Snoring & Obstructive Sleep Apnoea
One of the most frequent problems related to sleep is snoring and it may be a sign of a serious underlying health condition called Obstructive Sleep Apnoea.
In addition to sleep deprivation, daytime fatigue and chronic pain, sleep apnoea has been associated with other serious health problems such as hypertension and diabetes. Bed partners also suffer from disrupted sleep, making them irritable and tired on waking.
The Importance of Sleep
Sleeping well is as essential to survival as food and water. It impacts every aspect of our health and daily life and helps us look, feel and perform our best.
It affects almost every system in our body, from the brain, heart, and lungs to metabolism, immune function, mood, and disease resistance. Recent research even suggests that sleep plays an important role in removing toxins that build up in the brain when you are awake.
A chronic lack of sleep, or getting poor quality sleep, increases the risk of disorders including high blood pressure, cardiovascular disease, diabetes, depression, and obesity. It also makes it difficult to maintain the pathways in our brain that let us learn and create new memories, making it harder to concentrate and respond quickly.
One of the most frequent problems related to sleep is snoring. Is it estimated that more than 40% of the adult population snores, with snoring occurring most commonly in overweight men, and in women, especially during pregnancy and after menopause. Sleeping posture, nasal obstruction, alcohol and smoking also increase the risk of snoring.
Snoring indicates that there is some resistance to the normal path of air from the outside to the lungs.
During sleep the muscles of the upper airway relax, the tongue falls back under gravity, and the airway narrows, this resistance to normal airflow causes pressure changes to develop which in turn cause the soft tissues in the upper airway to vibrate creating the snoring sound we hear. This sound becomes more pronounced with age as the general muscle tone decreases, and is worse if we are overweight, have a large tongue, enlarged tonsils or a small retrusive lower jaw.
Whilst the snorer is usually unaware of the problem, except in very loud cases when it can also wake the snorer, it often disturbs the bed partner or roommate causing them to suffer from disrupted sleep, making them irritable and tired on waking. It has been known to break relationships.
The snorer is also likely to suffer from disrupted sleep and sleep deprivation, daytime fatigue and sleepiness, decreases in oxygen levels in the body and other serious health problems.
Obstructive Sleep Apnoea
Loud and frequent snoring can be symptom of a serious medical condition known as Obstructive Sleep Apnoea (OSA) and whilst not all snorers have OSA, virtually all OSA patients snore. Additionally, an individual suffering from OSA will also make ‘gasping’ or ‘choking’ sounds during sleep. Research shows that amongst people who snore the incidence of OSA can be as high as 50%. More than 90% of sufferers remain undiagnosed and untreated for OSA.
OSA is a chronic condition that occurs when your muscles relax during sleep, allowing soft tissue to collapse and block the airway. If the airway if completely obstructed, it will lead to breath holding, pauses in your breathing and a resultant decreased on blood oxygens levels. When we stop breathing, brain is suddenly alerted, sleep disrupted, and the individual partially wakes then falls back to sleep. This is referred to as an arousal, and in serious cases this may be repeated 50-60 times per hour with episodes lasting anywhere from a few seconds to more than a minute. A trained clinician must determine if your snoring is a sign that you have OSA.
Like snoring, OSA is more common in adults over the age of 65 years, men, post-menopausal women and among those under the age of 35 years. Having excess body weight, a narrow airway or retrusive lower jaw, all increase the risk of OSA. In the overweight, the increased tissue weight caused by fat and muscle deposits around the throat, chest and abdomen create extra resistance which can hamper breathing. However, just because someone is overweight does not mean they have OSA. The opposite is also true. Many thin people have OSA. A thick neck can narrow the airway and increase the likelihood of OSA. Higher risk of OSA is associated with a neck circumference greater than 17 inches for men and 15 inches for women.
A small jaw or enlarged tongue can narrow the upper airway and predispose individuals toward the development of OSA. Enlarged tonsils and adenoids can also restrict the size of the upper airway.
If you have family members with OSA, you may be at increased risk. Like eye colour, the shape and size of our airway and cranial facial features may be inherited from our parents and can have an impact on the likelihood of developing OSA.
OSA is most often associated in children with enlarged tonsils or adenoids.
How Sleep Apnoea affects your health
Snoring is often considered to be ‘a bit of a joke’, but there is evidence that even simple snoring (without OSA) may be detrimental to your health.
OSA is associated with many serious medical conditions. It can cause excessive daytime tiredness, increased risk of heart attacks and stroke. There is a strong correlation with hypertension, and it has been shown to be up to three times more common in those with diabetes, in chronic smokers and in those with frequent alcohol consumption. It is even associated with parafunctional habits and morning headaches, depression, mood changes and a lack of sex drive and impotence. By extension, these conditions also have a multitude of secondary social and occupational impairments.
The majority of snorers are unaware of the consequences of OSA and many individuals with OSA suffering from these conditions will have received symptomatic treatment, often leaving the underlying cause, i.e., OSA, undiagnosed and untreated.
Managing Snoring and Obstructive Sleep Apnoea
Mild or occasional snoring may be helped by a healthier lifestyle that includes exercise and proper diet encouraging weight loss, avoiding heavy meals and alcohol at least three hours before bedtime, establishing regular sleeping patterns, and sleeping on your side or even tilting your head of the bed up about 4 inches.
Heavy and chronic snoring, and individuals in whom OSA is suspect will require an assessment by an appropriate clinician, either a sleep physician or an ENT.
As part of a snoring and sleep assessment you will be asked a series of questions relating to daytime sleepiness. A referral may then be made to an ENT for examination (nose and pharynx blockage, thyroid function tests), or a sleep physician who will carry out a more comprehensive respiratory assessment using wither a portable sleep apnoea home test kit or may recommend an overnight polysomnography assessment at a sleep laboratory. The results of this study will help the sleep physician determine whether or not you have a sleep related breathing disorder that warrants treatment. The recommended treatment depends on the severity of OSA.
If you have snoring without OSA, your clinician may give you a prescription for an oral sleep appliance. If you have OSA, your clinician may suggest continuous positive airway pressure (CPAP) therapy. A CPAP machine keeps your airway open by providing forced air through flexible tubing and CPAP requires you to wear a mask covering your nose and mouth as you sleep. Although CPAP therapy is effective, some people are unable to adhere to it. If you are unable to tolerate CPAP therapy or prefer an alternate treatment, an oral appliance may be recommended.
An oral appliance is a device worn in the mouth during sleep. It is a shown to be an effective treatment option for snoring and for OSA. Your teeth and gums should be in a healthy condition before use. The appliance fits over your upper and lower teeth, posturing your lower jaw forward, and thereby preventing the airway from collapsing. Many people like them as they’re comfortable, quiet and portable. They can either be bought ‘over the counter’ from some pharmacists or over the internet, or they can be ‘custom made’ to your mouth. ‘Custom-made’ oral appliances are more stable in the mouth, less bulky, more comfortable to wear, and are much more effective at reducing snoring and OSA.
In some cases of severe and advanced OSA, a combination of CPAP and Oral appliance therapy, or even surgery of the upper airway or of the jaws may be recommended.
Lifestyle changes such as weight loss are sensible. Additionally, smoking cessation, avoiding alcohol late in the evening, and night time sedatives may help.
How we can help you
Chronic orofacial pain and tooth wear due to parafunction (clenching and grinding) and acid reflux problems may have some association with a sleep breathing disorder, of which OSA is part. Your dentist may be the first person to see these signs.
Additionally, trained dentists play an important role in working with ENT and sleep physicians in checking your mouth to see if a ‘custom made’ oral appliance would be suitable, and if so, help you decide on which appliance would be best for you. They would fit this appliance and make any necessary adjustments, ‘titrating’ the appliance for maximum benefit. The dentist will advise you to return for regular examinations to ensure that your appliance is functioning correctly and that your teeth, gums and jaw joints remain healthy.
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