Yes several private options are available. Solutions 4 Snoring has entered into a partnering arrangement with Respironics (UK) Limited to offer Sleep Tests to suspected sufferers of OSA using the “Star Dust” domiciliary sleep test. The cost to the patient is £250 inc VAT which includes an assessment of the results by a Physician. This can be arranged by calling 0114 250 0176.

Do the involuntary leg movements experienced by some sleep apnoea patients give rise to cramps and muscle spasms?

Cramps have not been recorded but equally there is a condition known as Restless Leg Syndrome, which can contribute to this excessive and characteristic movement. OSA patients do tend to thrash around as a result of increased neurological activity.

Is the CPAP machine quiet?

Most patients say it is like going to sleep with an air-conditioning unit switched on. However newer intelligent machines monitor the level of pressure that is required and can adjust accordingly. This can mean that they are quieter.

Is it so unreasonable to ask a patient to wear a MAS for the rest of their life?

The short answer is no and in the patient’s eyes definitely not because by comparison to the other treatment options available, the MAS is attractive. On the question of effectiveness the MAS is not as effective as CPAP in moderate to severe OSA patients.

Can you move a patient off CPAP and onto MAS?

There are a group of clinicians who use MAS in conjunction with CPAP, where the MAS helps in airway patency and means less pressure is required from the CPAP machine. Many of the patients that come to me are failed CPAP patients. Not failed because it doesn’t work, but more because they cannot or will not tolerate CPAP. If you do this you need to provide objective measures for comparison and other more contentious issues arise, such as compliance, especially if excessive daytime sleepiness has been reported.

Why do some people snore when lying on their front?

Anatomical issues can lead to snoring irrespective of sleeping position. Sleeping position is an aggravating factor and changing it can help but it is by no means curative. The soft palette could be larger there may be less upper airway dilatory muscle activity or there is an underlying craniofacial anomaly that pre-disposes to a narrowing of the pharyngeal airway. All of these will not be superseded by the sleeping position.

What percentage of people snore because of Obesity and what percentage for other reasons?

It has never really been looked at that level but clearly it would be a large project. The problem is that you have to be very careful because there are a lot of confounding variables and you would have to match patients to tell like for like.

So for overweight patients losing weight is an option but if they have anatomical issues they are destined to wear the MAS forever?

In reality if the patient is not overweight they have no weight to lose so their aetiology is more likely to be craniofacial in which case MAS, CPAP or possibly surgery (if judged appropriate) are the realistic treatment options.

What sort of fall in blood pressure do you see as a result of splint therapy?

There have been 2 trials and it is about 5 mmHg drop over the night which is statistically significant and is thought to be clinically significant. The reduction in nocturnal BP is only going to serve the patient well in terms of the other knock on diseases such as arthrosclerosis and cardiac anomalies.

You mentioned that sudden death is an issue for OSA patient is there any evidence to link this to the suffocating events?

A paper in 2005 managed to work out a relative risk ratio for patients with OSA versus the same controls matched for age and sex and was retrospective in nature. The cause of death was cardiac in origin but the time of death was very significantly different in OSA patients versus the norm. The authors of the study suggested that the strain put onto the heart by the apnoeic events could cause cardiac arrest.

If a patient comes in complaining of snoring, couldn’t you just fit the splint and tell them that you are treating the snoring and the rest of the examination will follow?

I would still say to you no, as you are very new to this field you could take the outlook of what harm are you going to do the patient. The reality is that if the patient has undiagnosed OSA and you give them a splint you may suppress their snoring but if they go on to keep this untreated very pathological sleepiness or other parameters in terms of apnoeas and hypopneas there are other significant medical sequalae which you have then basically ‘masked’.

What do we do with patients who present with really severe overbite problems like a class II div 2 malocclusion?

The issue with a patient with a very deep bite is that they most definitely can’t or they struggle to advance their mandible as much because of the amount of jaw opening required to achieve clearance of their increased overbite, in order to advance the lower jaw. In these patients, you will aim to achieve ‘bite-opening’ initially, to the point where 4mm of wax can be placed between the incisors. Patients with deep bites tend to show an upward and forward rotation of the mandible. Get them used to opening the jaw, and as a second stage, look to advancing the mandible.

What about class III malocclusions?

In patients with an edge to edge or reverse overbite the treatment works equally as well but as with class II patients there is an adaptation process.

How amenable are the sleep clinics to referrals from GDP’s?

We have approached them, but clearly the issue is one of awareness and currently a large number of these patients are going undiagnosed. Having a SBD has proven underlying medical sequelae, so it is beholden upon us as members of the medical profession to treat those patients. It is not good enough to say that the NHS cannot cope with this many referrals, the system will have to adapt. You may get mixed feelings, most have been fine because they realise that you are trying to make a difference in an area where there is no alternative. We are keeping them as much in the picture as possible because we want them to work with you.

What are the issues arising from referring private patient to an NHS sleep centre?

You may find that having assessed a patient and screened them privately the sleep consultant may wish to refer them for further private treatment, however this is a patient needing to be diagnosed. If a GP had sent the patient they would be treated on the NHS but the time to treat could be 6-12months. The situation will be the same for your patients, they may however choose private sleep study due to the strain on the system.

Before fitting a MAS to a patient who is referred do I need to achieve dental fitness and what issues arise from raising this with another GDP?

Yes, it is paramount whether the patient comes from an external or internal referral that the periodontal condition is suitable prior to treatment. You would be advised to liase with the patient’s regular GDP that you are sure that he/she is aware of the state of the gums and is monitoring them, however the difference with this treatment is that it burdens the teeth even more. That is a tactful way of suggesting that they address the periodontal condition prior to you treating them.

Do you treat children?

I haven’t and although snoring is prevalent with children, the problem is that with children they are still growing and by fitting a MAS you could encourage mandibular growth which could lead to class III malocclusions. This is highly specialist care and I would advise referral to an orthodontist.

What would be the mimimum age?

I class adults >18 years . The main reason for this is that the majority of the growth has taken place. Clearly we continue to grow throughout life, but by 18 I would class them as being adults.

Do you need further advancement of the mandible because the patient gains weight, or does the soft tissue become used to the new position?

The truth is that we don’t know. If the patient gains weight you don’t know whether it is the weight gain that has directly affected the airway or alternatively it is the muscles getting used to it and not getting as much stimulation as they were. My personal experience is that it is the weight gain. Largely due to the fact that in weight gain fat is deposited on the lateral and posterior walls of the airway which has a profound affect on the size of the airway. Furthermore, age seems to play a role in the pathogenesis.

Do they just turn the key once a week, and when do they stop?

You will be surprised how little they actually need to advance the mandible, lets take it from day one. They’ve got snoring, you fit the splint and lets say that you have been reasonably cautious and only advanced the mandible 1-2mm. They will immediately get some benefit as a result of that. Let them take 1-2 weeks to get used to wearing the splint. If they do not get too much discomfort then they can advance one full turn, then a week later another. If you review them after 1 month they should have had in total 3-4mm of advancement and the evaluation questionnaires should highlight that the snoring has been resolved.

We have been contacted by a company offering a nasal strip which diagnoses OSA are you aware of it and would you advocate its use?

I am aware of this and my feeling is that in order for this to work something has to be compromised. The world is not so slow that in some centres full polysomnography is being used and in another a little strip is doing the same thing, clearly it cannot record the same parameters. Until I have definite evidence I wouldn’t advocate its use to you.

What about nasal strips as a treatment?

What these airway dilators do is flare the nostrils to increase airflow. However a Cochran review has shown that no single behaviour modification factor could treat snoring and sleep apnoea.

The pre-screening depends on the ESS, surely patients could be tired for a number of reasons during the day?

It is right to say that our sleep is affected by a 1001 different things. A young child, stress at work, selling a house could all have an impact. However patients are astute enough to realise that if the sleepiness has only recently occurred it could be down to the birth of a child, for example. Equally the ESS has been validated against other more objective ratings of sleepiness. What you will be doing in using ESS will be no different to what a sleep centre would do. It is also worth remembering that you are targeting simple snorers who are non-apnoeic and therefore should not report excessive daytime sleepiness.

Is there any evidence that snoring is progressive, that a simple snorer could become and OSA sufferer? Also if you intervene could you be masking someone’s OSA?

There was a longitudinal study which was undertaken in Belfast and which followed patients over 12 years, it showed that progressively their airway compliance was compromised so you could argue that the aging process has a role to play. Another study has been done examining muscle biopsies - looking at the changes that have been induced in the uvula and the lateral walls of the pharynx in snorers and patients with sleep apnoea. They have found that there is similar pathology going on, which means that if left untreated snorers could become OSA’s especially when you add in obesity. Therefore it was estimated that the trauma caused by the uvula banging against the posterior pharangeal wall might induce the atrophic changes that we are seeing in the muscles. So by treating them you are providing a better quality of life now, stopping the snoring and you may almost be providing a preventative regime.

What is MAP score?

The Multivariant Apnea Prediction (MAP) score was developed by Greg Maislin M.S., M.A. Principal Biostatistician of Biomedical Statistical Consulting (Maislin et al., 1995, Sleep; www.biomedstat.com). It has been further developed by the Sleep Research Group at the Woolcock Institute of Medical Research, Sydney, where it has been applied as a screening instrument in clinical practice.