Chapter 22

Mandibular advancement devices

Increasingly, in recent years:

• doctors
• dentists
• respiratory physicians
• ear, nose and throat surgeons

have been seeing patients who are worried that their husband/wife/partner/friend or relative have disturbed sleep and/or snore.

They are concerned about:

• the noise from snoring which can range from gentle and rhythmic to very loud
• a tendency to ‘stop breathing’ when asleep, obstructive sleep apnoea (OSA). The patient stops mid snore for a few seconds, snorts or gasps and wake themselves up, and then fall asleep again. This can be repeated several times in an hour

Very often, it is not the patient who complains. They may feel tired but they do not always have broken sleep. It is the person who is kept awake that often gets the snorer to seek advice.

The first step is to see their own doctor (GP) to see what help is available.

These patients are then referred to a Sleep Clinic, usually at their local hospital and there they are assessed by a physician and a specialist sleep nurse.

They fill in an Epworth Sleepiness Test.

Patients use the following scale to choose the most appropriate number to assess how they react in certain situations. These range from:

• 0-wouldneverdozeorsleep
• 1-slightchanceofdozingorsleeping
• 2-moderate chance of dozing or sleeping
• 3-highchanceofdozingorsleeping

These situations include when:

• sitting and reading
• watching TV
• sitting inactive in a public place
• travelling as a passenger in a car for more than an hour
• lying down in the afternoon
• sitting and talking to someone
• sitting after lunch (no alcohol)
• stopping for a few minutes while driving, e.g. at traffic lights

If you add up the scores, the total you get is the patient’s Epworth Score.

If the Epworth Score is greater than 10, the patient may also suffer from OSA.

They may also be given:

• A medicale xamination
• A nasoendoscopy
• an overnight sleep study

Some children and teenagers snore.

This is often the result of:

• mouth breathing
• large tonsils

By the end of the mixed dentition/early second dentition, when other facial structures relative to the tonsils have grown, their problem usually disappears.

However, for adults diagnosed with OSA and/or snoring their problem does not go away.

SOCIAL PROBLEMS

It has obvious detrimental effects.

These include:

• an adverse effect on their social life
• marital problems, from sleeping apart in separate rooms to sleeping on the couch and even to separation and divorce
• poor-quality sleep, which affects concentration, reaction times, ability to cope, etc.
• sleep deprivation and tiredness experienced by the patient and those around them, which affects social interaction, tolerance, moods, etc.
• depression in some patients
• repercussions on their job, if they need to hold a driving license
• daytime drowsiness, often while travelling or driving
• loss of vitality, more time spent sitting, lack of energy, too tired to join in or be enthusiastic
• social embarrassment, e.g. fellow hotel guests complaining
• problems during holidays with a partner (having to book two separate rooms)
• sleeping on aircraft, etc.

Symptoms can include:

• raised blood pressure
• strain on the heart
• difficulty in concentration, sometimes affecting memory
• dry mouths, aggravating gingival/gum conditions
• depression, never feeling on top of things
• loss of libido

These are areas which can have a major impact on people’s daily lives.

WHAT CAUSES THE SNORING NOISE?

Snoring usually emanates as a noise in the back of the throat as a result of a turbulent air flow.

During sleep:

• the muscles of the face, mouth, tongue and neck relax
• there is narrowing of the breathing passages
• the tongue drops back encroaching on the airway space
• the soft palate ‘flutters’ causing a noise

Factors making the problem worse:

• being overweight, especially in men as they carry excess weight around their necks
• drinking alcohol, especially last thing at night
• going to sleep after a heavy meal
• taking muscle relaxants, e.g. sleeping medication
• anatomical features such as retrognathia (receding lower jaw)

WHAT ARE THE SOLUTIONS?

• try to reduce excess weight
• reduce the intake of alcohol
• exercise more

Self-prescribing and ‘over-the-counter’ remedies

There are a variety of remedies which are sold ‘off the shelf’.

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