Monday, September 27, 2010
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
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.
Friday, September 24, 2010
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.
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.
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. firstname.lastname@example.org
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
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. email@example.com
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."
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:
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:
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
bloggingawards.org/about/, or bloggingawards.org/disclaimer/.
Again, Congratulations, and I hope to see your badge soon!
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.
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]
Thursday, September 23, 2010
AVOID UVULOPALTOPHARYNGEALPLASTY AS A FIRST LINE TREATMENT OF APNEA!
Patients who undergo UP3 surgery first are more likely to have problems with velo-insufficiency related MaxilloMandibular Advancement surgery which according to the author "is as effective as CPAP in severe OSA"
The author also stated "Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients."
Again probably poor advice in most adults. The exception may be the patient with a severely recessive maxilla and mandible. In general, Maxillomandibular advancement should usually be preceded by oral appliance therapy to find an effective position of the jaw to eliminate apnea before doing surgery.
Tonsilectomy is a first line treatment for pediatric apnea but new studies show it should usually be done in conjunction with maxillary expansion.
The author never mentioned oral appliance therapy, but many physicians arre still taking the ostrich approach to oral appliances. Pretend it doesn't exist and it will go away.
Curr Opin Pulm Med. 2010 Sep 14. [Epub ahead of print]
Surgical treatment of obstructive sleep apnea: standard and emerging techniques.
Department of Otorhinolaryngology, Sleep Disorders Center, University Medicine Mannheim, Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg, Mannheim, Germany.
PURPOSE OF REVIEW: Patients with obstructive sleep apnea (OSA), as well as their physicians, seek alternative therapies to continuous positive airway pressure (CPAP) due to problems with CPAP adherence. A large variety of surgical options exist, and each intervention must be individually evaluated. The author performed a literature search concerning surgery for sleep apnea until May 2010. The studies were evaluated according to evidence-based medicine criteria.
RECENT FINDINGS: An increasing number of controlled and even randomized controlled trials are available. Minimally invasive surgery remains under debate due to the very limited efficacy versus very low morbidity. Uvulopalatopharyngoplasty is still the standard procedure for many patients with moderate OSA, whereas maxillomandibular advancement is as effective as CPAP in severe OSA. Multilevel surgery is reserved to secondary treatment after CPAP failure. Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients. There is increasing evidence that upper airway surgery has a positive impact on arterial hypertension, markers of cardiovascular disease, insomnia, daytime symptoms, quality of life, and CPAP adherence.
SUMMARY: Patients who are nonadherent to CPAP must be thoroughly evaluated before choosing any of the available surgical options. Upper airway surgery may improve disease markers of OSA, if appropriately chosen and properly indicated and performed.
PMID: 20842037 [PubMed - as supplied by publisher]
PATIENTS WITH UNTREATED SLEEP APNEA EXHIBIT "cortical excitability in patients with obstructive sleep apnea syndrome (OSAS) during wakefulness
This may be a cause of chronic headaches or migraines or other biochemical imbalances leading to stress disorders ofr depression.
I have included a few relevant pubmed articles below.
Sleep apne is the result of a TMJ disorder (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf)
Neuromuscular Dentistry can help reduce incresed corticl activity, Treatment of sleep apnea can do the same.
Patients with sleep apnea have a smaller airway 24/7 that collapses at night. Correction of apnea and daytime jaw position may be ideal for all patients with chronic pain and sleep apnea.
Sleep Med. 2010 Oct;11(9):857-61.
Altered cortical excitability in patients with untreated obstructive sleep apnea syndrome.
Joo EY, Kim HJ, Lim YH, Koo DL, Hong SB.
Sleep Center, Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Sleep Med. 2010 Oct;11(9):820-1.
OBJECTIVE: To investigate cortical excitability in patients with obstructive sleep apnea syndrome (OSAS) during wakefulness.
METHODS: The authors recruited 45 untreated severe OSAS (all males, mean age 47.2 years, mean apnea-hypopnea index=44.6h(-1)) patients and 44 age-matched healthy male volunteers (mean apnea-hypopnea index=3.4h(-1)). The TMS parameters measured were resting motor threshold (RMT), motor evoked potential (MEP) amplitude, cortical silent period (CSP), and short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF). These parameters were measured in the morning (9-10 am) more than 2h after arising and the parameters of patients and controls were compared. The Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS) were also measured before the TMS study.
RESULTS: OSAS patients had a significantly higher RMT and a longer CSP duration (t-test, p<0.001) compared to healthy volunteers. No significant difference was observed between MEP amplitudes at any stimulus intensity or between the SICI (2, 3, 5ms) and ICF (10, 15, 20ms) values of OSAS patients and healthy volunteers (p>0.05).
CONCLUSIONS: This TMS-based study suggests that untreated severe OSAS patients have imbalanced cortical excitabilities that enhanced inhibition or decreased brain excitability when awake during the day.
PMID: 20817550 [PubMed - in process]
Handb Clin Neurol. 2010;97:73-83.
Biological science of headache channels.
Several episodic neurological diseases, including familial hemiplegic migraine (FHM) and different types of epilepsy, are caused by mutations in ion channels, and hence classified as channelopathies. The classification of FHM as a channelopathy has introduced a new perspective in headache research and has strengthened the idea of migraine as a disorder of neural excitability. Here we review recent studies of the functional consequences of mutations in the CACNA1A and SCNA1A genes (encoding the pore-forming subunit of Ca(V)2.1 and Na(V)1.1 channels) and the ATPA1A2 gene (encoding the alpha(2) subunit of the Na(+)/K(+) pump), responsible for FHM1, FHM3, and FHM2, respectively. These studies show that: (1) FHM1 mutations produce gain-of-function of the Ca(V)2.1 channel and, as a consequence, increased glutamate release at cortical synapses and facilitation of induction and propagation of cortical spreading depression (CSD); (2) FHM2 mutations produce loss-of-function of the alpha(2) Na(+)/K(+)-ATPase; and (3) the FHM3 mutation accelerates recovery from fast inactivation of Na(V)1.5 channels. These findings are consistent with the hypothesis that FHM mutations share the ability to render the brain more susceptible to CSD, by causing excessive synaptic glutamate release (FHM1) or decreased removal of K(+) and glutamate from the synaptic cleft (FHM2) or excessive extracellular K(+) (FHM3).
PMID: 20816411 [PubMed - in pr
Handb Clin Neurol. 2010;97:47-71.
Bolay H, Durham P.
Department of Neurology, Gazi Hospital and Neuropsychiatry Centre, Gazi University, Besevler, Ankara, Turkey.
Headache treatment has been based primarily on experiences with non-specific drugs such as analgesics, non-steroidal anti-inflammatory drugs, or drugs that were originally developed to treat other diseases, such as beta-blockers and anticonvulsant medications. A better understanding of the basic pathophysiological mechanisms of migraine and other types of headache has led to the development over the past two decades of more target-specific drugs. Since activation of the trigeminovascular system and neurogenic inflammation are thought to play important roles in migraine pathophysiology, experimental studies modeling those events successfully predicted targets for selective development of pharmacological agents to treat migraine. Basically, there are two fundamental strategies for the treatment of migraine, abortive or preventive, based to a large degree on the frequency of attacks. The triptans, which exhibit potency towards selective serotonin (5-hydroxytryptamine, 5-HT) receptors expressed on trigeminal nerves, remain the most effective drugs for the abortive treatment of migraine. However, numerous preventive medications are currently available that modulate the excitability of the nervous system, particularly the cerebral cortex. In this chapter, the pharmacology of commercially available medications as well as drugs in development that prevent or abort headache attacks will be discussed.
PMID: 20816410 [PubMed - in process]
Cephalalgia. 2010 Sep;30(9):1101-9. Epub 2010 Mar 19.
Cortical hyperexcitability and mechanism of medication-overuse headache.
Supornsilpchai W, le Grand SM, Srikiatkhachorn A.
Department of Physiology, Faculty of Medicine, Chulalongkorn University, Patumwan, Bangkok, Thailand.
The present study was conducted to determine the effect of acute (1 h) and chronic (daily dose for 30 days) paracetamol administration on the development of cortical spreading depression (CSD), CSD-evoked cortical hyperaemia and CSD-induced Fos expression in cerebral cortex and trigeminal nucleus caudalis (TNC). Paracetamol (200 mg/kg body weight, intraperitonealy) was administered to Wistar rats. CSD was elicited by topical application of solid KCl. Electrocorticogram and cortical blood flow were recorded. Results revealed that acute paracetamol administration substantially decreased the number of Fos-immunoreactive cells in the parietal cortex and TNC without causing change in CSD frequency. On the other hand, chronic paracetamol administration led to an increase in CSD frequency as well as CSD-evoked Fos expression in parietal cortex and TNC, indicating an increase in cortical excitability and facilitation of trigeminal nociception. Alteration of cortical excitability which leads to an increased susceptibility of CSD development can be a possible mechanism underlying medication-overuse headache.
PMID: 20713560 [PubMed - in process]
Sunday, September 19, 2010
The TAP appliances are the most effective for severe sleep apnea. I discuss which appliance is most appropriate for each patient based on their sleep study results, overall health, dental health and many other factors.
This is why I always set up each patient for a one hour consultation to explore multiple alternatives and to help my patients make informed choices on which treatment is most effective for treating each individuals sleep disorder.
I believe each patient deserves to understand how sleep apnea occurs and all treatment alternatives not just be "sold" an Appliance.
It is also important to insure successful treatment by doing follow-up sleep studies with appliances in place to insure efficacy.
I always give a full year of necessary follow-up visits when I make a patient an appliance. Appliances are not 100% successful but with proper follow-up they are 90-95% successful and vastly prefered to CPAP. Most patients have minimal problems with appliances but a small percentage may need several problem solving appointments.
Chosing the proper appliance for each patient eliminates the majority of problems.
Friday, September 17, 2010
Although the majority of obstructive sleep apnea sufferers are men over age 50, women and even children can suffer from this potentially dangerous or deadly condition. If your child is restless, has trouble focusing in school or cannot remember lessons he may be suffering from Attention Deficit Disorder (ADD) or Attention Deficit Hyperactive Disorder (ADHD), or it may be the result of obstructive sleep apnea. In talking to your doctor about your child's behavior and learning problems, it is important to consider and discuss sleep apnea, which can often cause not just ADHD symptoms, but can lead to long-term health problems if not properly diagnosed and treated.
When children are diagnosed with ADHD, the typical treatment regimen is pharmacological, but ADHD drugs come with potentially serious side effects and a lifetime of dependence. Furthermore, if the root cause of the problem is sleep apnea, the drugs may not seem to work until the dosages are increased to very high levels. However, sleep apnea can be treated with much less invasive methods, including either continuous positive airway pressure (CPAP) or oral appliance therapy.
It is unknown how many children suffer from this condition, but it may be as much as 13% of children aged 3 to 6 and perhaps 8% in older children. As many as 30% of overweight teens may suffer from obstructive sleep apnea, and if a child has had a broken nose or has a deviated septum, he or she is at a high risk for sleep apnea.
If your child is having trouble in school, has difficulty focusing, or has consistent behavioral problems, he or she may be suffering from sleep apnea. To learn more about pediatric sleep apnea and how to treat it, please contact a local sleep dentist today.
Friday, September 10, 2010
Percy Harvin, the Minnesota Vikings wide receiver who collapsed during practice August 19, has received a positive diagnosis of sleep apnea, according to statements he made in a recent interview. Harvin--a promising young receiver--has long been plagued with migraines during his entire career. To combat these migraines, he was given a number of powerful medications. However, it turns out that his medications may have caused as many problems as they solved--they may even have caused his collapse and subsequent brief periods when his heart stopped beating.
Sleep apnea symptoms include such a wide array of problems, ranging from personality changes to heart failure to car accidents, that it is often mistaken for other illnesses, as was the case for Harvin. Misdiagnosed illnesses can lead to inappropriate treatments that cause significant side effects and may be as bad as the original problems. However, with appropriate treatment, sleep apnea patients can see renewed life and improved health.
Harvin has been prescribed CPAP treatment, and hopefully he is one of the 25% of patients who acclimate well to the highly-effective treatment. If not, perhaps oral appliance therapy may give him relief.
If you have a number of unexplained symptoms, including daytime sleepiness and headaches, you may have sleep apnea. To learn more about sleep apnea options, contact a sleep dentist today.
Friday, September 3, 2010
Sleep Apenea Surgery: Soft Palate Surgery is rarely, if ever a first line treatment for sleep apnea.
Note: For the morbidly obese CPAP is still the best treatment, for younger thinner and healthier patients oral appliances are effective and easy to fit into busy lifestyles.
Surgery, especiall soft palate surgery used to be considered a first line of treatment for sleep apnea but dismal results and high morbidity have relegated soft palate surery to a secondary proceedure, at best.
There were several types of soft palate surgery but the grandfather of all was the UP3, UPPP surgery or Uvulopalatopharyngoplasty. This surgery was excruciatingly painful, had a high morbidity and was usually unsuccessful in treating sleep apnea. According to Wikipedia the risks of UP3 surgery include:
"One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP experienced a worsening of their breathing following UPPP.
Others have spoken of severe acid reflux.
After surgery, complications may include these:
Sleepiness and sleep apnea related to post-surgery medication
Swelling, infection and bleeding
A sore throat and/or difficulty swallowing
Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery.
Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
Patients who have had the uvula removed will become unable to correctly speak French or any other language that has a uvular 'r' phoneme."
All surgeries to the soft palate carry risk and are painful. The LAUP procedure or Laser Assisted Uvuloplasty was less painful than up3 but still very painful. There was less chance of scarrig that dangerously narrowed the airway as seen with UP3.
Somnoplasty of the soft palate was less painful but equally ineffective in treating sleep apnea. Somnoplasty is a procedure to consider in patients with soft palate snoring and no sleep apnea. Other surgical alternatives are snoreplasty and pillars which again are useful for snoring but minimally helpful for treating sleep apnea.
Tracheotomy is the grandfather of surgeries and allows patients to breathe thru their throats. It is very successful but most patients do not want a long term tracheotomy.
The majority of sleep apnea is caused by the base of the tongue obstructing the airway or pressing on the epiglottis that blocks the airway.
There are several procedures that can be done to either advance the tongue or make it smaller. Somnoplasty on the base of the tongue is probably the preferred surgery for most patients contemplating reducing tongue size.
MaxilloMandibular Advancement is probably the most successful sleep apnea surgery but is extensive surgery carring definite risks. I strongly recommentd that patients undergoing this rocedure avoid ENT's and Plastic Surgeons and utilize Oral Surgeons with extensive experience in this type of surgery. The dental background of Oral surgeons make themthe first choice. They frequently do these surgeries for orthodontic purposes and understand stomatognathic function.
PATIENTS CONTEMPLATING MAXILLOMANDIBULAR ADVANCEMENT SHOULD ALMOST ALWAYS GO THRU A TRIAL OF AN ORAL APPLIANCE TO DETERMINE THE BEST POSITION FOR THE JAWS AFTER THIS RADICAL SURGERY. THIS WILL PREVENT NEEDLESS SECONDARY SURGERIES.
Nasal surgery is frequently helpful but rarely is a cure for apnea when done alone. Correction of deviated septums and turbinate reduction offer greater comfort for most patients with obstructed breathing due to anatomical or allergic problems.
Nasal surgery is usually and ENT procedure but is frequently one by oral surgeons as well.
Pediatric patients with sleep apnea are usually candidates for removal of tonsils and adenoids. While effective at opening the pharyngeal airway newer research suggests that orthodontic widening of the hard palate should be done either before or after T&A procedures. Widening prior to surgery may reduce post-operative complications.
Sleep apnea is probably responsible for at least 80% of the cases ADD and ADHD in children. The earlier the airway obstructions are addressed the healthier it is for future development.
Wednesday, September 1, 2010
ORAL APPLIANCES ARE A CONSERVATIVE METHOD OF TREATMENT ACCORDING TO THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE.
IN ADDITION TO THE WELL KNOWN SYMPTOM OF EXCESSIVE DAYTIME SLEEPINESS IT ALSO RECOGNIZES "morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression AS ASSOCIATED DISORDER.
WHILE MANY IN THE MEDICAL SLEEP COMMUNITY ALWAYS LOOK AT CPAP AS THE FIRST LINE TREATMENT THE NINDS RECOGNIZES ORAL APPLIANCES AS A CONSERVATIVE TREATMENT OF SLEEP APNEA. THE FIRST LINE THERAPY FOR SLEEP APNEA ARE CONSERVATIVE METHODS "Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep." AND CPAP IS COSIDERED A LESS CONSERVATIVE APPROACH ALONG WITH SURGERY. THE ARTICLE STATES "If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway.
THE SLEEP COMMUNTIY OFTEN MAKES CPAP THE FIRST AND SOMETIMES ONLY TREATMENT OF CHOICE. THE MORE RATIONAL APPROACH OF THE THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE OF THE NIH IS A FRESH APPROACH.
WHY CONSIDR CPAP A FIRST LINE TREATMENT WHEN MOST PATIENTS DO NOT TOLERATE CPAP.
CONSIDERING SLEEP POSITION, WEIGHT LOSS AND ORAL APPLIANCES AS CONSEVATIVE APPROACHES RECOGNIZE NOT JUST THE EFFECTIVENESS OF THESE TREATMENTS BUT ALSO THE CONSERVATIVE NATURE OF THESE TREATMENTS.
THE FOLLOWING IS INFORMATION FROM THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SITE.
What is Sleep Apnea?
Sleep apnea is a common sleep disorder characterized by brief interruptions of breathing during sleep. These episodes usually last 10 seconds or more and occur repeatedly throughout the night. People with sleep apnea will partially awaken as they struggle to breathe, but in the morning they will not be aware of the disturbances in their sleep. The most common type of sleep apnea is obstructive sleep apnea (OSA), caused by relaxation of soft tissue in the back of the throat that blocks the passage of air. Central sleep apnea (CSA) is caused by irregularities in the brain’s normal signals to breathe. Most people with sleep apnea will have a combination of both types. The hallmark symptom of the disorder is excessive daytime sleepiness. Additional symptoms of sleep apnea include restless sleep, loud snoring (with periods of silence followed by gasps), falling asleep during the day, morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression. Not everyone who has these symptoms will have sleep apnea, but it is recommended that people who are experiencing even a few of these symptoms visit their doctor for evaluation. Sleep apnea is more likely to occur in men than women, and in people who are overweight or obese.
Is there any treatment?
There are a variety of treatments for sleep apnea, depending on an individual’s medical history and the severity of the disorder. Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep. If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway. Some individuals may need a combination of therapies to successfully treat their sleep apnea.
What is the prognosis?
Untreated, sleep apnea can be life threatening. Excessive daytime sleepiness can cause people to fall asleep at inappropriate times, such as while driving. Sleep apnea also appears to put individuals at risk for stroke and transient ischemic attacks (TIAs, also known as “mini-strokes”), and is associated with coronary heart disease, heart failure, irregular heartbeat, heart attack, and high blood pressure. Although there is no cure for sleep apnea, recent studies show that successful treatment can reduce the risk of heart and blood pressure problems.
What research is being done?
The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research related to sleep apnea in laboratories at the NIH, and also support additional research through grants to major medical institutions across the country. Much of this research focuses on finding better ways to prevent, treat, and ultimately cure sleep disorders, such as sleep apnea.
ANOTHER ARTICLE IN J Adolesc Health. 2010 Feb;46(2):124-32. Epub 2009 Aug 3.
Sleep patterns and predictors of disturbed sleep in a large population of college students CONCLUDES THAT "insufficient sleep and irregular sleep-wake patterns, which have been extensively documented in younger adolescents, are also present at alarming levels in the college student population. Given the close relationships between sleep quality and physical and mental health, intervention programs for sleep disturbance in this population should be considered."
A THIRD ARTICLE IN Acta Otorrinolaringol Esp. 2009 Sep-Oct;60(5):325-31. Epub 2009 Aug 13.
[Neurocognitive and behavioural abnormalities in paediatric sleep-related breathing disorders] CONCLUDES THAT " A high prevalence of behavioural and neurocognitive abnormalities was observed in children with sleep-related breathing disorders compared to a control group of healthy children. The use of objective assessment such as psychological tests revealed more abnormalities than were expressed by parents in response to clinical interviews."
IT APPEARS THAT RGARDLESS OF AGE AND/OR HEALTH STATUS SLEEP DISORDERS WREAK HAVOC ON BOTH PHYSICAL AND EMOTIONAL WELL BEING.
Behav Sleep Med. 2010 Jul;8(3):157-71.
Sleepiness and health in midlife women: results of the National Sleep Foundation's 2007 Sleep in America poll.
Chasens ER, Twerski SR, Yang K, Umlauf MG.
School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15261, USA. firstname.lastname@example.org
The 2007 Sleep in America poll, a random-sample telephone survey, provided data for this study of sleep in community-dwelling women aged 40 to 60 years. The majority of the respondents were post- or perimenopausal, overweight, married or living with someone, and reported good health. A subsample (20%) reported sleepiness that consistently interfered with daily life; the sleepy subsample reported more symptoms of insomnia, restless legs syndrome, obstructive sleep apnea, depression and anxiety, as well as more problems with health-promoting behaviors, drowsy driving, job performance, household duties, and personal relationships. Hierarchical regression showed that sleepiness along with depressive symptoms, medical comorbidities, obesity, and lower education were associated with poor self-rated health, whereas menopause status (pre-, peri- or post-) was not. These results suggest that sleep disruptions and daytime sleepiness negatively affect the daily life of midlife women.
PMID: 20582759 [PubMed - in process]
J Adolesc Health. 2010 Feb;46(2):124-32. Epub 2009 Aug 3.
Sleep patterns and predictors of disturbed sleep in a large population of college students.
Lund HG, Reider BD, Whiting AB, Prichard JR.
Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA.
PURPOSE: To characterize sleep patterns and predictors of poor sleep quality in a large population of college students. This study extends the 2006 National Sleep Foundation examination of sleep in early adolescence by examining sleep in older adolescents.
METHOD: One thousand one hundred twenty-five students aged 17 to 24 years from an urban Midwestern university completed a cross-sectional online survey about sleep habits that included the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale, the Horne-Ostberg Morningness-Eveningness Scale, the Profile of Mood States, the Subjective Units of Distress Scale, and questions about academic performance, physical health, and psychoactive drug use.
RESULTS: Students reported disturbed sleep; over 60% were categorized as poor-quality sleepers by the PSQI, bedtimes and risetimes were delayed during weekends, and students reported frequently taking prescription, over the counter, and recreational psychoactive drugs to alter sleep/wakefulness. Students classified as poor-quality sleepers reported significantly more problems with physical and psychological health than did good-quality sleepers. Students overwhelmingly stated that emotional and academic stress negatively impacted sleep. Multiple regression analyses revealed that tension and stress accounted for 24% of the variance in the PSQI score, whereas exercise, alcohol and caffeine consumption, and consistency of sleep schedule were not significant predictors of sleep quality.
CONCLUSIONS: These results demonstrate that insufficient sleep and irregular sleep-wake patterns, which have been extensively documented in younger adolescents, are also present at alarming levels in the college student population. Given the close relationships between sleep quality and physical and mental health, intervention programs for sleep disturbance in this population should be considered.
PMID: 20113918 [PubMed - indexed for MEDLINE]
Acta Otorrinolaringol Esp. 2009 Sep-Oct;60(5):325-31. Epub 2009 Aug 13.
[Neurocognitive and behavioural abnormalities in paediatric sleep-related breathing disorders]
[Article in Spanish]
Esteller Moré E, Barceló Mongil M, Segarra Isern F, Piñeiro Aguín Z, Pujol Olmo A, Soler EM, Ademà Alcover JM.
Servicio de Otorrinolaringología, Hospital General de Catalunya, San Cugat del Vallès, Barcelona, España. email@example.com
INTRODUCTION: Behavioural and neurocognitive abnormalities in children may be a consequence of sleep-related breathing disorders. The effectiveness of assessments based on questioning parents is dubious and objective assessment tools are therefore required.
AIM: To ascertain the impact of these abnormalities in children with sleep-related breathing disorders and compare the reliability of questioning parents in relation to validated psychological tests.
METHOD: A prospective study was performed on 20 children with sleep-related breathing disorders and 20 healthy control children between 3 and 12 years of age. Both groups were subjected to a battery of validated psychological tests. The results of both groups were compared with each other and with the response to clinical questionnaires given to parents in the problem group.
RESULTS: More than 75% of the cases in the problem group presented abnormalities with regard to attention, anxiety, memory and spatial structuring. The percentage involvement in all concepts was higher in the problem group. Comparisons of attention (40% of children affected in the control group and 80% in the problem group), memory (50% and 84.2%), and spatial structuring (45% and 75%) were statistically significant. More abnormality was observed in the parameters assessed with psychological tests than the equivalent concept obtained from interviewing the parents. Comparison of abnormal concentration assessed from the questionnaires (40% of children affected) with attention during the psychological test (80%), memory (15% and 84.21%), and delayed language development (10%) compared to spatial structuring (75%) was statistically significant.
CONCLUSIONS: A high prevalence of behavioural and neurocognitive abnormalities was observed in children with sleep-related breathing disorders compared to a control group of healthy children. The use of objective assessment such as psychological tests revealed more abnormalities than were expressed by parents in response to clinical interviews.
PMID: 19814984 [PubMed - indexed for MEDLINE]Free Article
IS INSOMNIA A RISK FACTOR FOR POOR CPAP COMPLIANCE? THIS IS PROBABLY THE CASE ACCORDING TO AN ARTICLE IN SEPTEMBER SLEEP MEDICINE.
PATIENTS WITH COMPLAINTS OF INSOMNIA, PARTICULARLY SLEEP MAINTENANCE INSOMNIA MAY NOT BE GOOD CANDIDATES FOR CPAP TREATMENT. ORAL APPLIANCES ARE AN EXCELLENT ALTERNATIVE TO CPAP FOR PATIENTS WITH SLEEP MAINTENANCE INSOMNIA.
Sleep Med. 2010 Sep;11(8):772-6. Epub 2010 Jul 31.
Sleep maintenance insomnia complaints predict poor CPAP adherence: A clinical case series.
Wickwire EM, Smith MT, Birnbaum S, Collop NA.
Center for Sleep Disorders, Pulmonary Disease and Critical Care Associates, Columbia, MD 21044, USA. firstname.lastname@example.org
BACKGROUND: Although CPAP is a highly efficacious treatment for obstructive sleep apnea (OSA), low adherence presents a significant challenge for sleep medicine clinicians. The present study aimed to evaluate the relationship between insomnia symptoms and CPAP use. We hypothesized that pre-treatment insomnia complaints would be associated with poorer CPAP adherence at clinical follow-up.
METHODS: This was a retrospective chart review of 232 patients (56.5% men, mean age=53.6+/-12.4years) newly diagnosed with OSA (mean AHI=41.8+/-27.7) and prescribed CPAP in the Johns Hopkins Sleep Disorder Center. Difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening were measured via three self-report items. CPAP use was measured via objective electronic monitoring cards.
RESULTS: Thirty-seven percent of the sample reported at least one frequent insomnia complaint, with 23.7% reporting difficulty maintaining sleep, 20.6% reporting early morning awakening and 16.6% reporting difficulty initiating sleep. After controlling for age and gender, sleep maintenance insomnia displayed a statistically significant negative relationship with average nightly minutes of CPAP use (p<.05) as well as adherence status as defined by the Centers for Medicaid and Medicare Services (p<.02).
CONCLUSIONS: To our knowledge, these are the first empirical data to document that insomnia can be a risk factor for poorer CPAP adherence. Identifying and reducing insomnia complaints among patients prescribed CPAP may be a straightforward and cost-effective way to increase CPAP adherence.
PMID: 20673741 [PubMed - in process]
Patients with sleep apneathe article states "observational studies demonstrate a strong correlation between the severity of obstructive sleep apnea (OSA) and the risk and severity of hypertension, whereas prospective studies of patients with OSA demonstrate a positive relationship between OSA and risk of incident hypertension. Intervention trials with continuous positive airway pressure (CPAP) indicate a modest, but inconsistent effect on BP in patients with severe OSA and a greater likelihood of benefit in patients with most CPAP adherence."
The problem is that CPAP compliance is poor or non-existent for the majority of patients. Due to the severe problems that can result from untreated sleep apnea more and more concerned and compassionate cardiologists and internists are turning to Oral Appliances and Dental Sleep Medicine as the Best Sleep Apnea Treatment for their patients that do not tolerate CPAP.
There is no question that CPAP therapy is very effective when it is used. There is also no longer a belief that most patients will tolerate CPAP. Because non adherence and non-compliance is the rule not the exception in sleep apnea treatment the question about "What is the Best Sleep Apnea Treatment?" is still open.
Chest. 2010 Aug;138(2):434-43.
Sleep and hypertension.
Calhoun DA, Harding SM.
Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-1150, USA. email@example.com
Ambulatory BP studies indicate that even small increases in BP, particularly nighttime BP levels, are associated with significant increases in cardiovascular morbidity and mortality. Accordingly, sleep-related diseases that induce increases in BP would be anticipated to substantially affect cardiovascular risk. Both sleep deprivation and insomnia have been linked to increases in incidence and prevalence of hypertension. Likewise, sleep disruption attributable to restless legs syndrome increases the likelihood of having hypertension. Observational studies demonstrate a strong correlation between the severity of obstructive sleep apnea (OSA) and the risk and severity of hypertension, whereas prospective studies of patients with OSA demonstrate a positive relationship between OSA and risk of incident hypertension. Intervention trials with continuous positive airway pressure (CPAP) indicate a modest, but inconsistent effect on BP in patients with severe OSA and a greater likelihood of benefit in patients with most CPAP adherence. Additional prospective studies are needed to reconcile observational studies suggesting that OSA is a strong risk factor for hypertension with the modest antihypertensive effects of CPAP observed in intervention studies.
PMID: 20682533 [PubMed - indexed for MEDLINE]PMCID: PMC2913764 [Available on 2011/8/1
What kind of patient does not do well with CPAP? The article further states " though a search for consistent predictive factors related to CPAP adherence has proven elusive. Other influences, such as sex, age, socioeconomic status, and personality traits are less robust predictors." In essence all types of patients in every category do not tolerate or adhere to CPAP treatment.
Cpap is a very effective treatment but it is not the best sleep apnea treatment for those patients who do not use it. A recent study showed 60% of patients abandon CPAP. In other words when compliance is factored in the majority of patients are not helped by CPAP'
Dental Sleep Medicine and Oral Appliances may be the best sleep apnea treatment for the majority of patients. Even though they may not be as effective as CPAP they are far more effective than no treatment.
Cardiologists recognize that "the undertreated OSA patient at risk of development or worsening of comorbid medical conditions, including hypertension and cardiovascular disease.". They are also aware of the poor compliance that plagues CPAP.
The concerned and informed cardiologists are now recognizing that CPAP is a dismal failure for the majority of sleep apnea patients and are starting to refer more patients for oral appliance therapy. When patients lives are at stake there must be alternatives to CPAP offered to the patients who do not tolerate CPAP. Regardless of the effectiveness of CPAP it is a worthless treatment if it is not used.
Dental Sleep Medicine offers life-changing alternatives to CPAP to cardiac patients who do not tolerate CPAP.
Respir Care. 2010 Sep;55(9):1230-9.
Encouraging CPAP Adherence: It Is Everyone's Job.
Hays Medical Center-Sleep and Neurodiagnostic Institute, 2500 Canterbury Drive, Suite 108, Hays KS 67601. firstname.lastname@example.org.
Obstructive sleep apnea (OSA) is a chronic disease treated effectively with the use of continuous positive airway pressure (CPAP) therapy. Patient adherence to prescribed CPAP is variable, however, leaving . The severity of disease and the presence of daytime sleepiness appear to have some predictive quality for subsequent adherence, though a search for consistent predictive factors related to CPAP adherence has proven elusive. Other influences, such as sex, age, socioeconomic status, and personality traits are less robust predictors. The use of sophisticated therapy modalities such as auto-titration or bi-level PAP units has been shown to improve adherence in certain subsets of OSA patients. Adverse effects such as nasal congestion, dry mouth, or skin irritation occur in approximately 50% of CPAP users, and addressing these adverse effects may improve adherence in some patients. More encouraging, studies on the use of intensive patient education and behavioral interventions have shown more positive effects on adherence, leading to the conclusion that improvement in patient adherence to CPAP therapy requires a multi-layered approach, using combined technological, behavioral, and adverse-effect interventions.
PMID: 20800003 [PubMed - in process]
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