Bill Klaproth: This is OMS Voices, an AAOMS Podcast. I’m Bill Klaproth, and with me is Dr. Michael Han, Associate Professor and Program Director, UIC College of Dentistry, Department of Oral and Maxillofacial Surgery, as we talk about treatment options for obstructive sleep apnea, or OSA, from non-invasive to invasive solutions. Dr. Han, welcome.

Michael Han (Guest): Thank you for having me, Bill.

Bill Klaproth: You bet. Thank you for being here. So, Dr. Han, what are the most common non-invasive treatment options for obstructive sleep apnea, and how do they work?

Michael Han (Guest): So, like any other treatment modalities, you always want to start with the most conservative and the non-invasive. It’s the same for starting with sleep apnea as well. So, starting with what we call lifestyle modifications or sleep hygiene, things like avoiding stimulants, commonsense stuff like caffeine before going to bed. Posture has an effect on the sleep quality as well, so being supine on your back generally is associated with more obstruction, so encouraging patients to sleep on the side is one. And then things like weight loss, whether it’s through diet and exercise and other modifications or even bariatric surgery, those are considered some of the lesser first-line. And of course, there are some medications not used as commonly that stimulate breathing during sleep, but probably the most common, the work horse for non-invasive would be CPAP, or continuous positive airway pressure device, which is essentially a mask that tents open your upper airway while you’re sleeping. 

Bill Klaproth: Sure. We see the ads all the time.

Michael Han (Guest): Correct, yeah, and also, as it relates to the dental field, there are oral appliances that are specifically designed to open up your airway and those would cover most of the commonly used non-invasive measures for obstructive sleep apnea.

Bill Klaproth: So, when we talk about non-invasive treatments, who would be the ideal candidate? And then, when should a patient consider a more invasive option? How do you know?

Michael Han (Guest): So, the common denominator of the non-invasive modalities is that it’s good for mild to moderate severity. If someone has obstructive sleep apnea that’s very severe, generally not very amenable to non-invasive measures for curative intent. It could be a good adjunct, but for curative intent, non-invasive may not be ideal at all for, severe type of obstructive sleep apnea.

Bill Klaproth: For like slight or moderate sleep apnea, then sleep hygiene, those types of things, sleep on your side, avoid heavy meals before bed, those are ways to help manage it.

Michael Han (Guest): Correct, right. The thing with the non-invasive is a lot of this, if you look at it, requires compliance on the patient’s part. It’s like going to the gym, or everyone knows exercising and not smoking and eating right improves your health. But it’s how to actually implement that is another idea altogether, right? So, similarly for non-invasive things like CPAP oral appliances and lifestyle modifications, there are things where compliance sometimes is a limiting factor.

Bill Klaproth: Well, compliance in most things are key, especially in the healthcare field. So, then, say you try the non-invasive methods and they just don’t work. So, what are the different surgical options then available for treating OSA and what does each procedure entail?

Michael Han (Guest): Historically UPPP, or uvulopalatal pharyngoplasty, that’s quite a mouthful and nasal septal surgeries were kind of the first line when it comes to obstructive sleep apnea. So the UPPP, it’s essentially recontouring and trimming redundant tissues around the throat, the uvula and the soft part of the palate. Probably because, you know, one of the more common signs of obstructive sleep apnea, oftentimes what triggers patients to go seek care is snoring. And that’s the very area where snoring often takes place. So, it makes sense that historically they targeted this area. Same thing with nasal septal deviation. If the septum, which is the wall that separates the right and left side of the nose, if that’s deviated towards one side, then the deviated side will have a very narrow airway passage. Patients will not be able to breathe very well through that part of the nose. That has been historically the first line, although it has kind of fallen off because of less than reliable results.

And then other things like genioglossus advancement, which is essentially moving part of the lower jaw that tethers an important tongue muscle. So, it essentially decreases the collapsibility of the tongue. As the problem is when you sleep, your muscles relax and the tongue will relax and fall back as well, nearing the airway. And what this aims to do is to decrease the collapsibility by advancing that forward. And then there’s MMA or maxillomandibular advancement, which is essentially moving the upper and lower jaw forward. It’s something that aims to open up airway in different levels at the soft palate level, behind the tongue, and below that as well. And then newer, I don’t know if I can call this new anymore, but hypoglossal nerve stimulation is another modality where special sensors or devices, implantable devices placed and increases the tone of your tongue muscles during sleep that does not require any compliance.

Bill Klaproth: So, with each of these different options, you talked about the UPPP, the MMA, the GA, how do you determine which treatment approach is best suited for a particular patient with OSA? 

Michael Han (Guest): At the most basic level, identifying where the obstruction is occurring because the upper airway is quite long. It goes from all the way up kind of to the nose level down below near the vocal cord level. So, identifying what part of the airway is constricted is an important thing, and there are various different ways of doing it. One of which is what’s called the drug-induced sleep endoscopy, where patients are given certain medications to mimic natural sleep and then using a special scope, the provider will look at where the obstruction is to target, specifically. Another factor is the pattern of collapse. So, even if you have a narrowing of the airway during sleep, sometimes it could narrow more in a forward backward type of direction, or side to side, or just what we call concentrically, just all around. Different types of surgeries have different effects depending on the obstruction pattern. For example, if you have a concentric constriction, you may not respond well to certain things like hypoglossal nerve stimulation, which will work better for the more forward and backward type of constriction. So, when it comes to maxillomandibular advancement, MMA, where we’re moving the upper and lower jaw forward, inevitably there’s going to be some changes in the facial profile. Some people irrespective of sleep apnea have differences in jaw growth. For example, their lower jaw is smaller than the upper jaw. And if they have concomitant sleep apnea, they may kind of jump the ladder, so to speak, and be recommended MMA because their facial balance require moving the jaw anyway.

Bill Klaproth: So, can you talk to us about advances in OSA treatment? Things that have emerged in the previous years and how they are improving patient outcomes?

Michael Han (Guest): Probably I think the biggest advancement is introduction of widespread implementation of drug-induced sleep endoscopy. I think that’s one nice development in diagnosis because historically it used to be very algorithmic, okay, patients get this minimally invasive surgery first, and then if they don’t respond, they go to the next level, and then to the next level. It’s kind of a little bit of a shot in the dark type of approach, but the drug-induced sleep endoscopy greatly changed that. And so now the algorithm is a little bit more efficient, I would say. And then when it comes to therapeutics, hypoglossal nerve stimulation definitely, I think, shows a really good promise. I think we have enough data accumulated to demonstrate that it’s here to stay. And as it relates to MMA, advances in planning and execution of the surgery. So, I think most would be familiar with the fact that with advances in digital technology, planning is almost exclusively digital right now. I don’t think I’m exaggerating when I say that. So, there’s more sophisticated planning methods and also, improved technology that allows you to actually pull off what you’re planning, because you can plan anything on a computer or on paper, but what’s important to the patients is that that’s actually replicated, right? With advances in patient-specific implants, meaning plates and screws that are specifically made to the patient’s anatomy that are very rigid, now it’s becoming easier to actually execute your surgical plan, which is critical for the sleep apnea patient because it’s not about, oh, the patient, the patient could have had nicer facial change. No. It’s a medical procedure. So every millimeter counts.

Bill Klaproth: Well, it’s good that there are advancements taking place, and I know there will be more in the future. Dr. Han, when we think of sleep apnea, I don’t think we think of the OMS first. Why should people think about choosing an OMS for their sleep apnea issues?

Michael Han (Guest): As cheesy as it sounds, I think we’re in a very unique intersection between many healthcare specialties. So, I don’t like saying this, but I’ll say it now, we’re at a unique intersection of dentistry and medicine. And a lot of these patients don’t know that they have sleep apnea. So when, let’s say, a patient comes into an oral maxillofacial surgeon’s office to get his oral wisdom teeth evaluated, the standard screening questions, and if there’s any red flags, so to speak, then we’re in a unique position to recommend further workup. And especially because oral and maxillofacial surgeons offer sedation, which, you know, has a lot of airway implications, I would say that compared to the average provider in the healthcare field, the airway screening is more robust. So, the chances of picking up a potential OSA patient’s greater. And then there are a lot of modalities that overlap in scope with and oral maxillofacial surgeons, the most easy one being maxillomandibular advancement, genioglossal advancements and hypoglossal nerve stimulation. Not to say that we have a hammer and nail approach, of course. Just because we know how to do X, Y and Z doesn’t mean that the patient’s only in X, Y and Z.

But I think just how our specialty’s intertwined with healthcare puts us in a unique position.

Bill Klaproth: Well, this has been fascinating, Dr. Han. Thanks for stopping by. So, before we wrap up, any final thoughts as we discuss treatment options for OSA from non-invasive to invasive solutions?

Michael Han (Guest): I think the most important thing is to really understand your role within the healthcare system. Again, I use the hammer and nail analogy and I really believe in that. Just because my scope offers a certain thing doesn’t mean that everyone should be getting that. I think we should be responsible for providers knowing our place ultimately connecting patients to the right treatment. And I think with the broad skill set that we have, I do think that we play a prominent role even in the surgical management of care as well.

Bill Klaproth: Absolutely. Well, Dr. Han, thanks so much for spending some time with us today. We appreciate it.

Michael Han (Guest): Thank you very much.

Bill Klaproth: You bet. Once again, that is Dr. Michael Han. For more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social media, and don’t forget to subscribe. Thanks for listening.