Living with Sleep Apnea: Long-Term Management Tips

[Eon Engelbrecht E-Radio-SA] (0:04 – 0:32)

And as always, I’m joined by Dr Clifford Yudelman from OptiSmile, and we are ready to take a deep dive into the world of dental care from a consumer’s perspective. And now, for today, it is part three of the sleep apnoea and snoring series, so to speak, and I’m going to let Dr Yudelman introduce us to the topic there. Dr Yudelman, hello, welcome back.

[Dr Clifford Yudelman OptiSmile] (0:32 – 1:02)

Hi, Eon, great to be back. Thank you very much. And if someone’s listening to this for the first time, I do recommend you go back and listen to the previous two podcasts where we introduce, talk about what the difference is between sleep apnoea and snoring and so on.

And today is about living with sleep apnoea, long-term management and the better path to sleep. And we’ve got some great questions, so fire away.

[Eon Engelbrecht E-Radio-SA] (1:03 – 1:10)

So, Dr Yudelman, once diagnosed with sleep apnoea, what lifestyle changes can help improve symptoms?

[Dr Clifford Yudelman OptiSmile] (1:11 – 2:16)

So we get a lot of patients that report that they snore or have a lot of apnoea when they drink, for some reason, especially red wine. Also, if they take sedatives or antihistamines—if they have a lot of hay fever, the antihistamines can knock you out and your airway relaxes. Avoiding alcohol and sedatives before bedtime can maybe keep your airway more stable.

Establishing a regular sleep routine and improving sleep hygiene—there’s a lot of information about that, I think too much for us to cover here—but things like not watching TV or going on your phone close to bedtime, keeping the room nice and cool with lots of fresh air and no lights, so having the room nice and dark.

All of these things will help you get a better night’s sleep so that the next night you’re not also on your back and your throat is closing or your tongue is falling in the back of your throat, stuff like that.

[Eon Engelbrecht E-Radio-SA] (2:17 – 2:26)

Okay, and then the question I’ve been meaning to ask you is, can losing weight or maybe changing your sleep positions reduce snoring or sleep apnoea?

[Dr Clifford Yudelman OptiSmile] (2:26 – 4:43)

Yeah, so definitely losing weight—even 5 or 10 kgs in some cases—can actually get rid of snoring, especially if you’re not very overweight. When you lose 5 kgs, funnily enough, they’ve done research—the tongue loses a lot of fat, the tongue gets smaller. But when you lose weight, it also reduces the fat around your neck and your throat, and that really helps open up the airways and it also reduces severity. So if you’ve got severe sleep apnoea and you lose weight and you keep it off, it can reduce it to a moderate, which means that you can go off a CPAP and get on a mandibular advancement splint.

And like I said, even a modest reduction can improve symptoms. The other one is positional therapy. There is sleep apnoea that people get only when they’re on their back, and sleeping on their side can sort it out.

There are devices you can buy online like a little shark fin or like a backpack that, when it’s on your back, you can’t roll onto your back. The other trick is sewing a tennis ball or something similar into a T-shirt and wearing that. So when you’re on your back, it kind of digs into your back and you’re not lying flat on your back.

And there’s also special pillows that are made to sort of keep you on your side. There’s like a body pillow that you can hug, things like that. I’ve seen also devices being sold similar to, like a dog that when it barks, it beeps and it buzzes, it wakes you up.

There was a device that you put on your forehead, like a sweatband; on your back, it would buzz lightly, not enough to wake you up. But as soon as you rolled on your side, the thing stopped vibrating, and so it just made sure you were sleeping on your side. But the home sleep study doesn’t actually check position, unfortunately.

I mean, I think they could include it, but it only checks a certain number of things. But when you do a hospital sleep study, they tell you how many apnoeas you were having on your back or how many you were having when you’re on your side or your left or your right. Do you have more questions there?

Absolutely.

[Eon Engelbrecht E-Radio-SA] (4:43 – 4:52)

Quite a few, in fact. But let’s start with this one. What is the success rate of long-term treatment with oral appliances for sleep apnoea?

[Dr Clifford Yudelman OptiSmile] (4:53 – 6:43)

So we don’t promise everyone we’re going to cure them 100%. But research has shown, and in my experience, oral appliances are highly effective for patients with mild to moderate sleep apnoea with success rates up to 75%. We do get patients that we make these devices for that we need to adjust them a few times and they need to get used to having their jaw more forward.

It’s very rare that I have a patient that says, “This was the biggest waste of money. I hate you. Give me my money back.”

People tend to love these things. Compliance is much higher with oral appliances compared to a CPAP because, like we said, they’re more comfortable and more portable. And long-term success depends on regular follow-ups and adjustments.

Sometimes a patient that’s been wearing a device for two or three years may need the jaw pulled even further forward, especially if they put on weight. I did recently have an older patient. I made him a device in 2017.

Even though the OptiSleep company warranties their devices for two years—they recommend you change it every two years—it is quite pricey. And this guy, he had one made in 2017 and it worked really well for him up until earlier this year when he injured his knee, and his main exercise to keep his weight off was walking, and he put on a lot of weight quite rapidly, and his jaw was already quite forward. So 2017 to now, he’d been wearing it for nearly, what’s that, eight… still fit and everything, but it wasn’t working because he put on a huge amount of weight.

And I told him to have another sleep study. I wasn’t going to just make him another device, and he’s now on a CPAP. So that’s sort of the reverse of what we were talking about.

[Eon Engelbrecht E-Radio-SA] (6:44 – 6:51)

Okay. And how often should someone with sleep apnoea follow up with their dentist for treatment adjustments?

[Dr Clifford Yudelman OptiSmile] (6:52 – 7:16)

Yeah. So we see patients after two weeks and then as needed. Usually we don’t see them again, but we do recommend they come in once a year.

It’s a little bit through alignment or their bite has changed, but we don’t tend to see that. If for some reason their symptoms get worse or change, then they should come back to the dentist and see what’s going on. Yeah, that’s about it for that question.

[Eon Engelbrecht E-Radio-SA] (7:17 – 7:24)

Okay. And then what should patients do if they don’t see improvements after starting treatment?

[Dr Clifford Yudelman OptiSmile] (7:24 – 8:43)

So there are these over-the-counter devices that may work if you try them just for a few days. They boil and bite like a homemade mouthguard. Sometimes Melissa may recommend or give one to a patient just to try so that they can know that this device has some promise and they can work just for short term.

But those are the ones that are implicated in moving your teeth or messing up your jaw. If they don’t see improvements after starting treatment, they should definitely come back and check that the device is fitting properly. There are some dodgy devices that some dentists get their labs to make and they haven’t made many of these things.

And it’s a fixed device that just randomly places the jaw forward. There’s no hinges or any kind of movement allowed, and then they’re just kind of winging it. So those can cause jaw problems if the lab or the dentist doesn’t have the experience.

Losing weight, lifestyle changes, avoiding sedatives—things that we said earlier. And then a repeat sleep study to check the severity. Maybe the patient’s sleep apnoea, for one reason or another, has got a lot worse and the mandibular advancement splint is no longer recommended.

They need a CPAP at this point.

[Eon Engelbrecht E-Radio-SA] (8:44 – 8:49)

Okay. And can sleep apnoea actually be cured or is it a lifelong condition?

[Dr Clifford Yudelman OptiSmile] (8:49 – 11:30)

Yeah. So mild cases, and especially those that are linked to weight, can definitely be cured where you don’t need any device—you just lose the weight.

I have been working with a breathing coach, and I’m looking into things like mouth taping. In fact, I’ve got some Myo tape sitting on my desk right here. It’s kind of like a physio tape that you wear around your mouth, and it stops you from mouth breathing.

And there’s things like slow breathing and diaphragmatic nasal breathing exercises one can do, but I don’t know enough about it yet. Yeah. I would love to be able to sleep without apnoea and snoring and with no CPAP and no device.

So look, for most people, sleep apnoea is a chronic condition and it generally only gets worse with age, especially if you don’t control it, because when you have sleep apnoea, especially as a male, you’re not getting enough sleep at night. So the reason why I mention male is you make testosterone at night when you go into deep sleep, and the sleep apnoea keeps waking you up and you don’t make enough testosterone, and it’s a bit of a downward spiral. You then get metabolic syndrome, you put on weight around your waist, and that messes up your testosterone further, and you start getting glucose intolerance—insulin resistance, should I say—and your glucose goes up, pre-diabetic, heart disease, all of those things.

So one has to take this seriously. It’s not just about snoring. Yeah.

Some people try surgical intervention, but there’s very little that can be done surgically. I don’t think I’ll get into it here, but that’s definitely a very last resort, if at all, unless you have radical jaw surgery, which means moving your whole jaw forward. If you’ve got a very small jaw and you need that for aesthetic or orthodontic reasons—it’s called retrognathia, like a very underdeveloped jaw—in those cases, the surgery may be recommended for that, and then it could help sleep apnoea.

But definitely very radical to go and do surgery when something like a mandibular advancement splint or a CPAP would work. Getting your soft palate cut or your tongue lasered, things like that, I’ve not seen great research, and I’ve actually seen patients come after those types of surgeries with all kinds of problems.

[Eon Engelbrecht E-Radio-SA] (11:31 – 11:40)

Okay. And doctor, what happens if a dental appliance no longer works or the sleep apnoea worsens over time?

[Dr Clifford Yudelman OptiSmile] (11:40 – 12:48)

Yeah. So like I said, in severe cases, a CPAP may become necessary. If the device is no longer effective, maybe it doesn’t fit or maybe the dentist can adjust it.

It should be titratable, meaning that there’s room to move it forward by putting on a shorter—in the case of the OptiSleep—a shorter nylon connector. Sometimes if it’s been several years, you may need a new device or switching to a different type of device. There are literally hundreds of internationally patented devices and then a few South African ones.

So if one device doesn’t work for you, a different one may work. I’ve had patients who made a device and for one reason or another it didn’t work or they didn’t like it, and I’ve gone ahead and made them a different device at no further charge. I’ve just eaten all the costs myself just to make the patient happy.

But yeah, it does progress over time. So regular check-ups and making sure that you monitor it is very important.

[Eon Engelbrecht E-Radio-SA] (12:48 – 12:57)

Okay. And let’s say the oral appliances aren’t enough. Are there any dental or surgical alternatives that we can look at?

[Dr Clifford Yudelman OptiSmile] (12:57 – 15:23)

So the surgery that I spoke about—the short term for it is a UPPP, and I’ll try and pronounce it the first time properly. It’s a uvula—so that’s your uvula—palate—that’s your palate—pharyngeal—that’s your throat—and then the word is plasty, which means plastic surgery.

So uvulopalatopharyngoplasty, or a UPPP, removes excess tissue from the throat. That’s the one that I said a lot of ENTs overseas and maybe even in South Africa, if you see an ENT, they’ll straighten your nose and they’ll do that. And I can almost guarantee you’ll still end up with a mandibular advancement splint or a CPAP.

There’s not a lot of—except in very specific cases. So I don’t want to upset too many ENTs and just throw it out as a blanket statement and be unprofessional, but certainly not the first go-to. And then the other options that I mentioned, this maxillomandibular or bimaxillary, which is basically your upper jaw and your lower jaw.

And you position all the jaws forward. It’s a hectic surgery. It can take months and months, if not a year, to recover.

And that sometimes is done. They’re a lot more gung-ho with that overseas and in the States, especially if your insurance covers it—they’ll do anything on you over there. I lived there 16 years.

And then there are new devices, which I’m looking forward to perhaps even getting one myself. There’s something called Inspire, which is a surgically implanted device which somehow stimulates your airway muscles to keep them open. It’s like a pacemaker, but it’s for your muscles and your airway.

It contracts your tongue and it opens your throat. It’s quite radical. I did see a story on LinkedIn the other day about a patient having some device like that, and then some second device getting implanted.

It’s still, I think, in its early days. I’m not sure how successful it is in the States because it’s not available here. I’ve never really looked into it yet, so maybe in the future.

[Eon Engelbrecht E-Radio-SA] (15:24 – 15:32)

Okay. And then how do patients actually maintain their oral health while they’re using these appliances, doctor?

[Dr Clifford Yudelman OptiSmile] (15:33 – 16:25)

Yeah. So regular cleaning of the appliance—make sure you brush it with dish soap and water. You don’t want to use toothpaste on it because that can scratch it and actually make it go a bit cloudy.

Your regular dental check-ups to check your gums and your teeth. You don’t want to lose any teeth or get any cavities. If you get fillings or crowns, your device won’t fit and they are not cheap.

So you really want to try and make it last as long as possible. Yeah. Look, if you use a CPAP, you want to make sure you clean the mask regularly.

If someone has a lot of dry mouth caused by a CPAP, maybe fluoride treatments, but that’s not for this podcast really. Yeah. Look, it’s just part of everyday life.

There’s not a lot you need to do that’s special.

[Eon Engelbrecht E-Radio-SA] (16:26 – 16:36)

Okay. And just one more question before we wrap it up today. What advice would you give to someone who is nervous about starting treatment for sleep apnoea?

[Dr Clifford Yudelman OptiSmile] (16:36 – 19:02)

Yeah. Look, it’s very natural to be nervous just because we’re now in Movember—November—prostate cancer awareness. There are guys that are nervous to get a prostate exam or to do a PSA test.

If you’re over 40, I do recommend going to the doctor and getting the—it’s called a digital rectal exam—and getting your PSA checked. It could save your life. I had prostate cancer five years ago, over five years ago, and I’m 100% cured with no side effects.

Obviously, that’s quite nerve-wracking, but untreated sleep apnoea can also pose very serious health risks, including heart disease, stroke, diabetes, high blood pressure—you name it. If you Google sleep apnoea and health problems, and these are very real. It’s not just to scare people into coming and getting a device or going on a CPAP.

The rate of death from untreated sleep apnoea is right up there. I’m not sure how it compares to, say, prostate cancer or breast cancer or lung cancer, but certainly it’s highly implicated in people with heart disease, strokes, diabetes, and so on. Just starting with a consultation, or you can even go and get your GP to send you straight to Euphoria and Associates in Milnerton, or if you’re in Johannesburg or elsewhere, you have to see a sleep clinic to get a sleep study, whether it’s a home sleep study or a hospital sleep study, find out what your apnoea-hypopnoea index is.

Rather than worrying about how you’re going to treat it, you first need a diagnosis, and then to rest assured that if it is on the moderate to severe and you go on a diet because you know you’ve got to lose a bit of weight and you can get it down to moderate, you can just get a mandibular advancement splint or a MAD—mandibular advancement device. Many patients find once they start treatment, they quickly experience improved sleep. They’ve got more daytime energy.

A lot of people like myself—I went out and started gym and started cycling, and my whole life improved once I went on a CPAP.

[Eon Engelbrecht E-Radio-SA] (19:02 – 19:20)

Wow, that’s fantastic. Thanks for sharing your story as well with us, doctor. And that’s it for another episode of Save Your Money, Save Your Teeth.

It also wraps up the snoring and sleep apnoea series for it. It’s been very interesting. I definitely learnt a lot.

Doctor, thanks so much.

[Dr Clifford Yudelman OptiSmile] (19:20 – 19:36)

Pleasure. Thank you. And like always, I hope this helps people to save their money, save their teeth.

And in the case of something like sleep apnoea, maybe even save your life. So I hope this episode and the previous ones helped.

[Eon Engelbrecht E-Radio-SA] (19:37 – 20:12)

Yeah, great. For sure. And also remember, while we strive to provide valuable insights with these podcasts, always consult with your own medical professional for advice tailored to your personal health.

Then don’t forget to subscribe to the podcast for more enlightening discussions. And join us again next week. We’ve got about two podcasts left for 2024.

And then we’ll continue to explore the fascinating intersection of dental health and financial savvy. Until then, keep smiling and taking great care of your teeth.

[Speaker 3] (20:23 – 21:07)

Discover the world of dental excellence with OptiSmile. Join us for a weekly podcast featuring Dr Clifford Yudelman, a seasoned expert with 40 years of dental experience across four continents. Gain unique insights and expert dental advice by visiting OptiSmile.co.za for articles that illuminate the path to optimal oral health. If you’re seeking unparalleled dental care in Cape Town, get in touch with OptiSmile or book directly online on OptiSmile.co.za. OptiSmile—where global expertise meets local care.