Sleep & Snoring

Snoring is a common sleep disorder, commonly encountered in middle-aged individuals and may lead to a serious health problem called obstructive sleep apnea (OSA). If a snorer is having un-refreshing sleep, feeling of choking, recurrent awakening from sleep, daytime fatigue, and change in personality, he/she has crossed the line of demarcation between snoring and potentially life-threatening disease. There are many predisposing factors such as obesity, sedentary lifestyle, heredity, alcohol, and certain drugs that lead to this condition. OSA is affecting the population worldwide. Various studies have been done to date to evaluate its actual prevalence. The Wisconsin Sleep Cohort Study showed that 25% of middle-aged men and 10% of middle-age women had sleep-disordered breathing (AHI > 5/h), with 4% of men and 2% of women also having hyper-somnolence, fulfilling the current diagnostic criteria for OSA. OSA-related co-morbid diseases are hypertension (odds ratio 1.37), coronary artery disease, congestive heart failure, pre-diabetes (odds ratio 3.18) ,(3) type 2 diabetes mellitus (odds ratio 4.17), chronic kidney disease. Usually, OSA sufferers have disturbed sleep affecting their normal life as evidenced by two to three times higher rates of traffic accidents among individuals with OSA as compared to general population. (1) Therefore, early diagnosis and optimum management of snoring/OSA is of paramount importance. In a hospital-based study of urban men between 35 & 65 years from western India, the prevalence of OSA was 19.5% and is threefold higher in men as compared to women.

The reason behind OSA can be attributed to the fact that during sleep resistance to airflow is increased at certain areas in the upper respiratory tract. These areas may be further compromised by a sleep-related reduction in muscle tone and the effects of gravity related to being in the supine position. As a result, ventilation may be decreased (hypopnea) or absent (apnea) for several seconds until upper airway muscle tone increases, allowing the resumption of normal ventilation. This recovery is often associated with an arousal or shift to a lighter sleep stage. As deeper sleep resumes and muscle tone diminishes, the cycle may repeat itself.

Traditional screening methods for OSA is overnight polysomnography (PSG) and since it is an expensive procedure Berlin questionnaire and Epworth sleepiness scale has been designed to screen patients prior to PSG in resource limited settings like India.

Management protocol includes behavioral modifications such as weight loss, change in sleep position from supine to lateral and avoiding of alcohol, hypnotics, and narcotics before bedtime. Definitive modalities include continuous positive airway pressure (CPAP), surgery to enlarge upper airway, and oral appliances. CPAP has been the gold standard therapy since long but the cost of CPAP machine needs to be subsidized especially in developing countries like India.

Oral appliances are another simple, efficient and cost-effective alternative of treating OSA besides CPAP. An oral appliance is an oral device that is inserted in the mouth to modify the upper airway for the treatment of snoring and obstructive sleep apnea. Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, temporo-mandibular joint, dental occlusions, and associated oral structures. They basically allow the lower jaw and tongue to remain in a forward position during sleep, thereby preventing them from falling back and obstructing the airway. Some appliances such as palatal lift appliance elevate the soft palate and prevent its vibration which is the most frequent cause of snoring.

Thus, although not all snorers have OSA, snoring is a cardinal symptom of OSA and is now recognized as a clinical entity that may be related to conditions with increased morbidity. In developing countries like India, the social embarrassment and distress of loud snoring is now motivating middle aged individuals to request professional help.

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