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The Importance of Restful Sleep 4. Normal Breathing During Sleep 5. The Impact of Snoring on Sleep 6. Causes of Snoring 7

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Contributing

Authors

THEODORE M. BERMAN,

M.D.

isaboard certified medical specialist in sleep disorders medicine and pul-mcnary medicine. Dr. Berman isa partner of the Minn sota Sleep Institute and practices in Edina, Plymouth, Fridley, and Minneapolis, Minnesota.

JOAN FOX,

M.D.

is a sleep disorders and pul-monary medicine specialist board certified by the American Board of Sleep Medicine and American Board of Internal Medicine. Dr. Fox practices at the Minnesota Sleep Institute, Abbott Northwestern Sleep Center, and the Minnesota Lung Center.

JONATHAN A.

PARKER, D.D.S.

is the director of the Snoring and Sleep Apnea Dental Treatment Center in Minneapolis, Minnesota. He is an Assistant Clinical Professor of Dentistry at the University of Minnesota. Dr. Parker is on the consulting staff of six sleep disorders centers in the Minneapolis- St. Paul area. He has lectured throughout the U.S. on evaluation and treatment of snoring and sleep apnea.

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The Importance of Restful Sleep 4 Normal Breathing During Sleep 5 The Impact of Snoring on Sleep 6

Causes of Snoring 7

Factors That Affect Snoring 8

Obstructive Sleep Apnea 10

Five Negative Effects of Snoring

and Obstructive Sleep Apnea 11

Evaluation by a Doctor 12

Testing for Sleep Problems 13 Four Strategies to Minimize Snoring 14 Medical and Dental Treatments

for Snoring and Sleep Apnea 15 A Summary of Treatment Options 19

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Most adults need 7-8 hours of sleep for peak alertness and energy.

23% of adults reported that they fell asleep at the wheel of their car during the past year. 67% of adults said

that sleep deprivation affected their work, which translates into a $70 billion loss jn productivity.

The Importance of Restful Sleep

Agood night of sleep is very important to our overall health and abilityto function effectively throughout the day. However, when our lives become busy, sleep becomes less of a priority for many ofus. WilliamC.Dement, MD,PhD, the Dean of Sleep Disorders Research and Professor of Medicine at Stanford University, states: "Americans have gotten the message that good nutrition and plenty of exercise are important for health, but we have not paid enough attention to the third pillar of good health, which is adequate sleep."

Youcan improve the quality ofyour sleep by following these recommendations: Establish relaxing pre-sleep routines.

It is important to incorporate time to "wind down" from your daily activities. Minimize light, noise, and temperature

extremesin the bedroom.

Avoid large mealsjust beforebedtime. Small snacks are not a problem, but large meals keep the digestive system active and can disrupt leep.

Avoid strenuous exercisewithin two

to three hours of bedtime. Strenuous exer -cise can elevate body temperature and cause difficulty falling asleep at bedtime.

Avoid caffeine, nicotine, or other stimulantswithin four hours of bedtime.

(5)

Normal Breathing During Sleep

Keeping the air passages open during sleep is critical to normal breathing. As you breathe, air passes through the nose and mouth and inward into your lungs, moving past the following structures in the nose, mouth, and throat:

o

Soft palate: Softcurtain oftissue which is an extension of the palate at the back of the throat. This palatal

tissue blocks the opening between the mouth and nose during swallowing.

fl

Uvula: Floppy finger-like projection of tissue that hangs from the middle of the soft palate.

8 Tonsils: Sack-like structures along the side walls at the back of the throat. These tissues are part of the body'S immune system.

D Tongue: Largemuscle at the floor ofthe mouth that is important for taste, speech, chewing, and swallowing.

While you are awake, throat muscles actively maintain an open air passage so you can breathe easily.During sleep, these structures relax. For non-snorers, the airway stays clear so air can move easily into the lungs. But for snorers, this isnot the case, and it can have a significant impact on theirsleep.

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The Impact of Snoring on Sleep

Acalm, quiet setting is important to restful sleep. Snoring interrupts that restful quiet. Usually people do not hear themselves snore, but snoring can cause

disrupted sleep for both the snorer and the snorer's sleeping partner. It can lead to daytime sleepiness and fatigue,

which can affect the ability to function . effectively at home and at work, and

could lead tohealth problems. It is

important to eliminate snoring so

everyone can get a re tful night's sleep and maintain good health.

Ifyou snore, you are not alone inyour

struggle to find a solution to this problem. Statistics indicate that approximately 67% of adults snore and that number will

continue to grow, because the factors that

cause snoring continue to be prevalent in our population.

Normal, smooth, unobstructed breathing is a key to getting a restful night's sleep. The information in this booklet will help you learn about snoring and related complications so you can find a solution to your sleep problems.

Normal Airflow

~ Airflow ['l Soft palate D Base of the tongue

rn

Uvula

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Causes of Snoring

Snoring is the harsh sound you hear

when a snorer inhales during sleep. The

noise occurs when the soft palate and uvula vibrate against the back of the throat or the base of the tongue.

As you fall asleep, the soft tissues at the back of the throat, the muscles that

line the airway, and the tongue muscle all relax. Asthis occurs, the tongue drops back into the airway which cau es it to narrow. As air passes through this

narrower airway, it moves faster and

causes the tissues to vibrate against each

other, which creates a rattling or snoring sound. As the air passage continues to

narrow, pressure increases in the airway and snoring becomes louder.

The three primary causes of narrowing of the air passage are:

• Larger soft tissue size,

• Increased relaxation of the soft tissues, and

• Increased resistance in the airway.

Airflow During Snoring

Narrowing of the air passage leads to increased pressure in the airway and labored breathing, which causes loud snoring.

How loud is snoring

compared to other noises?

Jackhammer 85 decibels lawn mower 95 decibels Airplane 118 decibels loudest

recorded

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Alcohol and certain medications (valium, antihistamines, and others) can cause or worsen snoring.

Factors That Affect Snoring

The most common factors that cause increased snoring are:

Sleeping on your back. In this position gravity pulls the jaw and tongue down and back. This causes the mouth to open and the tongue to drop back into the airway, and

leads to narrowing of the air passage. Sixtypercent of all snorers will snore only or most often while sleeping on their back.

Difficulty with nasal breathing.

Breathing through the nose isa more efficientway to bring air intothe lungs than mouth breathing. Adeviated septum, allergies, pregnancy, or a cold can cause the blood vessels in the nasal area to swell, which can lead to congestion or stuffiness in the nose. This can cause mouth breathing and increased resistance inthe air passage.

Obesity. In overweight individuals, excess fat deposits in the area of the neck and throat cause an increase in the size of the tissues or increased pressure on the tissues that surround the air passage. This leads to narrowing of the airway. Obesity is a major predisposing factor to snoring.

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Enlarged soft tissues in the throat area.

Snoring is much more prevalent in

people who have a large tongue, long soft palate, large uvula, or large tonsils. \"V'henthose tissues are enlarged, there can be a decrease in airway space. Enlarged tonsils and adenoids are the primary cause of snoring in children. Asmall lowerjaw. People who have a

receding chin related to a small lower jaw are more likely to snore because there is less room in the back of the throat for the soft tissues and tongue. This reduction in space decreases the size of the au'passage and causes

increased snoring.

Certain medications and alcohol consumption. Some drugs (particularly certain tranquilizers and antihistamines) and alcohol can cause greater relaxation in the soft tissues and muscles in the throat. This can lead to narrowing of the air passage during sleep, which increases the chance of snoring.

Cigarette smoke and other irritants.

These irritants can cause increased

nasal congestion and mucous in the

throat area, which can lead to increased snoring.

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The most common

symp-toms of obstructive sleep

apnea are:

loud snoring Periodic stoppages

in breathing Significant daytime

sleepiness Restless sleep Difficulty concentrating

and poor memory Irritability Dr

personality change

Obstructive Sleep Apnea (OSA)

Obstructive sleep apnea is an illness inwhich the soft tissues at the back of the

throat completely close offthe airway so

that air cannot flow into the lungs. This

airway blockage can reduce the amount

of oxygen reaching the brain and body.

When that happens, the brain alerts the muscles in the airway to tighten up and, unblock the air pas age. As this occurs,

a loud gasp or snort is heard, and then breathing (and many times snoring)

begins again. This process of blocking

and unblocking the airway causes significant disruption of sleep.

People who suffer from obstructive

sleep apnea frequently complain of

daytime sleepiness, which can cause

difficulty staying awake during meeting ,

conversation, while reading, watching television, or driving. Daytime sleepiness can also impair the ability to concentrate,

both at work and at home.

OSA is a health problem that can be

associated with high blood pressure, heart problems, and stroke. It is important to see your physician or a sleep disorders specialist if you are experiencing snoring and daytime sleepiness.

Obstructive Sleep Apnea

Airflow is completely blocked.

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Five Negative Effects of Snoring

and Obstmctive Sleep Apnea

Snoring and obstructive sleep apnea

can lead to increased risk of:

1. Relationship and marital discord.

Loud snoring noises can disrupt the

sleep of not only the snorer but also

the snorer's bed partner and others in the household. This can be a source ofgreat frustration and anger in their relationship. 2. Heart attack, atrial fibrillation, stroke,

oreven death. Research confirms that

people with sleep apnea have a higher

incidence of high blood pressure, atrial

fibrillation,heart attack, and stroke.

It is estimated that 38,000 people in the

United States die each year from the

effects of obstructive sleep apnea.

3. Industrial and traffic accidents caused by daytime sleepiness and fatigue.

People with obstructive sleep apnea have

a three times greater risk of having an

automobile accident than the general

population and a seven times greater risk

of multiple accidents. The snorer's bed

partner alsohas anincreased riskoftraffic

accidents because of fatigue from

disrupted sleep.

4. Lost productivity at home and work from daytime sleepiness due to lack of restful sleep.

5. Depression as a result of lost productivity, relationship discord,

accidents, and health problems.

4% of men and 2% of women between the ages of 30 and 60 have obstructive sleep apnea that is severe enough to require treatment.

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Typical questions asked

:

How often do you snore? Is your snoring loud

enough to disturb the sleep of others? Are there periods of time

when the snoring and your breathing stop? Do you ever gasp or

snort during sleep? How many hours do you usually sleep? Whenyou wake up,

do you feel refreshed? Do you

etten

feel

sleepy during the day?

Evaluation

by

a Doctor

Allsnorers should be evaluated by a physician or sleep disorders specialist before pursuing treatment, especially ifthey: • Wake unrefreshed in the morning, • Fallasleep easily during the daytime

at inappropriate times (while watching. TV,reading, driving, or in meetings.) • Have periodic stoppages of snoring

or breathing during sleep, as observed by their bed partner. Yourdoctor's evaluation will probably include:

• Ahistoryofyour snoring and related symptoms. Itishelpful ifyour bed partner ispresent at thisevaluation to help answer the doctor's questions. A tape recording of the sounds you make while sleeping may also be helpful to the doctor.

• Acompletemedical history and physical examination to identify other health problems (high blood pressure, heart disease, stroke, diabetes, GI reflux,

headache, chronic pain) that may be caused or aggravated by an OSA condition. In addition, the physician

will identify other medical conditions (allergies, rhinitis, sinusitis, obesity, smoking) that may be a factor that contributes to OSA. • Additional testing of your sleep may be necessary if the doctor suspects that obstructive sleep apnea is present.

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Testing lor Sleep Problems

The testing for sleep problems, including snoring and OSA,is completed at a sleep disorders center that may be located in a hospital or independent

center. This overnight sleep study Cpolysomnogram) measures 16different

factors throughout the night and is con

-sidered the most accurate testing method. The patient arrives

at the center a few hours before their

normal bedtime and they are connected to special monitors that will assess their

sleep and confirm their diagnosis before the treatment isfinalized. In some cases, the doctor may use a testing system that can be used to evaluate your sleep while you are at home in your own bed. Some

of these home testing devices have been found to be very accurate in assessing

(14)

Four Strategies to Minimize Snoring

The strategies described below may reduce or eliminate your snoring. 0 matter what treatment you pursue for snoring or obstructive sleep apnea, the e recommendations will have a positive effect on its outcome.

1.Sleep on your side. leeping in this position counteract the effects of gravity and can reduce or eliminate snoring. 2.Normalize your weight. People who are overweight can reduce snoring and apnea symptoms by 10 ing weight. Proper diet and exercise are the keys to losing and maintaining an appropriate weight.

3.Relieve nasal congestion. Reducing nasal

congestion can help decrease

snoring. Nasal sprays can be prescribed by your physician. ( Tote: Some of the over-the-counter nasal prays should not be used longer than a few days.) Nasal strips which increase nasal air flow may also be beneficial.

4.Avoid alcohol orsleeping pills within four

hours of bedtime. Consumption of alcohol or sleeping pills will cause relaxation of the soft tissues and muscles in the airway and will make sleep apnea or snoring worse. It should also be noted that alco -hol consumption, even during the day, can increase your risk of an OSA problem.

(15)

Ifthe strategies previously described

do not improve your snoring or OSA,

your physician or sleep disorders

specialist may recommend one of the

following treatments:

1. Positional device.Mostbed partners

know that snoring is worse on the back.

Infact, research studies show that a high

percentage of snorers and about 49%

of people with mild sleep apnea have symptoms only when they sleep on their back. Therefore, treatments to keep them

on their side or stomach during the night can be very effective in resolving the

problem. The device pictured is one of a few that have been designed to keep

sleepers offtheir back. The cushion isinflatable and is worn like a soft, lightweight backpack that ispositioned along the middle of the back. It rests comfortably in place when you are sleeping on your side or stomach and itwillprevent

you from rollingonto your

back during sleep. The cushion can be successful when used alone or in conjunction with other

treatments for snoring or

obstructive sleep apnea.

Medical and Dental Trea

t

ments for

Snoring and Sleep Apnea

(16)

2. Continuous Positive Airway

Pressure (CPAP) Treatment. CPAPis generally the primarytreatment forpeople with moderate or severe obstructive sleep apnea. The device has an air blower connected to a cushioned plastic mask that cover the nose and sometimes the mouth. The blower blowsroom air through the hose and mask into the nose and throat to keep the air passage open during sleep. The airpressure from this device prevents the collapse of the airway and the pressure can be adjusted to maintain the airway for people with all severity levels of apnea. Research studies show this treatment to be highly effective intreatingmoderate orsevere sleep apnea;

thereby significantly improving quality of sleep and, as aresult, quality oflife.

Some patients may initially experience difficulty adapting to the device. Often these problems go away as the patient continues to use the CPAP unit. The sleep disorders center staff can be very helpful in guiding patients to u e the CPAPsuccessfully.

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3. Oral appliance therapy. An oral appliance is a small acrylic device that fits over the upper and lower teeth or tongue (similar to an orthodontic retainer or mouth guard). This device slightly advances the lower jaw or tongue, which moves the base of the tongue forward, opens the airway, improves breathing and effectively treats snoring and OSA. The appliance isfabricated and cu s-tomized for each patient by a dentist experienced in the treatment of snoring and obstructive sleep apnea.

Oral appliances are usually well-tolerated by patients. This treatment is effective for treating people with snoring and mild to moderate obstructive sleep apnea. Itcan also be effective for treating certain cases of severe obstructive sleep apnea.

Many different appliance designs are available, so the appropriate device can be customized to each patient's situation.

Consult your primary physician or sleep medicine physician for proper diagnosis prior to making a treatment decision.

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4. Surgery inthe throat areaorjaw.

urgery is usually targeted at the ite of the airway obstruction. There are several

surgical approaches that range from treatments to the soft palate or uvula to advancement of the upper and lower jaw. • The most common surgical procedure

for treating snoring isthe

Uvulopalatopharyngoplasty ( PPP). This technique isdone in the hospital and removes all of the uvula and about one-third of the soft palate. It requires

about two weeks of healing time, and it can be effective in treating people with snoring and mild sleep apnea. It isless effective in treating moderate or severe sleep apnea. Avariation of this technique uses a laser and is done in the office with local anesthesia. • Somnoplasty (radio frequency surgery)

is a minor surgical procedure completed in the surgeon's office using local anesthesia and a customized electrode that delivers radio frequency energy to stiffen the soft palate and/or tongue.

• The Pillar Procedure uses three

polyester strips that are inserted into the palatal tissue that stiffens the palate to reduce the vibration of snoring.

• Telegnathic surgery is jaw surgery that

advances the upper and lower jaw to open the airway and manage significant sleep apnea conditions that have not been effectively managed by

non-surgical treatments. This treatment

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A Summary of the Treatment Options

1. Athorough evaluation and accurate

diagnosis is the key tosuccessful treatment ofsnoring and sleep

apnea. • See a sleep medicine physician for a complete assessment 2. Treatments for snoring: • Positional therapy • Oral appliance therapy • Palatal surgery 3.Treatments for mild OSA: • Oral appliance therapy • CPAP • Palatal surgery

4.Treatments for moderate to severeOSA: • CPAP • Oral appliance therapy (if CPAPcan not be tolerated) • Oral appliance therapy combined with CPAP • Oral appliance therapy and CPAP combined with palatal surgery • CPAPand palatal surgery • Telegnathic (jaw) surgery (if non-surgical treatment not successful)

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Forfurther information regarding diagnosis and treatment of snoring and obstructive sleep apnea visit these web sites:

AmericanAcademyof Dental Sleep Medicine www.aadsm.org

AmericanAcademyof Sleep Medicine www.aasmnet.org

American Sleep Apnea Association www.sleepapnea.org National SleepFoundation

www.sleepfoundation.org

For comments or que tions regarding the information

in this booklet, you may contact:

Innovative Sleep Products Phon : (888) 766-6607 (roll free)

Phone: (952) 345-0290 Fax: (952) 920-0105 E-mail: jp@endsnoringnow.com

References

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