Background to snoring
During sleep the throat narrows due to a reduction in muscle tone. Snoring is simply the vibratory noise generated by the back of the relaxed tongue, palate and throat. Further narrowing produces louder snoring but also laboured inspiration (breathing in). Extreme narrowing can cause complete airflow obstruction otherwise known as obstructive sleep apnoea.
There comes a point where the increased inspiratory effort is sensed by the sleeping brain and a transient arousal is provoked (brief awakening to breathe before returning to sleep). A few of these arousals do not really matter.
However, when there are many (sometimes hundreds), sleep becomes seriously fragmented, resulting in daytime symptoms of excessive sleepiness. Snoring and sleep apnoea are part of a spectrum extending from ‘benign’ or ‘simple’ snoring with no sleep disturbance, through to obstructive sleep apnoea with severe daytime sleepiness symptoms and the physiological consequences of recurrent asphyxia (insufficient oxygen).
Is treatment really necessary?
Benign snoring can be far from benign. The social consequences can be extremely distressing: banishment from the bedroom, marital disharmony, no holidays because of enforced sleep disruption when sharing a hotel room, fear of travelling – falling asleep during long journeys on public transport and the consequent ridicule and embarrassment. Many of the stories we hear are very sad and not worthy of the all too common joking approach to snoring.
There is no doubt that treatment is essential for obstructive sleep apnoea and extremely appropriate for snorers. Obstructive sleep apnoea, resulting in serious sleep disruption, can produce greatly impaired performance at work, at home, and on the road. Car accidents are statistically much more common in those with sleep apnoea. The response to appropriate therapy can be extraordinarily dramatic with commonly, a return to a state of alertness and vitality often not previously experienced for years or even decades.
There is evidence that so called ‘simple snoring’ is also linked with persistent daytime hypertension (high blood pressure), insulin resistant diabetes and carotid artery atherosclerosis. Many now believe that ‘simple snoring’ may be a precursor to obstructive sleep apnoea.
Please note DVLA guidelines on those who have or are being investigated for obstructive sleep apnoea. (https://www.gov.uk/obstructive-sleep-apnoea-and-driving)
What risk factors are there for snoring and sleep apnoea?
The following are known risk factors for obstructive sleep apnoea. You may find that simple lifestyle modifications may help to reduce your risk.
- Nasal Stuffiness
- Late evening alcohol
- Use of night time sedatives
- Large tonsils
- Sleeping on your back
Appliance information & fee guide
A variety of appliances are available in the management of snoring, please read this section for information regarding the pros and cons of each appliance in addition to the charges.
There is good evidence to show that custom made intra oral appliances (mandibular repositioning devices) worn in the mouth at night can greatly help reduce snoring. All of the appliances work by altering the position of the lower jaw such that the tongue is lifted forwards increasing the area available for air flow, thus reducing snoring through the improvement of muscle tone. It must be remembered that the amount of advancement of the lower jaw varies from person to person and that adjustable devices offer greater flexibility.
Mandibular Repositioning Devices are primarily used for the management of simple, non apnoeic snoring as well as for mild to moderate obstructive sleep apnoea when prescribed and mentored as part of a multidisciplinary team. If symptoms of obstructive sleep apnoea are found then you will need to be referred to a respiratory or sleep physician for further investigations before treatment can be started. If you have poorly controlled epilepsy you will not be suitable for a mandibular advancement device.
MRDs consist of close fitting, custom made ‘rims’ that fit around the upper and lower teeth. These rims are connected in various ways to allow the lower jaw to be postured and held in a forward position. Many of these appliances will allow some horizontal and vertical lower jaw movement.
MRDs impose significant forces to the teeth and jaw joints and therefore it is important that these structures are healthy and able to withstand these forces, at least 8 healthy teeth are needed in each of the upper and lower jaw to provide adequate support. Additionally you must be able to maintain a good standard of oral hygiene – that is being able to keep your teeth spotlessly clean. When teeth are not kept clean when an anti snoring appliance is worn overnight an increased risk of tooth decay and gum disease is seen.
Side effects of treatment may include excess salivation (sometimes a dry mouth), jaw joint ache and tooth sensitivity. These are short-term side effects and usually disappear once you become accustomed to the appliance. Evidence of long-term side effects include minor tooth movements and bite changes. These side effects must be balanced against the benefits of treatment. Most patients do not find these side effects sufficiently intrusive to discontinue treatment. Some time may be required for the device to work and it is important that you are aware of this, in some instances no improvement will be achieved – it is impossible to predict in whom this will occur and so it is vital that you are prepared to accept this risk before embarking on treatment. Long term problems are rare, however jaw joint problems and unwanted teeth movement have been reported, therefore it is important that you do not suffer from any untreated dental disease.
When the mouldings of your mouth are taken we will take a special registration with your lower jaw pushed forwards. This will be used to make the anti snoring device. On occasions the initial measurement which is taken will not produce the exact desired outcome, this is where an adjustable device is advantageous. Being able to make adjustments means we can achieve a more bespoke outcome.
It is important to note that other options are available for the management of snoring and sleep apnoea; these include:
- no treatment
- ‘boil and bite’ devices which are often available commercially. It is important to note that there is no evidence base for the effectiveness of these devices in the management of snoring and sleep apnoea.
- CPAP treatment
- Surgical options – via an Ear Nose and Throat Surgeon
Typical appliance lifespan is two years
This is a simple one piece intraoral appliance which can often be used as a first line treatment in the management of snoring. This design is less complex and is thus the cheapest appliance that we offer. The appliance is made an accurate fitting latex free material which fits comfortably around the teeth.
Unfortunately this appliance cannot be adjusted once made so it is important to note that this does not offer as much flexibility compared to adjustable designs. We will endeavour to provide the optimal level of advancement but cannot guarantee that this can be achieved with this appliance. Thus if you decide that this is the appliance for you it must be accepted that you understand this risk. Additionally the relative bulk can reduce airflow which may prove uncomfortable
This patented device consists of upper and lower splints which are held together by a titanium screw which allows for precise adjustments to be made. The thinner material used in the construction makes this device less intrusive and more comfortable compared with many of the other available options. This device has a good track record and has been successfully used in the management of snoring and sleep apnoea in the UK and across Europe.
The upper and lower jaws are held together by the screw linked to the upper and lower jaws, you are able to move the jaws in a lateral direction and are able open your mouth to some degree. This makes the device far more user friendly that fixed appliances.
This appliance also has a one year warranty from the date of manufacture.
Available in clear or blue
This custom fitted device provides is one of the least restrictive available allowing for a vastly increased range of movement and comfort. A flexible inner soft lining provides a good fit and a comfortable feel. Unlike other devices it can fit over short teeth and those which have been crowned or bridged.
The screws present on either side allow for precise adjustment of this device, enabling great flexibility in the management of snoring and sleep apnoea.
This device comes with a three year warranty against manufacturing defects and has been used in over 200,000 cases worldwide.
Likely appointment structure and payment guide:
|Assessment following completion of questionnaire||£0|
|Impression for appliance and bite registration||50% of chosen appliance fee|
|Fit of appliance||Remaining 50% of chosen appliance fee|
|Review two weeks post fitting||£0|
|Review four weeks post fitting||£0|
|Reviews every six months||£45|
(NB 10% discount applies to Denplan Essentials patients).
Regular reviews are required to assess the success of the appliance and to ensure that the appliance is in good order and that there are no negative effects on the teeth, gums, bite and jaw joint. A new snoring/sleep apnoea history will be retaken. The attendance for reviews is a vital part of the process and patients are reminded that if they do not attend for reviews they increase the risk of problems.
For further information on snoring and sleep apnoea look on the British Society of Dental Sleep Medicine website at www.dentalsleepmed.org.uk.
Why have treatment at Llandeilo Dental Practice?
Not all dentists have undergone training to provide anti snoring mandibular repositioning devices, and therefore it is important that patients only see those dentists who have undertaken the appropriate training.
Tom has undertaken training run by the British Society for Dental Sleep Medicine and adheres to the Association for Respiratory Technology and Physiology Standards of Care for Mandibular Repositioning Devices and as such is well placed to provide mandibular repositioning devices for the management of snoring.
Dr Tom Bysouth is a member of the British Society of Dental Sleep Medicine; a society for Dentists who have an interest in the management of snoring and sleep apnoea.
For more information, or to book an appointment call us on 01558 823658 or contact us.