Snoring can signal sleep apnea

June 24--Writing about her decision one night to sleep with her dog instead, author Bailey White described her mother's snoring in disturbing terms.

"Her blood-curdling snoring," Bailey wrote, "with its gargling and squawking and its terrifying pauses, is like the sound the devil might make if he were alternately relishing and strangling on a pound of human flesh."

It's true, snoring can be pretty bad. But not just because of the strangling-devil noises. Chronic snoring can signal obstructive sleep apnea, a disorder in which breathing repeatedly stops and starts. Long treated with masks and machines that many people find cumbersome -- and therefore don't use -- apnea sufferers have other options, including custom-made oral appliances that open up constricted air passages, offered by a growing number of dentists.

Sleep apnea causes more problems than sleepiness, said Dr. David Ramey, who treats people with sleep disorders at the Providence Pulmonary & Sleep Disorder Clinic in Spokane.

"It is a health risk," Ramey said. "We know that it directly can increase somebody's blood pressure and indirectly increase the risk of other medical problems, like heart attack and stroke." Sufferers also face occupational hazards, such as sleepy driving and inattentiveness at work.

Snoring -- the noisy vibration of soft tissue in the nose or throat as a result of a narrowed airway -- is the most common symptom obstructive sleep apnea patients report to their doctors.

Obstructive apnea is more common in overweight people. Extra weight adds fat tissue in the area around the throat, crowding the upper airway. (The less-common central sleep apnea occurs when the brain doesn't send the right signals to the muscles that control breathing.)

CPAP machines are the most common treatment for obstructive sleep apnea and still considered the "gold standard" of treatment, Ramey said. Apnea happens when the airway collapses, preventing oxygenation and deep sleep. CPAP, or continuous positive airway pressure, deliver enough air through a mask worn at night to keep the airways open.

But some patients find CPAP machines uncomfortable and inconvenient. Adolescents and young adults, especially, may be reluctant to slap on a mask at night, Ramey said.

"Oral appliances for the right patient are very effective, and they're typically better tolerated by the patient simply because there's no mask and machine," he said. "They're much less invasive."

The removable oral appliances, worn at night, resemble mouthguards. They move the lower jaw forward to open the airway.

"Oral appliance therapy" is a growing segment of dentistry, as more patients become aware of the options and as more medical insurers have started to pay for the appliances, said Dr. Erin Elliott, whose Post Falls dental practice specializes in oral appliances to treat snoring and apnea.

But there's room for caution, Elliott said. There are more than 100 appliances on the market. Cheaper ones tend to be more uncomfortable. And she warned against "snore guards" made for patients who haven't undergone sleep testing -- performed in a "sleep lab" or at home -- to locate their obstruction.

She said she follows protocols recommended by the American Academy of Dental Sleep Medicine.

"It's kind of like the Wild West out there," Elliott said. "You have dentists making these cheap appliances. I make the more Cadillac version. ... You hope the patient does their research."

Elliott said the appliances work best in patients with mild to moderate apnea and thinner patients. To make them, dentists make impressions of their patients' upper and lower teeth and another measurement to determine how far forward the lower jaw should be moved during sleep, she said. They do joint testing to make sure patients can tolerate the appliance.

Sometimes patients report jaw stiffness, Elliott said. Rarely, they experience changes in their bite.

"Sometimes there's an adjustment period," Elliott said. "But a lot of patients, they can wear it easily from the very first night."

Dr. Eric Leavitt, a surgeon at Spokane Valley Ear, Nose & Throat and Facial Plastics, said patients come to his office to learn about treatment options for snoring or because they suspect their fatigue is caused by sleep apnea. After a sleep study, he said, he recommends patients with obstructive apnea try CPAP before surgery. He said oral appliances are worth a try.

"I'm very conservative on recommending surgery," he said, and most sleep apnea patients he sees decide against it.

But if other methods don't work, surgery is an option, Leavitt said.

Nasal surgery can help when the snoring is caused by nasal swelling, allergies or a deviated septum. Another procedure (uvulopalatopharyngoplasty -- doctors call it a U-triple-P) removes excess tissue on the soft palate and the throat to widen the airway. Sometimes surgeons will remove tonsils, too, Leavitt said. Some use implants to stiffen the soft palate.While medical insurance generally covers treatment for obstructive sleep apnea, it doesn't cover treatment for snoring alone.

For those patients, avoiding alcohol before bed can help, Ramey said. Used by some as a sleep aid, alcohol relaxes the airway, making it floppy and making snoring more likely. For others, losing weight might help.

And there's nothing wrong with using drugstore nasal strips to prevent snoring caused by congestion, Leavitt said -- "if you can stand sticking something on your nose all the time," ... la California Chrome, the horse granted permission to wear adhesive strips to improve his airflow as he competed recently for the Triple Crown.

"They do work," Leavitt said. "On racehorses, too."

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