Snoring and Obstructive Sleep Apnea: Diagnosis and Treatment

Tija Hunter, CDA, EFDA, FADAA

January 1, 2018 Course - Expires January 31st, 2021

American Dental Assistants Association

Abstract

Sleep apnea is considered a life threatening medical disorder in which a person stops breathing during sleep. The Institute of Medicine reports that 50 to 70 million Americans suffer from chronic sleep disorders including sleep apnea. Daytime drowsiness alone costs the economy $150 billion in lost productivity and workplace accidents, and another $48 billion in medical expenses related to auto accidents involving drowsy drivers. It is also estimated that nearly 1 in 5 car accidents causing serious injury are associated with excessive daytime sleepiness. Sleep apnea is also associated with memory loss, morning headaches, irritability, depression, decreased sex drive, and impaired concentration. When left untreated sleep apnea can lead to hypertension, stroke, heart attack and sudden death while sleeping. Bryan Keropian, D.D.S. calls “Cancer, AIDS, and obstructive sleep apnea (OSA), the most dangerous and destructive diseases on earth.”

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Sleep apnea is considered a life threatening medical disorder in which a person stops breathing during sleep. The Institute of Medicine reports that 50 to 70 million Americans suffer from chronic sleep disorders including sleep apnea. Daytime drowsiness alone costs the economy $150 billion in lost productivity and workplace accidents, and another $48 billion in medical expenses related to auto accidents involving drowsy drivers. It is also estimated that nearly 1 in 5 car accidents causing serious injury are associated with excessive daytime sleepiness. Sleep apnea is also associated with memory loss, morning headaches, irritability, depression, decreased sex drive, and impaired concentration. When left untreated sleep apnea can lead to hypertension, stroke, heart attack and sudden death while sleeping. Bryan Keropian, D.D.S. calls “Cancer, AIDS, and obstructive sleep apnea (OSA), the most dangerous and destructive diseases on earth.”

Millions of people suffer from fatigue and drowsiness during the day. The American Academy of Sleep Medicine estimates that 18 million Americans have sleep apnea in which 80 to 90 percent of cases remain undiagnosed and untreated. The lack of oxygen to the vital cells of the body can cause serious medical issues and even death.

Snoring occurs when the airway is partially constricted (Figure 1). The snoring sound is a result of a collapsed airway. The reduced size of the opening causes the tissues to vibrate, producing the sound. This is extremely common, and in many cases relatively harmless.

It is estimated that 24 percent of all adult women and 40 percent of all adult males snore (Table 1). Both men and women are likely to snore as they age. Alcohol, drugs, muscle relaxers and tobacco products contribute to snoring. Overweight individuals have more fatty tissue around their neck causing a closing off of the airway, and women who are pregnant have a tendency to snore more. It is estimated that over 2 percent of children under the age of 12 snore. It is important to remember, that while snoring is a symptom of sleep apnea, not all people who snore have obstructive sleep apnea. Many people do not realize they snore unless they are told by a partner. Even when told, since they do not awaken, they do not recognize it as a problem. Both parties can suffer from sleeplessness due to the loud snoring, causing stress and a strain in the relationship.

Obstructive sleep apnea, or OSA, is a sleep-related breathing disorder. It occurs when the tissues in the airway collapse, either partially or completely. These collapses can happen hundreds of times a night. The pause can last for as little as 10 to 30 seconds or be as long as a minute or perhaps even longer. When the collapse occurs, the brain causes the person to wake up and begin breathing, although the individual may not even be aware they have awoken. A person having 15 of these episodes per hour of sleep is considered to have mild or moderate sleep apnea.

If left untreated, the effects on a person's bed partner can be disastrous.

Stages of Sleep

There are two distinct sleep states; the first is called rapid eye movement, or REM. REM is the deep sleep the body requires to feel rejuvenated. It is typically entered about 90 minutes after initially falling asleep and can recur about five times in an eight-hour sleep cycle. Non-REM occurs in four separate stages, each describing a deeper state of restfulness. Snoring only occurs during non-REM sleep. When suffering from obstructive sleep apnea, the body is consistently being deprived of REM sleep. Symptoms of sleep deprivation may be evident even though the person believes he/she is sleeping soundly through the night. People with OSA report getting 8 to 10 hours of sleep a night only to catch themselves falling asleep at the wheel while driving to work the next morning.

Signs and Symptoms of Obstructive Sleep Apnea

• restless or fragmented sleep
• insomnia
• excessive daytime sleepiness
• loud snoring
• xerostomia (dryness of the mouth from breathing through it)
• trouble concentrating
• irritability
• memory loss
• depression
• morning headaches
• decreased sex drive
• inability to focus mentally on work or project
• family history

Children With Obstructive Sleep Apnea

Children with OSA have many of the same symptoms as adults: daytime sleepiness and an inability to concentrate, along with behavioral difficulties without any obvious cause, irritability, and bed wetting. It is believed that many children with OSA are misdiagnosed with either Attention Deficit Disorder (ADD) or Hyperactivity. Children also seem to not gain weight or grow at a normal rate due to lower levels of growth hormones. They also have trouble learning as they cannot concentrate on tasks such as school work.

Diagnosis

If symptoms suggest obstructive sleep apnea, further testing will need to be performed. A polysomnography is a “sleep study” that is done to evaluate the patient's sleep pattern by measuring the Apnea-Hypopnea Index using electrodes. This type of study requires an overnight stay in a sleep study facility. An Apnea-Hypopneas Index or AHI is the average number of partial and complete pauses in breathing that occurs per hour of sleep. A person with an AHI of more than 30 occurrences in a one-hour period is considered to have severe sleep apnea.

According to the American Academy of Dental Sleep Medicine, a physician is responsible for the diagnosis of sleep disorders and for recommending a treatment option. Dentists are not permitted to diagnose sleep apnea, but they can help screen patients for this serious condition. Because dentists see patients on a regular basis, they have the opportunity to engage in conversation about sleep apnea and advise at-risk patients to speak to their physician and visit a sleep center for further testing. Given that the number of practicing dentists is more than 180,000 in the United States, this increases access to patients and the opportunity to alert them about the serious risk of untreated OSA.

Summary

OSA is more common than most people realize. Because the biggest warning sign is snoring, most people pass it off as an annoyance; however, this disease is far more dangerous when left untreated. A person's health, work and everyday lifestyle can be greatly affected. It is important for any person to seek a medical evaluation if suffering from any of these symptoms. A sleep study is necessary to properly diagnose OSA; diagnosis and treatment can have a profound effect on children and adults. Treatment options vary from the simplest of lifestyle changes (Table 2) to oral appliances to surgery (Table 3). All options should be discussed with a physician to find the right choice of treatment.

Glossary

AADSM- American Academy of Dental Sleep Medicine; the only non-profit national professional society dedicated exclusively to the practice of dental sleep medicine

AASM- American Academy of Sleep Medicine; the only professional society dedicated exclusively to the medical subspecialty of sleep medicine

Apnea-Hypopnea Index/AHI- an index of sleep apnea severity that combines apneas and hypopneas; the apneas must last for at least 10 seconds and are associated with a decrease in blood oxygenation

continuous positive airflow pressure/CPAP- therapy utilizes a machine to help a person who has obstructive sleep apnea (OSA) breathe more easily during sleep

diabetes- metabolic disease in which the body's inability to produce any or enough insulin causes elevated levels of glucose in the blood

gastroesophageal reflux disease/GERD- condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach); this action can irritate the esophagus, causing heartburn and other symptoms

laser-assisted uvulopalatoplasty/LAUP- a surgical procedure performed with the aim of reducing or eliminating snoring

non-REM- a type of sleep that occurs in stages, each one getting deeper until the person reaches REM

obesity- the condition of being grossly overweight

obstructive sleep apnea/OSA- a type of sleep disorder characterized by pauses in breathing

polycystic ovary syndrome/PCOS- condition which can affect a woman's menstrual cycle, fertility, hormones and aspects of her appearance; it can also affect long-term health

polysomnography- a type of sleep study; a multi-parametric test used in the study of sleep and as a diagnostic tool in sleep medicine

rapid eye movement/REM- stage in the normal sleep cycle during which dreams occur and the body undergoes marked changes including rapid eye movement, loss of reflexes, and increased pulse rate and brain activity

snoring- breathing with a snorting or grunting sound while asleep

tracheostomy- an incision in the windpipe made to relieve an obstruction to breathing

uvulopalatopharyngoplasty/UPPP- surgical resection of unnecessary palatal and oropharyngeal tissue to open the airway; intended to cure extreme cases of snoring (with or without sleep apnea)

References

American Academy of Dental Sleep Medicine; www.aadsm.org. Accessed on October 8, 2014.

Aurora RN, Casey, KR, Kristo D, Auerbach S, Bista SR, Chowdhuri S, Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep, 2010 Oct; 33 (10) 1408-13.

Joshi, Arjun S. “Oral Appliances in Snoring and Obstructive Sleep Apnea” Medscape, www.emedicine.medscape.com, (2013) October 8, 2014.

Reports on Obstructive Sleep Apnea. University of Maryland Medical Center; http://umm.edu. Accessed on October 8, 2014.

Sleep Apnea Dentist; www.sleepapneadentist.com. Accessed on October 8, 2014.

About the Author

Tija Hunter, CDA, EFDA, FADAA

Tija Hunter, CDA, EFDA, FADAA is a practicing dental assistant/office manager in O'Fallon, Missouri. She is the author of numerous dental articles and continuing education courses. She is a member of the American Dental Assistants Association and sits on the state board in Illinois. She also is a member of several councils of the ADAA. Tija is also the Director of the Dental Careers Institute with five locations throughout the United States.

Figure 1. Depiction of Airway Obstruction

Figure 1

Table 1. Risk Factors for OSA in Adults and Children

Table 1

Table 2. Treatment Options

Table 2

Table 3. Other Options

Table 3

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PROVIDER: American Dental Assistants Association
SOURCE: American Dental Assistants Association | January 2018

Learning Objectives:

  • Differentiate between snoring and sleep apnea.
  • Identify who is at risk for obstructive sleep apnea (OSA).
  • Recognize the signs and symptoms of OSA.
  • Name the levels of sleep apnea and recognize their severity.
  • Discuss which entity can properly diagnose OSA.
  • Identify treatment options for snoring and OSA.