by Glennine Varga, AAS, RDA, CTA
Dental sleep team professionals predominantly provide treatment for snoring and OSA with oral device therapy. Therefore when asked about surgery as a treatment option, we may feel our therapy is superior to surgical procedures and with some surgeries having a low success percentage rate we can easily slip into the thought process that surgery is a foe to OSA. However, there are always two sides to every story.
We encounter patients, family and friends that have had surgery suggested as a treatment option and in most cases before an oral device. As team members we jump at the chance to educate them about oral devices and we may disregard the suggested surgical therapy. Well, let’s take a step back and evaluate what can we do as dental sleep team professionals to learn more about surgical procedures and what to say when asked about the therapy.
Our goal ALWAYS should be to help our patients succeed at OSA therapy. This means helping them with combination therapies in some cases. Some patients may need PAP therapy with an oral device to help reduce air pressures. Other patients may need surgery to remove obstructive anatomy and an oral device to maintain the airway. Some may need all three or any combination. Every patient is unique and depending on many factors may need one or multiple therapies.
To be part of successful therapy, it is important to understand that any recommendation from a physician should be promoted. Granted there will be times when patients are given treatment recommendations with no mention of an oral device in situations when it may seem to be the ideal choice. However, it is never a good idea to disregard a physician’s recommendation in any way. We never know the patient’s entire medical condition nor do we want to be responsible for it. Therefore, it is important to assume the patient’s treating physician has prescribed what is best for the patient. This may take some effort on your part to understand more about the various therapies so you can support the patient’s choices about what has been recommended.
Conversations with patients are the key to dental sleep medicine. Here are some facts about surgery for upper airway resistance that may help you educate patients regarding what’s been recommended:
There are about 7 types of surgical procedures for upper airway resistance. A dental team professional should know about them all. Visit http://www.aadsm.org/upperairway.aspx for more detailed information. Maxillomandibular Advancement (MMA) is currently considered the most efficacious surgical procedure for treatment of OSA, particularly severe OSA. Success rates ranging from 94-100%. This procedure surgically repositions both jaws forward to increase the airway. Anterior Inferior Mandibular Osteopathy with Hyoid Suspension (AIMO). This procedure pulls the tongue forward involving the chin bone and anterior neck muscles. Various surgeries of the soft palate are the most common and aim to reduce specific anatomic obstructions within the airway including Uvulo-
palatopharyngoplasty (UPPP), Laser-Assisted Uvuloplasty (LAUP) and Radiofrequency Volumetric Tissue Reduction (Somnoplasty). Nasal surgery to maximize nasal airflow is common. Tongue volume reduction and weight reduction, including Bariatric surgery and Cervicofacial Liposuction to remove excessive fatty issue around the neck, are recommended for appropriate patients. Tracheostomy typically is a patient’s last surgical option to bypass upper airway blockages.
So when a patient asks about surgery to reduce snoring or OSA, it is hard to make a generalized statement since there are several different types of surgery. If possible try to get more specific information as to what type of surgery is recommended. It never hurts to suggest an oral device as means of preservation. A physician recently told me, “Your own anatomy is best and working with that as long as possible is most favorable. Once options are exhausted with your own anatomy then surgery is the next best choice.” This suggests less invasive treatment first before moving forward with an irreversible treatment option.
Technology and procedures are advancing constantly. It is important to keep up with the latest surgical procedures as the sleep breathing industry is growing quickly. Check out http://www.sleepreviewmag.com/2014/09/alternative-therapies-obstructive-sleep-
apnea/ to learn more. It’s astonishing to think of how much effort, money and skill it takes to develop an electric stimulator that is surgically placed within your body to stimulate the hypoglossal nerve to move your tongue forward when your sleeping. WOW! Yes I will try that, once I have exhausted oral
device therapy since, after all, the end result is the same…keep the anatomy out of the airway.
Most physicians love referrals. Reach out to your local Ear Nose and Throat doctors, Oral Surgeons, and other physicians to find out what to look for and what would warrant a referral for surgery. All patients are different and there will be those that require more than one way to reduce upper airway resistance. It is critical to work with a number of physicians that feel the same way. If you get a chance, ask to observe patients in friendly offices – you’ll learn a bunch.
In my opinion surgery is a friend to OSA. Like many medical issues, there are often many treatment choices available; the more focused the clinician, the more likely she/he is to see many pathways to success. So long story short. Why not try the simplest approach when applicable and work your way up from there? Include lifestyle changes, sleep hygiene, sleep position, oral device therapy or PAP, surgery, or combinations of several therapies. Always remember every person is different and a full subjective and clinical evaluation is required for any treatment decision. Keep reaching for the goal of helping your patients succeed with OSA therapy!
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