When the face does not grow the way it should, and grows more downward and backward, the airway is often compromised. Both day and night, breathing can be compromised. For many, this leads to snoring during sleep or other medical problems such as “High Upper Airway Resistance” (HUAR) or “Obstructive Sleep Apnea” (OSA). With HUAR, sleep is interrupted, often without snoring or apneas, causing many problems. Interrupted sleep can affect fatigue, energy levels, memory, restfulness and more. When it worsens and becomes actual sleep apnea it is associated with many health problems, including: strokes, heart attacks, cardiovascular disease, high blood pressure, diabetes, GERD, depression, sexual dysfunction, and many other health problems.
When undiagnosed and untreated, OSA shortens lifespan by about 20%
How are breathing disorders diagnosed? Some signs are obvious, like mouth-breathing. Signs such as frequent snoring and daytime sleepiness, or another person seeing you stop breathing or gasp for air while sleeping, can all seriously point in the direction of OSA. Only a medical doctor can diagnose sleep breathing disorders. Generally, a sleep study is performed in a sleep lab, like a hotel room with a comfortable bed (bring your own pillow!), where medical monitors are used to check breathing, sleep levels, muscle movements, oxygenation and much more.
This is called a polysomnogram, and it’s the most accurate way for a medical doctor to diagnose the more advanced sleep disorders. Alternatively, some insurances only allow use of a monitor you take home and wear while you’re sleeping in your own bed, a “Home Sleep Test” (HST). Sleep breathing disorders in the more subtle stages, such as Inspiratory Flow Limitation (IFL) and Respiratory Effort-Related Arousals (RERAs) can be trickier to diagnose, yet they are more common among thin, fit women and children.
How are breathing disorders treated? Here are 3 approaches.
1. Push harder on the air through the compromised airway – CPAP
This is the option medical doctors typically prescribe, using Positive Air Pressure (CPAP and BiPAP), which is considered the “gold standard’ treatment for sleep apnea by the medical profession for the treatment of sleep apnea. For earlier stages of breathing problems, it is sometimes not recommended. CPAP and other PAP machines work by means of a pump hooked up to a mask that fits on your face, covering your nostrils, nose, mouth or all of the above. The pump pushes the air harder as you inhale, and it can help you get the oxygen and restful sleep you need.
• The Good: CPAP avoids surgery or oral appliances, and medical insurance might help with it. When it’s used, it can be very effective.
• The Bad: It can be terrible to wear. Many simply do not wear it. After 6 months, most CPAP users give up. It can dry your throat (a humidifier can help), restrict your sleep position, feel claustrophobic, be a hassle to carry around, or have other disadvantages. We treat many patients in our office who cannot or will not wear a CPAP.
2. Open the airway temporarily – Oral appliances
Wearing a special kind of dental appliance while you’re sleeping is a way to open the airway temporarily at night. Over 200 different types of appliances have been approved for this purpose, so a skilled dentist is the one to help with this type of treatment. Here are some sample appliances.
• The Good: An oral appliance can be as effective with mild to moderate sleep apnea for many patients. It’s more comfortable than CPAP for many patients, and it’s less expensive and less invasive than surgery.
• The Bad: Oral appliances run a risk that your bite may be permanently changed, like in the picture below showing that the back teeth do not meet. This may or may not be easily fixable with orthodontics. In the long run, these appliances might pull the upper jaw backward, part of the original problem that led to the obstructed airway.
3. Open the airway more permanently – using orthodontics, surgery, or both
There are ways that the airway can be increased more permanently: orthodontics, appropriate surgery, or both.
Some types of orthodontics increase the room in the mouth where the tongue has to fit. With more room, the tongue can come forward and get out of the way of a restricted airway. For some patients, this can improve or eliminate airway problems like sleep apnea.
An example of one type of orthodontics that helps the airway is shown. This patient had four bicuspids extracted, and we re-opened the spaces. Notice how much more room the tongue has. Why does this matter? Because the airway is more open when the tongue can come more forward.
Orthotropics (not pictured here) is a type of facial growth guidance that has been shown to improve the airway size, and is another example of orthodontics that can benefit the health of the airway.
• The Good: Orthodontics to open up more tongue space can work for some people. When permanent teeth have been taken out – or even when they haven’t, opening up room for the tongue can help. Not having to depend on CPAP, or risk bite changes with an oral appliance, or undergo surgery are all advantages.
• The Bad: Orthodontics takes time and there’s always the possibility that it might not be enough. In that case, CPAP, oral appliances, or jaw surgery still remain the options.
Possibly the most definitive solution for a small airway that’s causing breathing problems, is to move the jaws to the correct position in the face in order to open the airway. Like architects, jaw surgeons have many different ideas for how to “build the ideal.” These X-ray images show results from surgery done by Dr. Reza Movahed of St. Louis, MO. Notice the bigger airway. When it’s done right, jaw surgery has the potential to truly fix the underlying problem. Patients can throw away the CPAP!!
• The Good: Jaw surgery deals with the structural cause of the sleep apnea. It aims to fix the root of the problem. If the jaw joints have problems too, a surgeon like Dr. Movahed can treat them at the same time. If there are problems with the nasal airway, soft palate, etc., these can also be addressed. The way we do it, jaws can be widened as necessary at the same time too.
• The Bad: The cost and hassle of surgery, including the risks involved for any surgery, are all important factors to consider. Most surgeons are not experienced in the type of surgery we recommend, so well-worth-it travel will likely be involved.
It’s evident that there is a wide range of options you or a loved one may have for treating airway disorders like snoring and sleep apnea. Dr. Hockel is known for helping you sort through these options and consider the possibilities.
If you believe that you have an airway problem like sleep apnea, call our office at 925-478-7776 to learn more about possible treatments and schedule your initial consultation with one of our dentists.
Dr. Brian J. Hockel, Dr. Rebecca Jardine, and Dr. Kevin Adair are pleased to provide alternative treatments for Obstructive Sleep Apnea to patients from Walnut Creek, Clayton, and Concord, California, as well as from the greater San Francisco East Bay area and beyond.