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Expert Q & A

Opening a Passage to Better Sleep

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A: If a patient still can't tolerate C.P.A.P., my second-line therapy is a dental appliance. These small plastic devices, similar to orthodontic retainers or sports mouth guards, help prevent the collapse of the tongue and soft tissues in the back of the throat, keeping the airway open during sleep and promoting adequate air intake.

Nearly all appliances fall into one of two categories, classified by mode of action or design variation. Tongue retaining appliances function by holding the tongue in a forward position by means of a suction bulb. This keeps the back of the tongue from collapsing during sleep and obstructing the airway.

Mandibular repositioning appliances help to reposition and maintain the lower jaw in a protruded position during sleep. This opens the airway by indirectly pulling the tongue forward and making it more rigid. Such appliances also hold the lower jaw and other structures in a stable position to prevent opening of the mouth.

Q: Can surgery effectively treat sleep apnea symptoms?

A: Patients who cannot be treated with C.P.A.P. and have failed other conservative measures will often be advised to undergo uvulopalatopharyngoplasty, or UPPP. This is a surgical or laser procedure to remove part of the uvula — the small, fleshy tissue hanging in the back of the throat — and soft palate in an attempt to alleviate snoring and sleep-disordered breathing. Following surgery, a repeat sleep study is needed to determine whether the procedure reversed the sleep apnea.

A small subset of people benefit from UPPP surgery. Over all, however, I'm pessimistic about this procedure, because while it may alleviate snoring, it's not consistently effective in treating sleep apnea. When we do follow-up sleep studies, we often find the surgery hasn't really done very much to reduce the number of sleep apnea episodes.

Q: Is UPPP surgery overused?

A: As we've gotten to know more about the surgery and its outcomes, I think specialists have gotten less excited about performing UPPP surgery. It's still overused in some parts of the country, but in general there is less surgery for sleep apnea now than a few years ago.

Q: Why haven't better treatments been developed?

A: The fact that the disease has not taken seriously by sleep researchers has been part of the problem. From an anatomical perspective, however, airways don't always collapse at the same spot. C.P.A.P. works so well because it doesn't matter where your air passage collapses. The air pressure will keep the entire passageway open.

Q: Are drugs being developed for sleep apnea treatment?

A: That's certainly an area of keen research interest. Experiments have been tried with selective serotonin reuptake inhibitors, or S.S.R.I.'s, but these popular antidepressants have minimal efficacy in reducing the number of times a person's sleep is disturbed each hour. For example, if a person is typically bothered 40 times an hour, the drug may drop it to 30 times an hour. Granted, that's not enough to make a significant clinical effect, but it is enough to generate an interest in finding out why there was an effect at all.

Q: Are there ways to prevent sleep apnea?

A: Maintaining an ideal body weight is definitely a plus. We know from studies with men that when the excess weight comes off, the sleep apnea improves or vanishes. In addition, treating underlying nasal problems can also help sleep apnea symptoms. Finally, alcohol worsens sleep apnea because of its depressant effects, so avoiding alcoholic beverages a few hours before bedtime is recommended.

Publish date: 8/30/07

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