Obstructive Sleep Apnea Treatment
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Oral appliance therapy (OAT) for obstructive sleep apnea (OSA) is a way of mechanically expanding the upper airway so that it resists collapse when you sleep.
There are two kinds of oral appliances, but both involve moving the tongue. One type, the tongue retaining device (TRD), works by enveloping the tongue in a soft plastic cavity and holding it in place by suction. The TRD is shaped to fit on the teeth sort of like a mouth guard, in such a way as to position the tongue forward off the back of the throat. The other type, the mandibular advancing appliance (MAA), is a device that fits over the upper and lower teeth. The upper teeth serve as an anchor, and the part of the device on the lower teeth can be advanced so that the lower jaw, the mandible, is moved forward. Because the tongue is attached to the point of the lower jaw, moving it forward moves the tongue off the back of the throat and increases the size of the upper airway.
Of the two kinds of oral appliance the MAA is much more widely used, and most of the research on OAT involves this type of appliance. Research suggests that the appliances that are custom fitted to a patients teeth work the best, and this fitting is usually done by a dentist knowledgeable about MAA treatment of OSA. The adjustable appliances allow the advancement of the mandible to be titrated to maximize the treatment efficacy possible in any individual patient. In a sense the upper airway is a tube in a container of soft tissue in a bony box. The MAA enlarges the box, reducing the amount of collapsing pressure the tissue exerts on the airway.
MAA therapy can works even it those with quite severe PSA. Although it does not reduce the frequency of obstructive events, the apnea/hypopnea index (AHI), as dramatically as continuous positive airway pressure, it reduces the AHI by over 50% in about 60% to 70% of patients in whom it is used, and lowers the AHI to less than 10 in about half. It is more likely to be successful in younger patients, those with less obesity, and those who have most of their obstructive breathing when they are sleeping on their back.
Not everyone can use a MAA. For one thing, you have to have teeth. Some folks have jaw pain that prevents use. There are side effects such as changes in one's bite and excessive salivation. However most patients who have tried both CPAP and OAT prefer the later, and appear much more likely to use it properly.
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Diet and exercise may be able to help ease symptoms of obstructive sleep apnea, especially exercise four to five hours before bed, weight loss, and avoiding caffeine and alcohol, but it's almost impossible to beat sleep apnea with these lifestyle changes alone. Without enough quality sleep, it's hard to even imagine mustering up the energy for either one. What's more, sleep deprivation has been shown to inhibit your ability to lose weight, even if you're eating and exercising right.
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For the vast majority of people with obstructive sleep apnea (OSA) their condition is a chronic disease. If you have OSA it will last your lifetime. It can be successfully managed, but it will not be cured. In that way OSA is like other chronic diseases such as diabetes or high blood pressure.
In highly selected patients surgical cures of OSA have been reported. Cures have also occurred in those rare patients who lose enough weight and maintain that weight loss for a lifetime. Otherwise the tendency of a person's throat to collapse during sleep is always there, and must be treated every night. The good news is that treatments that successfully manage your OSA are available, but you will be the one responsible for treating it. Just like a patient with high blood pressure or diabetes must be responsible for taking daily medication, you must apply the CPAP or EPAP device when you are ready for sleep, or insert the oral appliance, or avoid sleeping on your back. Although your doctor prescribes therapy, and helps you understand your disease, you are the one who treats it. If you are unable or unwilling to comply with the first treatment prescribed, try another. If a treatment does completely eliminate your obstructive breathing events but it is the only one you can or will use, use it. Some treatment is better than none. Do not give up.
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A long list of drugs has been tried for the treatment of obstructive sleep apnea (OSA). Most of these have been medications that tend to stimulate breathing during wakefulness, such as progesterone, protripyline, nicotine, theophyline, naloxone, and acetazolamide. The hope was that these medications might increase the activity of the dilating muscles of the upper airway, activity that is normally decreased during sleep. Serotonin re-uptake blockers can increase activity in one of the dilating muscles, the tongue, but they have not been shown to significantly improve OSA. Unfortunately the search for a safe and effective "pill" to treat OSA has come up empty so far. There is no drug that can be recommended for treating the sleep induced collapse of the upper airway.
That is not the case for the symptom of daytime sleepiness. Excessive sleepiness is a primary consequence of OSA, one that does not always resolve completely with currently available treatments of the sleep-disordered breathing. The Food and Drug Administration has recently approved a drug – modafinil (Provigil®) – for the treatment of sleepiness that remains in spite of continuous positive airway pressure (CPAP) therapy for OSA. The mechanism of action of modafinil is not completely understood, but it clearly causes increased alertness, and is relatively free of unwanted side effects. Specifically it does not seem to have the unwanted effect on the heart and blood pressure that can occur with other stimulant medication. One concern is that patients might use the drug to make up for poor compliance with prescribed CPAP treatment of their OSA. Modafinil is NOT a treatment for sleep apnea; it is just a treatment for excessive sleepiness from any cause. It does not lessen the risk of serious cardiovascular consequences from inadequately treated OSA.
There are other central nervous system stimulants that can increase alertness. The most widely used is caffeine. Amphetamine-like drugs such as methylphenidate (Ritalin) are often prescribed for sleep disorders such as narcolepsy that cause severe excessive sleepiness.
Before you consider using a drug to treat your daytime sleepiness, be sure that you have treated your OSA as well as possible, and that you are getting enough sleep at night. Drugs are not a substitute for adequate sleep.
