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Beyond CPAP

Oral airway dilators and a host of tongue-based surgery dominate treatment offerings for those who can't tolerate CPAP

In one of the great ironies of modern American healthcare, sleep apnea is diagnosed in 22 million people, yet dental colleges have yet to offer residency education for the disorder.

"Many dentists dabble in it," noted Maurits Boone, MD, assistant professor, co-director of the voice and swallowing center at Jefferson University Hospital in Philadelphia. "Finding a dentist to properly treat sleep apnea is much more difficult than finding an ENT [for oral surgery]. However, who dispenses the oral appliance is not as important as getting it adjusted correctly and having a follow-up sleep study."

The influx of patients with sleep apnea is driving a host of new credentialing opportunities in sleep dentistry. Both the American Academy of Dental Sleep Medicine and Academy of Cranial Facial Pain have introduced mini-residencies and practice resources to train clinicians on treatment options.

Though continuous positive airway pressure (CPAP) devices are becoming smaller and more convenient, many patients instead choose an oral device or even surgery. Some patients become claustrophobic breathing against a closed air column and others say the noise disrupts their spouse's sleep.

"I am impressed with how the market has caught up with research as far as CPAP," said Eung-Kwon Pae, PhD, DDS, MSc, chairman and professor, University of Maryland School of Dentistry. "I'd say 80% of my patients choose CPAP. But there are those who can't tolerate it and many find it hard to travel through airports with a CPAP machine."

Oral Devices
Patients with mild to moderate obstructive sleep apnea or those with heavy snoring can benefit from oral appliances. Anecdotally Rush University Medical Center's Allen J. Moses, DDS, ABCP, AADSM, assistant professor, said he's had great success with patients with severe sleep apnea. Results aren't as predicable and depend heavily upon patients breathing through their noses during sleep.

The most common device is a form of the oral airway dilator (also called mandibular reposition device), which pushes the tongue and jaw forward, making the airway larger and improving airflow. With this device, the odds of tissue collapsing and thus narrowing the airway during nighttime breathing lessens. There are many oral airway dilators on the market today and the best selection depends on a patient's tolerance and allergies.

The device isn't without its detractions, though. According to Pae, protruding the jaw 6-7 mm forward strains the jaw joint muscles and ligaments. Especially in the days after the device is first fitted, patients complain that they can't bite all the way down.

Pae tells his patients to come back to his office if they think their device may need adjustment. Many times, it's just a matter of reducing the height of the appliance. Boone recommends his patients increase the device incrementally each night until they find a comfortable tolerance level.

New on the scene is the open anterior oral dilator, an acrylic appliance that is worn in the mouth at night. The device supports the lower jaw in a forward position of low muscle activity and prevents tongue collapse.

"People often don't like CPAP but everybody loves their oral appliances," said Moses. "A computer chip to monitor usage is on the horizon, putting appliances on equal footing with CPAP. The CPAP compliance rate is 4 hours, 4 nights a week and the device compliance rate is all, every night. CPAP is more effective but only if you use it."

Surgical Options

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Maxillomandibular Advancement Surgery

A Permanent Solution for OSA

For patients not wanting the hassle of fitting an oral device or committing to CPAP, surgery is an option. Traditionally, removal of the tonsils or androids and uvulopalatopharyngoplasty (UPPP) - a procedure that removes excess tissue in the throat to make the airway wider - were the standard.

"Surgery for sleep apnea has changed greatly in the last 10 years," commented Boone. "This is owed to recognition that the obstruction isn't just levels in the airway such as nose, soft palate or tongue. We've become more sophisticated about learning how they collapse, not just which area collapses. Because we can identify how the collapse occurs, surgery has evolved."

Boone and his colleagues frequently perform a modification of the painful and high-risk UPPP procedure called the expansion sphincteroplasty, which removes the remaining tonsil, creates an incision on the soft palate, pulls the muscles of the back wall of the tonsils forward to increase throat space and pulls stitches to further open the space. This surgery preserves the uvula most of the time.

Success rates have been high for anterior palatoplasty in a study by Singapore expert Kenny Pang, FRCSEd, FRCSI, of the Pacific Sleep Center. As published in the Official Journal of the American Academy of Otolaryngology, the overall success rate for this OSA group was 71.8% (at mean 33.5 months). The mean snore scores (visual analog score) improved from 8.4 to 2.5 (for all 77 patients). Lowest oxygen saturation also improved in all OSA patients. Subjectively, all patients felt less tired.

Operations on the tongue base are receiving a lot of publicity lately. Boone's Jefferson Hospital performs hyoid myotomy. During a tongue base advancement with hyoid myotomy, an incision is made under the chin and a device is used that places three screws into the undersurface of the jawbone. Each screw has a heavy suture affixed to it. Two of these sutures are passed around the hyoid bone (the bone that makes up the top part of the voice box) to pull it upward and forward. Because the tongue is attached to this bone, the sutures can advance or at least stabilize the back of the tongue to prevent collapse. The final suture is passed behind the back of the tongue to prevent the tongue from falling backward during sleep.

Penn Medicine received IRB approval for TransOral Robotic Surgery for patients with sleep apnea who have enlargement of the lingual tonsils and/or tongue base that contributes to the airway obstruction. This approach involves an area that was not previously accessible with minimally invasive techniques. According to Penn Medicine, of the more than 40 people already enrolled in the study to date, approximately 60% have experienced a dramatic improvement in their obstructive sleep apnea.

None of these surgeries are without complications and all require a long recovery. Swallowing problems are common post-op and many times, the surgery complicates a person's ability to use CPAP devices in the future.

Pediatric Predisposition
Andrew Hotaling, MD, professor, Loyola University of Chicago Stitch School of Medicine, works exclusively with children with sleep apnea. The majority of his surgeries are tonsil or android removal but he warns that neither is 100% curative.

He may be in the minority but said he doesn't necessarily need a sleep study before removing tonsils or androids. If effective, surgeries can yield significant improvements in a child's behavior, school performance, and even nutrition. Some children choke or gag because of the underlying sleep apnea or are classified as failure to thrive.

When tonsil or android removal doesn't result in an improvement, his facility can surgically shrink the turbanances, or structures on the side of the nose on the lateral wall. Because of resulting turbanant scabs, this procedure requires 3-4 post-op nose cleaning visits, but the surface area does get smaller after it heals. The procedure may need to be repeated years later.

Hotaling's work is becoming less of a specialized niche. The American Academy of Pediatrics recommended that pediatricians ask about snoring at well child visits. Though the frequency of tonsil removal is down nationally, he said recognition of sleep apnea in children is growing incrementally.

Robin Hocecar is on staff at ADVANCE. Contact

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