Snoring: More than just Noise: Dental Solutions
Have you ever heard someone say they cannot function in the morning until they get their coffee? Snoring may have robbed them of a good nights sleep. Either they are snoring, their sleeping partner, or the next door neighbor.
Snoring happens when the tongue falls back in the throat, and occludes the airway during unconsciousness or sleep. This closes down the mouth and nasal openings of the airway to the lungs and forces the body to push and pull air past this obstruction. It is when the air is forced past this obstruction that all of the various snoring sounds are emitted. This is why the ABC’s of cardio-pulmonary resuscitation (CPR) starts with the letter “A” for airway. If the unconscious person has difficulty breathing, then simply rotating the head back or lifting the chin will pull the tongue forward and open the airways.
This pulling of the jaw forward to open the airway is the basis behind most of the anti-snoring appliances on the market today. The prescribed appliance is usually anchored to the upper jaw so the lower jaw can be positioned correctly. A few of these appliances can be adjusted over time to find the optimal position and then fixed into that position for long term usage. Over-the-counter devices that open the nasal passages such as Breath-rite nasal strips are not repositioning the lower jaw and only address some mouth breathing issues.
Effects of Snoring:
- Heart attacks or irregular heart beats
- High blood pressure
- Morning headaches
- Dry mouth
- Gastroesophageal reflux disease (GERD)
- Impaired concentration
- Decreased libido
- Insulin resistance
For the most part, snoring can be prevented. Wearing an appliance does have some getting used to factors, and possibly TMJ/myofacial pain complication.
- Overweight: Being overweight has many health issues. Increasing the throat fat pads will make your throat more narrow and prone to snoring. Sometimes just loosing 5 to 10 pounds will dramatically decrease snoring.
- Alcohol: After drinking alcohol the throat tissues become irritated, red and swollen. Your muscles are in a more relaxed state and snoring can occur.
- Smoking: Cigarette smoke contains many types of irritants. These irritants make the throat red and swollen throughout the day. Many people smoke in the bed as well. Oddly enough, nicotine may actually decrease sleep apnea and may be a factor in why it is so hard to quit smoking.
- If you have an obstructed nasal airway you may be forced to breath through your mouth. This may cause snoring.
- Sleep position: Back sleeping may allow the tongue to slip back and occlude the airway. However, snoring has been reported in every conceivable sleep position.
- Anatomical structures: Enlarged tonsils and adenoids can block the airways and cause snoring. Removing them can help improve the flow of air and help prevent snoring. A few of my patient have actually had their uvula removed hoping this will help them stop snoring. Unfortunately, in most cases this type of treatment is not totally effective and may leave the person with a more nasal sounding voice. (Even the Muppets have uvulas). An enlarged tongue, sometimes found in edentulous patients can also promote snoring.
- Age: As you get older, a combination of factors come into play. Less muscle tension in the nasopharynx, sleep positions, lax lower jaw positions, increased weight, loss of teeth causing the mouth to shut more, and increased prescription medications can increase snoring.
- Obstructive Sleep Apnea: (OSA) This is a life threatening condition. It is where you actually stop breathing when you are sleeping. Long periods of not breathing lowers oxygen levels and increased carbon dioxide. Both the lowering of O2 and increasing of CO2 causes the body to gasp for a breath. This gasping creates a negative pressure inside your chest cavity putting pressure on your heart. This causes the heart to pump harder and increases your blood pressure high enough in some instances to cause a heart attack or stroke. This condition is diagnosed by a sleep study called a polysomnography(PSG). Approximately 30 million Americans have sleep apnea and is characterized by snoring, hypertension, cessation of breathing during sleep, being tired during the day, and a neck size of >17″ in males and >16″ in females.
- Upper and lower jaw mismatch: The position and size of your upper and lower jaws may have a lot to do with your propensity for snoring.
- Lossing weight: One of the biggest reasons why a person will snore when sleeping is excessive weight in the neck.
- Limit alcohol: Not only will excessive alcohol increase your weight over time, but it irritates the throat tissues and make them swell, shrinking the airway and causing snoring. Drinking alcohol should be limited and stopped within 3-4 hours before going to bed.
- Stop smoking: (Red swollen throat, heat, nicotine)
- Continuous Positive Airway Pressure (CPAP) uses a air pump and a mask to force air into your lungs all night long. The masks are custom fitted to your face for maximum comfort. It may be hard for you and your significant other to get accustomed to the noise. This positive airway pressure opens the airways like an “air stent” so a smooth flow of air can be achieved even through a restricted passageway. A new “Obama Care” ruling on insurance for CPAP states that the patient has to prove compliance with using the the device or it can be repossessed. I guess too many people are diagnosed with sleep apnea and are given this expensive equipment only to let it sit at their bedside without using it.
- Dental Appliances: There are many different types of dental appliances used to advance the lower jaw to help prevent snoring. The trick is finding the best one for you. Comfort is the most important factor in choosing an appliance. Other problems may include the size of the appliance, TMJ discomfort, sore teeth and gums. Currently they are rated as a class 2 medical device which means they require a prescription from a doctor. (SEE the review of dental appliances below).
- Surgical: (For extreme cases only)
- Uvulopalatopharyngoplasty is a surgery mean to open the posterior airways by removing the uvula and part of the back wall of the pharynx. I have several patients that have gone for this extreme surgical “cure” only to be disappointed with the overall results.
- Radiofrequency ablation is relatively new and uses a radio frequency and heat to scar the internal tissues on the nasopharynx to make them stiffer. The thought is that flabby tissue assists snoring and stiff tissue does not. Early reports show improvement, but not complete elimination of the snoring sound.
- Removal of tonsils and adenoids
- The Pillar Procedure: This is another surgical procedure mean to stiffen the soft palate so the tissues are less prone to vibrate during sleep. It consists of placing up to 6+ long dacron inserts into the soft palate. It is a relatively easy surgery that can be easily done with local anesthesia in just a few minutes. It again lessens the snoring and may not completely eliminate it due to other complicating factors.
- Orthognatic Surgery: This is moving either the upper or lower or both jaws to re-position the anatomical structures so that they are not restricting the airways to cause snoring. This is the most extreme surgical procedure to totally eliminate snoring and probably the most promising. Next to loosing excessive weight, limiting alcohol and stopping smoking, orthognatic surgery has been shown to be a good treatment for snoring. This is done by pulling the bones of the face outward away from the nasopharynx and creating more space to breathe through.
- Pharmaceutical: Either in the form of a nasal spray or orally, decongestants can help with snoring. This may not be advised to take on a routine basis due to side effects of the medications including rebound rhinorrhea (runny nose).
- Singing: This may strengthen the throat muscle enough to help prevent snoring.
- Didgeridoo: Playing a ancient Aboriginal instrument called the didgeridoo vibrates at such a low frequency it may actually strengthen your throat muscles enough to prevent snoring. However, playing other wind instruments in either a band, orchestra, or just for fun does not decrease the chances of you having sleep apnea or snoring.
Anti-snoring devices on the market:
There are as many different types of anti-snoring devices on the internet as there are snorers in the whole world! Some are okay and some are down right kookie.
- Blackstone Anti-Snoring Pillow (https://blackstonepillow.com)
- Brookstone Anti-Snore Pillow (http://www.brookstone.com/Anti-Snore-Pillow_8270337_2.html)
- Therapeutic Pillow (http://www.the-pillow.com.au/general/category_snoring.php)
- Snoreeze nasal & throat spray, oral strips, nasal strips (www.snoreeze.com)
- Breathe Right throat spray, oral strips, nasal strips (www.breatheright.com)
- Asonor nasal spray (www.asonormarketing.com)
- Breathe Right external strips (www.breatheright.com)
- NoZoVent internal strips (www.nosnorezone.com/nozovent-nasal-snoring-relief.html)
- Max-Air Nose Cones internal device (www.maxairnosecones.com)
- Pure Sleep (www.puresleep.com)
- Snore Guard (www.somni.com)
- RIP Snore (www.ripsnore.com)
- ZQuiet (www.zquiet.com)
- SnoreMeds (www.snoremeds.com)
- SnoreMate (www.snoremate.net)
- My Snoring Solution (https://snoringsolutionsite.com/)
- Snoozer USA (www.snoozer-usa.com)
- NoSnoreZone (http://www.nosnorezone.com/somnosupport-chin-strap.html)
- Zzoma (www.zzomasleep.com)
- Rematee (www.antisnoreshirt.com)
- Therapeutic Pillow Side Sleeper (http://www.the-pillow.com.au/general/category_snoring.php)
- AcuRest acupressure device for fingers (www.acurest.com)
- AntiSnor acupressure ring (www.snorenomore.net)
- SnorePro (www.hbiusa.com/4-001.html)
- HealioHealth Antisnore Watch (http://www.healiohealth.com/tek9.asp?pg=products&specific=jnmqlogmk)
The American Academy of Sleep Medicine has approved custom made dental appliances for:
- Mild to Moderate obstructive sleep apnea
- Mild to Moderate obstructive sleep apnea who prefer a dental appliance verse CPAP
- Moderate to Severe obstructive sleep apnea who cannot tolerate or do not respond to CPAP
Dental Appliances: (custom Class 2 Medical devices by prescription only)
- Thornton Adjustable Positioner. This device has gone through a few generations of invention and is currently on the third version called the TAP3. You must have teeth on the upper and lower arch for this to work or at least implants. It has an adjustable screw that can be adjusted by the dentist for optimal jaw comfort and effectiveness. To make this device the doctor will make accurate upper and lower models of your mouth and take a bite registration. The lab will then use and hard/soft thermoplastic material and suck in down over the models to make this device. Its retention in the mouth depends on if you have enough teeth in both arches with enough undercuts to secure the device. This is one of the most popular devices to substitute for CPAP when a patient cannot tolerate CPAP. If you do not have any teeth in one or both arches then implants can be used to not only fixate your dentures but to fixate the TAP as well. I like this appliance because it is one of the few that can be placed in the mouth one arch at a time and then you simply push your jaw forward to connect the two, positioning your lower jaw in a comfortable forward position. One draw back for this appliance is that it traps the tongue and doesn’t allow it the freedom it needs during the night.
- Somnodent MAS (Mandibular Advancement Splint) This appliance fits over the upper and lower teeth just most of the other dental snoring devices and is approved by the FDA and is back by over 7 years of research. It is one of the most comfortable mandibular advancement devices on the market today. It is fully adjustable and allows the lower jaw a great deal of freedom. It is effective in mild and moderate obstructive sleep apnea and snoring. The company notes that success in all cases cannot be guaranteed. It is a more expensive “knock-off” of the Nor-Snor 2.
- SUAD It also is a device to move the lower jaw forward. It does provide more freedom of movement than the TAP3, but not as much as the Somnodent MAS. It is also used in the treatment of mild and moderate sleep apnea when someone cannot tolerate CPAP. Their website states that since the year 2000, over 8000 have been made for patients. One would have to wonder that if there are over 30 million Americans suffering from snoring/sleep apnea, why are so few being dispensed?
- OASYS This is a most interesting device. It comes in two pieces just like most of the other appliances, but the upper is strictly for tooth retention. This retention is exactly the same as an Essix post-orthodontic retainer. The lower part fits over the lower teeth to support the lower jaw advancement, but instead of attaching to the uppers it uses a “bumper” over the front teeth to keep the lower jaw in proper position. This is supposed to use the front teeth’s proprioceptive abilities to “gently” keep the jaw in position. In addition to the jaw repositioning, they claim that by placing “nasal buttons” under the upper lip, they can stretch out the nasal opening thus increasing the air flow through the nasal cavity by some 48%! (Not a Class 2 medical device)
- Silent Nite This is one of the simplest mandibular advancement appliances out there on the market. We have used them in the past, but found they were too easy to break or chew up. They are not as adjustable as other more sophisticated devices, but generally do well if they are take good care of. It is basically a suck down hard/soft night guard material that fits over the upper and lower teeth with a piece of white nylon type material connecting the two together. This connection only allows the lower jaw to rotate forward when it becomes lax, thus repositioning the jaw forward when sleeping. (Not a Class 2 medical device)
- Silencer Professional Again, a device to repositioning your lower jaw forward, but this time it is done with a patented version of a velcro looking material. Simply place the upper and lower retention units in place and then put your jaw forward and bite the “velcro” together. When cleaning the device simply pull the upper and lowers apart. Pretty cleaver, however, gives no room for any movement throughout the entire night, and this may lead to TMJ discomfort in the morning. (Not a Class 2 medical device)
- Tongue Retaining Device are devices that generally “suction cup” onto the tongue not letting it fall back into the back of the throat during sleep. (Not a Class 2 medical device)
- AveoTSD (Tongue Stabilizer Device) I ordered one of these devices for myself. It looked like a giant pacifier. You squeeze the bulbous part that protrudes out of your mouth and “suction cup” it to the tip of your tongue. I found it most uncomfortable and hard to swallow, but I eventually got off to sleep. In the middle of the night I woke to find my tongue burning. I took off the suction cup (now half full of saliva) and noted in the mirror my tongue had a circular ecchymosis (hickey) where the device was attached. Throughout the next day my tastes were very metallic, and my tongue burnt. This is definitely a device I will not be prescribing for my patients. (Not a Class 2 medical device)
- The Moses Appliance: This is a new product on the market that is beginning to get more attention. It is made in two parts; upper Essix type suck down clear plastic splint to stabilize the upper arch and a lower adjustable jaw positioner. It allows the tongue freedom to move around at night and doesn’t lock together allowing you to speak and drink with it in place. I wear it every night to treat my moderate OSA.
- The Dorsal: This is the same as the “SomnoDent MAS” appliance design.
- The Nor-Snor: This is the original “SomnoDent MAS” appliance design.
Dental Appliance Troubleshooting:
- The retention of the device depends usually on undercuts between and around the teeth. This allows the device to “snap” into place. If these undercuts do not exist, then the device can be pushed out at night by the tongue. The doctor can place white filling material in spots throughout the mouth to assist in retention.
- After wearing the device, especially one that does not allow movement of the lower jaw, the teeth may not “match-up” immediately after removing it in the morning. This “acquired malocclusion” can sometime persist throughout the day and cause myofacial pain syndrome. The reason for this mis-match of your upper and lower teeth is that keep your jaw in one position all night allowed joint fluid to full all the spaces in the TMJ. Chewing on a “rubbery” strip on some kind (plastic straw, rubber, leather) immediately after taking it out in the morning for about 10 minute (or until you feel your teeth come back together the right way) will help gently push out these fluids in the TMJ, and prevent these problems. For our patient we make a thermoplastic repositioner that the patient puts into their mouth for up to 30 minutes in the morning and this prevents any feeling of malocclusion commonly felt when wearing an obstructive sleep apnea appliance or anti-snoring appliance or hard occlusal guard at night.
- Dry mouth: Placing a xylitol and/or fluoride containing non-alcoholic mouthwash into the device before placing it in the mouth can help.
www.ApneaDocs.com – Dental Organization for Sleep Apnea
www.QuietSleep.com – a sleep-breathing disorders resource for dentists and patients
www.DentalSleepMed.org – Academy of Dental Sleep Medicine
www.ApneaNet.org – the Apnea Patients New, Education and Awareness Network
2. Sleep Breath. 2011 Mar 2. [Epub ahead of print] Obstructive sleep apnea symptoms beyond sleepiness and snoring: effects of nasal APAP therapy. Cruz IA, Drummond M, Winck JC. Department of Pulmonology, São João Hospital, Faculty of Medicine, University of Porto, Alameda Professor Doutor Hernâni Monteiro, 4200-319, Porto, Portugal.
3. G Ital Cardiol (Rome). 2010 Nov;11(11):815-22. [Sleep apnea and heart failure: pathophysiology, diagnosis and therapy]. [Article in Italian] Monda C, Scala O, Paolillo S, Savarese G, Cecere M, D’Amore C, Parente A, Musella F, Mosca S, Filardi PP. Dipartimento di Medicina Interna, Scienze Cardiovascolari ed Immunologiche, Università degli Studi Federico II, Napoli.
4. Eur Arch Otorhinolaryngol. 2011 Feb 22. [Epub ahead of print] The role of the nose in snoring and obstructive sleep apnoea: an update. Georgalas C. Otolaryngology Department, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands, email@example.com.
5. Sleep Breath. 2011 Feb 12. [Epub ahead of print] The impact of pretreatment assessment of oropharynx on interstitial soft palate radiofrequency surgery outcome-a multi-center study in patients with habitual snoring. Bäck LJ, Koivunen P, Pyykkö I, Stene BK, Mäkitie AA. Departments of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Central Hospital and University of Helsinki, P.O. Box 220, 00029, HUCH, Helsinki, Finland, firstname.lastname@example.org.
6. Eur J Dent. 2011 Jan;5(1):84-8. Cephalometric comparison of pharyngeal airway in snoring and non-snoring patients. Kurt G, Sisman C, Akin E, Akcam T. Assistant Professor, Erciyes University, Faculty of Dentistry, Department of Orthodontics, Kayseri, Turkey.
7. Eur Arch Otorhinolaryngol. 2011 Feb 5. [Epub ahead of print] Long-term results of palatal implants for obstructive sleep apnea. Neruntarat C. Department of Otolaryngology, Faculty of Medicine, Srinakharinwirot University, Sukhumvit 23, Bangkok, 10110, Thailand, email@example.com.
10. Eur J Med Res. 2010 Nov 4;15 Suppl 2:36-40. Influence of body mass index on treatment of breathing-related sleep disorders. Dzieciolowska-Baran E, Gawlikowska-Sroka A, Poziomkowska-Gesicka I, Teul-Swiniarska I, Sroczynski T. Department of Anatomy, Pomeranian Medical University, Szczecin, Poland. firstname.lastname@example.org
11. Acta Otolaryngol. 2011 Mar;131(3):298-302. Epub 2010 Dec 7. Frequency of serious complications after surgery for snoring and sleep apnea. Franklin KA, Haglund B, Axelsson S, Holmlund T, Rehnqvist N, Rosén M. Department of Surgery, Umeå University, Sweden. email@example.com
12. J Assoc Physicians India. 2010 Jul;58:438-41. Obstructive sleep apnoea: a clinical review. Gupta RK, Chandra A, Verm AK, Kumar S. Department of Tuberculosis and Chest Diseases, SN Medical College, Agra.
13. J Craniofac Surg. 2010 Nov;21(6):1801-6. What is the efficacy of nasal surgery in patients with obstructive sleep apnea syndrome? Bican A, Kahraman A, Bora I, Kahveci R, Hakyemez B. Department of Neurology Medicine, Uludag University Medical Faculty, Bursa, Turkey. firstname.lastname@example.org
14. J Cardiovasc Nurs. 2011 Mar-Apr;26(2):106-16. Obstructive sleep apnea: a risk factor for cardiovascular disease. Reishtein JL. College of Nursing & Health Professions, Drexel University, Philadelphia, Pennsylvania 19102, USA. email@example.com
15. J Prosthodont Res. 2010 Oct 22. [Epub ahead of print] Modified mandibular advancement appliance for an edentulous obstructive sleep apnea patient: A clinical report. Nelogi S, Porwal A, Naveen H. Department of Prosthetic Dentistry, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India.
16. J Oral Maxillofac Surg. 2010 Oct;68(10):2431-6. Epub 2010 Jul 21. Effects of mandibular retropositioning, with or without maxillary advancement, on the oro-naso-pharyngeal airway and development of sleep-related breathing disorders. Demetriades N, Chang DJ, Laskarides C, Papageorge M. Department of Oral and Maxillofacial Surgery, Tufts University School of Dental Medicine, Boston, MA 02111, USA. firstname.lastname@example.org
17. Indian J Med Res. 2010 Feb;131:267-76. Surgical treatment of snoring & obstructive sleep apnoea. Ephros HD, Madani M, Yalamanchili SC. Oral & Maxillofacial Surgery & Department of Dentistry, St Joseph’s Regional Medical Center, Paterson, NJ, USA.
18. Ann Acad Med Singapore. 2008 Aug;37(8):677-82. Effect of orthognathic surgery on the posterior airway space (PAS). Lye KW. Department of Oral & Maxillofacial Surgery, National Dental Centre, Singapore. email@example.com
19. J Craniofac Surg. 2007 Jul;18(4):902-11. Surgical orthognathic management of sleep apnea. Schendel SA, Powell NB. Stanford University Medical Center, Stanford, California, USA. firstname.lastname@example.org
20. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001004. Surgery for obstructive sleep apnoea. Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Norfolk & Norwich University Hospital, Norwich, Norfolk, UK. email@example.com
21. J Craniofac Surg. 2005 Sep;16(5):770-7. Retrospective study of 18 patients treated by maxillomandibular advancement with adjunctive procedures for obstructive sleep apnea syndrome. Smatt Y, Ferri J. Department of Stomatology and Maxillofacial Surgery, Centre Hospitalier Universitaire de Lille, Lille, France. firstname.lastname@example.org
22. Ned Tijdschr Geneeskd. 2005 May 28;149(22):1223-6. [Obstructive sleep-apnoea syndrome: good results with maxillo-mandibular osteotomy after failure of conservative therapy]. [Article in Dutch] Rosenberg AJ, Damen GW, Schreuder KE, Leverstein H. Afd. Mondziekten, Kaak- en Aangezichtschirurgie, Universitair Medisch Centrum Utrecht, Postbus 85.500, 3508 GA Utrecht. email@example.com
23. Ned Tijdschr Tandheelkd. 2004 Jul;111(7):287-90. [Treatment of snoring and sleep apnea. Maxillo-mandibular advancement osteotomy]. [Article in Dutch] de Lange J, de Graaf J, Veldhuijzen van Zanten L, Waalkens HA. Afdeling Mondziekten en Kaakchirurgie, Isala Klinieken, Zwolle. firstname.lastname@example.org
24. J Craniofac Surg. 2002 Mar;13(2):298-302. Le Fort III distraction osteogenesis of midface-retrusion in a case of Hajdu Cheny syndrome. Satoh K, Tsutsumi K, Tosa Y, Mikawa M, Hosaka Y. Department of Plastic and Reconstructive Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan.
25. Laryngoscope. 1999 Jul;109(7 Pt 1):1045-50. Cosmetic enhancement associated with surgery for obstructive sleep apnea. Terris DJ. Stanford University Medical Center, Division of Otolaryngology/Head and Neck Surgery, California 94305-5328, USA. email@example.com
26. Int J Adult Orthodon Orthognath Surg. 1998;13(4):289-98. Anterior-inferior mandibular osteotomy in treatment of obstructive sleep apnea syndrome. Krekmanov L, Andersson L, Ringqvist M, Wilhelmsson B, Walker-Engström ML, Tegelberg A, Ringqvist I. Department of Oral and Maxillofacial Surgery, Specialist Centrum of Folktandvården, Västerås, Sweden.
27. HNO. 2010 Dec;58(12):1184-9. [Tongue fixation system for therapy of sleeping disorders. A feasibility study]. [Article in German] Punke C, Schöntag C, Hortian B, Behrend D, Hingst V, von Schwanewede H, Pau HW. Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf und Halschirurgie Otto Körner, Universität Rostock. firstname.lastname@example.org
28. Clin Otolaryngol. 2010 Jun;35(3):204-9. Randomised cross-over study of oral appliances for snoring. Maguire J, Steele JG, Gibson GJ, Wilson JA, Steen N, McCracken GI. School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK.
30. Indian J Dent Res. 2010 Jan-Mar;21(1):44-8. Four novel prosthodontic methods for managing upper airway resistance syndrome: an investigative analysis revealing the efficacy of the new nasopharyngeal aperture guard appliance. Venkat R, Gopichander N, Vasantakumar M. Department of Prosthodontics, SRM Dental College, Bharathy Saalai, Ramapuram, Chennai 600 089, India.
31. Am J Orthod Dentofacial Orthop. 2010 Apr;137(4):548-51. Oral appliance treatment for obstructive sleep apnea in a partly edentulous patient. Giannasi LC, Magini M, Costa MS, Oliveira CS, Oliveira LV. Rehabilitation Sciences Master’s Program-Nove de Julho University, São Paulo-SP, Brazil. email@example.com
32. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 May;109(5):724-31. Epub 2010 Mar 17. Treatment outcomes of mandibular advancement devices in positional and nonpositional OSA patients. Chung JW, Enciso R, Levendowski DJ, Morgan TD, Westbrook PR, Clark GT. Department of Oral Medicine and Oral Diagnosis, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea.
33. Brain Nerve. 2010 Jan;62(1):85-8. [Case of exploding head syndrome]. [Article in Japanese] Okura M, Taniguchi M, Muraki H, Sugita H, Ohi M. Sleep Medical Center, Osaka Kaisei Hospital, 1-6-10 Miyahara, Yodogawa-ku, Osaka-city 532-0003, Japan.
34. J Clin Sleep Med. 2009 Oct 15;5(5):431-8. The tongue-retaining device: efficacy and side effects in obstructive sleep apnea syndrome. Lazard DS, Blumen M, Lévy P, Chauvin P, Fragny D, Buchet I, Chabolle F. Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d’ORL et de Chirurgie Cervico-Faciale, Clichy, France. firstname.lastname@example.org
35. Oral Maxillofac Surg Clin North Am. 2009 Nov;21(4):413-20. Principles of oral appliance therapy for the management of snoring and sleep disordered breathing. Almeida FR, Lowe AA. Department of Oral Biological and Medical Sciences, The University of British Columbia, 2199 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada. email@example.com
37. Angle Orthod. 2010 Jan;80(1):30-6. Five years of sleep apnea treatment with a mandibular advancement device. Side effects and technical complications. Martínez-Gomis J, Willaert E, Nogues L, Pascual M, Somoza M, Monasterio C. Department of Prosthodontics, Faculty of Dentistry, University of Barcelona, Campus de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain. firstname.lastname@example.org
38. Sleep Breath. 2010 Sep;14(3):227-32. Epub 2009 Oct 11. Side effects of boil and bite type oral appliance therapy in sleep apnea patients. Tsuda H, Almeida FR, Masumi S, Lowe AA. Department of Oral Health Sciences, The University of British Columbia, Vancouver, BC, Canada. email@example.com
39. Int J Prosthodont. 2009 May-Jun;22(3):251-9. Effect of an adjustable mandibular advancement appliance on sleep bruxism: a crossover sleep laboratory study. Landry-Schönbeck A, de Grandmont P, Rompré PH, Lavigne GJ. Department of Prosthodontics, Faculty of Dental Medicine, Université de Montréal, Canada.
40. Clin Oral Investig. 2010 Jun;14(3):339-45. Epub 2009 Jun 18. Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea. Aarab G, Lobbezoo F, Hamburger HL, Naeije M. Department of Oral Function, Academic Centre for Dentistry Amsterdam ACTA, University of Amsterdam and VU University Amsterdam, Louwesweg 1, 1066 EA Amsterdam, The Netherlands. firstname.lastname@example.org
42. Sleep Breath. 2010 Nov 14. [Epub ahead of print] Socio-demographic characteristics, health behaviour, co-morbidity and accidents in snorers: a population survey. Torzsa P, Keszei A, Kalabay L, Vamos EP, Zoller R, Mucsi I, Novak M, Kopp MS. Department of Family Medicine, Semmelweis University, Budapest, Hungary.
44. Eur Arch Otorhinolaryngol. 2010 Jul;267(7):1147-56. Epub 2009 Dec 1. The influence of nocturnal alcohol ingestion on snoring. Riemann R, Volk R, Müller A, Herzog M. Department of Otorhinolaryngology and Plastic Facial Surgery, Städtische Kliniken Frankfurt a. M.-Höchst, Gotenstr. 6-8, 65929 Frankfurt am Main, Germany. email@example.com
45. Laryngoscope. 2009 Aug;119(8):1617-20. Radiofrequency-assisted uvulopalatoplasty for snoring: Long-term follow-up. Stuck BA. Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany. firstname.lastname@example.org
46. Laryngoscope. 2009 May;119(5):1000-4. Do palatal implants really reduce snoring in long-term follow-up? Saylam G, Korkmaz H, Firat H, Tatar EC, Ozdek A, Ardic S. ENT Department, Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey. email@example.com
47. Acta Otolaryngol. 2003 Jun;123(5):648-54. Nasal obstruction and sleep-disordered breathing: the effect of supine body position on nasal measurements in snorers. Virkkula P, Maasilta P, Hytönen M, Salmi T, Malmberg H. Department of Otorhinolaryngology–Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland. firstname.lastname@example.org
48. J Clin Sleep Med. 2010 Apr 15;6(2):117-23. Pharmacological treatment of obstructive sleep apnea with a combination of pseudoephedrine and domperidone. Larrain A, Kapur VK, Gooley TA, Pope CE 2nd. Clinica Servet, Santiago, Chile.
49. J Clin Sleep Med. 2006 Jan 15;2(1):21-5. Treatment of severe snoring with a combination of pseudoephedrine sulfate and domperidone. Larrain A, Hudson M, Dominitz JA, Pope CE 2nd. Clinica Servet, Santiago, Chile.
50. J Laryngol Otol. 2006 May;120(5):381-4. Ear protection as a treatment for disruptive snoring: do ear plugs really work? Robertson S, Loughran S, MacKenzie K. Glasgow Royal Infirmary, Scotland. Stuart@Glasgow.org
51. Sleep. 2008 Jun 1;31(6):801-7. Heavy snoring is a risk factor for case fatality and poor short-term prognosis after a first acute myocardial infarction. Janszky I, Ljung R, Rohani M, Hallqvist J. Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. email@example.com
52. J Sex Med. 2008 Apr;5(4):898-908. Epub 2007 Dec 17. Snoring as a risk factor for sexual dysfunction in community men. Hanak V, Jacobson DJ, McGree ME, Sauver JS, Lieber MM, Olson EJ, Somers VK, Gades NM, Jacobsen SJ. Mayo Clinic-Pulmonary and Critical Care Medicine, Rochester, MN, USA.
53. Stroke. 2008 Dec;39(12):3185-92. Epub 2008 Jul 17. Sleep duration and risk of ischemic stroke in postmenopausal women. Chen JC, Brunner RL, Ren H, Wassertheil-Smoller S, Larson JC, Levine DW, Allison M, Naughton MJ, Stefanick ML. Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill, NC 27599-7435, USA. firstname.lastname@example.org
54. Chest. 2005 May;127(5):1658-66. Predictors of heartburn during sleep in a large prospective cohort study. Fass R, Quan SF, O’Connor GT, Ervin A, Iber C. Section of Gastroenterology, Department of Medicine, Arizona Respiratory Center, University of Arizona College of Medicine, Tucson, AZ, USA. Ronnie.Fass@med.Va.gov <Ronnie.Fass@med.Va.gov>
55. J Am Dent Assoc. 2010 Mar;141(3):297-9. Transient morning headache: recognizing the role of sleep bruxism and sleep-disordered breathing. Lavigne G, Palla S. Faculté de Médicine Dentaire, Université de Montréal, Montréal, Québec H3C3J7, Canada. email@example.com
56. J Sleep Res. 2006 Sep;15(3):317-20. Dry mouth upon awakening in obstructive sleep apnea. Oksenberg A, Froom P, Melamed S. Sleep Disorders Unit, Loewenstein Hospital Rehabilitation Center, Raanana, Israel. firstname.lastname@example.org
57. Med Clin North Am. 2010 Sep;94(5):1047-55. Snoring and obstructive sleep apnea. Ulualp SO. Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9035, USA. email@example.com
58. Pediatr Dent. 2007 May-Jun;29(3):193-200. Sleep disordered breathing in infants and children: a review of the literature. Ivanhoe JR, Lefebvre CA, Stockstill JW. Department of Oral Rehabilitation, School of Dentistry, Medical College of Georgia, Augusta, Ga, USA. firstname.lastname@example.org
59. Eur J Med Res. 2010 Nov 4;15 Suppl 2:152-6. Obstructive sleep apnea and type 2 diabetes. Rasche K, Keller T, Tautz B, Hader C, Hergenc G, Antosiewicz J, Di Giulio C, Pokorski M. HELIOS Klinikum Wuppertal, Klinikum der Privaten Universität Witten/Herdecke, Wuppertal, Germany. email@example.com
62. Zhonghua Jie He He Hu Xi Za Zhi. 2010 May;33(5):344-9. [The influence of chronic intermittent hypoxia on insulin function in OSAHS patients]. [Article in Chinese] Xu CM, Zhu YH, Wang S, Huang JA. Department of Respiratory, the First Hospital Affiliated to Suzhou University, Suzhou 215006, China.
63. Int J Prosthodont. 2010 Nov-Dec;23(6):503-6. Questionnaire-based study on sleep-disordered breathing among edentulous subjects in a university oral health center. Tsuda H, Almeida FR, Walton JN, Lowe AA. Department of Oral Health Sciences, University of British Columbia, Vancouver, BC, Canada. firstname.lastname@example.org
64. Angle Orthod. 2010 Mar;80(2):267-74. A comparison study of upper airway among different skeletal craniofacial patterns in nonsnoring Chinese children. Zhong Z, Tang Z, Gao X, Zeng XL. Department of Orthodontics, School and Hospital of Stomatology, Peking University, Beijing, People’s Republic of China.
65. Pediatr Pulmonol. 2010 Mar;45(3):275-80. Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood. Kaditis AG, Kalampouka E, Hatzinikolaou S, Lianou L, Papaefthimiou M, Gartagani-Panagiotopoulou P, Zintzaras E, Chrousos G. First University Department of Pediatrics, Aghia Sophia Children’s Hospital, Thivon and Papadiamantopoulou St., Athens 11527, Greece. email@example.com
66. Clin Exp Otorhinolaryngol. 2010 Sep;3(3):141-6. Epub 2010 Sep 17. The effect of uvula-preserving palatopharyngoplasty in obstructive sleep apnea on globus sense and positional dependency. Kwon M, Jang YJ, Lee BJ, Chung YS. Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
67. BMJ. 2006 Feb 4;332(7536):266-70. Epub 2005 Dec 23. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. Puhan MA, Suarez A, Lo Cascio C, Zahn A, Heitz M, Braendli O. Horten Centre, University of Zurich, 8091 Zurich, Switzerland.
68. Sleep Med. 2009 Jun;10(6):657-60. Epub 2008 Nov 17. Risk of sleep apnea in orchestra members. Brown DL, Zahuranec DB, Majersik JJ, Wren PA, Gruis KL, Zupancic M, Lisabeth LD. Stroke Program, University of Michigan Medical School, The Cardiovascular Center – Stroke Program, 1500 E. Medical Center Drive – SPC#5855, Ann Arbor, MI 48109-5855, USA. firstname.lastname@example.org
69. Pneumologie. 2008 Feb;62(2):83-7. Epub 2007 Dec 13. [Pneumological aspects of wind instrument performance–physiological, pathophysiological and therapeutic considerations]. [Article in German] Kreuter M, Kreuter C, Herth F. Innere Medizin/Pneumologie und Beatmungsmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Heidelberg. email@example.com
70. Sleep Breath. 2008 Aug;12(3):265-8. Epub 2008 Jan 8. The effect of singing on snoring and daytime somnolence. Pai I, Lo S, Wolf D, Kajieker A. Department of Otorhinolaryngology-Head and Neck Surgery, St. George’s Hospital, Blackshaw Road, London, SW17 0QT, UK. firstname.lastname@example.org
71. Rev Mal Respir. 2000 Apr;17(2):467-74. [Results of 248 patients with sleep apnea syndrome treated by continuous positive pressure ventilation between 1990 and 1995. A study of compliance and outcome of the apnea-hypopnea index]. [Article in French] Lacassagne L, Didier A, Doussau S, Murris-Espin M, Birot P, Charlet JP, Thach KS, Tiberge M, Paoli JR, Pessey JJ, Léophonte P. Service de Pneumologie et Allergologie, CHR Rangueil, Toulouse.
72. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. Milo A Puhan, research fellow, Alex Suarez, didgeridoo instructor, Christian Lo Cascio, resident in internal medicine, Alfred Zahn, sleep laboratory technician, Markus Heitz, specialist in respiratory and sleep medicine, Otto Braendli, specialist in respiratory and sleep medicine(email@example.com)
80. Xue, Steve & Hao, Grace Jianping Changes in the Human Vocal Tract Due to Aging and the Acoustic Correlates of Speech Production. Journal of Speech, Language and Hearing Research Vol.46 689-701 June 2003. doi:10.1044/1092-4388(2003/054)apnea, causes, Dental, obstructive, sleep, snoring, treatment