• On snoring, 1

    You lucky duckies have an opportunity to watch me blog my way through some snoring and sleep apnea literature, though it may put you to sleep. I’m starting with snoring, right here, right now. (These are just quotes and notes. Some readers may recall I used to do this all the time.)

    Hoffstein, V., 2007. Review of oral appliances for treatment of sleep-disordered breathingSleep and Breathing11(1), pp.1-22.

    • This is a systematic review that covers oral appliance use for snoring or sleep apnea. Since many other reviews focus on the latter, I’m principally using it for the former.
    • “Treatment of sleep-disordered breathing (i.e. snoring, upper airway resistance syndrome, sleep apnea syndrome) can be divided into four general categories. These include: (1) lifestyle modification, i.e. weight loss, cessation of evening alcohol ingestion, sleep position training, (2) upper airway surgery, (3) oral appliances, and (4) CPAP.”
    • Not enough dentists are familiar with the treatment of sleep-disordered breathing with oral appliances. “Bian [7] surveyed 500 general dentists in the state of Indiana and found that 40% ‘knew little or nothing about oral appliances for treatment of obstructive sleep apnea’. Caution: This publication is 14 years old.
    • George Cattlin [8] [published 1861] was probably the first person who seriously thought that the route of breathing may influence sleep quality and daytime function. He attributed good health of the native North American Indians, compared to their immigrant European counterparts, to the fact that they are taught, from the early age, to breathe through the nose rather than the mouth. He pointed out that breathing through the nose promotes more restful and better quality sleep, which translates into better daytime function and better general health.”
    • Snoring and sleep apnea are on the same continuum, both due to obstruction (either partial or complete, respectively) of the upper airway.
    • Oral appliances were invented to treat snoring. My comment: Good ones aren’t cheap (in the four figures) and insurance won’t cover them for snoring, only sleep apnea. Since they’re made to fit, you can’t resell or return one if it doesn’t work. This makes it a challenging decision to try an oral appliance to address snoring.
    • “In some patients with sleep apnea these alterations [made by mandibular advancement devices] may prevent the obstruction, in others—worsen the obstruction, and yet in others, particularly in those with low level obstruction, the part of the airway where the obstruction occurs may be unaffected.” Comment: I don’t approve of this particular use of the em-dash.
    • “We note that the findings of all such studies are remarkably consistent—CPAP results in better improvement in AHI than oral appliances. […] However, patients subjectively prefer oral appliances over CPAP.”
    • There are lots of kinds of oral appliances. “There is no ‘best’ appliance. The best one is that which is comfortable to the patient and achieves the desired efficacy.”
    • This is my favorite part (emphasis added): “However, snoring is the cardinal symptom of sleep apnea. In fact, it is frequently the only reason why these patients come to the sleep clinic in the first place. Consequently, when polysomnography does not reveal sleep apnea in these patients, the physician still has to deal with their snoring. Unfortunately, this is often ignored by physicians. The most frequent scenario is that a patient is referred to a sleep specialist because of snoring, polysomnography is carried out, no sleep apnea is found, the patient is reassured, advised to loose weight, stop smoking and drinking alcohol, embark on an exercise program, and discharged from the clinic. Sometimes this advice, dispensed in the form of preprinted sheets, is given also to non-obese nonsmokers. Clearly, the patient leaves unhappy, the referring physician is dissatisfied with the help received from the specialist and nothing was accomplished to justify the
      expense incurred in the process of investigations. For apneic snorers, the problem is simpler because treatment with CPAP will abolish snoring.” Comment: Not sure we need to justify sunk costs. But it would be better to help the patient. But, as mentioned above, it’s not such a simple matter when insurance doesn’t cover oral appliances (or anything) for snoring.
    • “the majority of the investigations concluded that oral appliances are beneficial in reducing snoring in the majority of patients.”
    • “the conclusion from all of the investigations taken as a group must be that oral appliances improve daytime
      function, although they are not necessarily superior or consistently preferred than other treatments such as CPAP and UPPP.”
    • “There is not enough evidence at the present time to draw any conclusions regarding the effect of oral appliance therapy on vascular disease.”
    • Oral appliance side effects: excessive salivation, mouth, and teeth discomfort. “The conclusion, based on the results of most studies, is that when oral appliances are properly constructed by the dentist with expertise in this area, they are relatively comfortable in the majority of patients.”
    • Between 36% and 70% of patients are not compliant with oral appliances. Reasons for discontinuation include discomfort or perception of no benefit. However, if one is using an OA to address snoring that bothers a sleep partner, but that sleep partner is no longer bothered by it (or present for it), then use might be discontinued with no problematic clinical outcomes.
    • “The evidence available at present indicates that oral appliances successfully ‘cure’ mild-to-moderate sleep apnea in 40–50% of patients, and significantly improve it in additional 10–20%. They reduce, but do not eliminate snoring. Side effects are common, but are relatively minor. Provided that the appliances are constructed by qualified dentists, 50–70% of patients continue to use them for several years.”

    @afrakt

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