Driving within the 55 mile per hour speed limit on the New Jersey Turnpike will help save lives. There is little doubt of this.
Unfortunately, a huge percentage of motorists have a difficult time adhering to this.
That’s sort of how it works with sleep apnea.
An estimated 22 million Americans suffer from sleep apnea, with four out of five cases of moderate and severe obstructive sleep apnea going undiagnosed. Obstructive Sleep Apnea (OSA), which represents the majority of these cases, can lead to high blood pressure, chronic heart failure, atrial fibrillation, stroke, and other cardiovascular problems when left untreated. Furthermore, it is associated with type 2 diabetes and depression.
Due to its primary symptom of excessive daytime sleepiness, which can cause problems with concentration, those affected by OSA also endure a preponderance of motor vehicle, workplace and home accidents. And, evidence has shown that poor sleep patterns pose as much a factor in obesity as too much food and too little exercise. While OSA can strike people of any age, including infants and children, it is most frequently seen in men over 40, especially those who are overweight or obese.
CPAP –THE GOLD STANDARD
OSA and snoring occur when the airway is obstructed or collapsed. This condition is characterized by recurrent episodes of partial or complete upper airway obstruction during sleep.
The CPAP machine (for continuous positive airway pressure) has long been viewed as the gold standard for treating OSA. According to Dr. Mediha Ibrahim, director of the Center for Sleep Medicine at SBH Health System, the CPAP – which delivers air pressure through a mask while the patient sleeps, keeping the upper airway passages open – is the treatment offered to virtually every patient diagnosed with sleep apnea following a sleep study at her center.
“It is without question the first choice therapy,” she says. “Studies have long shown that it works best for most cases of sleep apnea.”
Unfortunately, as efficient as it may be, many users find CPAP cumbersome and/or uncomfortable. To OSA patients like Wilma, a home care attendant who lives in the Bronx, the CPAP mask was claustrophobic. “I didn’t like the way it felt,” she says. And, as a result, she stopped using it shortly after it was prescribed.
She’s hardly alone. Studies show that the adherence rates for CPAP are surprisingly low – dramatically impacting on the treatment’s benefits. It’s also why a growing number of patients like Wilma are searching out dentists like Dr. Brijesh Chandwani, a TMJ and sleep disorder specialist at SBH.
“The use of oral appliances for sleep apnea is actually pretty mainstream,” says Dr. Chandwani. “It is not experimental. There is a lot of good data supporting this.”
A 2016 review in The Journal of Otolaryngology – Head & Neck Surgery found that “despite numerous advances in machine dynamics including quieter pumps, softer masks, and improved portability, adherence to CPAP continues to be a problem frequently encountered in clinician’s offices, with adherence rates generally ranging from 30 to 60 percent. There are many reasons for this problem including comfort, convenience, claustrophobia, and cost. It is also understood that many patients who start on a path to non-adherence frequently remain non-adherent and eventually abandon the machine altogether, with a consequent return of symptoms and OSA-specific adverse consequences.
“The long-term effects of non-adherence bring to light the health-related impact of untreated OSA,” says the research. “It is not sufficient to simply prescribe a CPAP machine and consider the patient to be treated.”
The findings of the research have proved sobering. “Our data suggest that despite numerous changes to machine and mask dynamics as well as behavioral interventions, CPAP adherence remains a severe problem for management of patients with OSA – the concept of CPAP as [the] gold standard for OSA therapy is no longer valid.”
Dr. Chandwani uses customized oral appliances to treat OSA patients who either have mild to moderate sleep OSA or with more severe cases who don’t do well with the CPAP machine. Patients have several different devices to choose from, with options based on the patient’s tongue size, fat tissues in the cheek and how much the jaw moves.
He begins the process of fitting the mouthpiece by taking measurements and impressions of the patient’s teeth and jaw. Patients like Wilma typically return after several nights of using the device for minor adjustments.
“The mouthpiece needs to be tight, so it may be uncomfortable until the patient gets used to it,” says Dr. Chandwani. “It stretches the tight muscles. The more you wear it, the quicker you will adjust to it. We rarely have a patient who can’t tolerate it.”
An oral appliance, Dr. Chandwani explains, works by pushing the lower jaw forward while the patient sleeps. This keeps the airway open so that upon relaxing, the tongue and upper airway muscles do not close off the opening.
Once the mouthpiece fits properly and is worn nightly, Dr. Chandwani sends the patient back to the sleep doctor for an overnight sleep test to make sure the device works comfortably and effectively.
Wilma, who has been using the appliance intermittently to date, waiting for final adjustments, is already seeing benefits. She reports that her energy is much better than it’s been in years.
“ Our data suggest that despite numerous changes to machine and mask dynamics as well as behavioral interventions, CPAP adherence remains a severe problem for management of patients with OSA – the concept of CPAP as [the] gold standard for OSA therapy is no longer valid.”