Investigation of Obstructive Sleep Apnoea
The Flow-Chart of your investigation for Obstructive Sleep Apnoea (OSA) includes:
- Your initial Dental Consultation or Medical Consultation to determine whether you should have further investigations.
- At Future Dental, we will ask you a series of questions and perform an oral assessment to determine where the source of obstruction to your breathing is located.
- There are many occasions where that source is related to the nose, in which case we will refer you directly to an ENT Surgeon to arrange CT Scans and airway assessment.
- We will likely give you a written questionnaire called an Epworth Score/ Stop-BANG Score which gives us an idea of how your obstructed airways are affecting your life.
- Your GP Doctor, for Medicare rebate reasons, can refer you directly to see a Sleep Specialist but, as yet, we need to refer to the same specialist through your Doctor. We send our letters to your Doctor and the Sleep Physician, so that your consultation and sleep study can be arranged.
- The only Doctor who can legally make the diagnosis of OSA is a Respiratory, Thoracic or Sleep Physician. This doctor will generally see you for a consultation first, then arrange one of two types of Sleep Study. A Type 1 sleep study is known as a Polysomnography and is conducted in a Sleep Unit. A Type 2 sleep study is done in your own home.
- The Polysomnography involves you being booked into the Sleep Unit where you may have your usual evening TV or book-reading activities and have your usual alcoholic beverages that you would do at home. When you are ready for sleep, the nurse/technician will set you up with a series of monitors that are held onto your skin. Many feel that they did not get a decent night’ sleep but it is rare that insufficient sleep occurs wearing all this stuff, that a diagnosis cannot be achieved. You will be discharged early in the morning.
- The Type 2 sleep study has you set up with most of the same gadgets but then you go home to sleep in your own bed, which feels a lot more relaxing for some people. It does not measure all the parameters of the Type 1 sleep study, but enough still for a correct diagnosis.
- Type 3 and 4 sleep studies, done in your own home give an indication of the possibility of OSA without measuring enough for the formal diagnosis.
- It will most likely take a number of weeks before you hear back about the results of your sleep study. The Sleep Physician or your GP Doctor will contact you and may suggest you either do a trial period wearing a CPAP machine or come straight back to Future Dental to have a Mandibular Advancement Splint made. There may be a reason to consider other treatment choices and Dr Gibbins will coordinate the referrals to other specialists. The treatment options for OSA are available for your consideration.
- It will seem like a protracted process to get you on track to treat your Sleep Apnoea, but this problem has not just started in your life and has been developing over a number of years mostly. It is necessary to get the proper diagnosis and be seen by the right health care professionals to ensure correct management.
- For some people involved in the transportation industries, maintaining the correct licences to keep working in the same field may be dependent on proof that OSA is being treated and managed.
- If you are offered the choices of CPAP or a Mandibular Advancement Splint (MAS or MAD) made here, you need to be aware of the pros and cons of each option.
CPAP versus MAS.
- CPAP is still regarded as the Gold Standard of treatment and it can be very effective. Those who persevere and use it all night 7 nights a week for life, have excellent results in most cases.
- There are a number of down-sides to CPAP use including:
- A feeling of claustrophobia
- Strap pressure around the head, neck and face being very irritating and causing pressure soreness and rashes
- Lack of portability meaning you need to have 240V mains power (or a generator) to power the machine.
- It dries the mouth and throat.
- Difficulty in rolling over while sleeping due to the hose connection to the machine.
- Lack of effectiveness.
- Very high failure rate in any patient who does not breathe freely through their noses while asleep.
- High air pressures required in some patients means the straps are quite tight around the face which can cause some slight skeletal changes in the face pushing the maxilla (upper jaw) in somewhat. Rarely does this require correction.
- Not great for intimate relationships.
- A very high rate of cessation of using CPAP due to the above factors. By 1 year, up to 50% have stopped using it and by 2 years, up to 83% have stopped using it.
- The average timeworn is about 4 nights a week and about 4.5 hours a night leaving long periods where you have no treatment occurring where you are vulnerable to the many problems of OSA.
- There is an on-going need to buy consumables like straps, masks, hoses etc during the life of the CPAP machines.
MAS devices also have down-sides:
- The vast majority, except for 1 brand (Oventus), work purely by pulling the lower jaw forward to get the base of the tongue away from the back of the throat.
- Some types require the lower jaw to be pulled a long way forward to clear the airway while you sleep.
- By pulling the lower jaw forward, if you already have any TMJ troubles or MPD (Myofascial Pain Dysfunction, a hyper-activity of the muscles that move the jaw, causing facial pain, tension, headaches etc), a MAS can worsen this condition. I have only seen 2 patients who could not persist in wearing their MAS, as this most often passes within a few weeks.
- You will produce a lot of saliva getting accustomed to wearing these devices. Most think this will quickly pass but it may be continued every time you wear your MAS. For the vast majority, this is only a mild and temporary annoyance, but you may dribble a bit in your sleep.
- Long term use of most types of MAS will result in some bite changes in many patients. Certain types have a greater tendency for this to occur. While our usual choice of MAS has a lower risk of significant bite changes, all MAS devices, over time, may cause some changes. How much of a problem is this? When comparing this as a problem to not treating OSA, a bite change pales into insignificance as the lesser of the two evils. Having made these devices since the 80s, I have never yet had a patient choose to correct the bite changes that may occur. In general, it is possible through orthodontic treatment.
- The teeth require to be well maintained using these oral appliances.
- There is still a small consumable product requirement. The devices may require repairs, adjustment and maintenance. They wear out eventually and will require replacement. The average life of MAS devices is from 3.5-5 years.
- Traditional MAS devices have a success rate of 56%. Oventus OPTIMA devices, with the added Ex-Vent Valves, have a success rate of 78-80%. This is about the success rate of well-tolerated and regularly worn CPAP.
- Traditional MAS devices, just like CPAP, have a low success rate for anyone with nasal obstruction while sleeping. The one exception is the Oventus OPTIMA device, which has an in-built airway that allows it to work just as well in those with nasal obstruction.
CPAP Availability in Cairns:-
- During a diagnostic sleep study conducted in a Sleep Unit, quite often a CPAP machine will be fitted during the night to determine its effectiveness.
- CPAP Shop 2D Flecker House, Cairns
- Air Liquide Healthcare CPAP and Oxygen Services, 147 Martyn St, Cairns
- Calanna Pharmacies around Cairns
- CPAP Cairns, O’Brien Healthcare 3/320 Sheridan St
- Marlin Coast Amcal Pharmacy, Campus Shopping Village, Smithfield
CPAP Machines are usually trialled by hiring a machine for 1 month although some outlets allow up to 3 months hiring before need to return or purchase.
They can also be rented or purchased out-right.
Your Mandibular Advancement Splint, as the alternative to CPAP, is constructed through Future Dental.
Dr Gibbins is one of the most experienced Dental Surgeons in the country in dealing with MAS devices and amongst the first trained and accredited in the use of Oventus Medical MAS devices.
- A detailed full oral examination is required first.
- Any dental work needs to be completed first, as any change to the shape of teeth through crowns, large fillings, extractions etc, will prevent the MAS from fitting accurately as they are a precision-fitted device.
- You may likely be recommended to have a Sleep Study, as above, in which case we will refer you to see the Sleep Physician through your GP Doctor, who may also wish to see you for the referral.
- Any referral to the ENT Surgeon for airway assessment is done directly through our office.
- We will likely recommend a full mouth radiograph (OPG X-Ray) to get a preliminary over-all assessment of your oral and nasal health.
- Dr Gibbins will discuss with you any dental work required first and will be happy to conduct that work if you do not specifically prefer to see another dentist.
- Dr Gibbins will discuss the particular type of MAS is best suited to your needs.
- Either on the same first appointment, if you are ready to commit to treatment and no dental work is required first, with a MAS device, or at a subsequent visit, we will take the impressions or digital scans to have your device made.
- Generally, we receive your MAS back here in 3-4 weeks, at which time, we will call you and arrange to insert your MAS.
- A brief follow-up visit 2-4 weeks later will be scheduled to monitor your progress.
- A subsequent follow-up sleep study will likely be recommended to ensure you are getting the maximum benefit from your MAS. With Oventus OPTIMA devices, Oventus Medical has two further additions to their OPTIMA devices awaiting TGA approval, both of which are proving to further improve the success rate of the appliance.
- We would advise you to bring your MAS device to any subsequent appointments at Future Dental.
- If you already own a CPAP Machine, Dr Gibbins will advice you to keep it because, at times, the use of the OPTIMA appliance and CPAP at the same time can greatly improve the results.
- Further to that, the second addition that can be fitted to your OPTIMA device, is a direct connection through the device to your CPAP machine, eliminating any straps and significantly reducing the pressures required.
What treatment alternatives are there for Obstructive Sleep Apnoea (OSA)
Once you have been diagnosed with Obstructive Sleep Apnoea (OSA) there are a number of potential treatment options, but each person will have only a select few choices that may suit their particular reason for having OSA.
- CPAP (Continuous Positive Airway Pressure) is still the Gold Standard of treatment and we will encourage most people to have at least a trial with CPAP which will initially be done during the diagnostic Sleep Study (Polysomnography) done in the Sleep Unit. This is often followed up by you hiring a CPAP machine from the various outlets available. Some will allow a hire of 1 month and some up to 3 months. While CPAP works very well most of the time, there is a high rate of discontinuation of use through intolerance or through lack of efficacy.
- BiPAP Bi-level positive airway pressure. Similar but lower expiratory pressure and higher inspiratory pressure.
- ASV Therapy adaptive servo-ventilation
- Mandibular Advancement Splints (MAS) are custom made by your dentist with broad experience in Sleep Medicine. These are designed to draw the lower jaw forward thus reducing the tendency of the tongue dropping back during sleep causing obstruction to breathing. There are numerous different types all of which work simply by pulling the jaw forward. All except one, the Oventus Optima, which does that too but also incorporates an in-built airway, that bypasses large tongues and long floppy soft palates. This particular brand has been further improved by the addition of a small valve called an ExVent Valve, which works by creating slight resistance to breathing out through the device, thus reducing the vacuum effect that causes the collapsibility of the airway. It is called EPAP and works quite a lot like CPAP but with no hoses, machine or face masks.
- Tongue Retaining Devices
- Twin Arch advancement Osteotomy Surgery by an experienced Oral and Maxillo-Facial Surgeon (OMF Surgeon). This can be a very effective form of eliminating OSA.
- OMF Surgeon Distraction Osteo-Genesis Maxillary Expansion Surgery for very high narrow palates that prevent good nasal breathing.
- Tongue volume reduction surgery by OMF Surgeon
- ENT Surgical procedures like :-
- UPPP Surgery (Uvulopalatopharyngoplasty) removal of soft tissue from the soft palate and uvula removal
- Palatopharyngoplasty, same as UPPP except Uvula is preserved
- Lateral Pharyngoplasty for those with tonsils still onlyrepositioning soft tissue of the soft palate and side of throat
- Uvulopalatal Flap surgery for very thin soft palate to shorten the soft palate
- Sphincter expansion pharyngoplasty repositioning of palatopharyngeus muscle forther forward and laterally
- Relocation Pharyngoplasty a way of sewing together muscles of the side of the throat
- Advancement palate pharyngoplasty removing some bone of the roof of the mouth then pulling the soft palate forward
- Z-Plasty partially divides the soft palateand pulling each half forward and laterally
- Inferior Turbinate reduction by RF Coblation or surgery
- Hypoglossal Nerve Implant Pacemaker/Stimulator placement surgery
- Tumour removal
- Tracheostomy as a last resort surgery
- Orthodontic treatment to correct severe malocclusions like :
- Deep Overbite correction
- Rapid Maxillary Expansion
- Deep overjet correction
- Lifestyle changes
- Sleep posture changes
- Myo-Functional Therapy
- Desensitization from allergic rhinitis and allergic sinusitis
- Laser procedures to stiffen the soft palate using a Fotona NightLase device.
- Nasal devices for holding the nostrils open like:
- Apnea Guard
- Breathe Right Strips
- Boil and Bite over-the-counter devices
- Chin straps
Lifestyle changes and some tips on management of Obstructive Sleep Apnoea (OSA):
- One of the factors frequently involved in OSA is Body Mass Index, or weight. Often reducing weight can significantly improve the outcome for OSA sufferers. Easier said than done, as OSA leaves people feeling listless and with low energy levels. Perhaps a gradually increasing level of activity but with medical supervision.
- Positional sleep changes. Lying on the back is invariably the worst sleeping position for snoring and sleep apnoea. There are special electronic devices that can be worn around the abdomen or chest to send a warning when lying Supine (on the back). A simple remedy is to sew a tennis ball or similar sized ball into the middle of the back of a singlet or T-Shirt.
- Avoidance of a large meal before going to bed. Making the main meal of the day, the mid-day meal and the evening meal smaller and at least 3 hours before going to bed.
- Avoidance of alcohol consumption within 2 – 3 hours before bed. If you like a beer or a glass of wine, have it earlier in the evening.
- Avoidance of medications that make you drowsy or muscle relaxant medicines in the evening.
- Myo-functional therapy is a set of exercises for the tongue that strengthens the tongue and reduces the severity of OSA, although it is normally used along with other treatments. We will provide a list of exercises if you are prepared to commit to them.
- Exercise, in general, is a useful adjunct to other forms of treatment.
Myo-Functional Therapy as part of the management of Obstructive Sleep Apnoea (OSA) and Sleep Disordered Breathing (SDB) for Children and Adults.
There are times when breathing and tongue exercises alone may be sufficient to treat both OSA and SDB.
More commonly, it is a useful adjunct to treatment.
It is difficult to have small children conduct these exercises, especially for the time required for it to be effective. In general, we would not recommend this treatment for children under school-age.
For it to adequately re-train the tongue, it needs to done about:
- 4 times a day, repeating each exercise
- A total of at least 10-12 minutes for each session
- Each exercise held for 10 seconds, with some only held for 5 seconds as below.
- Each exercise repeated 10 times per session
- The overall program of using these myofunctional exercises needs to become a habit practiced for about 2 full years to have maximum effectiveness.
- Hold the tip of the tongue on the hard palate just behind the upper front teeth firmly. Open the mouth as widely as possible with the tongue still in contact. Hold this exercise for 5 seconds.
- Repeat the exercise above but this time moving the tip of the tongue from just behind the front teeth as far back along the palate as possible taking a similar period of time for each repetition.
- Push the tongue out and downwards towards the chin.
- Push the tongue outwards and upwards towards the nose.
- Push the tongue and as far to each side as possible alternating from left and right.
- Push the tongue outwards as far as possible and roll up the sides of the tongue to look like a Taco Shell.
- Push the tongue out and hold it firmly against a craft-stick or spoon. Iced confection sticks, tongue depressor or sticks from a Craft Shop are ideal.
- Click the tongue repetitively against the hard palate for 10-15 seconds at a time and repeat.
- Hold a craft stick, as above, firmly between the lips not holding it with teeth. Roll the sides of the tongue around the stick.
- With practice, this can be further strengthened by placing a coin on the end of the stick outside the mouth.
- Using a large button of about 2.5 cms ( 1 inch) in diameter, run a string or floss through the buttonholes. Hold the button inside the closed lips and pull the string from side to side resisting the pressure with the lips.