Scientists solver snoring using 3D printing

Notes from Dr. Norman Blumenstock

This oral device is not made in the USA as of yet nor have they applied for FDA approval. The Narval from Res-Med is a 3D printing appliance that I provide as one of many options.

Submitted by Dinesh Chandra Gaur on Wed, 05/07/2014 - 09:34 

The revolutionary 3D printing is now being used by scientists to create mouthpieces made of titanium which will assist snorers to breather much easily when they sleep. People who snore suffer from obstructive sleep apnoea which leads to disrupted sleep.

These mouthpieces work by diverting air around the teeth to the windpipe which is where it is actually required and then bypassing the obstructive mouth tissue which can cause blocking of normal breathing during sleep.


CSIRO's John Barnes says that these can be made especially effective since 3D printing allows to create custom fitted mouthpieces for every patient.

He says that all humans have different faces with different sizes and shapes of jaw. He agrees that it is indeed a revolution that they can now make customised mouthpieces which are any day more effective than any earlier device or therapy.

He says that the patient just needs to bite into it and it fits accurately. These titanium mouthpieces made using 3D printing are coated in medical-grade plastic which looks like a large mouthguards with a small spout which looks like a duckbill which pokes through the lips.

Crystalline Obstructive Sleep Apnea and the Eye

Notes from Dr. Norman Blumenstock

A recent  study by the University of North Carolina, adds ocular diseases to the long list of obstructive sleep apnea associations.

By Matheson A. Harris, MD, Syndee J. Givre, MD, PHD, and Amy M. Fowler, MD
Edited by Ingrid U. Scott, MD, MPH, and Sharon Fekrat, MD

Sleep is something we all need and, especially as physicians, often cherish. While eyelids that are tired and droopy may be one of the first signs to herald sleepiness, sleep disorders such as obstructive sleep apnea (OSA) actually have many ocular sequelae, some of which are vision-threatening. It is important for ophthalmologists to understand and identify sleep disorders—especially OSA—and their ocular associations, as these can occasionally be the source of unusual and often perplexing conditions.

About OSA

The increasing prevalence of obesity in our society has been associated with an upsurge in OSA, a disease that results in the cessation of breathing during sleep for 10 seconds or longer due to partial or complete obstruction of the upper airway. It is estimated that as many as 24 percent of Caucasian men and 9 percent of Caucasian women in the United States have OSA, though many of these cases remain undiagnosed.¹

Taking a good sleep history is the key to diagnosis and includes questions about day- and nighttime symptoms, specific obstructive breathing symptoms, and medical history of conditions associated with increased risk of OSA. Common daytime symptoms include sleepiness, difficulties with concentration and memory, and depression. Patients may also experience decreased productivity, anxiety, gastroesophageal reflux and sexual dysfunction. Nighttime symptoms include insomnia, frequent awakenings, and nocturia. Obstructive symptoms include loud snoring, choking and gasping, and witnessed apneas, which may be reported only by the patient’s bed partner. As patients age, the classic history of obesity, snoring and witnessed apneas is less common, and a careful history of sleep disturbances may be more revealing. Additional examination findings include increased neck circumference, tonsillar hypertrophy, enlarged soft palate, retrognathia and lower extremity edema.

Conditions associated with increased risk of OSA include positive family history of the disease, hypertension, diabetes, pulmonary hypertension, menopause and increased alcohol use. OSA patients also have an increased risk of automobile accidents as well as a higher risk of heart failure, stroke and death. Numerous ocular disorders have been found to be more prevalent in patients with OSA, including floppy eyelid syndrome, glaucoma, nonarteritic anterior ischemic optic neuropathy and papilledema with raised intracranial pressure.

Floppy Eyelid Syndrome

Floppy eyelid syndrome (FES) is probably the most common ocular disorder that has been associated with OSA. It is characterized by rubbery, redundant upper eyelid tissue and papillary conjunctivitis, and is seen most commonly in obese middle-aged men.²

The affected eyelid may correspond to the side on which the patient prefers to sleep. The etiology is uncertain, but current theories include an upregulation of elastin-degrading matrix metalloproteinases possibly caused by direct eyelid trauma, ischemia-reperfusion injury due to pressure placed on the eyelid, or low arterial oxygen tension during sleep.

When FES is severe, the eyelid may spontaneously evert during sleep and rub on the patient’s pillow, causing an acute exacerbation of mechanically induced conjunctivitis.

When a thumb is placed on the lateral upper eyelid and traction is applied, a striking laxity will be found and the eyelid will easily evert. These patients typically present with eye irritation, tearing and blurred vision, all of which are worse upon awakening. Examination findings may include beefy, red, palpebral conjunctiva with velvety papillary changes, diffuse punctate keratopathy, eyelid and eyelash ptosis, and loss of eyelash parallelism. As many as 10 percent of patients may have associated keratoconus.³

While the prevalence of OSA in patients with FES has been reported to be as high as 90 percent, only 2 to 5 percent of patients with OSA may have FES.⁴ Thus, it is impractical to screen all patients with OSA for FES. However, all patients with FES who do not have an established diagnosis of OSA should have a thorough sleep history taken and, when appropriate, should be referred for sleep evaluation including polysomnography.

Treatment of FES initially involves the use of lubricating eye drops and ointment, in addition to preventing mechanical injury during sleep by taping of the eyelid or use of an eye shield. Patients with FES and OSA who are already being treated with continuous positive airway pressure (CPAP) need to have their masks properly fitted to avoid additional eye injury due to misdirected air further drying out the eyes. Surgical treatment includes a full-thickness tarsal wedge resection, usually pentagonal in shape, or horizontal eyelid tightening with a traditional lateral tarsal strip procedure.

Common OSA Signs and Symptoms

Daytime Symptoms Excessive sleepiness Morning headache Difficulty with concentration/memory Depression Nighttime Symptoms Loud snoring/gasping Witnessed apneas Insomnia Frequent awakenings Nocturia Signs Obesity Increased neck circumference Enlarged soft palate/tonsils Retrognathia Lower extremity edema

Glaucoma

The link between glaucoma and OSA is controversial. Most studies have shown a higher prevalence of both primary open-angle glaucoma and normal- tension glaucoma among patients with OSA, with one study showing a prevalence as high as 27 percent.⁵ Several small studies have identified OSA in patients with glaucomatous optic disc cupping and associated visual field defects who do not respond to medical or surgical IOP-lowering treatments, but whose visual fields stabilize when treated with CPAP. One Chinese study showed that patients with OSA were four times more likely to have glaucomatous optic disc changes and visual field defects than age-matched controls.⁶ The higher rate of normal-tension glaucoma among patients with OSA strongly indicates the two are correlated.

Several theories have been used to link OSA to glaucoma, one of which is that optic nerve head (ONH) damage is caused by apnea-induced ischemia. This would explain the lack of IOP elevation and family history of glaucoma in most persons affected with OSA. In addition, the vascular endothelium of the ONH vessels has been shown to function poorly in those with sleep- disordered breathing, which can lead to poor autoregulation of ONH blood flow and further ischemic damage. This is especially important at night when nocturnal fluctuations in systolic blood pressure are poorly compensated.

Current evidence suggests that at the very least a sleep history should be elicited from any patient diagnosed with normal-tension glaucoma who either has none of the classic risk factors for glaucoma or who has failed medical and surgical therapy. Also, it is important to confirm that persons with OSA and suspected or documented glaucoma are being treated adequately for OSA.

Other Optic Nerve Pathology

Nonarteritic anterior ischemic optic neuropathy. Multiple studies have shown that the incidence of OSA is higher in patients with NAION than in the general, age-matched population. In fact, NAION is more commonly associated with OSA than it is with diabetes or hypertension. It has been suggested that patients with NAION be questioned about their sleep habits. One research group that did this elicited a history of OSA 2.5 times more often in patients with NAION than in controls.⁷

Papilledema. Also associated with OSA, papilledema is thought to be caused by nocturnal increases in intracranial pressure. Potential mechanisms include raised venous pressure due to forced inspiration against a closed airway or hypercapnia-induced cerebral venous dilation.

When neuroimaging is normal, a careful sleep history in a patient with papilledema is critical in order to determine whether OSA is a causative factor. In such patients, treatment of the OSA has been shown to improve or resolve the papilledema.

Conclusion

Because OSA is associated with sight-threatening disorders in addition to systemic conditions with significant associated morbidity and mortality, we as ophthalmologists cannot afford to miss the diagnosis of a sleep disorder. Asking a few simple questions about your patient’s sleep habits may be the difference between making a sight-saving diagnosis or just looking like you’re asleep on the job.

Is snoring ruining your sex life?

Notes from Dr. Norman Blumenstock
Going on vacation can get expensive if you need two rooms.

DONALD M. SESSO, D.O., FOR PHILLY.COM/HEALTH

POSTED: Wednesday, April 30, 2014, 4:34 AM

Are you sleeping in a different room because your partner is snoring? If you are, you’re not alone. The New York Times reports that 25% of couples sleep in separate rooms due to snoring and that 60% of custom homes will be constructed with dual master bedrooms by 2015.

While partners of snorers reported better sleep when sleeping alone, the majority also stated that the arrangement had a negative impact on their relationship.

When couples sleep apart, one of the first things to suffer is their sex life. Moreover, Tina B. Tessina, Ph.D. (aka "Dr. Romance"), a psychotherapist and author of Money, Sex and Kids: Stop Fighting About the Three Things That Can Ruin Your Marriage, confirms that "sleeping apart can contribute to the disconnect that plagues marriage and relationships." Instead of spontaneous interaction, couples have to make a planned effort to meet up. Over time, the loss of sexual activity can lead to a lack of intimacy and bonding.

Spending time in bed together is crucial for couples because it is devoid of the distractions of work, children and obligations. In addition to sex, couples cuddle, touch, and chat, which is an important part of the bonding process that holds relationships together.

Without private time, couples may only interact with each other when dealing with daily activities, which makes them more housemates than intimate partners. This lack of bonding inevitably leads to one feeling distant from the other. Furthermore, getting accustomed to not having sex can reduce the sex drive in both partners.

To avoid the untimely death of your sex life, have your partner’s snoring treated. Doing so will not only improve your relationship but also address sleep apnea, which affects almost 30% of snorers.

Sleep apnea is a medical condition that causes interrupted breathing and a lack of oxygen to vital organs. As you can imagine, sleep apnea can pose serious health risks such as heart disease and stroke which may physically limit people from having sex. In addition, research has shown a strong link between sleep apnea and erectile dysfunction. Men can suffer from reduced testosterone production as a result which may, in turn, cause impotence. Men are not alone. A study performed by the International Society for Sexual Medicine found that women with sleep apnea were also at significant risk of serious sexual dysfunction and decreased libido.

Snoring also takes its toll on your bed partner. People who sleep next to loud snorers report high levels of fatigue, stress, sleepiness, a lower quality of life, and an increased risk of depression due to interrupted sleep. This often leads to a lack of physical intimacy, causing many couples to wonder if they should remain together.

The good news is that snoring and sleep apnea are very treatable. In most cases, snoring, fatigue, erectile dysfunction, decreased libido and other health issues that may be preventing sex can be reversed with proper treatment. Talk to a snoring doctor to determine which treatment is best for you.

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Dr. Donald M. Sesso, the Director of The Pennsylvania Snoring and Sleep Institute, is the only triple certified snoring doctor in the tri-state area. He specializes in the surgical treatment of obstructive sleep apnea and sinus disorders and is a Board Certified ENT Otolaryngologist in Head and Neck Surgery, Facial Plastic Surgery, and Sleep Medicine. 

The Comparison of CPAP and OA in Treatment of Patients with OSA

Li W, Xiao L, Hu J.

Respir Care. 2013 Jan 3

A systematic review and meta-analysis was performed to compare the outcomes of oral appliances (OA) with those of continuous positive airway pressure (CPAP) in treatment of patients with obstructive sleep apnea (OSA). Relevant studies were retrieved from the following electronic databases up to and including September of 2012: MEDLINE, PubMed, EMBASE, and Central Register of Controlled Trials. The main variables were epworth sleepiness scale (ESS), health-related quality of life, cognitive performance, blood pressure, apnea and hypopnea index (AHI), arousal Index (AI), minimum saturation (Min SaO2), rapid eye movement sleep, % (REM%), treatment usage, side effects, treatment preference and withdrawals.

Fourteen trials were finally included in this review. The investigators results demonstrated that the effects on ESS, health-related quality of life, cognitive performance, and blood pressure of OA and CPAP were similar. Besides, pooled estimates of cross-over trials suggested a significant difference in favor of CPAP regarding AHI, AI, and Min SaO2, while pooled estimates of parallel-group trials showed a significant difference in favor of CPAP regarding AHI and REM%. Moreover, OA and CPAP yielded fairly similar results in terms of treatment usage, hours/night in cross-over trials and, hours/night, nights/week in parallel-group trials), treatment preference, side effects and withdrawals.

The authors concluded that CPAP yielded better PSG outcomes especially in reducing AHI than OA, indicating that OA was less effective than CPAP in improving sleep disordered breathing. However, similar results from OA and CPAP in terms of clinical and other related outcomes were found, suggesting that it would appear proper to offer OA to patients who are unable or unwilling to persist with CPAP. 

Metro-North to Require Sleep Apnea Evaluation.

Notes from Dr. Norman Blumenstock

Train engineers need to be test now on the Metro North trains.

http://abclocal.go.com/wabc/story?section=news/local/northern_suburbs&id=9512820#

Eyewitness News

NEW YORK (WABC) -- A new Metro-North directive would require the 350 engineers who work for the railway to be evaluated in the coming months for sleep apnea.

Earlier this month, the National Transportation Safety Board revealed that the engineer, William Rockefeller suffered from a severe form of sleep apnea in a derailment late last year. The incident left four people dead and dozens injured.

Mike Doyle, general chairman of the Officials with the Association of Commuter Rail Employees union, told Eyewitness News in a statement that, "recognizing that an undiagnosed sleep disorder likely was a major contributing factor to the tragic accident ... our organization is working with Metro-North to establish a program to help identify engineers who may suffer from the same medical condition."

MTA chief spokesman Adam Lisberg said there are still a lot of questions about the screening and that it will be extended to all safety-sensitive personnel. "We haven't agreed on what to do in the program," he said. "We're working on plans for addressing sleep apnea for critical safety personnel, but have no final plans yet for what we'll do."

Dr. Steven Feinsilver, of Mount Sinai, is an expert on sleep disorders. He applauded the move, but warned that screening for sleep apnea is easier said than done.

Feinsilver said the best testing is an overnight sleep study which can be a "relatively complicated thing to do."

"It's a serious public health problem. It's a common disease," he said.

How Snoring Can Cause Weight Gain

Notes from Dr. Norman Blumenstock

This is true especially if the snoring is related to obstructive sleep apnea.

Dr. Donald M. Sesso, For Philly.com/Health

Posted: Tuesday, April 22, 2014, 4:14 AM

As a sleep specialist, my patients often ask about the relationship between snoring and weight gain. The National Center for Biotechnology Information (NCBI) has demonstrated that obesity is a risk factor for snoring and sleep apnea and that snoring may cause weight gain or the inability to lose weight.

The relationship between snoring and weight gain is linked to alterations in our metabolism, increased appetite and decreased energy expenditure. In other words, snoring and fatigue from interrupted sleep make us hungrier and less active- and both lead to weight gain. It may also explain why some people have difficulty losing weight despite attempts to modify their diets. Bed partners of snorers may be at risk of weight gain, too. If you are not sleeping because of your partner’s snoring, the resulting fatigue may be the reason you’ve become inactive and packed on weight.

Snoring and weight gain should not be ignored as the combination may cause life-threatening health conditions. Fortunately, both can be treated with simple changes that include: sleeping on your side, avoiding alcohol before bed, and getting 7-8 hours of sleep each night. Be aware that snoring could also be a sign of sleep apnea, so consult a sleep specialist for the treatment option that is best suited to you.

Excess weight and sleep apnea

According to the Centers for Disease Control and Prevention (CDC), more than 35% of adults 20 years and older are overweight. In addition, more than two-thirds of obese patients have obstructive sleep apnea (OSA), which poses a major health risk. We commonly notice weight gain in our abdomen or buttocks, but fat tissue can also deposit in our neck, tongue and airway. It is believed that excess fat deposits in the neck can change the size and shape of our airway and make it smaller.

Furthermore, fat in the neck and throat can displace muscle tissue and result in less muscle tone in the airway. These changes cause the airway to become weaker and more likely to collapse. The end result is snoring and sleep apnea.

Are you at risk for sleep apnea?

One simple method to determine if you are at risk for having sleep apnea is to check your shirt collar size. It has been shown that men with a collar size larger than 17 inches (16 inches for women) are more prone to snoring and sleep apnea.

Q&A: Have questions about sleep disorders, snoring and sleep apnea? Ask Dr. Sesso

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Dr. Donald M. Sesso, Director of the Pennsylvania Snoring and Sleep Institute, is the only triple certified sleep apnea surgeon in the tri-state area and specializes in the surgical treatment of obstructive sleep apnea and sinus disorders. He is a Board Certified ENT Otolaryngologist in Head and Neck Surgery, Facial Plastic Surgery, and Sleep Medicine.

Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring: A Report of the American Academy of Dental Sleep Medicine

Notes from Dr. Norman Blumenstock

In response to the demands of an emerging profession to set standards of care, the Board of Directors of the American Academy of Dental Sleep Medicine (AADSM) brought together leaders in the profession to develop the definition of an effective oral appliance for the treatment of sleep disordered breathing based on current research and clinical experience. On February 15-17, 2013, a consensus conference was held in Tampa, Florida. Fifteen leaders in the profession used the modified RAND/UCLA Appropriateness Method to craft an empiric definition of an effective oral appliance with emphasis on purpose, physical features and function. A definition was developed and in March 2013 was accepted by the Board of Directors of the AADSM.

The purpose of this report is twofold. First, it presents a systematic review of all available level one and two literature (based on Oxford Centre methodology) to validate the accepted definition of an effective oral appliance. Second, this report details the processes employed and clarifies inclusion and exclusion rationale.

Future research, improved methods, and innovations in biomaterials will continue to advance the profession of dental sleep medicine. This definition provides a foundation and framework to guide both future investigations and current treatment of individuals with sleep disordered breathing.

Citation:

Scherr SC, Dort LC, Almeida FR, Bennett KM, Blumenstock NT, Demko BG, Essick GK, Katz SG, McLornan PM, Phillips KS, Prehn RS, Rogers RR, Schell TG, Sheats RD, Sreshta FP. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep Medicine. Journal of Dental Sleep Medicine2014;1(1):39–50.