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Alternative Therapies for Obstructive Sleep Apnea

Dennis Jurcevic, MD Sleep Medicine Fellow

Case Western Reserve University May 25, 2012

Anatomical Causes of Sleep Apnea •  Nasopharynx

–  Nasal Turbinate Hypertrophy/Swelling –  Nasal Polyps –  Deviated Septum

•  Oropharynx –  Enlarged Tongue –  Enlarged Tonsils –  Soft palate abnormalities

•  Pharynx –  Excess tissue –  Muscle Relaxation

•  Bone structure abnormalities –  Maxillary Hypoplasia –  Mandibular Hypoplasia

Treatment effectiveness

American Sleep Apnea Association

Provent

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Positive Airway Pressure (PAP) Therapy

•  Gold- Standard therapy •  PAP therapy only definitive therapy

regardless of severity of sleep apnea •  Positive pressure titrated on individual

basis to keep airway open

Nasopharynx

Treatment of Nasopharynx

•  Swollen turbinates –  Nasal steroids

•  Decrease swelling

–  Turbinate Reduction

•  Septal deviation –  Surgical correction

•  Nasal Polyps –  Resection

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Nasal Turbinate Reduction

Positional Therapy

•  Off back sleeping

Rematee

Zzoma

Tennis ball

Pillow between knees Pillow behind back

Avoiding substances that relax muscles

•  Things to avoid if have sleep apnea: – Alcohol – Muscle relaxers – Pain medications

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Nasal EPAP (Provent) •  Nasal valves that are

open on inhalation •  Valves close on

exhalation •  Causes increased

pressure in pharyngeal airway

•  Pressure opens airway •  Use in mild to moderate

sleep apnea

Oropharynx

Oral Appliances •  Treatment for snoring and mild to moderate

obstructive sleep apnea •  Fits in the mouth during sleep like a mouth guard

or orthodontic retainer •  Prevents collapse of tongue and soft tissues in

back of the throat •  Oral appliances may be used alone or in

combination with other management –  Weight management –  Surgery –  CPAP

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Indications for Oral Appliances

•  Non-responders of positional therapy or weight loss in mild OSA

•  Intolerant or refuse CPAP in moderate to severe OSA

•  Not candidates for tonsillectomy and adenoidectomy, cranofacial operations, or tracheostomy

Oral Appliance Therapy •  Involves selection, fitting and use of a specially designed

oral appliance when worn during sleep •  Custom-made are proven to be more effective than over-

the-counter devices •  Collaboration of dentist with physician for diagnosis,

treatment and ongoing care •  Evaluation can take weeks to months

–  Examination –  Evaluation of most appropriate appliance –  Fitting –  Maximizing adaptation of appliance –  Function –  On-going short- and long-term follow-up is essential

Advantages of Oral Appliances

•  Can be comfortable and easy to wear •  May take only a couple of weeks to

become acclimated •  Small and convenient easy for travel

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Disadvantages of Oral Appliances

•  Can lead to Temporomandibular joint dysfunction

•  Can alter teeth structure

How Oral Appliances Work

•  Repositioning the lower jaw, tongue, soft palate and uvula

•  Stabilizing the lower jaw and tongue •  Increasing the muscle tone of the tongue

Types of Oral appliances •  Mandibular Repositioning Appliances

–  Maintain lower jaw in a protruded position –  Opens the airway by indirectly pulling tongue forward –  Stimulating activity of muscles in the tongue making it

more rigid –  Holds the lower jaw and other structures in a stable

position to prevent the mouth from opening •  Tongue Retaining Appliances

–  Hold the tongue in a forward position using a suction bulb

–  Keeps back of the tongue from collapsing during sleep and obstructing the airway

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FDA approved Oral appliances •  Thornton Adjustable Positioner (TAP) •  SomnoMed MAS - Dorsal Fin Appliance •  Respire - Dorsal Fin Appliance •  The SUAD™ Device •  The Temporary SUAD™ Appliance (TSA) •  Herbst Telescopic Appliance •  Clasp Retained Mandibular Positioner •  Elastomeric Sleep Appliance •  OSAP •  Sleep Apnea Goldilocks Appliance (SAGA) •  Mandibular Inclined Repositioning Splint (MIRS) •  Nocturnal Airway Patency Appliance (NAPA)

FDA approved Oral appliances •  SnoreFree •  SnoreGuard •  SomnoGuard 2.0 •  Adjustable PM Positioner •  APM Ultra •  Hilsen Adjustable Positioning appliance •  Klearway Oral Appliance •  OASYS •  Silencer System •  Elastic Mandibular Advancement Appliance (EMA) •  NORAD Appliance •  Silent Nite •  Snore-Aid •  Z-appliance •  TheraSnore Adjustable •  SomnoGuard AP® •  SomnoGuard AP PRO® •  CPAP PRO

FDA Tongue Retaining Devices

•  Tongue Retaining Device (TRD) •  SNOR-X •  AVEO TSD •  Nose Breathe Appliance

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Thornton Adjustable Positioner (TAP)

•  “Most Effective for Severe Apnea”

•  Only appliance that can be titrated while patient is asleep •  Pulls lower jaw forward to prevent collapse of the airway •  Adjustable to fit individual

SomnoMed MAS - Dorsal Fin Appliance

•  Custom-made •  Upper and lower dental plates •  “Fin-coupling” component •  Allows normal mouth opening and closing •  Can add an adjustable component •  Can provide incremental lower jaw advancement •  Jaw is moved only as far as is required to alleviate snoring and

reduce OSA –  Allows speech and drinking –  Full lip-seal –  Easily adjustable

•  Made from acrylic –  Claims to last at least four-five years

Respire - Dorsal Fin Appliance •  Custom made oral device •  Upper and a lower component that are not connected •  Jaw can open and close •  Dorsal fin holds jaw forward •  Anterior opening to allow mouth breathing •  Has an advancement screw

–  Can protrude the jaw to total advancement of 5.5 mm

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The SUAD™ Device

•  For treatment of snoring and all levels of obstructive sleep apnea

•  Moving the lower jaw •  Withstands bruxism •  Supposed to prevent actual tooth

movement •  Custom-made •  Ability to open and close mouth •  Speak clearly, yawn, and take meds

while wearing appliance •  Unlimited advancement •  Adjusted by adding additional nylon-

type or metal advancement spacers

The Temporary SUAD™ Appliance (TSA)

•  Temporary appliance mimics the SUAD™ Device •  FDA cleared to market for snoring and sleep apnea •  Positioning lower jaw forward to maintain an open airway •  It is not a boil-and-bite •  Not a chair-side fit appliance •  Custom fabricated using impressions of patient’s teeth •  Used as a trial appliance for first-time patients •  Back-up appliance for CPAP users

Herbst Telescopic Appliance •  Chronic snoring and mild to moderate obstructive sleep apnea •  Move laterally and vertically without disengaging appliance •  Two options of adjustability

–  Traditional 1,2 and 3 mm shims for advancing –  Telescopic version advance in ¼ mm increments by one full turn up to

6-8mm from the start.

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Clasp Retained Mandibular Positioner

•  Multiple clasps lock mandible into the appliance

•  Prevents retruding •  Able to change height of the appliance

Elastomeric Sleep Appliance

•  Soft, custom-injected silicone •  Tooth retained •  No clasps or wires to adjust •  Not protrusively adjustable •  Vertical opening is 5 mm •  Some mandible movement is possible

OSAP •  Full coverage mandibular advancement mouthpiece •  Soft and flexible material •  Custom made with or without an oral air passage •  Compatible with home/office based bleaching techniques •  Can work with upper edentulous and some full

edentulous patients

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Sleep Apnea Goldilocks Appliance (SAGA)

•  Hard acrylic shell laminated to a soft vinyl liner

•  Two arches connected in posterior to hold the mandible in protrusive and open position

Mandibular Inclined Repositioning Splint (MIRS)

•  Holds mandible in a downward and foward position with an incline flange

•  Boil and bite appliance •  Body of the appliance is made out of hard acrylic •  Body snap fits to the upper arch •  Breathing hole placed in anterior portion of the appliance

Nocturnal Airway Patency Appliance (NAPA)

•  Rigid acrylic and tooth retained by Adam's clasps

•  Anterior positioned "breathing beak –  Allows for oral breathing

•  Mandible held firmly in position

•  Prevents jaw movement •  Vertical opening is 5 to

10mm.

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SnoreFree •  Mandibular repositioning

SnoreGuard

•  Creates a ramp behind the lower anteriors •  Ramp prevents jaw from receding •  Tongue placed in opening between upper

and lower portion of device

SomnoGuard 2.0 •  Boil and bite device

Has 3.0 mm thicker molar biting zone •  Fitting is faster and easier for those with a "deep bite"

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Adjustable PM Positioner

•  Provides patient control of adjusting the jaw position under dentist's supervision

•  Expansion screws on the right and left buccal areas

•  Maximum tongue space

APM Ultra •  Boil and Bite •  No clasps •  Allows for mouth breathing •  Can move jaw laterally

Hilsen Adjustable Positioning Appliance

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Klearway Oral Appliance •  Small increments (0.25mm) of forward lower jaw advancement •  Initiated by the patient under the direction of a dentist •  Lateral and vertical jaw movement is permitted

OASYS

•  Mandibular repositioning •  Also acts as a nasal dilator reduced nasal

resistance

Silencer System

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Elastic Mandibular Advancement Appliance (EMA)

•  Moving the mandible forward •  Uses interchangeable elastic straps for varying degrees

of mandibular advancement •  Flexibility of elastic straps allows for lateral movement •  Maximum anterior tongue space because no projections

in the palate

Medical Dental Sleep Appliance (MDSA)

NORAD Appliance

•  Auto titratable •  Immediate placement •  Mandibular

repositioning device •  Moves jaw downward

and forward

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Silent Nite

Snore-Aid •  Adjustable mandibular bite plate •  Advances the mandible and repositions the tongue anteriorly and superiorly. •  External lip shield •  Occlusal coverage to minimize tooth pressures •  Can be used for bruxism and TMD patients

Z-appliance

•  The Z-appliance is a combination of a soft palate lifter and a mandibular advancement device[the herbst].

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TheraSnore Adjustable

•  No laboratory construction •  Easily fitted chairside from a boil and bite •  Non-adjustable device

SomnoGuard AP® •  Mandibular advancement device •  “Infinitely” adjustable protrusion •  Bite and boil

SomnoGuard AP Pro®

•  Components are very durable •  Inexpensive •  Often reused when the oral appliance has to re-made •  Patients with missing teeth or dentures can wear it

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CPAP Pro

•  Nasal pillow device •  Held in place by custom or boil and bite

appliancee •  Can attach to a mandibular repositioning

appliance

Tongue Retaining Device (TRD)

•  Flexible polyvinyl •  Uses general contours of the teeth and dental arches. •  Does not depend on teeth for retention •  Tongue is held forward by negative pressure in the vacuum bulb on

the front of the appliance •  Only custom fit Tongue Retaining Device Available

SNOR-X •  Mouth guard that gently holds the tongue forward during

sleep •  Keeping upper airway open and free from obstruction •  Prevention of this obstruction relieves snoring •  Made of two pieces

–  Tongue sleeve –  Plastic ring that goes around the device and is held in place by

notches on each side of the sleeve •  Place tongue into tongue sleeve •  Squeezes the front end to create gentle suction •  This holds the tongue in an extended position •  Tongue extension can be adjusted for comfort and

effectiveness •  Air vents sculpted onto upper surface of device for

mouth breathing

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aveoTSD •  Tongue retaining device •  Does not attach to the

teeth •  Does not require

specialist fitting by a dental professional

•  Non-adjustable universal device

•  Most cost effective and simple to use

•  Approved by the F.D.A as a medical device

Nose Breathe Appliance •  Tongue-retaining oral appliance •  Tongue is held at the roof of the mouth •  Retained by a natural lip seal and tongue suction •  Only works with nasal breathing

Oral Pressure Appliance (OPAP) •  Oral positive air pressure delivered by a newly conceived

dental appliance •  Alternative to nasal positive airway pressure

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Weight Loss

•  Diet and Exercise – Weight loss is shown to decrease sleep

apnea and even cure it

•  Bariatric Surgery

Bariatric Surgery

Surgical Procedures •  Maxillo-Mandibular Advancement (MMA) •  Uvulopalatopharyngoplasty (UPPP) •  Genial Bone Advancement (GBAT) •  Tongue Base Suspension (Repose •  Soft Palatal Implants •  Soft Palatal Procedures •  Modified UPPP and other pharyngeal procedures •  Distraction osteogenesis in pediatric patients •  Laser Assisted Uvulopalatoplasty (LAUP) •  Upper Airway Radiofrequency Treatment

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Bone abnormalities

Maxillary Hypoplasia Mandibular Hypoplasia

Maxillo-Mandibular Advancement (MMA)

•  Goal to enlarge the velo-orohypopharyngeal airway without direct manipulation of the pharyngeal tissues

•  Advances anterior pharyngeal tissues (soft palate, tongue base, and suprahyoid musculature) attached to the maxilla, mandible, and hyoid bone

•  Accomplished by LeFort I and bilateral sagittal split rami osteotomies that are stabilized with screws, plates, or bone grafts

MMA

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Uvulopalatopharyngoplasty (UPPP)

•  Excision of the tonsils •  Posterior soft palate •  Uvula •  Closure of tonsillar pillars

Uvulopalatopharyngoplasty (UPPP)

Downsides to UPPP Surgery

•  Downsides: – Risk of complications

•  Nasopharyngeal regurgitation (UPPP) •  Infection

– High failure rate (50%) – Reoccurence of sleep apnea

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Genial bone advancement (GBAT)

•  Advancement of genioglossus muscle

•  Performed in conjunction with UPPP

•  Goal to enlarge the posterior airway space

Repose (Tongue Base Suspension)

•  Tongue suspension •  Alternative to Genial

Bone Advancement •  Uses a suture to pull

hyoid bone forward •  This pulls tongue

forward •  Held in by a screw in

the chin

Pillar Implant (Soft Palate)

•  Implants surgically inserted soft palate

•  Stiffens soft palate to prevent collapse

•  Can be effective in snoring

•  Does not treat sleep apnea

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Transpalatal Advancement Pharyngoplasty

•  Increases upper oropharyngeal and retropalatal airway size by advancing the soft palate

Lateral Pharyngoplasty

•  Operation of soft palate and throat

•  Goal to produce a greater radius of opening in the soft palate and throat

Tonsillectomy and Adenoidectomy-Hypertrophic Tonsils

•  First-line treatment in children with sleep apnea

•  Some adults •  Adenoids can grow

back

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Distraction Osteogenesis in Pediatric patient

•  Removal of part of bone

•  Mandible is expanded •  New bone growth

occurs between the gap

Laryngeal View

Hypoglossal Nerve Stimulation

•  Produces dose-related airflow increases in patients with obstructive sleep apnea

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Tracheostomy •  Historically the first treatment for sleep apnea •  Definitive treatment for OSA •  Permanent opening in the neck to the trachea •  Tube is placed in the airway to let air in •  Valve closes tube during the day

–  Patient can speak and breathe normally •  Valve is opened at night so air can go around

the blockage during sleep •  Done only if severe OSA, failed other treatments

or and other surgery is not appropriate

Tracheostomy

References •  Practice parameters for the surgical modifications of Morganthaler et. al. Sleep. 2010 Oct;33(10):1408-13. •  American academy of dental sleep Medicine http://www.aadsm.org/oralappliances.aspx •  American sleep apnea association •  Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. Braendil, O. et. al, Feb 2006. BMJ 2006;

332:266 •  Targeted hypoglossal neurostimulation for obstructive sleep apnoea. A 1 year pilot Study. Mwenge GB, Rombaux P, Dury M, Lengelé B, Rodenstein D. Eur Respir J. 2012

May 17. [Epub ahead of print] •  Microimplant-based mandibular advancement therapy for the treatment of snoring and obstructive sleep apnea: a prospective study. Ngiam J, Kyung HM. Angle Orthod.

2012 May 10. [Epub ahead of print] •  Respiratory Perioperative Management of Patients With Obstructive Sleep Apnea. Porhomayon J, Nader ND, Leissner KB, El-Solh AA. J Intensive Care Med. 2012 May

15. [Epub ahead of print] •  Effectiveness and outcome of oral appliance therapy. Pliska BT, Almeida F. Dent Clin North Am. 2012 Apr;56(2):433-44. Epub 2012 Mar 2. •  Obstructive Sleep Apnea Severity Correlates with Cellular and Plasma Oxidative Stress Parameters and Affective Symptoms. Franco CM, Lima AM, Ataíde L Jr, Lins OG,

Castro CM, Bezerra AA, de Oliveira MF, Oliveira JR. J Mol Neurosci. 2012 Mar 9. [Epub ahead of print] •  Future Research Needs for Treatment of Obstructive Sleep Apnea: Identification of Future Research Needs From Comparative Effectiveness Review No. 32 [Internet].

Balk EM, Chung M, Chan JA, Moorthy D, Patel K, Concannon TW, Ratichek SJ, Chang LKW. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Feb. •  Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea? Eichler C, Sommer JU, Stuck BA, Hörmann K,

Maurer JT. Sleep Breath. 2012 Jan 22. [Epub ahead of print] •  Comparison of conventional continuous positive airway pressure to continuous positive airway pressure titration performed with sleep endoscopy. Civelek S, Emre IE,

Dizdar D, Cuhadaroglu C, Eksioglu BK, Eraslan AK, Turgut S. Laryngoscope. 2012 Mar;122(3):691-5. doi: 10.1002/lary.22494. Epub 2012 Jan 17. •  The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Aurora RN, Chowdhuri S,

Ramar K, Bista SR, Casey KR, Lamm CI, Kristo DA, Mallea JM, Rowley JA, Zak RS, Tracy SL. Sleep. 2012 Jan 1;35(1):17-40. Review. •  How to treat patients with obstructive sleep apnea syndrome during an altitude sojourn. Latshang TD, Bloch KE. High Alt Med Biol. 2011 Winter;12(4):303-7. •  Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure? Chopra A, Chao E, Etkin Y, Merklinger L, Lieb J, Delany H. Surg Endosc. 2012

Mar;26(3):831-7. Epub 2011 Dec 17. •  The effects of altitude associated central apnea on the diagnosis and treatment of obstructive sleep apnea: comparative data from three different altitude locations in the

mountain west. Pagel JF, Kwiatkowski C, Parnes B. J Clin Sleep Med. 2011 Dec 15;7(6):610-5A. •  Use of cluster analysis to describe desaturator phenotypes in COPD: correlations between pulmonary function tests and nocturnal oxygen desaturation. •  Toraldo DM, De Nuccio F, Gaballo A, Nicolardi G. Int J Chron Obstruct Pulmon Dis. 2011;6:551-61. Epub 2011 Nov 9. •  Tongue position controller as an alternative treatment for obstructive sleep apnea. Tsuiki S, Isono S, Minamino O, Maeda K, Kobayashi M, Sasai T, Takahashi Y, Inoue

Y. Sleep Breath. 2011 Nov 25. [Epub ahead of print] No abstract available. •  Obstructive sleep apnea is common among patients referred for coronary artery bypass grafting and can be diagnosed by portable monitoring. Danzi-Soares NJ, Genta

PR, Nerbass FB, Pedrosa RP, Soares FS, César LA, Drager LF, Skomro R, Lorenzi-Filho G. Coron Artery Dis. 2012 Jan;23(1):31-8.

•  Evaluation and management of pediatric obstructive sleep apnea beyond tonsillectomy and adenoidectomy. Shott SR. Curr Opin Otolaryngol Head Neck Surg. 2011 Dec;19(6):449-54.

•  Renal denervation for sleep apnea and resistant hypertension: alternative or complementary to effective continuous positive airway pressure treatment? Tsioufis C, Papademetriou V, Thomopoulos C, Stefanadis C. Hypertension. 2011 Dec;58(6):e191; author reply e192. Epub 2011 Oct 31. No abstract available.

•  Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathing. •  Dieltjens M, Vanderveken OM, Heyning PH, Braem MJ. Sleep Med Rev. 2012 Apr;16(2):177-85. Epub 2011 Oct 26. •  Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome. •  Villa MP, Miano S, Rizzoli A. Sleep Breath. 2011 Sep 23. [Epub ahead of print]

•  Management of obstructive sleep apnea associated with Down syndrome and other craniofacial dysmorphologies. Rosen D. Curr Opin Pulm Med. 2011 Nov;17(6):431-6. Review.

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References •  http://www.voicedoctor.net/sites/default/files/Flexible-videoscope-exam-3.jpg •  http://dynamicchiropractor.files.wordpress.com/2012/01/

getty_rm_photo_of_pregnant_woman_sleeping_with_pillow_between_knees.jpg •  http://www.glidewelldental.com/images/patient/landing/aveo.jpg •  http://sleepgroupsolutions.com/2.0/uploads/images/content_img_4f022d7c5a7c2.jpg •  http://doctorspiller.com/images/SnoreGuard/Nappa.jpg •  http://chicagosleepapneasnoring.com/wp-content/uploads/2012/01/UPPP-

Uvulopalatopharygoplasty-Chicago.jpg •  http://www.sleepapneala.com/pix/genioglossal.gif •  http://www.horlamacerrahisi.com/wp-content/uploads/2010/10/horlama-cerrahisi-9.gif •  http://www.cmfsinstitute.com/SleepApneaSurgery_LateralPharyngoplasty_5340727.aspx •  http://www.stevens.edu/ses/me/fileadmin/me/senior_design/2004/grp7/

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•  http://www.nycoms.com/media/personal/assets/distraction.jpg •  http://www.rhinocircus.com/wp-content/uploads/2010/12/pillar_implant.jpg •  http://smc.kramesonline.com/HealthSheets/7529.img •  Sleep apnea health care.

http://www.webmd.com/sleep-disorders/sleep-apnea/tracheostomy-for-obstructive-sleep-apnea •  http://www.beliefnet.com/healthandhealing/images/tracheostomy_tube.jpg •  http://www.drrahmatorlummc.com/DSC04982EE.jpg •  http://www.weightlossexercisediet.com/images/gastric-bypass-surgeries.jpg

Didgeridoo playing

•  May work in mild to moderate sleep apnea

•  Need to play and average of 5.9 days/week for 25.3 minutes