NAPC Review - Spring 2007
CURRENT TRENDS IN THE TREATMENT OF SNORING & SLEEP APNOEAby Marianne J Davey MSc, Director
British Snoring & Sleep Apnoea Association
Snoring is common but it is not normal and none of us is immune from it. Middle aged men are more prone to snoring than any other group but women tend to snore more during and after the menopause. Snoring is a frequent occurrence during pregnancy due to hormonal and physical changes but usually desists following birth. Many children snore due to allergy or craniofacial abnormalities which, if left unaddressed, may continue to cause snoring into adulthood.
Snoring may not be a weapon of mass destruction, but it is certainly a weapon of mass irritation. Every night an estimated 15 million snorers in the UK disturb the slumber of their bed partner and other family members with noise levels reaching in excess of 90dB. Not surprisingly, a reliable and effective resolution to this troublesome complaint has been the subject of research for over 100 years. Snorers have been bombarded with a plethora of treatments all claiming to stop them snoring - some with robust clinical evidence of their effectiveness, others of no practical use at all.
The evidence base to support pharmacological treatment is small and SIGN(10) has concluded that no medication has demonstrated a consistent positive effect. The clinician then has to make the decision whether to 'invade' the airway with one of a number of surgical procedures, 'fight' the problem with mandibular advancement therapy (MAD), or hope that the problem will go away. Both clinicians and patients should be aware that snoring rarely resolves itself. In many instances clinicians are not only having to treat the snorer because evidence strongly suggests that bed partners exposed to loud snoring have a high rate of health complaints(11).
IN SEARCH OF THAT ELUSIVE CURE
The tongue, soft palate, lateral pharyngeal walls and mandible interact to control airway calibre and the use of mandibular advancement therapy induces complex changes in these structures resulting in improved airway stability and cessation of snoring. In February 2005, the BBC programme 'How To Sleep Better' presented by Professor Lord Robert Winston, featured a woman whose life had been transformed by MAD therapy. Since then this treatment has gained enormous popularity among snorers and sleep apnoea sufferers. The clinical evidence that MAD therapy is effective in the management of snoring and sleep apnoea is undisputed in the medical literature(1,3,6,8). Its simplicity, portability and relatively low cost gives patients an affordable therapy and MADs are now readily available for all to purchase.
Recent research presented by the British Snoring & Sleep Apnoea at the British Sleep Society conference 2006(5), found a range of devices on the market. Each with its own unique features, they range from 1-piece and 2-piece 'boil & bite' devices to custom made devices fitted by an orthodontist. The research considered whether the advantages of such devices outweighed any disadvantages and whether MAD therapy really was the miracle cure it was hailed to be on the TV.
DO PATIENTS COMPLY WITH DOCTOR'S ORDERS?
Acceptance of the device can be an issue. According to Bates(4) 'It is important to recognise that generally 40-50% of patients do not comply with any treatment prescribed and that compliance is not associated with age, sex, education, economic status or disease characteristics'. Data on long term compliance with MAD therapy is limited, and in the BSSAA study, 31% of men and 33% of women had discontinued using their device within the first 6 months. However, 68% of users in the study were still using their device, some, for more than 2 years.
SNORING CAN HAVE A DEVASTATING EFFECT ON THE BED PARTNER
It is known that snorers experience many symptoms which have a profound effect on their career, social life, and marital harmony. A study by Scott(9) found that snorers were more concerned about the sleep of others rather than their own sleep quality. However, otolaryngologists in the study reported relationship difficulties to be the most frequently cited issue. Scott found that one in five snorers who presented as hospital out-patients no longer share a bed with their partner. The otolaryngologists believed the 'clinical presentation of snoring to be a symptom of marital distress and the equivalent levels of snoring would be better tolerated within a more harmonious relationship'.
According to Cistulli(6) 'The overall benefit of treatment is related to the product of its effectiveness and the patient's adherence to treatment, the latter being determined to a large extent by the acceptability of the treatment to the patient, and often the bed partner'. As evidence suggests, much of the suffering associated with snoring and sleep apnoea is borne by the bed partner who frequently suffers the effects of extreme sleep deprivation.
The BSSAA(5) study considered the motivation for MAD use in 3 categories; partner, self and doctor-motivated. 49% of patients were motivated by their partner to use a MAD, 40% were self-motivated and 11% were advised to use a MAD by a health professional. Given the results of the Scott study, it is of no surprise that nearly half of snorers in the BSSAA study were motivated by their partner. However, the results of the BSSAA study found no significant difference in compliance in any of the motivation categories.
HORSES FOR COURSES
'Oral appliance compliance might differ depending on the type of appliance, disease severity and perhaps patient management' says Almeida(2). Many MAD purchasers do not appreciate that MADs have differing features and are often misled by manufacturers' advertising puff. One respondent to the BSSAA study remarked 'The differences between models is striking and I think this should be emphasised to customers. I have previously tried one device which was extremely uncomfortable and ineffective, but I have now tried another which is completely different'.
Cistulli(6) states, 'There is general consensus that customized appliances are better tolerated and tend to be more effective than the less commonly used prefabricated (boil & bite style) appliances, but this is not based on research evidence'. BSSAA disagrees, as 'boil & bite' style devices have robust clinical evidence to support their effectiveness and are no less common than customised appliances.
Many of these appliances have been subject to clinical trials and have CE marking and/or FDA approval. BSSAA found no other research that upheld Cistulli's opinion. Their research found only 2.7% of patients who had success with a custom made device as opposed to 72% who said their 'boil & bite' device had either stopped or reduced their snoring to an acceptable level.
The condition Obstructive Sleep Apnoea (OSA) is at the severe end of the snoring continuum. It is defined as a complete cessation of breathing lasting 10 seconds or more, at least 10 times per hour with an accompanying dip in oxygen saturation of 4% or more. An overnight sleep study such as polysomnography will distinguish simple snorers from those with clinically recognised OSA. The clinical features of OSA can be divided into two categories: sleep related and wake related. Sleep related symptoms include:
- Choking (caused by cessation of breathing)
- Abnormal motor activity
Symptoms occurring during wakefulness include:
- Excessive daytime sleepiness, e.g., falling asleep at work, whilst driving, during conversation or when watching TV (this should not be confused with excessive tiredness with which we all suffer occasionally).
- Morning headache
- Short temper
- Changes in mood or behaviour
- Anxiety or depression
- Decreased interest in sex
The 'gold standard' treatment for OSA is Continuous Positive Airway Pressure (CPAP) which acts as a mechanical splint to prevent the airway from obstructing. As well as being extremely effective in terms of preventing snoring and airway obstruction, CPAP produces positive outcomes in terms of sleep quality, daytime function and blood pressure. However, criticism has been levelled at its expense, obtrusive nature and consequent effects on compliance. The side effects of CPAP include rhinitis, conjunctivitis, sinusitis, skin abrasions and abdominal distention, and therefore CPAP is not ideal for all patients. According to Dort(7) 'CPAP compliance is limited, with 5 - 50% of patients either refusing to begin therapy or discontinuing in the first weeks and a further 12 to 25% discontinuing therapy in the next 3 years'. This has prompted a search for an alternative solution. MAD therapy has been shown to be a successful treatment for OSA and is recommended(10) as an alternative for those who refuse or are unable to tolerate CPAP as a primary treatment for mild or moderate OSA.
Mrs Marianne J Davey MSc, Director, British Snoring & Sleep Apnoea Association
Chapter House, 33 London Road, Reigate RH2 9HZ
Tel: 01737 245638, Fax: 0870 052 9212
(1) Aarab G et al (2005) Short-term effects of mandibular advancement device on OSA. Journal of Oral Rehabilitation 32 564-570
(2) Almeida FR et al (2005) Long-term compliance and side effects of oral appliances used for the treatment of snoring and OSA. Journal of Clinical Medicine 1 (2) 143-152
(3) Battagel JM & Kotecha B (2005) Dental side effects of mandibular advancement splint wear in patients who snore. Clin Otoloaryngol 2005 30 149-156
(4) Bates CJ & McDonald JP (2006) Patient's and sleeping partner's experience of treatment for sleep related breathing disorders with a MAD. British Dental Journal 200 (2) 95-101
(5) British Snoring & Sleep Apnoea Association (2006) Is mandibular advancement therapy really a miracle cure? Poster presented at the British Sleep Society Annual Conference 2006.
(6) Cistulli P et al (2004) Treatment for snoring and OSA with mandibular repositioning appliances. Sleep Medicine Reviews 8 443-457
(7) Dort L & Hussein J (2004) Treatment for snoring & OSA: compliance with oral therapy. The Journal of Otolaryngology 33 (3) 172-175
(8) Johal A et al (2005) The effects of mandibular advancement splints in subjects with sleep related breathing disorders. British Dental Journal 199 591-596
(9) Scott S et al (2003) A comparison of physician and patient perception of the problem of habitual snoring Clin Otolaryngol 28 18-21
(10) Scottish Intercollegiate Guidelines Network (June 2003) Management of Obstructive Sleep Apnoea/Hypopnoea Syndrome in Adults. (SIGN 73) A national clinical guideline June 2003
(11) Ulfberg J et al (2000) Adverse health effects among women living with heavy snorers. Health Care Women Int 21 (2) 81-90