 1. Diagnose headache according to standardized criteria. Specific diagnoses are associated with increased risk for specific sleep and psychiatric disorders. 2. Collect sleep history in relation to headache patterns. Screening questionnaires and prediction equations are cost-effective. 3. Rule out sleep apnea headache in patients with awakening headache or higher-risk headache diagnoses (cluster, hypnic, chronic migraine, and chronic tension-type headache); patients with signs and symptoms of obstructive sleep apnea warrant polysomnography and treatment according to sleep medicine practice guidelines. There is no evidence for suspending conventional headache treatment in suspected or confirmed cases of sleep apnea. Treatment of sleep apnea with CPAP may improve or resolve headache in a subset of patients. The impact on sleep apnea headache of other treatments for sleep apnea (eg, oral appliances, surgery, weight loss) is largely untested. At a minimum, sedative-hypnotic drugs should be avoided in suspected apneics until the sleep apnea is treated. 4. Among patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients. Patients who suffer from chronic migraine or tension-type headache may benefit from behavioral sleep modification. Pharmacologic treatment may be considered on a case-by-case basis, with hypnotics, anxiolytics, or sedating antidepressants used to manage insomnia, tailoring treatment to the symptom pattern. 5. Individuals with chronic headache are at increased risk for psychiatric disorders. Assessment for depression and anxiety may be warranted when either insomnia or hypersomnia is present. Psychiatric symptoms affect the choice of sedating versus alerting versus neutral pharmacologic agents for headache. 6. All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management.

The Inventor of CPAP, Colin Sullivan is speaking on the emerging role of Dental Sleep Medicine in treating Sleep Apnea

I have just received the following post that Colin Sullivan the inventor of CPAP is speaking in Germany at the Dental Sleep Meeting on the Role of Dental Sleep Medicine.

I have heard an unconfirmed rumor that Colin Sullivan the inventor of CPAP actually wears an oral appliance. I have e-mailed him for confirmation but he has not yet replied.

""Dear All,
Next weekend there will be the 10th symposium on dental sleep medicine of our German Academy of Dental Sleep Medicine DGZS in Bremen, Northern Germany.
You find the program here www.dgzs.de/tagungen.

This year I have invited Prof. Colin Sullivan , the CPAP inventor, for the key note lecture to speak to our DGZS dental sleep professionals.

He gave a great lecture at the Asian Sleep conference last year in Osaka and talked about the emerging role of dental sleep medicine.

I have recommended to the AADSM board to invite Prof. Sullivan for the key note lecture in Minneapolis 2011 J

Best regards

Susanne Schwarting""

Is Sleep Apnea the Chief Risk Factor for Coronary Artery Disease?

We have long known that sleep apnea increases a person's risk of coronary artery disease (CAD) and other cardiopulmonary conditions. However, a study presented last week at the European Respiratory Society's 2010 Annual Congress last week shows that of all the associated risk factors, obstructive sleep apnea may be the most common. The results come from the Swedish Randomized Intervention with CPAP in Coronary Artery Disease and Sleep Apnoea [sic] (RICCADSA) trial.

In the study population, 64% of those with CAD had obstructive sleep apnea. This was higher than hypertension (58%) and obesity (28%), commonly recognized risk factors for CAD. However, However, the population that had sleep apnea also tended to have a number of other conditions. The average body mass of sleep apnea patients with CAD was 29.4 vs. 25.5 for those without sleep apnea, and CAD patients with sleep apnea were nearly six times more likely to be obese. Sleep apnea patients were more likely to have hypertension (61% vs. 48%), diabetes (25% vs. 13%), and atrial fibrillation (20% vs. 9%).

Surprisingly, the trial also found a high adherence with CPAP treatment for sleep apnea. Nearly 70% of all patients remained on CPAP at one-year follow-ups.

However, not everyone is comfortable with CPAP, and if you have been prescribed CPAP but are finding it difficult to keep on the treatment, oral appliance therapy may be for you. To learn more about this CPAP alternative, please contact IHateCPAP today.

Problems with TAP 3, What to do?

I am frequently asked questions like the one that follows. There are often many answers to problems. This question is not from one of my patients. I always suggest you discuss all problems with your sleep physician and your dentist.

Question from Phil:
I had been diagnosed with moderate/severe sleep apnea approximately 10 years ago and tried using CPAP as a treatment option. After trying it for a while, I found it to be detrimental to my sleep and noisy both for myself and my wife. Therefore, I first threw the mask off during the night and finally quit alltogether. Since then, I have had multiple back surgeries and a knee replacement which necessitate my taking Advil before sleep in order to eleviate discomfort. I can sleep well most of the time. However, my regular physician recommended that for all of the right reasons, that I have another sleep study done which again confirmed my sleep apnea condition.
As the CPAP and I did not get along the first time, I now chose the 2nd option of an oral device, TAP 3, applied by a certified dentist after fighting with Blue Cross for 11 months before they gave in and agreed to pay. However, the necessary adjustments to allow the desired airflow ha ve proven to hurt my jaw and the long-term side effects can be undesirable as confirmed by my wife as a former dental assistant. What are the thoughts of other users of such a device on the long-term side effects vs. using a CPAP machine which, I understand, have become easier to use since I last tried one?

Dr Shapira Response
Phil,

If you are having jaw pain with the TAP 3 it can be altered occlusally for comfort.(possible posterior stops) More frequently it means you were adjusted forward too fast. You may be able to back it up and bring it forward more slowly. There are long term bite changes and/or tooth movement that are controllable with morning exercises and or retainers.. Studies show no long term joint problems. Approximate 1/2 of patients find changes favorable. Almost all problems are manageable.

It is essential that the apnea be treated. A stroke or heart attack is a lot more serious than a change in bite. Sometimes you can alternate between cpap and applainces. Even though the new CPAP machines and Masks are more comfortable 60% of patients still abandon CPAP treatment.

The Tap 3 can be turned into a TAP-PAP giving you more comfort, lower cpap pressure and less jaw advancement. It can retain your mask with no straps

Most of my patients stay oral appliance therapy long term, though some do alternate with CPAP.

Dr Shapira

"Landmark" New FAA Fatigue Rules Ignore Sleep Apnea

Earlier this month, the Federal Aviation Administration (FAA) announced that it was creating "landmark" new pilot fatigue rules that would "help protect 700 million air passengers each year," but the FAA rules continue to leave these passengers at risk by ignoring the danger of obstructive sleep apnea.

The new rules come from an extensive study of pilot fatigue that began after the crash of Colgan Air flight 3407 in February 2009. A number of safety forums were held and the recommendations of safety and fatigue specialists were consulted. However, although they addressed many key points relevant to pilot fatigue, they ignored the important issue of sleep apnea.

The potential significance of sleep apnea was highlighted by an incident one year before the Colgan Air crash. In February 2008, go! Flight 1002, a short-haul flight from Honolulu to Hilo, Hawaii, flew past its destination when the pilot and copilot both fell asleep for at least 18 minutes. In subsequent investigation, the pilot was found to have undiagnosed obstructive sleep apnea. As a result, the National Transportation Safety Board (NTSB) recommended that the FAA revise its medical examiner guidelines to better inform them of when pilot candidates need to be evaluated for this dangerous condition, due to the following rationale:

• About 7% of the US population is estimated to have obstructive sleep apnea
  
• Only about 0.5% of commercial airline pilots have been diagnosed with obstructive sleep apnea
  
• 1% of Air Force pilots have been diagnosed with obstructive sleep apnea
  
• Commercial airline pilots are more likely to be obese than Air Force pilots. Obesity is a major risk factor for obstructive sleep apnea, and studies indicate that 15 to 24% of commercial airline pilots are obese.
  
• The FAA is the only US Federal agency overseeing passenger safety that does not collect or utilize subjective data relevant to obstructive sleep apnea (such as reports of snoring).
  

Despite the alarming consequences of pilots with sleep apnea and its potential prevalence, the FAA's new fatigue rules ignore this condition, and despite a pilot education program, the actual rules regarding sleep apnea remain unchanged. Once diagnosed, the FAA recommends treatment with CPAP, oral appliances, medication, or surgery, but the FAA does not screen its pilots, so many of them may have undiagnosed sleep apnea.

Tell the FAA that your safety matters and that it should include sleep apnea in its recommendations for passenger safety. To learn more about sleep apnea, please contact a local sleep dentist today.

MaxilloMandibular Sugery very successful treatment for sleep apnea. TONGUE REDUCTION AS AN ALTERNATIVE.

A recent article "Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis." in Sleep Medicine Review (abstract below) looked at the success of MaxilloMandibular (MMA) surgery for treating sleep apnea. The study concluded that "conclude that MMA is a safe and highly effective treatment for OSA."

This is very good news for patients who want a permanent treatment cure. Complication rates for this extensive surgery were relatively low. The report also stated " Younger age, lower preoperative weight and AHI, and greater degree of maxillary advancement were predictive of increased surgical success" again all excellent news. The The mean apnea-hypopnea index (AHI) decreased from 63.9/h to 9.5/h following surgery however an AHI of less than 5 is considered a cure. 86% were considered successful and 43% were considered cured.

If you are contemplating MMA surgery it is probably best to begin with an Oral Appliance. If complete resolution of apnea is obtained that jaw position will serve as a surgical landmark to insure success. Cure rates can be dramatically increased by using oral appliance titration end points to determine degree of advancement. The TAP 1 appliance is probably the most efficacious apppliance to determine ideal jaw position due to its ability to advance the lower jaw past maximum voluntary protrusion position.

MANY PATIENTS WHO CONSIDER SURGICAL CORRECTION WILL OPT TO CONTINUE WITH A COMFORTABLE ORAL APPLIANCE AFTER TITRATION. THIS AVOIDS ALL SURGICAL RISK. THOSE PATIENTS WHO ELECT SURGERY HAVE AN INCREASED PROBABILITY OF SUCCESS AND CURE.

The success of the oral surgery procedure far excedes success of soft palate surgery including UP# (uvulopalatopharyngealplasty) LAUP (Laser Assisted Uvuloplasty) Somnoplasty (radio frequency surgery) and nasal surgery.

Base of the Tongue reduction surgery has also shown positive results though the procedure can be brutal. Reduction of the base of the tongue with Somnoplasty (SEE ABSTACT BELOW) requires multiple surgeries but can achieve the same results and is far less brutal.

I have seen several patients who have done 1 or 2 somnoplasty procedures on the base of tongue and decided to use an oral appliance and they have all been easy to manage with appliances.

Dr Shapira



Sleep Med Rev. 2010 Oct;14(5):287-97. Epub 2010 Mar 2.
Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis.
Holty JE, Guilleminault C.

Stanford University Sleep Medicine Program, Stanford University School of Medicine, Stanford, CA, USA. jholty@stanford.edu
Abstract
The reported efficacy of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) is uncertain. We performed a meta-analysis and systematic review to estimate the clinical efficacy and safety of MMA in treating OSA. We searched Medline and bibliographies of retrieved articles, with no language restriction. We used meta-analytic methods to pool surgical outcomes. Fifty-three reports describing 22 unique patient populations (627 adults with OSA) met inclusion criteria. Additionally, 27 reports provided individual data on 320 OSA subjects. The mean apnea-hypopnea index (AHI) decreased from 63.9/h to 9.5/h (p<0.001) following surgery. Using a random-effects model, the pooled surgical success and cure (AHI <5) rates were 86.0% and 43.2%, respectively. Younger age, lower preoperative weight and AHI, and greater degree of maxillary advancement were predictive of increased surgical success. The major and minor complication rates were 1.0% and 3.1%, respectively. No postoperative deaths were reported. Most subjects reported satisfaction after MMA with improvements in quality of life measures and most OSA symptomatology. We conclude that MMA is a safe and highly effective treatment for OSA.

PMID: 20189852 [PubMed - in process]

LinkOut - more resources

SOMNOPLASTY PROCEDURE:
Acta Otolaryngol. 2002 Jul;122(5):531-6.
Tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction for treatment of obstructive sleep apnea syndrome.
Stuck BA, Maurer JT, Verse T, Hörmann K.

Sleep Disorders Center, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany. boris.stuck@hno.ma.uni-heidelberg.de
Abstract
In recent years a considerable effort has been made to establish the use of different surgical techniques for the treatment of obstructive sleep apnea syndrome (OSAS). Nevertheless, treatment of hypopharyngeal obstruction due to tongue base hypertrophy remains in many ways an unsolved problem. The aim of this study was to evaluate the safety and efficacy of tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction in the treatment of OSAS. Twenty patients with OSAS and tongue base hypertrophy were treated with radiofrequency tissue ablation. An intensified treatment protocol was used, delivering 2,800 J per treatment session under local anesthesia. Two nights of polysomnography testing were performed before and after treatment. Daytime sleepiness, snoring and postoperative morbidity were assessed using questionnaires. Mean respiratory disturbance index (RDI) was reduced from 32.1 to 24.9/h after a mean of 3.4 treatment sessions. Six patients (33%) were cured after the procedure (reduction in RDI of > or = 50% and a postoperative RDI of < 15/h) and ten (55%) showed an improvement of > 20% in their RDI. Daytime sleepiness and snoring improved significantly. Peri- and postoperative morbidity was low; one severe complication occurred (tongue base abscess). We were able to achieve similar cure and responder rates to those reported in a recently published pilot study but with a reduced number of treatment sessions. We believe that this technique may improve patient acceptance and have beneficial cost implications.

PMID: 12206264 [PubMed - indexed for MEDLINE]

I HATE CPAP! blog is winner of top blog award! Determined to be one of best blogs that "exude overall brilliance."

I JUST RECEIVED THIS E-MAIL AND WANT TO THANK ALL THE INTERNET FANS THAT HELPED ME WIN THIS AWARD.
DR SHAPIRA

LETTER FOLLOWS:

Dear Dr. Shapira,

Congratulations! Sarah here, and your blog, I Hate CPAP!, was determined to

be one of the best blogs to exude overall brilliance. And so, it has

received our 2010 Top 15 Sleep Disorder Blogs award presented by Medical

Billing and Coding!


You can see your name amongst our winners here at:

www.medicalbillingandcoding.org/top_sleep_disorders/#I_Hate_CPAP

Winners were chosen through a scoring system that included Internet

nominations, which came from your reader base!

You can let your readers know you won by embedding the badge code to one of

the different awards graphics found at:

www.medicalbillingandcoding.org/top_sleep_disorders/badges/.

If you choose to accept or decline the award, please let me know.

Please do not hesitate to call or em ail if you have any questions. Many

questions can be answered at

www.medicalbillingandcoding.org/top_sleep_disorders/about/,

bloggingawards.org/about/, or bloggingawards.org/disclaimer/.

Again, Congratulations, and I hope to see your badge soon!

Cheers,

Sarah Johns

bloggingawards.org

OBESITY A PROBLEM? YOUR ANSWER CAN COME TO YOU IN YOUR SLEEP.

A new article "Chronic intermittent hypoxia caused by obstructive sleep apnea may play an important role in explaining the morbidity-mortality paradox of obesity." in Medical Hypothesis (abstrct below) may explain the problems of morbidity and mortality related to obesity. Obesity has become pandemic according to the article and "threatens the health of millions of people and is associated with numerous morbidities such as hypertension, type II diabetes mellitus, dyslipidemia, cor pulmonale, gallbladder disease, obstructive sleep apnea (OSA), certain cancers, osteoarthritis, increased surgical risk and postoperative complications, lower extremity venous and/or lymphatic problems, pulmonary embolism, stroke/cerebrovascular diseases and coronary arterial disease"

The article sttes that it may be the repetitive intermittent hypoxia from sleep apnea that is responsible for the adverse health effects of obesity.

TREATMENT OF SLEEP APNEA HAS BEEN SHOWN TO HELP A WIDE ASSORTMENT OF MEDICAL CONDITIONS ASSOCIATED WITH OBESITY. UNFORTUNATELY MOST PATIENTS DO NOT TOLERATE CPAP. IN PATIENTS THAT DO NOT TOLERATE CPAP ORAL APPLIANCES MAY BE A LIFE-SAVING THERAPY.

Med Hypotheses. 2010 Sep 3. [Epub ahead of print]

Ozeke O, Ozer C, Gungor M, Celenk MK, Dincer H, Ilicin G.

Bayindir Hospital Sogutozu, Department of Cardiology, Ankara, Turkey.
Abstract
Obesity has reached global pandemic that threatens the health of millions of people and is associated with numerous morbidities such as hypertension, type II diabetes mellitus, dyslipidemia, cor pulmonale, gallbladder disease, obstructive sleep apnea (OSA), certain cancers, osteoarthritis, increased surgical risk and postoperative complications, lower extremity venous and/or lymphatic problems, pulmonary embolism, stroke/cerebrovascular diseases and coronary arterial disease. Despite all these adverse associations, numerous studies and meta-analyses have documented an "obesity paradox" in which overweight and obese population with established cardiovascular disease have a better prognosis than do their lean counterparts. There are potential and plausible explanations offered by literature for these puzzling data; however, it still remains uncertain whether this phenomenon is attributable to a real protective effect of high body fat mass. In recent years, the survival advantage of patients with OSA, combined with the potential cardioprotective effects of chronic intermittent hypoxia, raise the possibility that apneas during sleep may activate preconditioning-like cardioprotective effect. Chronic intermittent hypoxia, one of the physiological markers of OSA, is characterized by transient periods of oxygen desaturation followed by reoxygenation, and is a major cause of its systemic harmful (oxidative stress, inflammation, sympathetic activity, vasculature remodelling and endothelial dysfunction) and/or protective (preconditioning-like cardioprotective) effects. Since many OSA subjects are obese, and obesity is an independent risk factor for many comorbidities associated with OSA; and also most OSA has never been diagnosed in obese patients, we hypothesed that the chronic intermittent hypoxia caused by OSA in obese patients may be one of the underlying mechanisms in morbi-mortality paradox of obesity.

PMID: 20822856 [PubMed - as supplied by publisher]