Dental Professional

A fully integrated and multi-disciplinary approach to treatment

At OASYS we firmly believe in a fully integrated multi-disciplinary approach to the management of OSA. Obstructive sleep apnea may present with a wide range of symptoms resulting in a variety of referral pathways. A multidisciplinary approach to examination and diagnosis helps to determine the most appropriate treatment plan for each individual. The patient is seen by each member of the team, appropriate investigations undertaken and a further meeting arranged at which all opinions are discussed. A reasoned treatment regime is produced, taking into consideration the patient's wishes and overall medical condition.

Although patients may be referred from a variety of sources, OASYS suggests that all patients consult a Sleep Physician to assess their suitability for the OASYS, and then to a dentist for device fitting. General Practitioners may also be involved, both in the initial diagnosis and in the referral to the Sleep Physician.

Sleep Apnea & SDB

The term "sleep-disordered breathing" refers to conditions where apneas and hypopneas are present during sleep.

The most common form of sleep-disordered breathing (SDB) is obstructive sleep apnea (OSA), but sleep-disordered breathing also occurs in conditions experienced by patients with chest wall, neuromuscular, amyotrophic lateral sclerosis (ALS), or lung disease, such as chronic obstructive pulmonary disease (COPD).

Because the symptoms of sleep apnea present themselves as a result of a precursor, SDB has become the general term used to describe any disease state that manifests apneas and/or hypopneas during sleep.

While the mechanisms of these apneas and hypopneas differ, a basic explanation of sleep apnea may provide the best in-road to understanding the significance of sleep-disordered breathing.

Sleep Disordered Breathing

Sleep-disordered breathing is characterized by numerous, brief (10 second or so) interruptions of breathing during sleep. These interruptions, which usually occur when relaxation of the upper airway muscles decreases airflow, lower the level of oxygen in the blood and, as a result, affected individuals are frequently aroused from deep sleep as they struggle to breathe. Symptoms of sleep-disordered breathing include loud snoring and daytime sleepiness. The most common form is SDB is Obstructive Sleep Apnea (OSA).

OSA can occur in men, women and children of all ages and sizes. Most people who have OSA do not realize they suffer from the condition. Often, it is someone else who witnesses the first signs of OSA.

The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to determine. The most common signs and symptoms of obstructive and central sleep apneas include:

Excessive daytime sleepiness (hypersomnia)
Loud snoring, which is usually more prominent in obstructive sleep apnea
Observed episodes of breathing cessation during sleep
Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
Awakening with a dry mouth or sore throat
Difficulty staying asleep (insomnia)
Snoring (people with OSA usually snore but not always)
Impaired concentration
Impaired memory
Morning headaches
Sexual dysfunction

Things to consider when asking a patient about their sleeping:

Is their snoring loud enough to disturb the sleep of others or yourself?
Does shortness of breath awaken you from sleep?
Experience intermittent pauses in your breathing during sleep?
Experience excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving?

Many people don't think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores. However as a medical professional you should talk to think about sleep apnea and SDB is any of your patients experience loud snoring, especially snoring that's punctuated by periods of silence.

The Problem Extends Beyond the Patient.

People who sleep next to a snorer have more pain, higher levels of fatigue and sleepiness and may even be at higher risk for hearing loss, according to two recent studies. Complaints of snoring and apnea have risen sharply in recent years along with the general increase in obesity, a risk factor for sleep problems. Research shows2: People who sleep next to snorers may wake up as often during the night as people with documented sleep disorders.

One Mayo Clinic study found that spouses of snorers woke at least partially an average of 21 times an hour, nearly as often as the 27 times the snorers were awakened by their documented sleep problem. Spouses of snorers and people with sleep apnea complain of excessive daytime sleepiness and fatigue, which can affect relationships at both work and home.

What are the Risk Factors?

Sleep apnea may occur if you're young or old, male or female. Even children can have sleep apnea. But certain factors put you at increased risk:

Excess weight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has sleep apnea is overweight. Thin people develop the disorder, too. Snoring (Snoring can cause the soft palate to lengthen, which in turn can obstruct the airway)

Neck circumference. The size of your neck may indicate whether or not you have an increased risk of sleep apnea. That's because a thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17.5 inches (44 centimeters) is associated with an increased risk of obstructive sleep apnea.

High blood pressure (hypertension). Sleep apnea is not uncommon in people with hypertension.

A narrowed airway. You may inherit a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway.

Being male. Men are twice as likely to have sleep apnea as women are. However, women increase their risk if they're overweight, and the risk also appears to rise after menopause.

Family history. If you have family members with sleep apnea, you may be at increased risk.

Other disorders and syndromes. Hypothyroidism, acromegaly, amyloidosis, vocal cord paralysis, post-polio syndrome, neuromuscular disorders, Marfan's syndrome, and Down Syndrome.

Other physical conditions. Conditions such as immune system abnormalities, severe heartburn or acid reflux and high blood pressure. It isn't clear whether the conditions are the cause or the result of sleep apnea.

Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat.

Smoking. Smokers are three times as likely to have obstructive sleep apnea as are people who've never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk likely drops after you quit smoking.

Heart disorders. People with atrial fibrillation or congestive heart failure are more at risk of central sleep apnea.

Stroke or brain tumor. These conditions can impair the brain's ability to regulate breathing.

What happens if a patient refuses to treat their sleep apnea? (Viewer clicks here)

Sleep apnea is considered a serious medical condition. Left untreated, complications may include:Cardiovascular problems. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. If you have obstructive sleep apnea, your risk of high blood pressure (hypertension) can be up to two to three times greater than if you don't. The more severe your sleep apnea, the greater the risk of high blood pressure.

Stroke. Obstructive sleep apnea also increases the risk of stroke, regardless of whether you have high blood pressure. People with sleep apnea are three times more likely to suffer a stroke or die, compared to people in a similar state of health but without sleep apnea.3

Daytime fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. You may have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving. You may also feel irritable, moody or depressed. Children and adolescents with sleep apnea may do poorly in school or have behavior problems.

Traffic accidents. Studies have shown that patients with OSA perform poorly on driving simulation tests and have an accident rate 2-7 times as high as people without OSA.4

Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to go to another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore are sleep deprived as well.

Memory problems, depression and other complications. People with sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, a need to urinate frequently at night (nocturia), and impotence. Gastro esophageal reflux disease (GERD) may be more prevalent in people with sleep apnea. Children with untreated sleep apnea may be hyperactive and may be diagnosed with attention-deficit/hyperactivity disorder (ADHD).

Complications with medications and surgery. Obstructive sleep apnea is also a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea. Undiagnosed sleep apnea is especially risky in this situation.

Type II Diabetes. Recent reports have indicated that the majority of patients with type 2 diabetes also have obstructive sleep apnea (OSA). Data suggests that OSA is also independently associated with alterations in glucose metabolism and places patients at an increased risk of the development of type 2 diabetes. 5

How is OSA treated? (Viewer clicks here)

For milder cases of sleep apnea, you may recommend lifestyle changes such as losing weight or quitting smoking. If these measures don't improve patient signs and symptoms or if patient sleep apnea is moderate to severe, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.

Treatments for obstructive sleep apnea may include

Continuous positive airway pressure (CPAP). If you have moderate to severe sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air, and is just enough to keep your upper airway passages open, preventing apnea and snoring.

Although CPAP is a preferred method of treating sleep apnea, some people find it cumbersome or uncomfortable. In fact, many sleep apnea patients are experiencing even greater success with the use of an oral appliance such as the OASYS.

Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more effective than oral appliances, but oral appliances may be easier for you to use. The OASYS is the first dental device to address both vulnerable regions of the respiratory tract. By repositioning the mandible it holds the lower jaw forward to keep open the pharyngeal area in back of the tongue. Acting as a nasal dilator, it decreases airway resistance so it improves ease of airflow through the nasal passage.

Benefits of dental devices such as the OASYS seem to offer the following benefits:

Significant reduction in apneas for those with mild-to-moderate apnea, particularly if patients sleep either on their backs or stomachs. They do not work as well if patients lie on their side. The devices may also improve airflow for some patients with severe apnea.
Improvement in sleep in many patients.
Improvement and reduction in the frequency of snoring and loudness of snoring in most (but not all) patients.
Higher compliance rates than with CPAP.

Dental devices have also shown better long-term control of sleep apnea when compared to uvulopalatopharyngoplasty (UPPP), the standard surgical treatment. There are also few complications with a dental device.

Surgery
The goal of surgery for sleep apnea is to remove excess tissue from your nose or throat that may be vibrating and causing you to snore, or that may be blocking your upper air passages and causing sleep apnea. Surgical options may include the following: uvulopalatopharyngoplasty, maxillomandibular advancement, nasal surgery and tracheostomy.

1 Punjabi Naresh M., Caffo, Brian. and Et al. Sleep-Disordered Breathing and Mortality: A Prospective Cohort Study.

2 Tara Parker-Pope, "Dangers of Second-Hand Snoring: When Bedtime Is a Health Hazard," Wall Street Journal, November 18, 2003

3 American Physiological Society (2009, January 12). What Is The Connection Between Sleep Apnea, Stroke And Death?

4 Santos-Teran J., Jimenez-Gomez, A. and et al. Association between Sleep Apnea and the Risk of Traffic Accidents. The Cooperative Group Burgos-Santander

5 Tasali E, Mokhlesi B, and Van Cauter E.. Type II Diabetes and Sleep Apnea. University of Chicago, Department of Medicine.

Questions and Answers

Is the OASYS® comfortable?

Unlike other treatment devices, such as the CPAP, which are mass produced and not fitted for unique facial structures, the OASYS® is custom made to fit your mouth providing you with the ultimate in comfort.

When do I wear the OASYS®?

The OASYS® is worn when you sleep. Not only is the product very comfortable and easy to wear but it is also not obvious that you are wearing it. When you travel you will enjoy the freedom and comfort of the OASYS® enabling you to catch some sleep on your journey.

What will the dentist do?

On your first visit, the dentist will thoroughly examine your teeth and mouth and may use X-rays to confirm your oral health status, as well as ensuring that you are dentally appropriate for the device. Dental impressions are required to fabricate the OASYS®. The impressions are taken, sent to a laboratory where the appliance is made and then sent to your dentist. Once custom made for you, the appliance will be inserted by a dentist who will show you how to insert and remove it yourself, as well as how to clean and care for it.

What is an oral appliance?

Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. An oral appliance is a small device, similar to an orthodontic retainer or an athletic mouth guard. It is worn in the mouth during sleep to prevent the soft throat tissues from collapsing and obstructing the airway. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it.

Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit you with one of these devices. Devices include:

Mandibular advancement device (MAD) such as the OASYS®. These are the most widely used dental devices for sleep apnea. It is similar in appearance to a sports mouth guard. MAD forces the lower jaw forward and down slightly, which keeps the airway open.
Tongue retraining device (TRD). This is a splint that holds the tongue in place to keep the airway as open as possible.

Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.

What are the benefits of a Mandibular Advancement Device such as the OASYS®?

MAD and similar devices seem to offer the following benefits:

Significant reduction in apneas for those with mild-to-moderate apnea, particularly if patients sleep either on their backs or stomachs. They do not work as well if patients lie on their side. The devices may also improve airflow for some patients with severe apnea.
Improvement in sleep in many patients.
Improvement and reduction in the frequency of snoring and loudness of snoring in most (but not all) patients.
Higher compliance rates than with CPAP.

According to a 2006 review, dental devices help control sleep apnea in 52% of treated patients. A 2002 report indicated that long-term use of a dental device achieved an 81% success rate in apnea improvement, which was significantly higher than the 53% success rate noted for uvulopalatopharyngoplasty (UPPP), the standard surgical treatment.1 There were also few complications with the dental device.

How effective is the OASYS®?

One of the major advantages of the OASYS® MAS is improved patient compliance. The ability to freely open the mouth, speak and drink with the splint fitted is a quantum leap forward in this type of medical treatment.

Are all Oral Devices the same?

Not at all. As with any medical device in the treatment of a condition, there are many different types of products available to treat the same condition. Not all products are right for all people. For the treatment of sleep apnea, there is a full range of products available, some of which are not custom-made or adjustable. Many products are ineffective, uncomfortable and have lower compliance rates. The unique dual patent design of the OASYS® ® MAS enhances comfort and improves patient compliance. Read our patient testimonies about the OASYS® products to learn for yourself. (Hyper link to patient testimony section)

What is the OASYS®?

The OASYS® is a custom made medical device, designed to hold your lower jaw (mandible) forward while you sleep. The OASYS®™ repositions the mandible forward which brings the base of the tongue forward, opening and strengthening the upper airway. This results in greater resistance to airway collapse. By holding against the front teeth it repositions the mandible in a gentle way. In addition, the OASYS®™ is easily adjusted to position the mandible in the most effective forward posture. The OASYS® provides freedom of motion by allowing movement of the mandible in all directions without locking onto the upper arch. For more details about the OASYS® system click here (hyperlink to About your therapy)

A family member snores and it worries me. Where can I find the OASYS® oral appliance?

Oral appliance therapy to treat snoring should be provided by an experienced dentist. A qualified dentist near you can be located by clicking here (hyperlink to find a dentist section) or calling 1-8888SomnoMed on 1-888-8NO-CPAP. We work closely with sleep physicians and dentists to treat snoring and OSA in the most effective way. If daytime drowsiness is a concern, a referral to a sleep physician can be arranged through your family doctor.

What if I have a bridge or denture?

Patients with crowns or bridges can be successfully fitted with the OASYS®. Adjustments are made in the appliance to ensure that fragile crowns and bridges are not harmed.

Sufficient healthy teeth are required in order to use an oral appliance. Most devices require at least 10 good teeth both upper and lower jaws. Patients with partial dentures may be successfully fitted with the OASYS ®, as long as there are sufficient teeth on the lower arch for optimal retention. The OASYS® may also be fitted over dental implants.

Can the OASYS® be adjusted?

Yes. The OASYS® ™ is easily adjusted to position the mandible in the most effective forward posture. Simply moving the lower base segment forward to slide the connecting wire through the tube and locking the stop collar back down to the new position, the OASYS® is now ready to wear.

Will the OASYS® be covered by insurance?

If you are going to file for insurance to cover the costs of the OASYS® Oral Nasal Airway System®, coverage for treatment of obstructive sleep apnea is provided under your medical insurance carrier. Therefore it is critical that you file for medical insurance not dental insurance.

Usually oral appliances fall under the same category as DME, durable medical equipment and prostheses. If this is not the case, ask if oral appliances are covered by the insurance benefits. Be sure to tell the claims personnel that you have a CPT code. This will speed up the approval process.

For more information on insurance coverage click here.

1 Medical Journal Chest, Issue 220:121, 739-746