Oral Appliance Therapy was first endorsed as effective management of obstructive sleep apnea by the American Academy of Sleep Medicine in 1995. In 2005, the Standards of Practice Committee of the AASM updated the practice parameters for the use of oral appliances as appropriate first line therapy for snoring and mild to moderate Obstructive Sleep Apnea. Occasionally, Dr. Marinkovich will prescribe a different appliance when he decides the care warrants that decision.
Most patients with narrowed airways will have increases in the volume of the airway and decreased resistance to airflow when the mandible is advanced. This is the fundamental principle of airway management, utilized in cardio-pulmonary resuscitation (CPR), where the tongue is moved from the airway by head and mandibular posture.
The base of the tongue is moved farther from the airway tissues to a position where contact and obstructions are less likely or unable to occur. Increased airway volume causes a slower rate of flow, which increases air pressure (Bernoulli’s Principle), and increased tone is imparted to the tongue by the stretching of the masseter muscles. This keeps the tongue from blocking the airway.
Dr. Marinkovich is versed in using several different appliances and will select the best appliance for each individual case. These are the two appliances he uses most.
The Herbst Appliance is a mandibular repositioner that has been used for many years for orthodontic and TMJ therapy, but has now been modified for treatment of Sleep Disordered Breathing.
This appliance allows the patient to move laterally and vertically without disengaging the appliance. Also if the initial position does not relieve symptoms, this appliance can be adjusted to move the mandible farther forward quite easily. This appliance is typically fabricated of hard acrylic and is quite durable.
The SomnoDent Appliance has a patented fin-coupling mechanism on the lower arch to ensure that your jaw remains in the correct position whether you sleep with your mouth openor closed. Like the Herbst Appliance you can open vertically to speak or get a drink of water. Patients report the Somno Dent Appliance is very comfortable.
The appliance is typically made of hard acrylic but a softer lining material is available when appropriate. This appliance is very durable. Like the Herbst Appliance the Somnodent is custom fin to each patient’s mouth.
The Tap III Elite is a custom-made two piece appliance. The top appliance has a hock which engages an internal mechanism on the lower appliance. A tool can be used to adjust the position of the hock which in turn is used to move the mandible farther forward if needed.
OTHER TREATMENT OPTIONS
Continuous Positive Airway Pressure (CPAP) (At your Physician’s office)
Airway collapsibility is reduced by the application of increased air pressure which “splints” the airway open. This therapy is termed the “gold standard” by sleep physicians but unfortunately many patients simply cannot tolerate the form of treatment.
Surgery as Primary or Adjunctive Therapy (At your Surgeon’s office)
Surgery can be used to remove or reposition redundant tissue to reduce the noise of snoring and the potential for obstructions. Resulting airway volume increases may increase air pressure. Radio-frequency ablation (“Somnoplasy”) of the soft palate may reduce the volume of tissue while preserving its anatomy.
Surgery is invasive and irreversible. The proper case selection and work up are essential to decrease your risks, and to increase your chances of improvement. Surgical interventions now also include implants to stiffen the soft palate, permanent advancements of the upper and lower jaws, stomach alteration surgeries to reduce weight in the very obese, and even tracheostomies to bypass the obstructions during sleep. All of these procedures have significant risks, and understanding those risks as they apply in individual cases is necessary for proper informed consent. It is recommended that patients request documentation from peer reviewed medical journals describing outcomes for any of the surgical procedures that are contemplated.
For some patients, avoiding sleeping on the back (supine position) will either correct the problem or help reduce the airway collapsibility. When supine position avoidance is hybridized with other therapies such as the use of the TAP Appliance, the overall outcome is often enhanced.
Our home monitoring system will accurately determine the patients’ habitual body positions during sleep, and when analyzed against the airway collapsibility data, the potential usefulness of this additional therapy can be easily determined.
Sleep Hygiene/Weight Loss
All patients, regardless of diagnosis, or severity of sleep disordered breathing should follow basic principles of good sleep hygiene.
- Most Adults require 7-9 hours of sleep per night
- Optimize sleeping conditions
- Quality bed
- Optimal temperatures
- Minimize allergens
- Avoid stimulants and alcohol within 3 hrs of bedtime
- Don’t eat or drink in excess before bed
- Keep a regular sleep-wake schedule
- Develop relaxing bedtime rituals
- Reserve only appropriate activities for the bedroom
- Don’t read in bed
- Don’t watch TV in bed
- Don’t eat in bed
Exercise and weight loss is an essential part of all patients’ treatment plan. You may be referred to a weight loss / nutrition program if you are at all overweight.