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Oral appliance therapy improves craniofacial growth direction and snoring

According to new research that will be presented Saturday, June 11, at the 20th Anniversary Meeting of the American Academy of Dental Sleep Medicine (AADSM), children with enlarged tonsils and adenoids who wore an oral appliance for six months experienced more favorable craniofacial growth, enlargement of pharyngeal dimensions, and improved breathing and snoring during sleep.

Enlarged tonsils and dental malocclusion have a strong relation with sleep disturbance in children. Its consequences can include abnormalities of craniofacial growth and facial morphology more suitable to the development of obstructive sleep apnea (OSA).

Forty children from the waiting list for adenotonsillectomy at the ENT Department of the University of São Paulo Medical School were included in the study. The children ranged from 6 to 9 years of age. All of them presented snoring, tonsil and adenoid enlargement grades III and IV, and dental malocclusion (constricted maxilla and/or jaw deficiency). Patients were divided into two randomized groups: 24 patients were treated with the Bioajusta X dental appliance and 16 were controls.

The researchers evaluated the craniofacial growth in children with enlarged tonsils and adenoids, after dental appliance (Bioajusta X) treatment. They also compared the prevalence of snoring before and after treatment.

“The primary finding of the study was the positive influence of this treatment on snoring in children with enlarged tonsils and adenoids and narrow maxillary arch,” said principal investigator Walter R. Nunes Jr., DDS, MS, who is affiliated with the Otolaryngology Department of the University of São Paulo Medical School in Brazil.

“This method of treatment acted on the normalization of the respiratory function and sleep, which reflected positively on the quality of life of those children and their families, and also resulted in a better pattern of craniofacial growth,” said Nunes. “This normalization on the growth pattern may possibly reduce the incidence of obstructive sleep apnea in the future.”

Cephalometric analysis was used to access the growth direction comparing the vertical jaw relationship according to the angle of the palatal plane with the mandibular plane (ANS-PNS / ML). The parents filled out a questionnaire about respiratory symptoms. They were re-evaluated and compared after six months.

Cephalometry showed in the treated group a reduction on the palatal x mandibular angle of – 2,75 º : Media at T1 = 30.08 º (sd 3.8) ; Media at T2 = 27.33 º (sd 3.4)  and an increase of this measurement in the untreated group of +1,25 º : Media at T1 = 28.38 º (sd 3.8) ; Media at T2 = 29.60 º (sd 3.5) at  the untreated (p<0.001).


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US Army Suggests Oral Appliances Should be First-Line Treatment for Sleep Apnea

FORT KNOX, Ky., Nov. 21, 2011 /PRNewswire via COMTEX/ — Patients with mild to moderate obstructive sleep apnea (OSA), a condition in which the airway collapses and blocks breathing for 10 seconds or more, may consider adjustable oral appliances (OAs), devices that fit within the mouth to prevent upper airway collapse, as an effective first-line treatment, according to two studies conducted by sleep medicine specialists from Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Md.

The retrospective, peer-reviewed studies, published in the December 2011 issue of CHEST, the official journal of the American College of Chest Physicians, and in the current issue of the Journal of Clinical Sleep Medicine (JCSM), the official journal of the American Academy of Sleep Medicine, provide findings on OAs from the largest patient populations studied to date. The studies found that adjustable OAs are nearly as effective as continuous positive airway pressure (CPAP) treatment for patients with a mild form of OSA and are more effective than fixed oral appliances, particularly in patients with moderate to severe OSA.

“Historically, CPAP has been the primary treatment for OSA, but only half of patients tolerate this therapy, which requires wearing a face mask hooked to a machine each night,” said Lt. Col. Christopher Lettieri, M.D., one of the studies’ authors, an Army medical director and the chief of sleep medicine in the pulmonary, critical care and sleep medicine department at WRNMMC. “This new data offers a fresh look at adjustable oral appliances as an initial treatment for OSA in both the military and civilian sectors.” Eighteen million Americans, or 4 percent of men and 2 percent of women, suffer from sleep apnea, which can cause daytime sleepiness and has been linked to high blood pressure, heart attack, and stroke.

The military is interested in the potential of adjustable OAs, also called mandibular advancement devices, as alternatives to CPAP systems since some active duty service members deploy to austere environments where electricity needed to run CPAP machines is not always available. In these cases, reliance on CPAP may result in duty restrictions or separation from service.

“Adjustable OAs would eliminate duty assignment limitations associated with CPAP, allowing Soldiers to travel to remote areas as needed,” said Lettieri.

The study in CHEST, titled “Efficacy of an Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome,” evaluated and compared results of overnight sleep studies in which patients used adjustable OAs or CPAP devices. Results were measured by the apnea-hypopnea index (AHI) score, used to assess the severity of sleep apnea based on the total number of complete cessations (apnea) and partial obstructions (hypoapnea) of breathing that last for at least 10 seconds per hour of sleep. Researchers found that a significantly higher percentage of patients using an adjustable OA experienced successful reduction of their AHI score to below five apneic events per hour in this study compared to past reports (62.3 percent versus 54 percent).

In the JCSM study, “Comparison of Adjustable and Fixed Oral Appliances for the Treatment of Obstructive Sleep Apnea,” patients were treated with either adjustable or fixed OAs and a sleep evaluation was conducted before and during treatment with the devices. Patients using adjustable OAs had a greater reduction in obstructive events (AHI), revealing that adjustable OAs had a greater efficacy than fixed devices (57.2 percent vs. 46.9 percent) among this patient cohort.

A total of 497 patients were prescribed adjustable OAs in the CHEST study and 602 patients in the JCSM study. The studies included patients who participated in an overnight sleep study at the sleep disorders center at Walter Reed National Military Medical Center.


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The secret behind your snoring

Are you disrupting your partner’s sleep with your loud and regular snoring? Do you choke while you sleep or do you fall asleep on your office table even if you had a sound sleep the previous night? If yes, then its time to consult a pulmonologist as it indicates that you could be a patients of sleep apnea and may need immediate medical attention.

Sleep apnea, are breathing obstruction that cause the sleeper to wake up multiple times to breath properly.

  • For 23-year-old Raja, this disorder proved dearer when he started sleeping during his classes. Repeated warnings and punishments could not help and finally parents were called to meet the college authorities. Realizing her son was not deliberately doing this, his mother took him to the pulmonologist who diagnosed him with obstructive sleep apnea, which is the most common type of sleep apnea and occurs when the soft tissue in the back of the throat relaxes during sleep, causing a blockage of the airway.
  • Another case is when Upendra missed colliding with a bus while riding his scooter. After a couple of repeated episodes of close shaves with accidents and upon his visit to the doctor, he was diagnosed with sleep apnea.

According to the experts, untreated sleep apnea prevents one from getting a good night’s sleep. When breathing is paused, the person is jolted out of his natural sleep rhythm. It can be dangerous and detrimental to health. Overweight is also known to be a major risk factor of the condition. Dr Shiv Kumar Veeraiaha, HOD department of physiology, Bangalore Medical College and Research Institute (BMCRI) says that because of the disturbed sleep, a person feels confused and is not able to concentrate on his work during day time.

However, this fatal disease is not only confined to snoring or disturbed sleep but it also leads to improper functioning of heart, stroke, pulmonary hyper tension, diabetes and cholesterol.

Sleep apnea: major cause of road accidents: Speaking with City Express Dr HB Chandrashekar, HOD department of pulmonary medicine at Mahavir Jain Hospital which receives 30 to 40 patients going for sleep test every month in its sleep lab, says, we have the database of 3,000 patients and of them 12 per cent have involved in some kind of road accidents or just missed the accidents. Patients with sleep apnea have more chances of accidents than a person who consumes alcohol or has epileptic fits. He also maintained that ‘head on collision and near misses are some of the most common in sleep apnea. Lack of awareness about sleep apnea: “Though sleep apnea in treatable. However it often goes unrecognized due to lack of awareness about the disease among people. People do not know much about the disease. Now in order to educate people, we are regularly conducting lecture programme for medical practitioners,” added Dr Chandrashekar.

Sleep test: Sleep test or studies are done to measure how much and how well does one sleep. It also checks how long has one been facing a problem with the same.  Its severity and frequent episodes of obstructed breathing during sleep are another topic that are observed during the tests. Now with more increased incidents, not only private but government hospital are also studying the sleep patterns.


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Sleep apnea raises death risk

Moderate to severe obstructive sleep apnea raises the risk of dying from any cause in middle-aged adults, says a new study.

The study provides the strongest evidence to date of a link between increased risk of death and sleep apnea, a common disorder in which the upper airway is intermittently narrowed during sleep, causing breathing to be difficult or completely blocked.

Overall, study participants with severe sleep apnea were at a 40 percent increased risk of death compared to those who did not have the breathing condition. The mortality risk was most apparent in men, who were more likely to die from any cause as well as from heart disease if they had severe sleep apnea. In particular, men between the ages of 40 and 70 with severe sleep apnea were twice as likely to die during the study compared to their peers who did not have the condition.

“Sleep-Disordered Breathing and Mortality: A Prospective Cohort Study,” is published in the August 18 issue of the open-access journal PLoS Medicine.

To reach the conclusion, researchers from the Sleep Heart Health Study (SHHS) studied more than 6,000 men and women aged 40 years and older who had no sleep apnea or had mild, moderate, or severe sleep apnea as determined by a standard at-home sleep test at the beginning of the study.

After an average of eight years, participants who had severe sleep apnea at enrollment were one and one-half times more likely to die from any cause, regardless of age, gender, race, or weight, or whether they were a current or former smoker or had other medical conditions such as high blood pressure, heart disease, or diabetes.


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Bury the myths about snoring

Dr Viranchi Oza, Omnisleep Solutions, addresses a few important facts and busts a few myths surrounding snoring:

Myth: Everybody snores therefore it’s normal.
Fact: Snoring is not a normal condition. Labelling it as “normal” diminishes the seriousness of the condition. Snoring is not just about annoying your partner; it is a sign that the body is struggling to breathe properly during the night. If it occurs on a frequent or regular basis it has been associated with hypertension. It can also be an indication of sleep apnea (pauses in breathing). Sleep apnea sufferers have been reported to have diminished gray cells in their brains, most likely due to the oxygen deprivation of untreated sleep apnea. Over time, sleep apnea increases the risk of cardiovascular disease if not treated. In addition, insufficient sleep affects growth hormone secretion that is linked to obesity. As the amount of hormone secretion decreases, the chance of weight gain increases.

Myth: Snoring Can’t Be Treated.
Fact: There are many different options for treating snoring. Some treatment options are rather drastic, possibly requiring surgery or prescription drugs, but prior to exploring such options it would be wise to first seek out alternative treatments. One of the most comfortable and popular options is to use the custom fabricated oral appliance Silent Sleep TM oral appliance fitted by trained Omnisleep dentists.

Myth: I know I don’t snore, or I know I don’t have apnea. I feel fine.
Fact: There are people who snore excessively and have sleep apnea but feel absolutely normal. But they’re at increased risk for heart disease, heart attack, and stroke. The only definitive way to prove that you don’t have sleep apnea is with a sleep study. However, screening questionnaires like the GASP or the Epworth have shown high reliability in identifying patient risk for sleep apnea. At Omnisleep, depending on your risk for sleep apnea, we offer a variety of choices in diagnosing sleep apnea to provide the optimal solution for your condition.

Myth:Insomnia is characterised only by difficulty in falling asleep.
Fact: Usually there are four symptoms associated with insomnia: difficulty in falling asleep, waking up too early and not being able to get back to sleep, frequently waking up, waking up not feeling fresh. Insomnia can also be a symptom of a sleep disorder or other medical, psychological or psychiatric problems. Sometimes, insomnia can really be a case of undiagnosed sleep apnea. At Omnisleep, our home sleep studies will help provide the correct diagnosis of your sleep disorder which will help in determining a suitable treatment plan for you.

Myth: Daytime sleepiness means a person is not getting enough sleep.
Fact: Excessive daytime sleepiness can occur even after a person gets enough sleep. Such sleepiness can be a sign of an underlying medical condition or sleep disorder such as narcolepsy or sleep apnea. Please seek professional medical advice to correctly diagnose the cause of this symptom. Omnisleep Solutions provides turnkey solutions for diagnosis and treatment of snoring and obstructive sleep apnea.

Myth: Getting just 1 hour less sleep per night than needed will not have any effect on your daytime functioning.
Fact: This lack of sleep may not make you noticeably sleepy during the day, but even slightly less sleep can affect your ability to think properly and respond quickly, and it can compromise your cardiovascular health and energy balance as well as the ability to fight infections, particularly if lack of sleep continues. Lack of sleep has also been associated with road accidents (up to 60% of road accidents involve lack of sleep) and air crashes (Air India Mangalore plane crash in 2010 was due to lack of sleep). Sleeping for less than 6 hours a night is equivalent to legal levels of alcohol intoxication.

Myth: Extra sleep at night can cure you of problems with excessive daytime fatigue.
Fact: Not only is the quantity of sleep important but also the quality of sleep. Some people sleep 8 or 9 hours a night but don’t feel well rested when they wake up because the quality of their sleep is poor. A number of sleep disorders and other medical conditions affect the quality of sleep. Sleeping more won’t alleviate the daytime sleepiness these disorders or conditions cause. However, many of these disorders or conditions can be treated effectively with changes in behaviour or with medical therapies.

Myth: If I lose weight, I’ll cure myself of sleep apnea.
Fact: Sometimes, yes. It’s definitely worth trying, but in general, it’s very difficult to lose weight if you have sleep apnea. This is because poor sleep aggravates weight gain by increasing your appetite. Once you’re sleeping better, it’ll be easier to lose weight. This is the one ingredient with many dietary and weight loss programs that’s missing or not stressed at all. It’s not enough just to tell people to sleep more.

Myth: Sleep apnea occurs only in older, overweight, snoring men with big necks
Fact: Although the stereotypical description does fit people in the extreme end of the spectrum, we now know that even young, thin women that don’t snore can have significant obstructive sleep apnea. Sleep apnea begins with jaw structure narrowing, and later involves obesity. It’s estimated that 90% of women with this condition are not diagnosed. Untreated, it can cause or aggravate weight gain, depression, anxiety, diabetes, high blood pressure, heart disease, heart attack, and stroke.
Myth: Health problems such as obesity, diabetes, hypertension, and depression have no relation to the amount and quality of a person’s sleep.
Fact: More and more scientific studies are showing correlations between poor quality sleep and insufficient sleep with a variety of diseases. Blood pressure is variable during the sleep cycle; however, interrupted sleep negatively affects the normal variability. Recent studies have shown that nearly 80% cases of hypertension, 60% cases of strokes and 50% cases of heart failures are actually cases of undiagnosed sleep apnea. Research indicates that insufficient sleep impairs the body’s ability to use insulin, which can lead to the onset of diabetes. Fragmented sleep can cause a lowered metabolism and increased levels of the hormone Cortisol, which results in an increased appetite and a decrease in one’s ability to burn calories.

Myth: Snoring only affects the health of the snorer.
Fact: Snoring doesn’t just negatively affect the health of the person snoring, but also the health of the person lying next to them in bed. A typical snorer usually produces a noise that averages around 60 decibels (about the level of a vacuum cleaner) but with some people this can reach 80 or even 90 decibels (about the level of an average factory). Sleeping with a partner who snores during the night has been shown to increase the blood pressure in the other person, which may be dangerous for their health in the long term. Snoring also causes the partner to have fragmented sleep and lose up to 1 hour of sleep every night.

Myth: Snoring comes from the nose, so if I unclog my nose, my snoring will stop.
Fact: Having a stuffy nose can definitely aggravate snoring and sleep apnea, but in general, it’s not the cause. A recent study showed that undergoing nasal surgery for breathing problems cured sleep apnea in only 10% of patients. Snoring vibrations typically come from the soft palate, which is aggravated by having a small jaw and the tongue falling back. It’s a complicated relationship between the nose, the soft palate and the tongue.


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Snoring can damage heart, say docs

Does your loud snoring disturb others at home? Don’t just ignore it as a sign of a good night’s sleep. Doctors say snoring is a serious medical condition and in some cases can even lead to high blood pressure, diabetes and heart problems. In fact, snoring is also a sign of serious sleep apnea.

Not just adults, even children are found to snore. But in their case the reasons are different and can be managed with age. “In children snoring is often due to tonsillitis, as it blocks the airway behind the tongue or due to obesity. These children often face difficulty in breathing while sleeping and have disturbed sleep. Obesity is an important reason in both children and adults,” said Dr SK Sharma, head of department, medicine, and in charge of sleep medicine clinic at AIIMS.

Snoring occurs when the airway gets obstructed. And this could be due to excess fat around the neck, which forces the muscles to narrow down or due to infection. “We hear the sound of snoring as the airway gets narrow, thereby increasing the airflow in the respiratory system through the small opening. The air, before reaching the lungs, vibrates the soft tissues and as a result we produce the loud sounds,” said Dr Vikram Sarbhai, senior consultant and in charge of sleep medicine, Max healthcare.

The obstruction of airway can be in the nostrils or behind the tongue. The nostril obstruction can be treated with a special nose strip available in the market that helps in opening the nasal blockages. But if it is due to obstruction in the throat, then it is important to see an expert, as it could lead to serious medical conditions.

“A lot of people don’t consider it a serious problem. If a person snores then he/she should get themselves screened at a sleep medicine clinic, as in the long run it could result in high blood pressure, diabetes and heart problems. Due to decrease in oxygen supply, the body gets stressed and produces certain chemicals and hormones that can bring about changes in the body’s metabolism,” said Dr Manvir Bhatia, chairman of sleep clinic, Sir Ganga Ram Hospital.

Sleep Apnea is a dangerous consequence of ignoring a snoring problem. In this, patients don’t breathe for more than 10 seconds due to obstructed airway. As a result, they have disturbed sleep at night and make up for it by sleeping in the day. Experts say this can be dangerous as people can suddenly fall asleep while driving. “Sleep apnea should be taken seriously. Such people have to be kept on continuous positive airway pressure (CPAP) machine. In such cases, the throat muscles collapse, closing the airway completely. This can be dangerous. This machine acts like a splint and keeps the airway open with air pressure. A person diagnosed with sleep apnea has to sleep wearing a mask hooked to a machine,” said Dr R S Chatterji, head of department, pulmonology and sleep clinic, Rockland hospital.

Doctors say it is important to diagnose this problem in the initial stages as it can be cured. “The biggest problem with snoring is that it is the commonest problem, yet under-diagnosed and unrecognized,” said Dr Sarbhai.


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Heavy snorers more prone to heart condition

Do you snore loudly? If so, then get a sleep study done.

A latest study — conducted by the All India Institute of Medical Sciences and Fortis Hospital — has found that heavy snorers face a tremendously high risk of suffering from metabolic syndrome – a combination of medical disorders that shoots up your chances of suffering from cardiovascular diseases.

In a study “Obstructive Sleep Apnea is Independently Associated with the Metabolic Syndrome” published in the US medical journal “Metabolic Syndrome and Related Disorders”, Dr Randeep Guleria from AIIMS and Dr Anoop Misra from Fortis have found that 67% of patients with Obstructive Sleep Apnea (OSA) suffer from metabolic syndrome.

In comparison, around 40% patients, who don’t suffer from OSA, are plagued with metabolic syndrome.

When an obese person, featured in the study with OSA, was pitted against his counterpart, not suffering from OSA, the former had a 190% increased possibility of suffering from metabolic syndrome.

“The study has found that those who suffered from severe OSA had a 80% chance of suffering from metabolic syndrome. It shows that OSA is a serious independent risk factor, and should be treated immediately. Those suffering from OSA must undergo a sleep study, get oxygen therapy and lose weight in order to avoid heart disease.”

The metabolic syndrome is characterized by a group of metabolic risk factors in a person. They include Abdominal obesity (excessive fat tissue in and around the abdomen), Atherogenic dyslipidemia (blood fat disorders high triglycerides, low HDL cholesterol and high LDL cholesterol that foster plaque buildups in artery walls), elevated blood pressure, Insulin resistance or glucose intolerance (the body cannot properly use insulin or blood sugar), and elevated C-reactive protein in the blood.

Those suffering from metabolic syndrome are at an increased risk of coronary heart disease, and other ailments related to plaque buildups in artery walls like stroke and peripheral vascular disease and Type 2 diabetes.

The metabolic syndrome has become increasingly common in India.

“Obesity and the metabolic syndrome are rapidly increasing in developing countries. Whether the metabolic syndrome is independently associated with obstructive sleep apnea was not clear. This study investigated the association between OSA and the metabolic syndrome in obese Asian Indians. We studied 240 obese subjects with body mass index greater than 25 kg/m, 121 with OSA and 119 without OSA, matched for age, BMI and percentage body fat. Full-montage digital polysomnography, fasting blood glucose (FBG), lipid levels, and blood pressure (BP) were done in all subjects. Our conclusion is that OSA is independently associated with the metabolic syndrome in Asian Indians in northern India,” Dr Mishra said.

Sleep apnea is a condition in which people stop breathing for long stretches in their sleep. Nearly 60% of those who snore suffer from sleep apnea, a debilitating breathing disorder that results in cessation of breathing for 10 seconds, at least five times per hour of sleep.

In India, 36 million people are expected to suffer from OSA.

According to experts, 90% of people who have sleep apnea don’t know that they have it.

Usually, it is the bed partner who first notices that the person is struggling to breathe during sleep.


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Sleep apnea leads to heart disease

A new study has revealed that people with obstructive sleep apnea (OSA), a sleep disorder associated with obesity, have more non-calcified or “bad” plaque in their coronary arteries.

“Our study reveals that individuals with obstructive sleep apnea are prone to developing an aggressive form of atherosclerosis that puts them at risk for impaired blood flow and cardiovascular events,” said U. Joseph Schoepf, director of cardiovascular imaging at the Medical University of South Carolina in Charleston, S.C.

OSA is caused by obstruction of the upper airway during sleep and is characterized by periodic pauses in breathing, which last for 10 or more seconds. OSA is also commonly associated with snoring.

In the study, 49 obese patients, mean age 61, with OSA and a mean body mass index of 33, and 46 obese patients without the disorder underwent coronary CT angiography (cCTA), which provides detailed pictures and information on plaque buildup and narrowing in the vessels.

The OSA group included 26 men and 23 women, and the matched control group included 22 men and 24 women.

The imaging revealed that the amount of calcified plaque in the coronary arteries was not significantly different between the two groups, but the overall composition of vessel plaque was notably different.

“Compared to the non-OSA group, the patients with OSA had a significantly higher prevalence of non-calcified and mixed plaque,” Schoepf said.

Non-calcified plaque is considered bad plaque, because it is more vulnerable to rupturing and causing a blood clot, which could lead to a heart attack or other cardiovascular event.


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Daytime sleep is injurious for the elderly

A new study has suggested that the risk of death is more than two times higher in older adults who have sleep apnea and report struggling with excessive daytime sleepiness.

Results of adjusted proportional hazards modeling show that older adults with moderate to severe sleep apnea who reported struggling with excessive daytime sleepiness at baseline were more than twice as likely to die as subjects who had neither problem.

The risk of death was insignificant in older adults with only excessive daytime sleepiness or sleep apnea. Participants had a mean age of 78 years at baseline, and about 55 per cent died during an average follow-up period of 14 years.

“Excessive daytime sleepiness, when associated with sleep apnea, can significantly increase the risk of death in older adults,” said principal investigator and lead author Nalaka S. Gooneratne, assistant professor of medicine in the University of Pennsylvania Health System inPhiladelphia, Pa.

“We did not find that being sleepy in and of itself was a risk. Instead, the risk of increased mortality only seemed to occur when sleep apnea was also present,” added S. Gooneratne.

The study has been published n the journal SLEEP.


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