History
Until the early 1980’s, the medical community
erroneously attributed the cause of most sleep disordered breathing (“SDB”) to
be neurological in nature. With the
introduction of modern diagnostic techniques, the medical community was able to determine
that the vast majority of SDB cases (over 95%) were a result of an anatomical / physical
problem, related directly to constriction of the airway.
Modern techniques, such as polysomnography give
physicians the tools to define and categorize Obstructive Sleep Disordered Breathing
("OSDB") and to differentiate the conditions of OSA, UARS and snoring from
neurologically-based disorders such as narcolepsy. Previously,
many patients suffering from the less critical and more treatable conditions were
misdiagnosed with narcolepsy or other neurologically based conditions, the treatments for
which, in many cases, worsened the apnea conditions.
Treatments, introduced during the 1980’s, designed
to alleviate constrictions of the airway fall into two categories:
- Surgery to remove excess tissue from the airway, and,
- Devices to open the airway using air pressure (Continuous
Positive Airway Pressure, CPAP).
The surgical treatment, uvulapalatopharyngeoplasty
(“UPPP”), was first described by Dr. Fujita et al in 1981. At the same time the first use of CPAP in the
treatment of OSA was being pioneered by Dr. Colin Sullivan of Sydney, Australia. With the development of laser surgery came the
laser-assisted uvulopalatoplasty (“LAUP”) popularized following a report by Dr.
Y.V. Kamami of the Marie-Louise Clinic, Paris, France.
Throughout this period various types of oral appliances
were introduced. However, during the
1980’s, physicians generally concurred that CPAP was the one and only treatment
alternative to surgery.
Research projects conducted during the early 1990’s
indicated the efficacy of mandibular advancement devices (oral appliances or airway
dilators) by opening the airway. This resulted
in a major review and focus on treatment alternatives and protocols. The effects of this review are best illustrated by
the 1995 American Sleep Disorders Association Review titled
“Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea”,
and the report “Practice Parameters for the
Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances”. The review stated that comparison of the risk and
benefit of oral appliance therapy with the other available treatments suggested that oral
appliances (or airway dilators) presented a useful alternative to CPAP for patients with
all but the most severe cases of OSA and, especially for those who cannot tolerate CPAP
therapy. As well, the review determined that
airway dilators were an effective treatment for those with less severe forms of OSDB,
including snoring and UARS. Since 1995, studies have continued to reinforce oral
appliances as first line treatment for patients with snoring and mild to moderate sleep
apnea.
Medical diagnosis and treatment protocols traditionally
develop from identification of the simple leading to the more complex. The simple signs and symptoms being first
described, and eventually the more complex symptomatology being revealed. The development of diagnostic and treatment
protocols for obstructive sleep disorders has been the reverse of this established
principal in medicine. Complex diagnostic
systems have been established to deal with the overall problems in OSDB. As these systems become more adept, it is evident
validated screening can allow the diagnosis to
be tailored to the level of severity of the conditions.
The introduction of ambulatory sleep screening devices, oximetry, and pharyngometry
are examples of this trend.
Together with the relaxation of the demands for high
level diagnostics has come the realization that the
less debilitating and life threatening conditions of snoring and the milder forms of
obstructive sleep apnea may be more effectively treated with less invasive and complicated
treatment modalities such as oral devices.
We believe that these recent developments in sleep
screening, and the growing medical acceptance of oral appliance therapy indicate that
universal acceptance of oral appliances as first line treatment for snoring and mild to
moderate sleep apnea will be achieved within the next several years. This belief is supported by evidence of
considerable enthusiasm within the sleep diagnostic community and primary health care
professionals. It is further supported by an
increasing level of interest in these products and services by major health care product
suppliers and insurers.
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Treatment Solutions for OSDB
Virtually all obstructive events
occur in the area of the airway that is surrounded by collapsible, often inadequately
supported tissue.
This collapsible airway tissue starts at the front of the
soft palate and extends to the top of the voice box or larynx. The soft palate, tongue and side and back walls of
the throat may intrude on the airway individually or in concert with one another, causing
the tissue to vibrate or seal off the airway during normal breathing. Different therapies attempt to address all or some
of these collapsible airway tissues by their own unique methods.
Parts of the Airway
