Bill Klaproth (host): This is OMS Voices, an AAOMS podcast.

I'm Bill Klaproth. And with me is Dr. Brian Farrell, who is here to discuss, is it just snoring? As we talk about obstructive sleep apnea or OSA. Dr. Farrell, thanks for being here.

Brian Farrell: Yes. Great to be here.

Bill Klaproth (host): Yeah. So excited to talk about this because this afflicts so many people. So, what is obstructive sleep apnea?

Brian Farrell: Obstructive sleep apnea is essentially disturbed sleep. Individuals, unfortunately, do not get the chance to rest. I always use the analogy of a phone that didn't get put back on the charger at night. So when you wake up the next that day, that phone is in low power mode. A body is in low power mode when you do not get restful sleep.

Bill Klaproth (host): That is a great analogy and an easy way to think of what OSA does to your body basically. You're not getting that restorative sleep. That's the main problem. Is that right?

Brian Farrell: That is correct.

Bill Klaproth (host): So when a person snores, does that mean they automatically have obstructive sleep apnea?

Brian Farrell: It does not. Snoring generally is basically reverberation or the rattle of the soft palate. We've all heard of people snoring. We've heard you go on a trip and you can hear either a mom or a dad or an aunt or an uncle in the room next to you, and you can hear the snoring. Snoring does not necessarily mean obstructive sleep apnea.

Obstructive sleep apnea is essentially where the tissues become redundant and airways that are narrow allows the opportunity for that to close, obstruct. Unfortunately, the body wakes itself up and that disrupts sleep. It throws off the night, it throws off the day and it basically ends up being a vicious cycle.

Bill Klaproth (host): Yeah. So outside of OSA, are there nonmedical treatments that someone may use to reduce or eliminate snoring?

Brian Farrell: Everybody generally begins to snore the older we get. More and more people begin to snore because as we get older, there's laxity, the soft tissue becomes more redundant. So, a lot of people begin to snore as we get older.

Once again to delineate between the snoring versus obstructive sleep apnea, generally we're going to do workups. Those workups include paperwork that you can simply ask questions about how a person sleeps. During the day, are you likely to fall asleep at a stoplight? Are you likely to fall asleep when you turn on a movie? Those are questionnaires that allow us to begin to get initial understanding if that person has obstructive sleep apnea. If it appears as though that individual may be a candidate for further studies, then we typically refer them to get a sleep study or a polysomnography where we're going to send them to a sleep lab. At the sleep lab, they're essentially going to be monitored while they sleep. The blood pressure is monitored. Electrical brainwaves are monitored. Blood pressure is monitored. They're essentially going to watch and monitor how you do at night.

Unfortunately, with the sleep study, it's in a lab. It's a different environment. It's someone yelling at you to turn over and roll over. So, it may not be the best of sleep, but essentially it allows us to get an understanding of the sleep patterns. From that diagnosis, a person is generally categorized as of course not having it, maybe it is just snoring or it can be categorized as mild, moderate or severe.

Sleep apnea and what it does essentially to a person when you do not get the opportunity to rest and have regenerative sleep, we're learning a lot about what it can cause to other parts of the body. You can have high blood pressure. You can be susceptible to heart attacks, irregular heartbeat. You aren't thinking clearly. You can be irritable, grumpy, quick to get upset. So, it has a tremendous effect on other body parts, other systems, such as the cardiovascular, mental, thinking and such.

Once a person again is diagnosed with obstructive sleep apnea, again a lot of it depends on what diagnosis it is, meaning a mild, a moderate or severe. Most therapies are going to start conservative. And conservative means, basically, better sleep patterns, avoid alcohol, avoid caffeine before bedtime, essentially sleep hygiene is what they're calling it, you're going to get to sleep, hopefully. Do your best to avoid those things that are going to keep you up or not allow you a deep, restful sleep.

Bill Klaproth (host): Okay. Let me ask you this. You mentioned fatigue, high blood pressure, not thinking properly. Are these also symptoms of OSA that might not be as recognizable as snoring?

Brian Farrell: Well, I think that that's very important because there's certainly a lot of overlap. There's a lot of reasons a person may have headaches, may have not the best of clarity when they wake up in the morning. Well, ultimately, sleep apnea can cause that, but there's a lot of things that can cause headaches. And so, it's sort of making sure that you're sifting through and coming up with the proper diagnosis.

Bill Klaproth (host): So, where does an OMS fit into this picture?

Brian Farrell: The OMS has an opportunity to help because we have a place at the table. We have a tremendous opportunity to help treat obstructive sleep apnea. Whether it's mild, if it's mild, most individuals are going to potentially try a sleep appliance. A sleep appliance is basically a night guard that is used to posture the jaw forward. The benefit of it is by holding the jaw forward, that keeps the soft tissue, particularly the tongue musculature forward, it avoids the collapse at night. The potential challenges with a sleep appliance are it's obviously foreign. It's in the mouth. It can cause increased salivation. It can cause problems with TMJ, because you're posturing the jaw forward all night. And long-term use can cause problems with bite, a bite can get distorted.

Bill Klaproth (host): So, of course, when we think of sleep apnea, we think of the CPAP machine. But one of the ways is with a mouth guard at night.

Brian Farrell: A mouth guard at night is what the oral surgeon or other dental providers may provide if they have a mild type. Certainly, our sleep medicine colleagues prefer to start with CPAP. And the CPAP obviously is a machine that is used to help keep airways open by providing pressure inside the pipe, so to speak.

Bill Klaproth (host): Okay. So, we talked about possibly wearing a mouth guard at night. We've talked about CPAP. And you've mentioned sleep hygiene as well, which is very important. These are the ways that you normally start treating OSA. Is that correct?

Brian Farrell: That is correct. Remember, it's going to be conservative in the beginning. It's going to be sleep hygiene. Avoid sleeping on your back. Potentially better exercise, better diet. Losing weight can help tremendously. But all of the therapy is going to start conservative. Only when an individual is refractory to conservative measures is when the possibility of the CPAP or a sleep appliance might be implemented.

Bill Klaproth (host): Okay. That's really interesting. So, you start with lifestyle modification first. When it comes to surgery, where does the OMS fit into that then? What are the surgical treatments, the options available?

Brian Farrell: The surgical treatments for a person who has obstructive sleep apnea is an oral and maxillofacial surgeon can perform maxillomandibular advancement surgery. We have truly one of the best methods of correcting obstructive sleep apnea by advancing anatomy. By us moving the maxilla and the mandible forward, we have the opportunity to pull the genioglossus muscle, the tongue, forward. And by us advancing the skeleton, we can take airways that start the size of a pencil or a pen and make it bigger than a garden hose. So by advancing the maxilla and the mandible, we have the ability to open the airway posteriorly.

Bill Klaproth (host): Well, this is interesting to hear about because if you watch TV, all you hear about is CPAP machines basically and other things. This surgery that an OMS is able to perform is not something I don't think the general public is readily aware of. I could be wrong on that, but it's interesting to hear you talk about what you can do to help fix this. And obviously, OSA is a major problem in this country with people not getting restorative sleep. So, it's fascinating to hear you say that.

Brian Farrell: Absolutely. Remember, if a person is middle aged and they're using a CPAP, we anticipate that that individual is going to sleep for 30 years, 40 more years, 50 more years. And to truly be sort of limited by the utilization of a CPAP, as long as it's tolerated, that's great. Unfortunately, many people cannot tolerate CPAP, the pressures get high. Sometimes it doesn't fit the best. You can be claustrophobic. You can get a leaky mask, which can cause dry eyes. So, there's a lot of challenges with CPAP. In fact, I think a lot of oral surgeons see individuals who certainly have attempted CPAP, but unfortunately they're refractory to it. They can't tolerate it. They're not compliant with it. And those are the individuals that certainly now would look toward a surgical path.

Bill Klaproth (host): It seems like people should maybe see an OMS first before going the CPAP route. Would that be fair to say?

Brian Farrell: Oh, I think that's fair to say. I think it's something that you have an opportunity to educate that individual in front of you. You can explain to them, "Well, you've now been diagnosed with sleep apnea," and maybe it came from an oral surgery office, maybe we were the ones that directed them to get the sleep study, the polysomnography. Once that information is back, then certainly we will educate them on their paths. One might be the conservative measure, better sleep hygiene, lose weight. Some individuals recommend sewing a tennis ball or a ball in the back of your shirt. That way at night when you're in your sleep shirt, you can't lay on your back. It keeps you on your side. But you have an opportunity to basically help provide options for these individuals. And they may choose to go the route of nonsurgical with CPAP. And that is their prerogative. And if it's successful, great. Unfortunately, many people probably are coming back through the door months down the road unable to tolerate it. And those individuals now are wonderful candidates to do something surgical.

Bill Klaproth (host): Absolutely. So let's talk about candidates, someone who might be listening to this podcast right now thinking, "Okay, that sounds great. But what is this surgery? What does it entail?" So, what do you do when it comes to surgery?

Brian Farrell: Well, with surgery, records are taken obviously by the surgeon for preoperative preparation. In the world today, we now use industry and technology to understand where the skeleton is. We can plan the advancement. We can plan where we want to move things in space. Understanding by bringing the upper and the lower jaw forward, in fact, bringing the genioglossus forward with another technique, we have the ability to plan that prior to the surgery.

Once we actually get to the surgical procedure, essentially, we now make cuts that allow us to mobilize the upper and the lower jaw. We advance it based on the plan. Small plates and screws are used to hold that together. That allows an individual to open and close following the procedure, so they can function. The procedure's generally done in a hospital environment. It takes several hours for the oral and maxillofacial surgeon to do it. They are going to spend likely a night in the hospital setting where they're going to be evaluated.

The following day, those individuals generally are discharged and, ultimately, they begin the recovery. The recovery following jaw surgery is admittedly a little slow and dark the first week. Ultimately, however, particularly when you provide plenty of education prior to what you're doing and what you're trying to accomplish, those individuals are going to recover and climb the ladder and, hopefully have much, much better sleep.

Bill Klaproth (host): Well, when you talk about someone having 30 to 40 years of sleep left, that week of recovery seems minuscule, you know, in the big picture of things.

Brian Farrell: Well, I think that's exactly right, Bill. It's all about quality of life, meaning putting it on the scale.

Bill Klaproth (host): Well, this has been fascinating, Dr. Farrell, as we talk about OSA. Anything else you'd like to add?

Brian Farrell: I don't know.

Bill Klaproth (host): I've asked you everything. I've asked questions.

Brian Farrell: Yeah. Well, I hope that we've had an opportunity to kind of cover all the bases. But ultimately, an oral and maxillofacial surgeon has a tremendous opportunity to help those people that have obstructive sleep apnea.

Bill Klaproth (host): Yeah. And you've certainly brought that message to us. And it's really appreciated. And this has been very educational, Dr. Farrell. Thank you so much for your time.

Brian Farrell: Thank you so very much. I appreciate it.

Bill Klaproth (host): You betcha. That is Dr. Brian Farrell. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.