“I’d use my sleep apnea machine, but it comes with a big mask that you have to put over your face, and it’s not too sexy,” my patient said during his appointment. Do you know what my response was? “Snoring isn’t so sexy either.” The American Sleep Apnea Association states that about 90 million people snore. Not all suffer from obstructive sleep apnea.
We want to help people, and that’s what we do each time we see a patient. We prevent oral cancer by performing screenings and detecting tissue changes at the earliest stages. We prevent heart attacks by checking blood pressure on each patient. Can we prevent a poor quality of life and even death by asking a patient how they are sleeping at night? Some of us do, and some of us don’t. We all should.
Sleep apnea is far more common than we think, because most of the time it goes undiagnosed. According to the National Sleep Foundation, “more than 18 million people have sleep apnea.” This figure does not include pediatric sleep apnea. Sleep apnea can affect a person at any age. In other words, it affects anyone. In fact, we all know at least one person close to us who suffers from sleep apnea. Maybe you even have some sleep disrupted breathing (SDB) issues. A lot of times this can be overlooked because not all fit the classic description of overweight, high BMI, and a neck circumference greater than 17 inches.
For example, both of Timbrey’s parents and her sister suffer from sleep apnea. Besides the dark circles under their eyes, their complaints of daytime sleepiness, and the constant loss of focus, they snore and have been witnessed to stop breathing while snoring.
Let’s talk about what sleep apnea is and the different types there are, as well as how orofacial myofunctional therapy can help, before looking at more “traditional” treatments.
WebMD provides a pretty good definition of sleep apnea as “… a serious sleep disorder that occurs when a person’s breathing is interrupted during sleep. People with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times. This means the brain-and the rest of the body-may not get enough oxygen.”
May not get enough oxygen? Isn’t that how comas happen?
Recognizing Sleep Apnea
From an anatomical perspective, the oropharynx is the part of the body that includes the mouth and throat. In simple terms, the oropharynx is a tube lined by muscular tissues. These muscles help us to eat, talk, and breathe. They also help to keep the airway open, especially during sleep.
When the muscles of the oropharynx are weak, they disrupt the flow of air, and that is when snoring happens. If the tube collapses, the airway becomes blocked, such as what happens during sleep apnea. Moreover, a weak and floppy tongue may fall back into the throat and create an obstruction.
An orofacial myofunctional therapist can help manage those muscles. Sleep apnea is categorized into two different types: obstructive sleep apnea (OSA) and central sleep apnea (CSA). Central sleep apnea is caused when the brain fails to signal the muscles to breathe. It’s pretty serious, and orofacial myofunctional therapy is limited in effectively treating it.
On the other hand, obstructive sleep apnea is far more common. It’s caused by a blockage in the throat (which is usually the soft tissue, namely the soft palate) while sleeping. Orofacial myofunctional therapy can help this kind of sleep apnea by working with the muscles of the oropharyngeal complex, although the therapy is considered adjunctive.
One more category should be added to this discussion. This category is often missed, because it doesn’t “qualify” as a type of sleep apnea. Yet, an uncounted number of people are affected by it. Upper airway resistance syndrome (UARS) is a type of sleep disorder that is characterized by resistance of the airway while sleeping. It’s similar to OSA in the sense that there’s abnormal airway blockage or resistance, but it doesn’t get to the point where the airway is totally obstructed.
UARS is underdiagnosed because it doesn’t show up as a problem on a classical sleep study while examining the apnea/hypopnea index (AHI). UARS may be caused by allergies or structural conditions such as small maxillae.
Home Sleep Studies
Let’s walk through a home sleep study. Many important things are recorded during a sleep study-for example, eye movement, heart rhythms, breathing patterns, and brain activity. The most important recording is the oxygen desaturation index (ODI). Oxygen saturation is the percentage of oxygen that is in our blood. So we pay attention to how much the ODI drops when someone is sleeping.
When someone has obstructive sleep apnea, their oxygen saturation levels drop every time they stop breathing, which in turn makes the heart work harder trying to get oxygen to the cells.
Two other major indexes are the apnea/hypopnea index (AHI) and the respiratory disturbance index (RDI). AHI measures the apneic events in an episode of fully occluded breathing that lasts 10 seconds or more, and a hypopnea event is an episode of partial occlusion. The respiratory disturbances measured are called RERAs (respiratory effort related arousals), which is a short arousal that follows partial occlusion of the airway. In a 2012 article in SLEEP, Krakow studied over 500 awakenings and found 90% were preceded by sleep breathing events. The patients didn’t know they had a sleep breathing event before they woke up. They thought they had a nightmare, had to go to the bathroom, or had some kind of pain.
When patients present with high RDI results, it’s labeled as an upper airway resistance syndrome. Researchers have reported lately that, although these patients don’t qualify as having obstructive sleep apnea, there was a reason the RDIs were coming back so high. They found that the patient was receiving enough oxygen, but struggling to do so.
This is a chance to treat early on, before the patient falls into the category of obstructive sleep apnea. A majority of patients fall into this category, especially women in the 30-55 age range. Christian Guilleminault wrote a study titled “Upper Airway Resistance Syndrome (UARS): A Common Cause of CFS and Fibromyalgia.” Those with OMT training can help people with UARS to find out early what is best for the patient. Once obstructive sleep apnea is diagnosed, the job becomes a little more difficult.
Treating Sleep Disorders
Now that we know a little bit about the different types of sleep disorders and which are appropriate for OMT referrals, let’s look into how they are treated.
It is always a good idea to have two referrals for your patients: a sleep doctor and airway focused dentist. In most states, dentists are not allowed to interpret sleep studies, so a sleep physician is good to have on your team. The sleep doctor is important in order to get the sleep readings, and it is always a good idea to get a full PSG (polysomnogram) for patients you suspect as having obstructive sleep apnea. Also, referrals to an airway focused dentist can lead to oral sleep appliances, as well as a closer look into why patients are struggling with sleep apnea in the first place.
Sleep appliances alone, or in conjunction with orofacial myofunctional therapy, are a widely used and very effective way to treat sleep disorders. Mandibular advancement devices (MAD) are especially helpful in patients with mild to moderate range disorders such as UARS. Dental appliances are also good for treatment in conjunction with a CPAP (continuous positive air pressure).