Larry Barsh is a man with a new mission. The retired dentist from New York City wants to help Americans recognize that they may have obstructive sleep apnea, a chronic condition among snorers that disrupts sleep. Dr. Barsh started a Web site, SnoringIsn'tSexy.com, to help educate patients and help dentists play a role in identifying patients with sleep apnea.
Barsh says the vast majority of people with apnea don't know they have the condition. Dentists are in a unique position to help patients who might suffer from sleep apnea, he says. Typically, dentists see patients more often than physicians, at least two times a year for teeth cleaning.
The National Institutes of Health estimates that more than 12 million American adults have obstructive sleep apnea. Among older Americans, the rate is especially high: at least one out of 10 over the age of 65 has it.
Doctors don't know exactly why sleep apnea occurs, but it is associated with obesity, aging and anatomy, says Dr. Clete Kushida, a neurologist and director of the Stanford Center for Human Sleep Research and president of the American Academy of Sleep Medicine.
The obstructed breathing can result from a variety of factors, such as a large tongue, a large uvula (that cone-shaped projection of tissue in the back of the throat) or a lot of large, crowded teeth. As muscles relax, which they do when people fall asleep — especially on their backs — the tongue muscles tend to pull back and block the airway.
Snoring And Apnea
Snoring is a sign of apnea. Only about 5 to 10 percent of snorers actually have sleep apnea, says Barsh, but everyone who has the most common form of apnea — obstructive sleep apnea — snores. (People with central sleep apnea, caused by incorrect signals from the brain, may not snore.)
"Snoring is an indication of the possibility of a serious medical problem," he says, because sleep apnea is linked to heart disease, stroke, depression and diabetes.
Struggling For Air
During obstructive sleep apnea episodes, snoring patients become quiet for 10 seconds or more — and literally stop breathing. The silence is followed by choking or gagging sounds when the sleeper is partially aroused and breathing resumes. Finally, snoring resumes and the cycle starts over. This cycle can happen anywhere from five times an hour to sometimes hundreds of times a night. Because people with sleep apnea partially awaken to resume breathing, their sleep is fragmented and they are sleepy in the daytime. The lack of breathing also causes the oxygen level in the blood stream to fall, contributing to medical problems.
Treatments Differ With Severity
The gold standard of treatment for sleep apnea is called CPAP, which means continuous positive airway pressure. An air pump connected by a tube to a face mask, sort of like a vacuum cleaner in reverse, gently pushes air up through the nostrils and mouth into the upper airway, keeping it from collapsing.
But the CPAP can be loud and cumbersome, and many patients who could benefit from CPAP just don't use it. However, experts say, for those with severe apnea, it's the only effective treatment.
Surgical procedures can also help by removing excess tissue in the back of the airway or actually moving parts of the jaw or tongue forward. They're particularly effective with younger patients.
The third treatment option is an oral appliance, which looks much like a mouthguard used in sports or a dental retainer typically used after orthodontry.
"Research shows the oral appliance works to treat mild-to-moderate sleep apnea," says Kushida. Studies have been limited, but the appliances appear to not only treat apnea but also conditions associated with apnea, such as high blood pressure, he says.
There are many brands of oral appliances, but all of them work basically the same way, says Dr. Mark Friedman, who specializes in treating snoring and sleep apnea in Encino, Calif., and worked as a clinical professor for over 25 years. He says the appliances work to keep the airway open and allow for comfortable breathing. They move parts in the mouth out of the way. They move the tongue forward by moving the jaw forward. So, the lower jaw juts forward a certain amount.
One Patient's Experience
Rani Stoddard is one of Friedman's patients. She is a nurse who describes her husband as a gem, since he put up with her loud snoring for years.
"He says, on a scale of one to ten, I was like a ten plus on snoring," Stoddard says. Today, she wears an oral appliance, "and now I'm like a two," she says. "You know, a little mild, delicate (snoring) in the beginning and then ... it's quiet!"
Stoddard can't speak highly enough about the oral appliance. "I'm a believer!" she says, adding that now, she "sleeps like a baby." She says the appliance is comfortable and she can even take a drink of water while wearing it.
Although most sleep apnea is initially diagnosed after a study is performed at a sleep center and a physician evaluates the study, apnea can also be measured at home to determine how well treatments are working. To do this, the patient wears a compact device on an armband with two finger-sensors attached. The device measures a number of respiratory functions, including the amount of oxygen getting into the blood. Friedman reports that Stoddard's apnea has been dramatically reduced as a result of the appliance.
Friedman says the oral appliance is at least 60 percent effective for most patients. "For some patients, it's 100 percent effective," he says.
The Role Of The Dentist
Barsh says screening in a dentist's office takes only a few minutes and a few pointed questions, and dental hygienists can also be trained to screen for apnea. It involves asking whether patients suffer from high blood pressure, if their bed partner has ever observed them stopping breathing during the night, if they feel sleepy during the day and if they snore. A patient's neck size, particularly if it's large, can also be an indicator of apnea.
Friedman, a dentist who specializes in treating snoring and sleep apnea, also asks patients whether they are aware of dreaming during the night. Sometimes patients are confused about why a dentist would be asking such a question, he says.
"But people who don't dream often are not getting into REM sleep," says Friedman, If that's the case, he says, they're probably not getting good deep sleep either. And that, he says, can "lead me to have an inkling that the patient might have a sleep issue."
Since he started focusing on sleep disorders about six years ago, Friedman says the majority of patients with sleep problems are longtime patients. "You would be amazed at the number of people that we have diagnosed within our own practice," he says.
Because a sleep-apnea appliance must be fitted precisely to the mouth, Friedman says it's important for a dentist trained in sleep medicine to fit the device. Dentists can take training at various academic centers, but the American Academy of Dental Sleep Medicine offers courses during its annual meetings.
Although there are many appliances advertised on the Internet and on TV, there are only about 60 FDA-approved devices. Of those, Friedman says, he considers only about six to be effective. And, Friedman says, if potential patients are interested in researching what types of oral appliances are available and most effective, the Academy website is a good place to start.