Sleep Apnea

Sleep apnea is a prevalent and often underdiagnosed condition affecting a significant portion of the global population. It is estimated that nearly 1 billion people worldwide suffer from sleep apnea, with obstructive sleep apnea (OSA) being the most common form, accounting for over 80% of sleep-disordered breathing cases in the U.S. alone​​​​. The incidence of sleep apnea is particularly high among certain demographics, such as older adults and men. It is closely associated with conditions like obesity, high blood pressure, and cardiovascular disease​​​​​​.

The role of dentists in diagnosing and managing sleep apnea is critical. Dentists are uniquely positioned to identify risk factors and symptoms of OSA during routine oral examinations. They can screen for signs like large tongues or tonsils, mandibular retrognathia, a high-arched palate, and a large neck circumference. This screening is crucial, as OSA is often undiagnosed and untreated, which can lead to serious health implications​​.

Dentists play a crucial role in the diagnosis and referral of patients with OSA and the long-term management of the condition. At The Lakewood Dentist, we work collaboratively with primary care physicians and sleep specialists to provide comprehensive care, which includes the fabrication and maintenance of oral appliances​​.

An Overview of Sleep Apnea

Sleep apnea, a potentially serious sleep disorder, is characterized by repeated stopping and starting of breathing during sleep. This condition derives its name from the Greek word “apnea,” meaning “breathless.” There are three main forms of sleep apnea:

1. Obstructive Sleep Apnea (OSA) – The most common type of sleep apnea occurs when throat muscles excessively relax during sleep, causing a blockage of airflow into the lungs​​.
2. Central Sleep Apnea (CSA) – Less common; it arises when the brain fails to send proper signals to the muscles controlling breathing, leading to pauses in breathing without physical airway obstruction​​​​.
3. Treatment-Emergent Central Sleep Apnea – Complex sleep apnea develops in individuals initially diagnosed with OSA, which then converts to CSA during OSA therapy​​.

The human sleep cycle is disrupted by sleep apnea, affecting both the quality and restfulness of sleep. When breathing is paused (apnea) or shallow (hypopnea), the body’s oxygen levels drop, triggering a reflexive awakening just enough to resume breathing. This process disturbs the sleep cycle and can lead to various health complications, including increased stress on the heart​​.

Sleep apnea affects a wide demographic, from infants to older adults, with varying prevalences based on age, gender, weight, and ethnicity. In people under 50, it is more commonly seen in men and people assigned male at birth (AMAB), but after age 50, the rates equalize between genders.

Obesity is a strong risk factor, and the condition is more prevalent in certain ethnic groups. CSA is particularly common in older adults, individuals on opioid pain medications, and those with heart conditions like atrial fibrillation or congestive heart failure​​.

The severity of sleep apnea is gauged using the Apnea-Hypopnea Index (AHI), which measures the average number of apnea or hypopnea events per hour. This index helps determine whether the condition is mild, moderate, or severe and is critical in guiding treatment and management strategies​​.

Obstructive Sleep Apnea (OSA)

As mentioned above, obstructive sleep apnea (OSA) is the most prevalent form of sleep apnea. It happens when the head and neck muscles relax during sleep, resulting in the surrounding tissue pressing on the windpipe and obstructing airflow. This obstruction hinders the ability of air to pass through the windpipe, causing breathing difficulties while asleep​​.

Central Sleep Apnea (CSA)

Central sleep apnea (CSA) arises from a problem in the brain responsible for managing breathing at all times, including during sleep. In CSA, the brain fails to relay signals to keep breathing-related muscles working.

This form of sleep apnea can occur due to various reasons, including heart failure, low blood oxygen levels, nervous system damage (particularly in the brainstem or spinal cord), or as a result of CPAP treatment for obstructive sleep apnea. Individuals with nervous system conditions such as amyotrophic lateral sclerosis (ALS) are also prone to CSA​​.

Complex Sleep Apnea Syndrome

Complex sleep apnea, or treatment-emergent central sleep apnea, is a form of sleep apnea that develops during the treatment of OSA. This condition happens when a person receiving positive airway pressure (PAP) therapy for OSA develops central sleep apnea (CSA).

Complex sleep apnea can result from various factors, including loop gain (the body’s response to changes in breathing), increased ventilation due to PAP therapy, and air leaks from PAP masks, causing sudden drops in CO2 levels.

It is estimated that up to 20% of people undergoing CPAP titration for OSA develop complex sleep apnea, though only around 2% continue to have symptoms on long-term CPAP therapy. Risk factors for developing complex sleep apnea include male sex, advanced age, sleeping on the back, opiate usage, heart disease, severe obstructive sleep apnea, higher altitude, and treatment with CPAP or BiPAP in high settings​​.

Symptoms of complex sleep apnea may include:

• Excessive daytime fatigue.
• Poor sleep quality.
• Frequent nighttime waking.
• Morning headaches.
• Chest pain.
• Difficulty concentrating.
• Mood changes.

Unlike OSA, snoring is not a common symptom of complex sleep apnea. Treatment typically involves continuing CPAP therapy and monitoring progress. In cases where the condition persists, healthcare providers may recommend adaptive servo-ventilation or bilevel-positive airway pressure (BiPAP) with a backup rate to ensure adequate breathing​​.

Sleep Apnea Prevalence and Risk Factors

Sleep apnea is a prevalent sleep disorder, affecting an estimated 1 billion people worldwide. The majority of these cases are obstructive sleep apnea (OSA), amounting to approximately 936 million cases. However, a significant portion of sleep apnea cases remain undiagnosed, with estimates suggesting that 80 to 90% of sleep apnea cases go undetected​​.

In the United States, sleep apnea is a common condition, as prevalent as diabetes and more common than asthma. More than 30 million Americans are believed to be affected by this sleep-breathing disorder, with only about 6 million of these cases being officially diagnosed. This indicates a large number of undiagnosed and potentially untreated sleep apnea cases—nearly 24 million—in the US alone​​.

1. General Sleep Apnea Risk Factors

Gender and Age Differences

Sleep apnea impacts men more than women, with severe sleep apnea being more common in men. However, after menopause, women’s risk of developing sleep apnea increases. Menopause is known to significantly increase a woman’s risk of sleep apnea, and women with the condition may be more impacted in their daily lives compared to men​​.

Older adults, particularly those over 65, are twice as likely to be affected by sleep apnea compared to middle-aged adults. About 50% of people over 65 may have mild sleep apnea, and 20% may have moderate to severe sleep apnea. Aging appears to have a more significant impact on women with this condition than on men​​.

Impact of Obesity in Apnea Patients

Obesity significantly increases the risk of developing sleep apnea. Approximately 40% of people with obesity are affected by sleep apnea, and 20% of obese individuals with Obstructive Sleep Apnea/Hypopnea Syndrome also have Obesity-Hypoventilation Syndrome. Additionally, 15 to 20% of obese pregnant women will develop sleep apnea. Interestingly, BMI contributes less to sleep apnea risk with age.

Other Risk Factors

Certain lifestyle factors and medical conditions also elevate the risk of developing sleep apnea. Heavy drinkers increase their risk by 25%, and smokers are 340% more likely to develop sleep apnea compared to nonsmokers. Chronic use of opioid drugs significantly increases the risk of both OSA and CSA. Congestive heart failure (CHF) is another contributing factor, with 40% of people with CHF also experiencing CSA​​.

Common Symptoms of Sleep Apnea

Sleep apnea, encompassing both obstructive and central types, presents several common symptoms affecting daily life and overall well-being. These include:

• Loud Snoring. A notable and common symptom in sleep apnea cases.
• Episodes of Breathing Cessation. Others typically notice these as the person stops breathing during sleep.
• Gasping for Air. This can occur during sleep as the body struggles to maintain regular breathing.
• Awakening with a Dry Mouth. A frequent symptom due to mouth breathing during sleep.
• Morning Headaches. Often related to reduced oxygen levels during sleep apnea events.
• Insomnia. Difficulty staying asleep is common in individuals with sleep apnea.
• Excessive Daytime Sleepiness (Hypersomnia). This results from disrupted sleep patterns.
• Difficulty Concentrating. Cognitive impairment is a common issue due to poor sleep quality.
• Irritability. Mood changes can occur due to a lack of restful sleep​​.

Symptoms Specific to Central Sleep Apnea (CSA)

CSA may not always present noticeable symptoms, but when they do occur, they can include:

• Excessive daytime tiredness.
• Poor-quality sleep.
• Insomnia.
• Attention and concentration difficulties.
• Waking up with shortness of breath.
• Morning headaches.
• Nighttime chest discomfort.

Health Implications of Untreated Sleep Apnea

Untreated sleep apnea, a condition marked by repeated interruptions in breathing during sleep, poses significant health risks that extend far beyond poor sleep quality.

Sleep apnea is directly linked to an increased risk of cardiovascular and metabolic disorders.

Studies show that individuals with sleep apnea have almost double the risk of cardiovascular-related death and sudden death from any cause compared to those without sleep apnea.

The condition is also associated with type 2 diabetes and glaucoma. Chronic cycles of accelerated heart rate and increased blood pressure due to sleep apnea result in systemic inflammation, which can contribute to atherosclerosis, heightening the risk of heart attack or stroke. Additionally, this chronic inflammation can damage the pancreas and lead to type 2 diabetes​​​​​​.

Sleep apnea can also increase the risk of other serious health issues:

• Metabolic Syndrome. Risk factors include high blood pressure, abnormal cholesterol levels, elevated blood sugar, and excess body fat.
• Heart Disease. Conditions like atrial fibrillation, heart attack, and heart failure are linked to sleep apnea.
• Pregnancy Complications. Research suggests an association between sleep apnea and complications like gestational diabetes, high blood pressure during pregnancy, and preeclampsia.
• The prevalence of asthma is high among individuals with sleep apnea and vice versa.
• Liver Damage. Sleep apnea can exacerbate nonalcoholic fatty liver disease in both adults and adolescents.
• Studies indicate an increased risk of tumors and cancer in those with sleep apnea, possibly related to oxygen deprivation caused by the disorder​​​​​​​​.
• Sleep apnea can lead to neurocognitive problems and adversely affect mood due to chronic deprivation of restorative sleep. This can manifest as:

• Daytime sleepiness and fatigue.
• Attention problems.
• Difficulty concentrating.
• Memory issues.
• Irritability.
• Depression.
• Decreased sex drive​​.

Diagnosing Sleep Apnea

The diagnosing process involves a combination of clinical evaluation, symptom assessment, and specialized tests. The initial stage involves a detailed clinical evaluation, focusing on the patient’s symptoms and sleep history. This assessment can be supported by input from someone who shares the patient’s bed or household.

Key factors or elements a healthcare provider may ask you about include the following:

• Daytime tiredness or sleepiness.
• Snoring or observed pauses in breathing during sleep.
• Difficulty staying awake during activities like driving or reading.
• Smoking history.
• Family history of sleep apnea.

A physical examination also plays a crucial role, where the doctor considers factors like weight, neck circumference, blood pressure, and other medical conditions that may increase the risk of sleep apnea​​.

Polysomnography or Sleep Study

Polysomnography, conducted in a sleep lab or at home, remains the gold standard for diagnosing sleep apnea. This comprehensive test monitors bodily functions during sleep, such as breathing, heart rate, brain wave activity, and blood oxygen levels. The data from polysomnography are critical for confirming the presence and severity of sleep apnea​​.

A split-night sleep study might be performed when the likelihood of sleep apnea is high. This study’s first half of the night is dedicated to diagnosis. If significant sleep apnea is detected, the second half is used to trial a Positive Airway Pressure (PAP) device​​.

Home Sleep Apnea Tests (HSAT)

For individuals suspected of having moderate-to-severe obstructive sleep apnea, HSATs are a viable option. These tests involve fewer measurements than in-lab studies and usually track heart rate, blood oxygen level, airflow, and breathing patterns. HSATs are particularly beneficial for their convenience and comfort in one’s environment, although they might miss some cases of sleep apnea​​.

Diagnostic Criteria and Severity Assessment

The diagnosis of obstructive sleep apnea is based on polysomnogram results and the presence of certain symptoms. Key indicators include the number of apneas/ complete stoppage of airflow, hypopneas/ shallow breathing, or respiratory effort-related arousals (RERAs) per hour of sleep.

A diagnosis is usually made if at least five breathing events occur per hour. The severity of sleep apnea is determined by the average number of these events per hour, along with the patient’s symptoms and medical history​​.

Treatment Options for Sleep Apnea

Sleep apnea treatment has evolved significantly over the years, with various options available depending on the severity and type of sleep apnea. The current treatment methods include:

Hypoglossal Nerve Stimulation

Hypoglossal nerve stimulation (THN) is a newer treatment for obstructive sleep apnea (OSA). A randomized clinical trial with 138 patients demonstrated that targeted hypoglossal nerve stimulation significantly improved sleep apnea, sleepiness, and quality of life.

The treatment was effective across a broad spectrum of patients with OSA, regardless of their apnea-hypopnea index and body mass index values. In this study, participants showed substantial improvements in AHI (52.3% vs. 19.6% in the treatment Vs. control group).

Additionally, 83% of participants were satisfied with their outcome, and 88% expressed willingness to undergo the treatment again. The treatment also proved safe, with only two serious adverse events and 100 non-serious related adverse events observed​​​​​​.

Transvenous Phrenic Nerve Stimulation

Transvenous phrenic nerve stimulation (PNS) has shown promise for improving quality of life and disease severity in people with central sleep apnea (CSA). This analysis pooled data from a pilot and research study of the remedē system in patients with predominant moderate to severe CSA.

Among 210 patients, PNS reduced the apnea symptoms at six months by a median of 60% from baseline. PNS was associated with improved systolic function and a reduced ejection fraction in patients with heart failure. Transvenous PNS significantly improves CSA severity, quality of life, ventricular function,  and sleep quality, with sustained improvements at one year and acceptable safety​​.

Lifestyle Modifications

Lifestyle changes, including weight loss, throat exercises, changing sleep positions, avoiding alcohol and certain medications, and quitting smoking, can reduce the severity of OSA symptoms. Weight loss, in particular, has shown considerable effectiveness in reducing sleep apnea symptoms​​​​.

Credible studies have revealed that an intensive lifestyle modification program (LMP) focusing on diet and exercise is superior to usual care in lowering apneic and hypopnea events among patients with moderate to severe OSA. The study highlights a significant reduction in the intervention group’s apnea-hypopnea index (AHI) and body mass index (BMI) compared to controls. It concluded that weight loss programs should be viewed as an adjunctive treatment for OSA​​.

Continuous Positive Airway Pressure (CPAP)

CPAP is the gold standard for treating obstructive sleep apnea (OSA). It involves using a machine that delivers a steady stream of air through a mask to keep the airway open during sleep. CPAP is highly effective, but its success hinges on consistent nightly use. Although ideal for OSA, CPAP is less effective for central sleep apnea (CSA)​​​​.

CPAP therapy is an effective treatment for many people living with sleep apnea. It has been shown to improve cardiovascular health, lower blood pressure, reduce the occurrence of nighttime arrhythmias, and improve heart function in patients with heart failure.

CPAP therapy can significantly decrease daytime sleepiness, with research suggesting that 75% of CPAP users resolve their daytime sleepiness symptoms. The therapy also improves mental health by lessening symptoms of depression and anxiety and reducing the risk of vehicle accidents due to improved alertness and reduced daytime sleepiness​​.

Oral Appliances

Oral appliances, such as mandibular advanced splints (MAS) and tongue-retaining devices, are typically used after PAP treatments are found intolerable. They physically open the airway by repositioning the jaw or tongue. While not as effective as CPAP, they can be useful, especially for mild to moderate OSA​​.

Oral appliances, such as mandibular advancement devices (MADs) and tongue-retaining devices (TRDs), are effective alternatives to CPAP therapy, especially for those who cannot tolerate CPAP. MAD therapy can reduce the severity of OSA by more than half in about 70% of people and completely resolve symptoms in a third of patients.

TRDs, while less studied, have shown benefits in decreasing interrupted breathing and reducing daytime sleepiness. Oral appliance therapy is recommended for mild to moderate sleep apnea, with emerging evidence supporting its use in severe OSA cases​​​​.

Surgery

Surgery may be recommended when non-invasive treatments fail. This includes tissue removal or shrinkage surgeries, jaw repositioning, tongue-related surgeries, and nasal surgeries. Tracheotomy is the most effective but also the most invasive surgical option​​​​​​.

Various surgical options are available for treating sleep apnea, including:

• Uvulopalatopharyngoplasty (UPPP). This common surgery for OSA involves removing or shrinking parts of the tonsils, uvula, and soft palate, with radiofrequency UPPP showing 60% to 70% success rates​​.
• Tonsillectomy. Particularly useful for adults and children with mild to moderate OSA and enlarged tonsils, tonsillectomy significantly reduces symptoms and cures over 57% of participants​​.
• Tracheotomy. An invasive procedure used as a last resort when a person’s life is at risk involves creating a direct airway through the neck​​.
• Maxillomandibular Advancement. This surgery, which moves the jaw forward, has a success rate of nearly 86% and cures OSA altogether in 39% of patients​​.
• Genioglossus Advancement and Midline Glossectomy. These surgeries, focusing on the tongue, vary in success rates but can effectively reduce OSA symptoms​​.
• Hyoid Suspension. Often combined with other OSA surgeries, this technique has varying success rates​​.

Find an Experienced Dentist Near Me

Addressing sleep apnea, a complex and potentially serious condition, requires a multi-faceted approach. Sleep apnea is not just a sleep disorder but can have significant impacts on overall health, including cardiovascular risks, daytime sleepiness, and mental health issues. The role of dental professionals in managing sleep apnea, particularly in providing oral appliance therapy, is significant. If you struggle with sleep apnea, seeking help from an experienced dentist specializing in sleep-related breathing disorders is crucial.

At The Lakewood Dentist, you can access comprehensive care for sleep apnea. We have the expertise and tools to diagnose and treat sleep apnea effectively. We utilize treatments like oral appliances, which are almost as effective as CPAP therapy. With higher compliance rates, we can tailor a treatment plan suited to each patient’s unique needs​​. Contact us at 562-423-1441 to schedule a consultation and take the first step towards better sleep and overall health.