Part Seven: Revealing the Latest Innovations in Sleep Apnea Diagnosis & Treatment

Overview

Sleep apnea and sleep-disordered breathing require accurate diagnosis and root-cause treatment—not guesswork or symptom-only solutions. This article explains how airway obstruction (often involving the tongue, jaw position, and nasal breathing) is evaluated using advanced tools like CBCT imaging, pharyngometer and rhinometer testing, and home sleep studies.

It also outlines modern treatment options, including oral appliance therapy, myofunctional therapy, breathing techniques, laser therapy, and structural correction of the jaws or palate. You’ll learn why home sleep studies are often more convenient and informative than sleep centers, how to understand sleep study results, and why some night guards or snoring-only appliances can make sleep apnea worse.

The key takeaway: effective sleep apnea care requires collaboration between dentists, ENT specialists, and sleep physicians to deliver personalized, long-term solutions that improve breathing, sleep quality, and overall health.

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In this article, we will delve into the latest methods for effectively diagnosing and treating sleep apnea, snoring, and sleep-disordered breathing. By understanding the underlying causes and employing innovative techniques, we can provide a more restful and healthier sleep experience.

Diagnosing Sleep Disorders

The key to resolving sleep-disordered breathing lies in identifying and addressing the obstruction in the airway. In most cases, the tongue plays a significant role in causing this obstruction, leading to snoring and impaired oxygen flow. To overcome this challenge, repositioning the tongue is crucial. While ear, nose, and throat (ENT) specialists typically handle structural issues in the nasopharynx and oropharynx, such as deviated septa and enlarged tonsils, oral physicians and dentists can also address these concerns in the middle part of the throat.

Cutting-Edge Technologies for Diagnosis

Modern advancements in medical imaging have revolutionized the diagnosis of sleep-disordered breathing. One such technology is the 3-D cone beam computed tomography (CBCT), which provides a three-dimensional evaluation of the airway. By detecting obstructions, deviated septum, and fluid buildup in the sinuses, CBCT offers valuable insights. However, it is important to note that CBCT alone cannot render a diagnosis, as anatomy does not always predict physiological effects accurately.

Another useful instrument for diagnosis is the Rhinometer. This device measures nasal airway openness and flow exchange, allowing medical professionals to assess the effectiveness of nasal decongestants in improving airflow. If nasal breathing remains compromised, referral to an ENT specialist may be necessary for further treatment options.

Treating Sleep-Disordered Breathing

In addition to addressing structural issues, it is essential to focus on promoting normal nasal breathing and improving the airway’s collapsibility during sleep. Myofunctional therapy and the Buteko breathing technique can help patients return to normal nasal breathing, stimulating the parasympathetic nervous system and enhancing cardiovascular health. Nasal breathing also reduces exposure to microorganisms and environmental toxins. The small structures inside your nose are called turbinates. These structures cleanse, heat, and humidify the air as you breathe. They also produce nitric oxide.

To measure airway collapse and determine the appropriate appliance position, the pharyngometer is a valuable tool. The dental team will take multiple readings, including baseline measurements and subsequent readings, after moving the jaw forward or opening the bite. By titrating the appliance position, we aim for optimal improvement, ensuring the patient’s comfort and efficacy of treatment.

The detection and treatment of sleep apnea and sleep-related breathing problems have greatly improved because of advanced technologies and creative methods. By combining the expertise of ENT specialists, oral physicians, and dentists, we can provide tailored solutions for each patient’s unique needs. Remember, a professional evaluation from a certified sleep center or a Board Certified Sleep Physician is essential for accurate diagnosis. In our next article, we will discuss ineffective solutions and over-the-counter appliances that you should avoid. Stay tuned for more valuable insights in our series on sleep apnea management.

The Power of Technology

The pharyngometer, though an older piece of technology, remains unparalleled in its ability to determine the optimal position for oral appliances. While some dentists rely on guesswork or other tools, we firmly believe in the precision and reliability of the pharyngometer at the Julian Center. However, the future holds even more promise with the imminent arrival of MATRx, a remote-controlled device that titrates the perfect position for an oral appliance to combat sleep apnea. This device is used while a patient is sleeping at a certified sleep center. These advancements highlight the commitment of the dental community to providing superior care to our patients.

The Rise of Home Sleep Studies

Historically, sleep centers were the go-to option for sleep studies, but today, we have a new option in the form of home sleep studies. At the Julian Center, we prefer the convenience and comfort of home sleep studies, eliminating the need for additional consultations with primary care providers. By offering this option, we streamline the process, ensuring our patients can receive the necessary care without unnecessary hassle. It is important to note that the interpretation of these studies still requires the expertise of a board-certified sleep physician, and we encourage collaboration with the patient’s primary care provider. A diagnosis can only be made by a physician, not a dentist.

Evolution of Sleep Centers

The landscape of sleep centers has shifted over the years. Once in high demand, these centers charged exorbitant rates for sleep studies until insurance companies intervened. This led to closures, leaving only a handful of centers that still require overnight or multi-night stays. In the past, dentists faced challenges in treating sleep-disordered breathing as they had to refer patients to sleep centers for diagnosis. This lack of control over patient care post-referral often resulted in missed opportunities for oral appliance therapy. However, times have changed, and dentists now play a crucial role in diagnosing and treating mild-to-severe sleep apnea, thanks to increased acceptance from the medical community.

Benefits of Home Sleep Studies

Home sleep studies offer numerous advantages over traditional sleep centers. Patients can avoid sleeping in unfamiliar environments and enjoy the comfort of their own homes. Moreover, the cost of home sleep studies is significantly lower compared to sleep centers, making it a more accessible option for many individuals. The NOXT3 system used in our office not only diagnoses sleep apnea but also evaluates bruxism, a condition closely related to sleep-disordered breathing. By capturing a comprehensive picture of the patient’s issues, from clenching to snoring to oxygen desaturation, we can devise a more tailored treatment plan.

Identifying the Need for a Sleep Study

Patients reporting symptoms such as snoring, gasping/choking, or daytime sleepiness should consider a sleep study. Other indications include headaches, dry mouth, sore throat, neck and shoulder pain, and cognitive or mood changes. Dental indicators such as worn or broken teeth, and gum recession can also point to the presence of sleep-disordered breathing. A Mallampati Score of 3 or 4 (a review of the tongue position in the back of the throat), restricted airway space, and CBCT findings further warrant a sleep study.

With advancements in technology and the increasing acceptance of dentists in the realm of sleep apnea diagnosis and treatment, patients can now enjoy more accessible and convenient options. From the pharyngometer to home sleep studies, these innovations empower dentists to provide comprehensive care to those suffering from sleep-disordered breathing. By working in collaboration with primary care providers and sleep physicians, we can ensure that patients receive the highest standard of care, leading to improved quality of life and overall well-being.

The Hidden Truth of Sleep-Disordered Breathing

Unrecognized by many, sleep-disordered breathing can wreak havoc on our health while we sleep. Fortunately, a home sleep study can provide valuable insights into the underlying issues. In this article, we will explore the importance of interpreting sleep study results and delve into the various treatment options available to combat sleep apnea and other related conditions.

Understanding Sleep Study Results

The home sleep study not only reveals clenching and airway obstruction but also provides crucial information, such as the number of bruxism events, apnea/hypopnea episodes, oxygen desaturation, and snoring occurrences per hour. This undeniable proof allows for a comprehensive understanding of the patient’s condition. However, many patients remain in denial because they lack awareness of what occurs during their sleep. Therefore, we strongly suggest the utilization of home sleep studies, regardless of whether you seek confirmation or treatment. Additionally, before we schedule a patient for extensive dental treatment, conducting a sleep study becomes imperative. This provides information regarding bruxism, gingival recession, and tongue position that will affect successful restorative dental treatment.

Decoding Sleep Study Terminology

Apnea refers to the complete collapse of the airway, resulting in a temporary cessation of airflow for at least ten seconds. This causes a drop in oxygen levels and leads to sleep disturbances. On the other hand, hypopnea involves abnormally shallow breathing or a low respiratory rate. A hypopnea index of 1 indicates a 4% reduction of oxygen saturation. While some consider hypopnea less severe than apnea, studies suggest that both can significantly affect sleep quality. The apnea-hypopnea index (AHI) measures the number of disruptions (the sum of the number of Apnea event plus the number of Hypopnea events) per hour and categorizes them into severity levels, ranging from within normal limits to extremely severe.

Furthermore, the Oxygen Desaturation Index (ODI) quantifies the frequency of oxygen levels falling below 97 percent during sleep. Oxygen saturation, ideally between 98-100 percent, reflects the available oxygen in the blood. The Snore Index (SI) measures the duration of snoring throughout the recording, while the Bruxism Episode Index (BEI) indicates the frequency of clenching/grinding events during the test.

Treatment Options:

With the expertise and resources at the disposal of oral physicians, determining the best treatment course for sleep-disordered breathing becomes possible. By designing a custom appliance worn during sleep, oral physicians can assist patients by carefully repositioning the jaw and alleviating airway obstruction caused by the base of the tongue. However, while this approach may address the symptoms, it does not correct underlying issues such as crowding, recession, narrow jaws, overbite, underbite, crossbite, and open bite.

Enhancing Intraoral Appliances for Improved Sleep and Breathing

In the ever-expanding market of intraoral appliances (with over a hundred FDA-approved options), each inventor claims that their product is the ultimate solution. However, many oral physicians limit themselves to offering just one appliance due to insufficient training or lack of seminars provided by manufacturers. This often leads to appliance selection based solely on the dentist’s educational background in obstructive sleep apnea (OSA). For a more comprehensive approach tailored to your specific needs, it’s essential to seek a dentist with a wide range of options and a solid understanding of OSA. Although this article won’t delve into every available appliance, it emphasizes the importance of finding the right fit for oral therapy, considering factors like comfort and individual requirements. Factors also include if the patient has TMJ problems or if they grind their teeth side to side.

Dental Appliance Options

Thankfully, medical insurance now covers numerous devices, ranging from $2,500 to $6,500, depending on the appliance type, dentist’s expertise, and additional treatments or services included. The key lies in creating a properly fitting, biocompatible appliance. Various options cater to specific patient needs, such as appliances designed for those with a low gag reflex, patients missing upper teeth, or individuals experiencing sinus issues. The oral physician’s expertise determines the most suitable appliance for each case.

When a dentist prescribes a nighttime appliance for bruxism, it’s crucial to inquire if it also addresses sleep apnea. In some instances, a bruxism appliance may worsen the jaw position for sleep apnea patients, particularly those with appliances that pull the jaw forward using “fins.” While these appliances protect the teeth from damage, they restrict lateral jaw movement, which is detrimental for bruxers. Using a night guard won’t resolve the underlying cause of bruxism—sleep apnea—allowing clenching and grinding to persist. Additionally, temporomandibular joint problems may arise from unaddressed bruxism. Over time, the appliance may wear out or fracture, requiring frustrating replacements. It’s clear that without a proper Home Sleep Test (HST), the cause remains unresolved and potentially exacerbates the issue. We recommend using an HST for patients who are only seeking a nighttime appliance, that they gauge the effectiveness of the appliance by using the appliance during the sleep study one night and not using it the next night.

Similar caution applies to appliances exclusively targeting snoring. While they may minimize or eliminate snoring, preventing disturbances for a bed partner, they can worsen sleep apnea by removing the body’s natural alarm system. If an appliance eliminates snoring without opening the airway, it can inadvertently create a life-threatening situation by allowing the spouse to sleep soundly. Without that “foghorn,” the partner may sleep through a potentially dangerous event. Therefore, we strongly advise that patients conduct an HST both with and without the appliance.

At the Julian Center, we frequently utilize the Mandibular Repositioning-Nighttime Appliance for moderate-to-severe OSA cases. Consisting of upper and lower pieces, this two-part appliance positions the jaw forward when the wearer bites down, thereby moving the tongue away from the back of the throat. It also encourages a more favorable position of the soft palate. To maximize efficacy, we encourage patients to adopt nasal breathing and may provide myofunctional therapy or Buteko breathing techniques, as well as mouth taping, to help keep their lips closed.

Laser Therapy

Laser therapy presents a relatively new treatment option. Using the innovative NightLase laser, we can tighten a drooping soft palate in the back of the throat, which obstructs the airway. By initially pulling the jaw forward to displace the tongue and then performing laser therapy on the soft palate, we effectively open the airway and create a larger breathing space. This minimally invasive procedure requires no anesthesia. Laser therapy does not remove any tissue – it’s nonablative. Studies indicate that patients should have the laser procedure repeated every twelve to eighteen months.

At the Julian Center, our approach focuses on addressing the root causes of your issues. This entails ensuring a stable bite, proper breathing, and optimal jaw function. Only after we address these foundational aspects can we proceed with restoration or rehabilitation of your teeth, resulting in improved aesthetics, stability, longevity, and overall oral function and health. This approach differentiates us from most dental practices that solely treat symptoms. While it may initially appear daunting, the long-term results prevent the need for repeated dental treatments as well as relapsing of the dental arch.

A Comprehensive Approach to Oral and Facial Health

In the realm of addressing underlying issues, a transformational journey awaits those seeking to improve their oral and facial structures. This voyage may involve a complete overhaul of the bone structure within the mouth or a meticulous remodeling and reshaping of the very foundation that supports our oral and facial components. As we delve into this realm, we discover the power of expanding the upper and lower arches, creating ample space for the tongue to roam freely.

To achieve these structural corrections and expand the palate, we employ our Phase I treatment at the Julian Center. Here, the art of widening the palate takes center stage, allowing for the liberation of the airway and the coexistence of the tongue and nasal cavity. By expanding the palate sideways and forward, we provide the tongue with the space it needs, while simultaneously lowering the nasal cavity floor, increasing air volume. The benefits are many and varied, as this harmonious interplay improves breathing, alleviates chronic nasal issues, and even enhances facial esthetics. This widening does not cause any significant changes in your appearance, but the changes are positive.

At the forefront of this groundbreaking treatment stands the creation of the Homeoblock, created by Dr. Theodore Belfor. A pioneer in the fields of pneumopedics and craniofacial epigenetics, Belfor has gifted us with a revolutionary tool. With the Homeoblock, widening the palate becomes a permanent transformation, eliminating the need for lifelong reliance on appliances. This lengthier yet comprehensive treatment option is a godsend for individuals plagued by a high-pitched, V-shaped palate that limits nasal breathing.

Another remarkable instrument in our arsenal is the Advanced Lightwire Functional (ALF) dental appliance, birthed from the brilliance of Darick Nordstrom. This extraordinary appliance not only expands the arches but also rectifies craniosacral imbalances, providing greater control over growth and development. Unlike removable appliances, the ALF remains in place, eliminating concerns about compliance. However, it does present challenges in maintaining daily oral hygiene, a small sacrifice for the tremendous benefits it provides.

Addressing the tongue is also necessary to improve airway obstruction. When the frenulum, that delicate band of tissue under the tongue, is too tight, it restricts the movement of the tongue, hindering its upward and forward motion, which is called tongue-tie. This limitation prevents the tongue from venturing beyond the confines of the mouth or resting atop the roof during swallowing, disrupting the natural order. This tongue aberration also creates impaired swallowing and potential speech impediments like a lisp. Thankfully, a gentle yet transformational laser procedure can release the frenulum, granting patients freedom of movement. Ideally, this treatment should be administered during infancy to avoid hindrances in breastfeeding, which prevents proper growth and development of the tongue and jaw muscles, leading to restricted arch development, teeth crowding, and obstructed airways. The release of the tongue-tie may also result in myofascial release, leading to overall improvement in musculoskeletal issues.

Myofunctional Therapy

Enter myofunctional therapy, a refuge for muscle re-education within the oral cavity. This therapy primarily focuses on training the tongue to reclaim its rightful position during swallowing, while also honing the coordination of other oral facial muscles, including the lips. In a perfect world, the tongue presses firmly against the roof of the mouth during a swallow, an art learned during the sacred act of breastfeeding. Regrettably, the decline in breastfeeding practices has birthed a generation plagued by “infantile swallowing reflexes.” These reflexes manifest as the tongue curling back into the mouth to impede milk flow when bottle-fed or developing a forward thrust. Even if the baby receives breast milk through a bottle, which provides natural immunity, the absence of oral-facial musculature stimulation hampers jaw development and the nurturing of a natural swallowing reflex. This tongue curling, a learned muscle behavior, troubles individuals well into adulthood, contributing to sleep apnea and snoring. An additional cause during infancy and early childhood is the lack of foods that require mastication. This is due to an increase in providing soft, mushy foods to infants.

The Julian Center offers innovative myofunctional therapy and at-home exercises that effectively reestablish the strength and coordination of the muscles surrounding the mouth’s opening. Through our comprehensive approach, patients will not only gain proper tongue positioning and swallowing techniques but also benefit from our referral to a Myofunctional therapist. This collaboration allows us to further enhance the rehabilitation process by helping patients unlearn incorrect swallowing reflexes and improve the opening of the throat through the use of an intraoral appliance that gently pulls the jaw forward. Our ultimate objective is to achieve proper swallowing reflexes, which then promote correct tongue function throughout the day. This includes the tongue pressing against the roof of the mouth during swallowing and resting against the floor of the mouth with the tip of the tongue against the back of the incisors (the front teeth) during periods of rest.

In addition to the cosmetic benefits of a well-positioned tongue and improved swallowing reflex, our therapy also addresses important health concerns, such as sleep apnea and sleep-disordered breathing. By retraining the muscles and ensuring proper tongue posture, we can effectively alleviate these conditions and enhance overall well-being.

At The Julian Center, we pride ourselves on our professional approach to myofunctional therapy. As a dedicated team of experts, we are committed to providing personalized care and guidance to each patient, ensuring optimal results. Join us on the journey to reestablishing proper muscle function and achieving a healthier, more balanced lifestyle.

Tongue retraining needs to be done under the guidance of a qualified professional. Attempting to correct your swallow on your own can lead to serious issues such as an anterior open bite. An anterior open bite will push the tongue too far forward and disrupt the alignment of the teeth. This occurs when individuals forcefully thrust their tongue forward to fix their swallow, resulting in the front teeth not coming together properly when biting down. The tongue, being a powerful muscle, often overpowers the lips in this battle. To find a balance between the tongue muscle and the lip muscles, myofunctional therapy can be very beneficial. Throughout the treatment process, we continuously monitor the patient’s swallow to ensure they are on track. If it seems they are deviating from the correct pattern and thrusting their tongue forward during a swallow, we assist them in strengthening the muscles around the upper and lower lip to keep the tongue in its correct position. We call this approach the Julian Protocol, and without it, there is a risk of relapse in orthodontic treatment. I always recommend seeking the help of an experienced professional for dental and sleep-disordered breathing issues rather than attempting to address them yourself. In the next article, we will discuss some alternative options that you should avoid, along with the reasons behind this recommendation.

Don’t Bet on a Second Chance

It is crucial to remember that sleep apnea can lead to sudden heart attacks, and second chances may not be granted. If you suspect that you or a loved one is experiencing sleep apnea, it is important to seek the assistance of a certified professional without delay. While an experienced professional can often recognize the signs of sleep apnea, testing is necessary to accurately assess the severity and impact on your overall health. With numerous treatment options available today, there is no reason to postpone getting checked.

Consider the following questions:

• Do you know someone who might have sleep apnea?
• Are you avoiding seeking professional help to determine if you have sleep apnea?
• Do you know of any professionals in your area who offer testing for sleep-disordered breathing?
• Are you concerned about a loved one due to their chronic snoring?
• Have you dismissed snoring or gasping for air as unimportant?
• Do you have any swallowing issues?
• Do you breathe through your mouth?

These questions are essential in addressing sleep apnea and sleep-disordered breathing.

Keep reading this series of articles to find out more!

Next Article: Part Eight – Evaluating the Flaws in Sleep Apnea Diagnosis and Treatments

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