No sleeping in the snore business
Dentists tap into the market for an alternative to a CPAP machine.
There is often a lot of swearing entailed when the discussion centers around snoring, sleep apnea and the now-ubiquitous CPAP machine: Some CPAP users swear by them and other people swear they would never use one, no matter what.
Dentists around the nation now are offering a less complicated alternative to the CPAP — a plastic “oral appliance” like a mouth guard that is worn while sleeping to maintain an open, unobstructed airway.
Dr. Daniel J. Burton, who has been a dentist for more than 35 years, has opened a Dental Sleep Office at the Women’s Health Center off Michigan Street in northeast Grand Rapids. He has undergone specialized training in fitting patients with mild or moderate obstructive sleep apnea disorder for “oral appliance therapy,” an alternative to the continuous positive airway pressure (CPAP) machine.
Burton said most patients with sleep apnea are advised to use a CPAP, “which is a very good, predictable solution. Unfortunately, some patients are unable to tolerate CPAP,” he said.
Burton said the oral appliances now on the market provide “a comfortable, effective, FDA-approved treatment alternative. Oral appliances are easy to wear and can end (users’) breathing problems during sleep to achieve a better night’s sleep.”
According to Mercy Health’s Hauenstein Neurosciences Center in Grand Rapids, snoring can be a symptom of sleep apnea, a serious sleep disorder. Although not everyone who snores has sleep apnea, those who do stop breathing again and again during sleep. The non-breathing episodes may last 10 to 90 seconds, and in very severe cases can occur hundreds of times each night. An estimated 18 million Americans have sleep apnea.
The most common form of sleep apnea is obstructive sleep apnea, which is when the muscles in the back of the throat fail to keep the airway open, despite efforts to breathe. Obstructive sleep apnea can cause fragmented sleep and low blood-oxygen levels. For people with sleep apnea, the combination of frequently disturbed sleep and low oxygen levels may lead to hypertension, heart disease, and mood and memory problems.
The Hauenstein Center says sleep apnea is a serious health disorder and anyone who thinks they may have it should consult a doctor. The center has published an online guide that lists factors that can contribute to sleep apnea, including having a small upper airway (or large tongue, tonsils or uvula), being overweight, having a recessed chin, a large overbite, a large neck size (17 inches or greater in a man; 16 inches or greater in a woman), and being age 40 or older.
The U.S. Department of Health & Human Services says overweight people with sleep apnea should first try to lose weight “because overweight is a key factor.”
Sleep apnea can be life threatening, according to Burton, because the repeated interruption in oxygen intake can have serious ramifications both physically and emotionally. The afflicted individual is often very tired throughout the day, which impairs work performance, and some cases of drivers falling asleep at the wheel in the middle of the day are thought to be a result of sleep apnea.
The majority of people who have sleep apnea are not even aware of it, according to the Hauenstein Center. The most common test used to diagnose it is a sleep study, which may require an overnight stay at a medical sleep center. The study monitors a variety of functions during sleep including sleep stage, rapid eye movement (indicative of the deepest stage of sleep), muscle activity, heart rate, respiratory effort, airflow and blood oxygen levels. The test is used both to diagnose sleep apnea and to determine its severity.
One of the most common and effective forms of treatment is the CPAP, which involves a mask that fits over the nose and/or mouth, connected by hose to a pump that gently blows air into the mouth to help keep the airway open during sleep.
“We treat people who are CPAP intolerant,” said Burton. “Intolerant” may mean emotionally as well as physically intolerant. Many individuals simply do not want to use the CPAP, which requires them to lie on their backs all night with minimal movement.
The U.S. Centers for Disease Control published a study of obstructive sleep apnea, or OSA, conducted at the Cincinnati Veterans Affairs Medical Center from 2005 to 2007. A sleep study or polysomnography, which involves electronic monitoring of the individual throughout the night, was done on 596 veterans (almost all male) who were suspected of having sleep disorders. It showed that 76 percent of them had OSA — 30 percent mildly, 23 percent moderately and 47 percent severe.
Eighty-one percent of those with OSA were started on CPAP machines, but only 59 percent of them reported “good” adherence to the recommended use of the machines. Of those who used the CPAP as recommended, those with severe OSA reported a higher percentage of excellent results than those with mild or moderate OSA.
But, as noted by HHS, many men aren’t interested in using the CPAP. HHS cited a report from the Lifespan health care system in Rhode Island, which compiled data on 53 truck drivers who were suspected of having sleep apnea. The truckers were referred for follow-up examinations, but 33 did not go. The other 20 did go and were diagnosed, but only one complied with the recommended therapy.
Some men with sleep apnea “are in denial,” said Burton, because they are determined not to use a CPAP — even when the man’s wife will testify that he stops breathing frequently at night and then gasps for breath.
“That’s where we come in,” said Burton, with the oral device alternative to the CPAP machine.
According to Anjoo Ely of the American Academy of Dental Sleep Medicine, dental sleep medicine is a growing segment of dentistry, and dentists trained in it work in conjunction with a physician. When Burton suspects one of his patients may have sleep apnea, he refers that person to their doctor for an examination. The patient must present Burton with a prescription from the doctor for an oral device.
“I can’t do anything unless I have a medical diagnosis from their physician,” he said.
Burton makes an impression of the patient’s teeth and jaws and sends it to the lab that makes the device. Over the next few weeks, he helps the patient learn how to use the oral appliance and ensures that it fits properly.
One of the best known brands of oral appliances for treating snoring and obstructive sleep apnea is the Moses, named for its inventor, Allen J. Moses, a Chicago dentist.
Burton said the process of being fitted with an oral appliance can cost about $2,800 or $2,900. Medical insurance generally covers it, even though the treatment is being provided by a dentist.
But CPAPs still have legions of fans. As Ely pointed out in a recent newspaper column, CPAP therapy “is still considered the gold standard for severe apnea.”
“Many patients just love them. They can’t sleep without them,” said Burton.