Women in the third trimester of pregnancy are particularly susceptible to sleep-related breathing disorders.  Studies show that during this time there is considerable upper airway narrowing due to the weight gain and edema that can accompany a pregnancy.  

Studies show that approximately 17% of non-pregnant women snore while as many as 28% of women in the third trimester of pregnancy report snoring.  Interestingly, 75% of women with pre-eclampsia report snoring!

Featured patient #108 came to our office for her regular dental examination during her third trimester.  When asked how she was sleeping, she replied that she was sleeping badly, snoring horribly and awakening in the morning feeling tired, groggy and in a bad mood.

An oral appliance was made to help open her airway during sleep.  The first morning after wearing her appliance, she left the following message on our answering machine, “This is wonderful!  I woke up in a great mood and not groggy at all!  By the way, my husband is very happy!”

Featured patient of the week #107 is a classic example of the difficulty that many patients have in finding out options for the management of their sleep apnea.  This patients is a physician who had been diagnosed with sleep apnea quite a few years ago and who had been prescribed CPAP therapy.  I have been very clear throughout this website that CPAP is a godsend for untold hundreds of thousands of sleep apnea patients.  However, there are huge numbers of patients that absolutely cannot tolerate CPAP.  

There is a belief in much of the medical community that if you merely educate the patient about the need for therapy and try enough different CPAP masks, that the patient will soon tolerate CPAP.  This physician needed no education about the need for his therapy.  As a doctor, he well knew the danger of sleep apnea coupled with his heart condition.  He tried every possible CPAP combination before abandoning that treatment.  Luckily he heard my interview on “Sound Medicine“, the National Public Radio program sponsored by the Indiana University School of Medicine and quickly scheduled an appointment.  Patients do best in dealing with any medical condition when they have information about the options for the management of their disease!

The photo at right shows Patient #107’s dental condition showing the deep overbite so common in many patients with sleep apnea.  This dental condition represents less room for the tongue making it easier for the tongue to block the airway during sleep with the muscles in the base of the tongue are relaxed.

Sleep apnea puts a great deal of stress on the cardiovascular system, making this disorder particularly important to manage with Patient # 107.  Shown below is a chart documenting the tremendous improvement is maintaining appropriate oxygen levels throughout the night that were obtained with oral appliance therapy use in this patient.  Before using oral appliance therapy, this patient 68 times during the night when his oxygen levels dropped between 4 and 9% and 24 times when O2 levels dropped between 10 and 20%, a significant stress on the heart!  Using his oral appliance no significant oxygen desaturations were noted.

Featured patient is a wonderful example of blending therapies that, by themselves, would not provide optimum results.  This patient is also an example that initial diagnostic tests may not give the correct information.

This patient came to see us for help with his “horrible snoring”.  He frequently traveled with friends and no one ever wanted to share a room with him.  He had recently had a sleep study at a local hospital and received the following diagnosis, “The patient was a very loud snorer……..Mildly abnormal sleep apnea with no desaturation and preservation of REM sleep.  The patient does not require treatment.”

Surprisingly, this diagnosis was given despite the patient’s uncontrolled blood pressure of 154/95 while being on blood pressure medication  (those people with drug resistant hypertension have an 80% chance of having obstructive sleep apnea).  This patient had worked with his primary care physician for some time in an unsuccessful attempt to get his blood pressure under control.  In addition to his concern about his uncontrolled blood pressure, this patient reported a significant amount of daytime sleepiness with an Epworth Sleepiness score of 16.

Given the significant daytime sleepiness as well as the presence of drug resistant hypertension, a Watch PAT home sleep study was ordered.  The sleep data gathered from this report suggested the presence of severe sleep apnea.  Even though the diagnosis from the hospital sleep study indicated that no treatment was needed, the wording “mildly abnormal sleep apnea” provided the opening for this patient’s medical insurance company to approve treatment.  Oral appliance therapy was chosen by this patient because he regarded himself as being “severely claustrophobic” and knew he could not tolerate a CPAP mask.

Oral appliance therapy provided patient #106 immediate relief from much of his daytime sleepiness, taking Epworth score from 16 to a more normal 9. However, over the first several months of treatment there was no change in his drug resistant hypertension.  A follow-up home study to assess treatment effectiveness indicated that he was obtaining a significant increase of REM sleep, indicating a much more restful sleep.  In addition, the number of hourly respiratory events had been dramatically reduced but not eliminated.  

This situation shows clearly the disadvantage of oral appliance therapy.  CPAP therapy when used full time would almost always completely eliminate any residual respiratory events while oral appliance will not always completely normalize sleep breathing as in this case.  However, for those patients who will not or cannot wear CPAP full time, oral appliance therapy can usually accomplish identical or better results.  For this patient, a comparison between weekly unmanaged respiratory events with oral appliance therapy and for average CPAP compliance is shown in the chart below.

This chart shows clearly that oral appliance therapy used in this patient exceeds the benefits that he would derive from CPAP used with average compliance.

However, even though patient #106 was doing better with oral appliance therapy than CPAP used with average compliance, it was reasoned that the remaining unmanaged respiratory events were contributing to his still uncontrolled hypertension.  Patient #106 was still unwilling to use CPAP due to his claustrophobia but was willing to consider surgery.  Patient #106 was sent to a local ears, nose and throat physician for a consultation.  When presented with the surgical options this patient decided against surgery.

This decision to avoid surgery allowed us to try again to get patient #106 to consider CPAP.  It was decided to deal with his feelings of claustrophobia by combining the oral appliance with a CPAP nasal interface as shown below:

In this photo, the upper part of the oral appliance is shown joined to the CPAP nasal pillow.  When worn with the lower part of the oral appliance, the patient receives the benefits of BOTH therapies at the same time.  The oral appliance moves the lower jaw and tongue base forward which helps lower CPAP air pressure necessary to eliminate the remaining airway obstructions.  In addition, since the CPAP nasal pillow is joined firmly to the oral appliance there is no need for head straps and the patient is free to turn from side to side during sleep without the mask being pulled away from the face causing sleep disturbing air leaks.

Patient #106 was seen for follow-up a month after joining the oral appliance and CPAP together.  Happily, his previously uncontrolled hypertension was now completely under control and his primary care physician was in the process of reducing the medication.  In addition the CPAP compliance card was downloaded and it was seen that patient #106 was easily able to wear his hybrid PAP full time.

Patient #105 demonstrates the enhanced level of health that results when a patient has their sleep breathing more normalized.  Our initial home sleep monitoring showed him with an oxygen desaturation index of 23, a significant amount of sleep apnea.  Initially, his daytime sleepiness was very significant with an Epworth Sleepiness Scale number at 15.  This level of daytime sleepiness is significant enough to put him and others at severe risk if he were to drive a motor vehicle a significant distance.  In addition, his fatigue level as measured by the Fatigue Severity Scale was 40, indicating a high level of fatigue. 

Six months later, his sleep breathing was almost normalized with his oxygen desaturation index at 7, his Epworth score was a normal 4 and his daytime fatigue score a greatly improved 25.  During this time he had lost 21 pounds with his neck size has decreasing from 17″ to 16.25″.  

Patient #105 is an example of someone who was too fatigued to exercise and, yet, was unable to tolerate CPAP therapy.  However, he was easily able to use an oral appliance to help manage his problem.  Once he started using his oral appliance, he immediately started feeling better.  This renewed feeling of alertness and energy inspired him to start light exercise.  With the light exercise came the weight loss.  With the weight loss, came the reduction in neck size.  With less fatty tissue in the neck, more room was available for the upper airway.  

It is impossible to diminish the importance of a good night’s sleep!

Featured patient #104 came with her husband to our office for a consultation regarding her snoring which was interfering with her husband’s sleep. She had been to see an ENT physician who had referred her to the hospital’s sleep lab to rule out sleep apnea.  The result of the sleep study indicated “loud snoring but otherwise unremarkable polysomnography”.  In other words, this was medical terminology for “Other than the fact that you snore loudly, you don’t have a problem.” In further consultation with the ENT, she had ruled out a surgical approach to snoring relief.

At the initial consultation, patient #104 denied any daytime sleepiness or fatigue.  However, when asked how she felt when she awakened in the morning, she replied, “Waking up is hell.”  Her husband indicated that once she had her shower, she was fine for the rest of the day, but that he often had to go the bedroom several times to get her out of bed.

Since it had been several years since she had her sleep study, we did a home sleep study to verify that she did not have obstructive sleep apnea.  The result of the home sleep test agreed with the hospital test, but indicated a significant amount of upper airway resistance which is often overlooked by hospital sleep evaluations.

An oral appliance was fabricated for patient #104 and her immediate response at our follow up appointment was “Waking up is wonderful”  I no longer hit the snooze alarm 3-4 times before getting up.”  Follow up home sleep evaluation revealed that her pulse rate during sleep dropped 7 beats per minute with her oral appliance in place indicating a much more restful sleep.  In addition the Watch PAT home sleep monitor indicated a dramatic increase in REM sleep from a sub-normal 10% to 30%.

Patient #103 was referred to our office by her physician.  She was suffering from obstructive sleep apnea.  In addition she had been diagnosed with fibromyalgia and was taking Lyrica 3 times a day to help manage the symptoms.  She complained of severe daytime sleepiness which forced her to take Provigil, an alerting medication, since her job required her to drive long distances each day.  She had attempted CPAP to manage her obstructive sleep apnea, but was not able to tolerate the therapy.

An oral examination revealed a dental condition that predisposes people to having obstructive sleep apnea.  As shown in the photo, this patient has a significant overbite.  This means that her mandible did not fully develop into its normal position in the skull.  Because of this, the tongue base is positioned too far back in the throat and sleep apnea easily results.

Patient #103 was fitted with an oral appliance and immediately noticed a relief of her symptoms of severe daytime sleepiness.  In addition, she also noticed that her symptoms of fibromyalgia were significantly reduced.  As a result, she was able to significantly reduce her Lyrica dosage.

Before and after home sleep monitoring with the Watch PAT showed that her sleeping pulse rate dropped by 10 beats a minute using her oral appliance!  This indicates a much more restful sleep.  In addition her nightly percentage of REM sleep increased from a below normal 10% to a normal 20%.

In her words, featured patient of the week #103 said: “I feel 100% better!”

Patient #102 came to our office for relief from his snoring which was keeping his wife awake.  Further questioning revealed that he was suffering from a significant amount of daytime fatigue and sleepiness.   To rule out the existence of obstructive sleep apnea, we sent him home with a Watch PAT home sleep monitor.  

Patient #102 is a classic example of someone who would never get a diagnosis of obstructive sleep apnea if evaluated by a sleep lab. Patients like this do not meet the minimum criteria for obstructive sleep apnea but still have a significant amount of upper airway collapse (heard as snoring) through the night which results in significant sleep fragmentation.  In other words, while they do not stop breathing during sleep and their oxygen levels do no drop, they have to labor to breath through a partially collapsed airway.  This is much like trying to breathe through a very narrow straw.  This is a very unrestful sleep.  To see the results of his initial home sleep test click on the image below.

Initial home sleep test

Patient #102 is joining a long list of patients we have treated who had a sleep study and were told they had no problem.  However, after sleeping with their oral appliance to eliminate the snoring that was effecting the sleep of their bed partner, these patients report feeling better.  Since everyone reacts to sleep deprivation in different ways, the reports from these patients vary.   Most will say that they awaken more refreshed.  However, many of these patients report a significant reduction of daytime sleepiness and fatigue as did this patient as illustrated by the following chart.

The Epworth Sleepiness Scale is a subjective assessment of daytime sleepiness.  The Fatigue Severity Scale measures fatigue as perceived by the patient.  Notice the dramatic improvement in both daytime sleepiness and fatigue as experienced by this patient with oral appliance therapy.  Not only has this patient’s life been enhanced by this therapy, but his bed partner is now sleeping better with the elimination of his snoring.

Patient # 101 (face masked out for privacy) was referred to us by her physician.  She had been diagnosed with obstructive sleep apnea and was not able to tolerate CPAP therapy.  Her fatigue level was 45 out of 63 on the Fatigue Severity Scale. In addition, she was diabetic and was not able to keep her blood sugar under control.  She had high blood pressure which was well treated with medication.  She reported that she would normally awaken 4-5 times a night to go to the bathroom and also stated that she would vomit in the middle of the night most nights.  

To understand vomiting in the night better watch the following video. Notice how much effort the woman in this video is making to breath in air. This effort generates negative pressures within the abdominal cavity and the contents of the stomach can literally be sucked out of the stomach. This is why heart burn occurs commonly with sleep-related breathing disorders.  In our patient’s case, this phenomenon caused night time vomiting.

The first night using her oral appliance, she slept through the night without awakening to go to the bathroom and she did not vomit in her sleep.  Now, one month after using her oral appliance, her blood sugar is under control and her physician is reducing her diabetes medication.  To understand why there is a significant connection between her blood sugar and sleep go here.  In addition to having her diabetes medicine reduced, her physician is now reducing her medication for high blood pressure.  The change in her fatigue level is shown in the following chart:

Furthermore, with no change in her exercise schedule or food consumption, she is now, for the first time in years, loosing about a pound a week.

A patient called our office today with some interesting/unfortunate comments about his oral appliance that we made for him several months ago. He had previously had a sleep study with a diagnosis of “borderline” obstructive sleep apnea. This is the kind of diagnosis that will cause most sleep physicians to not recommend treatment due to a lack of severity. However, based on his symptoms of waking up not feeling refreshed and his loud snoring, we fabricated an oral appliance for him to wear at night.

He called today to tell us how wonderful the oral appliance was and how much better it had made him feel—until he lost the part that fit his upper teeth! After looking everywhere with no luck, he concluded that it must have ended up in the wastebasket by his bed and was thrown away unintentionally. Now, without the appliance, he is, in his own words, “miserable without it”.

It is fascinating to contemplate the diseases and disorders that are encompassed within the wide net of sleep-related breathing disorders. I read today in the latest issue of the journal, Sleep of a study correlating heavy snoring and the development of atherosclerosis.

In this study, 110 volunteers, each with mild, non-hypoxic sleep apnea were studied. In other words, these volunteers were so mild that many of them would likely not qualify for treatment by prevailing insurance standards. These volunteers were grouped according to whether they were considered “mild” snorers (snoring 0-25% of the night), “moderate” snorers (snoring 25-50% of the night), or “heavy” snorers” (snoring more than 50% of the night).

All of these volunteers had their carotid arteries evaluated with ultrasound for the presence of atherosclerosis. 20% of the mild snorers had atherosclerosis developing in the carotid artery, as did 32% of the moderate snorers and 64% of the heavy snorers.

This study has enormous public health implications regarding the management of atherosclerosis and stroke prevention!