Sleep Apnoea Syndrome

What is the sleep apnoea syndrome?

Obstructive Sleep Apnoea Syndrome (OSAS) is defined as a breathing disorder during sleep where the passage of air decreases due to the recurrent obstruction or collapse of the upper airway. This causes in the patient a lack of oxygen in the lungs and frequent awakenings during the sleep making it difficult for the patient to reach the deep and restful phase of sleep. This obstruction can be in any section of the path between the nasal wings and the hypopharynx for structural reasons, excessive relaxation of the muscles during sleep, the weight of the tissues themselves and other temporary reasons such as tonsillitis.
When the apnoea disappears, the muscles regain their normal tone, the flow of air into the lungs resumes and then it is when snoring occurs.

There are different types of apnoea, and the OSAS (obstructive sleep aponea syndrome) is the most frequent type and, as already mentioned, it is due to an obstruction or collapse of the airway for different reasons. There is another type of apnoea called CENTRAL aponea. The origin of this one is neurological, and it causes a lack of signal from the brain to the respiratory muscles even though
there is no actual obstruction.

MIXED forms (complex sleep apnoea syndrome) can also coexist. Given the prevalence of OSAS, we will focus on it

Causes and diagnosic
Symptoms

OSAS can be caused by excessive relaxation of the more than 30 muscles that make up the upper airway or by the patient’s medical conditions including obesity, certain genetic syndromes, endocrine disorders, neuromuscular disorders, enlarged tonsils, heart and kidney failure or even premature birth.

The main test to determine OSAS and its severity is the sleep study (polysomnogram) that must be evaluated by a pulmonologist (a physician who specialises in the respiratory system). This test requires spending a night in a sleep unit or it can be carried out at the patient’s home. With this study we seek to analyse how the patient breathes while sleeping, the levels of oxygenation in blood, and ultimately, to check the quality of the patient’s sleep.

After performing the test, the apnoea/hypopnoea index (AHI) is evaluated, which analyses the number of apnoea/hypopnoea (episodes characterised by the lack of entry or exit of air into the lungs for 10 or more seconds) in the patient for 1 hour. The following results can be obtained in terms of severity:

Normal: less than 5
Mild: 5 to 15
Moderate: 15 to 30
Severe: more than 30

This syndrome usually goes unnoticed and the relatives are the ones who let the patient know about the snoring.
The most common symptoms that can cause the OSAS are the following:

Loud snoring
Episodes of stopped breathing during sleep
Fragmentation of sleep and frequent awakenings that the patient does not usually remember
Feeling of having slept poorly
Tiredness
Nighttime sweating
Daytime drowsiness, which increases the risk of causing you to fall asleep while you’re working, watching television or even driving a vehicle
Morning headache and that gets better after a few hours
Dry mouth
Irritability, depression, memory problems
Decreased performance
Loss of concentration and memory
Decreased libido
Need to urinate at night

In cases where the apnoea is severe, apart from the symptoms mentioned above, the risk of suffering from cardiovascular diseases (hypertension, ischemic heart disease such as heart attacks or angina pectoris and cerebrovascular accidents), diabetes and cancer increases. These symptoms can be controlled with devices (CPAP-MAD), which assure that the air flows properly into the lungs, furthermore preventing some of these diseases to appear. That is why it is so important to attend a specialised centre for a treatment for sleep apnoea. At Gross Dentistas we count on a qualified team and the latest technology to offer a customised and effective treatment.

Possible treatments

CPAP
MAD (mandibular advancement device)

It is a device that delivers continuous positive pressure to the airways through a mask (that covers the nose and mouth or only the nose) or nasal bridge preventing it to collapse.

It is used in cases of severe or moderate apnoea together with drowsiness and/or considetable cardiovascular symptoms.

The MAD (mandibular advancement device) allows the mandible, tongue, hyoid and suprahyoid muscles to advance, making it easier for the air to flow through the oropharyngeal route.
This allows the passage of adequate air flow into the lungs and, therefore, to the rest of the structures.
It generally has a high tolerance index and has been proved to improve the AHI (apnoea/hypopnoea index), hourly saturation index, and snoring.
The device is tailor-made which allows it to be adapted to each mouth. It consists of two acrylic splints (upper and lower) joined anteriorly by a screw mechanism that controls the degree of mandibular advancement.
It has the advantage, due to its design, of allowing the opening and lateral mobility of the jaw within certain limits as well as mouth breathing in the contact position between the splints, together contributing to greater acceptance by the patient.

When is it NOT advisable to place a MAD?

Drowsiness as the main symptom
Active TMJ pathology (temporomandibular joint)
Insufficient dentition to retain the splint (edentulous) since there must be at least 5 teeth per quadrant.
Periodontal problems
Dolichofacial biotype with open bite as it could get worse
Class III malocclusion where we start from a forward position of the jaw, which limits the ability of taking forward the jaw and in addition, it could also worsen said malocclusion
Active growing, since the forced forward position of the jaw could have orthopaedic effects (modification of growing)
Overbite, as we would have to raise considerably the splint to allow the jaw to go forward and this can cause a later rotation of the jaw which would worsen the air obstruction
Morbid obesity
Severe oxygen desaturation

Do you have questions about sleep apnea?

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Manufacturing process

First visit
Second visit
Third visit
Fourth visit
After 6 months

When the patient comes to the dental clinic, the professional assesses the existence of OSAS based on the symptoms and requests the main diagnostic test (sleep study). For this, the dentist will ask specific questions, assess if you have any risk factor that predisposes you to have this disorder and will perform a physical examination. After carrying out the polysomnogram and the corresponding evaluation by the pulmonologist, you can come to the clinic again with a detailed report of your pathology.

If the indicated treatment for the OSAS is MAD, then we will carry out the Epworth test (in order to assess drowsiness), a physical examination and a complementary study consisting of photographs, study models and X-rays.

In order to manufacture the MAD, we take a mold of your upper and lower quadrants with silicone or intraoral scanner and a bite which will be 60 % of the range of movement between the most posterior and most anterior position of the jaw. Then we will send everything to the laboratory.

When the device is ready, it will adapt perfectly to your mouth. We will show you how to put it on and how to put it out, how to clean it and keep it in proper conditions. We will also show you some exercises to do at home that you will have to carry out when removing the device in the morning to maintain your normal occlusion.
At the beginning, we will only carry out frequent check-ups until we achieve the proper adaptation of the device. Afterwards, the check-ups will take place every 2 months, every 6 months and finally, once per year.
In case it is necessary, it is possible to increase or decrease the forward movement of the jaw thanks to the screw mechanism of the MAD (variable rate of advance), but this is always performed by the dentist.

After 6 months, it would be advisable to perform a second sleep study (polysomnogram) to check the efficacy of the device, in addition of the improvement of the symptoms.

Care

Once the device is placed, some guidelines must be followed, such as carrying out some specific exercises and to use a teether in the morning. When we remove the MAD, to maintain the occlusion of the teeth, check-ups should be performed by the dentist from time to time to check the adaptation and whether it is necessary to adjust the device, hygiene measures to follow and the following recommendations to sleep better:

Receiving at least 2 hours of sunlight
Doing exercise avoiding to do it 2-3 hours before going to sleep
Not to use digital devices 2 hours before going to sleep
Avoiding taking caffeine or alcohol at night
Following a routine when going to sleep (same time every night, doing activities that help us to relax)
Avoiding heavy meals at night

Do you think you have sleep apnea?

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Frequently asked questions about sleep apnea

What kind of discomfort can I feel at the beginning of the MAD treatment?

It is possible to feel light toothache on the incisor teeth, increased salivation or, on the contrary, dry mouth and muscle pain and pain on the TMJ (temporomandibular joint). These effects are normally light and tend to disappear with the time.

Should I use the MAD every night?

How long does it take for the MAD to take effect regarding improvement of sleep quality?

As the OSAS is a chronic disorder, certain people feel an immediate improvement and other people may need longer. If the problem is just snoring, without episodes of apnoea, it will take effect faster.

What kind of discomfort can I feel at the beginning of the MAD treatment?

Correctly placing a MAD requires qualified training for both design and placement. In the right hands, it has been proven to be highly effective both in the treatment of snoring and obstructive sleep apnoea, thus improving the sleep quality of patients and, therefore, their quality of life. Studies show that up to 90 % of patients improve the AHI (Apnoea Hypopnoea Index/hour) and 89 % achieve an AHI below 10 (mild).

How often would I have to change the MAD? Would I have to pay the same amount of money I paid at the beginning of the treatment?

If the care is performed properly, it can last several years. At Gross Dentistas we offer a two-year guaranteeand from then on, if the device has to be replaced, it is possible to keep the screw mechanism. Only the acrylic splints would need to be replaced, thus reducing the cost compared to the amount payed at the beginning.