When sleep brings no rest — and how surgery can help

When a Dalhousie University Faculty of Dentistry team was presented with the Daniel M. Laskin Award last autumn in San Francisco, it marked the culmination of 18 years of work on snoring and sleep apnea.

The award, which recognizes the year’s most outstanding article in the Journal of Oral and Maxillofacial Surgery, is the result of studying hundreds of patient records and analyzing data relating to snoring, extremely high levels of obstructive sleep apnea, and the effectiveness of surgery in treating the condition.

The winning team was comprised of oral maxillofacial surgeon Dr. Reg Goodday (DDS ’79, MSc ’88), who teaches in the Faculty of Dentistry; Dr. Susan Bourque (DDS ’07, MSc ’13), an oral and maxillofacial sciences (OMFS) resident at the time of the research; and Dr. Pember Edwards (DDS ’16), a dentistry student during the research.

Obstructive sleep apnea: the scale of the problem

Although snoring might be a cartoon cliché, it is no laughing matter if it happens to be a symptom of obstructive sleep apnea syndrome (OSAS). This frequently undiagnosed chronic condition causes breathing to stop and start repeatedly when the soft tissues in the throat intermittently relax and partially or completely block the airway during sleep.

Not surprisingly, obstructive sleep apnea can severely disrupt a sufferer’s sleep and cause daytime sleepiness and the risks that come with that. Even more seriously, it is also linked with hypertension, diabetes, cardiovascular events, strokes and death. Approximately two per cent of women and four per cent of men between 30 and 60 years of age — millions of people in North America alone — suffer from obstructive sleep apnea, many without realizing it.

At the mild end of the spectrum, sufferers stop breathing between five and 15 times an hour, while sufferers with severe sleep apnea can experience over 30 episodes an hour. And it was at the higher end of the spectrum that Dr. Goodday and his colleagues focused their research.

“We found that no study had ever been undertaken on those who suffer from extremely severe sleep apnea: those who stop breathing over 100 times per hour,” says Dr. Goodday. “Our study analyzed the records of 265 patients who had had surgery performed on them to assess the objective data — the numbers — and the subjective results that the patients themselves reported.”

Treating the problem

Until recently, the gold standard for treating obstructive sleep apnea was continuous positive airway pressure (CPAP). However, the CPAP device, which involves a facial mask, must be worn every night to achieve the best results. Many patients find it uncomfortable and stop using it.

There is a surgical option. Maxillomandibular advancement (MMA) surgery opens up the airway and decreases the potential for its collapse during sleep. Dr. Goodday and his fellow maxillofacial surgeons use the Delaire method of architectural and structural craniofacial cephalometric analysis, which Dr. David Precious, former dean of the Faculty of Dentistry and an oral and maxillofacial surgeon, brought to the Dalhousie OMFS department from France, to help the surgeons plan their surgeries in advance.

“A lot of health professionals do not realize that the tongue is attached to the chin and the soft palate is attached to the upper jaw,” explains Dr. Goodday. “If the chin and the upper jaw are not correctly aligned, the airway can collapse during sleep.

“Using the Delaire method of analysis, we are able to see what the normal facial balance for each patient should be. This information enables us to carry out MMA surgery that corrects the abnormal position of the jaws and opens the pharyngeal airway in a way that eliminates trial and error and achieves consistent results.”

Analyzing the impact of treatment

Dr. Goodday and his colleagues conducted a chart review of the 265 patients who had undergone MMA surgery for OSAS at the QE II Health Sciences Centre in Halifax between 1996 and 2014. Because their study concentrated on patients with extremely severe OSAS, with over 100 instances of interrupted breathing per hour, they narrowed down the records they studied to 13.

“These patients had an average score of 117 episodes of decreased or stopped breathing per hour,” says Dr. Goodday. “After surgery, that number was reduced to an average of 16 for the group. Eight of those patients had a score of six or below, which is within the normal range.”

The patients who underwent the surgery completed questionnaires afterward, in which they reported less daytime sleepiness, decreased snoring, a better quality of life and a favourable change in facial appearance.
 
Receiving this award is a significant achievement for Drs. Goodday, Bourque and Edwards. Of the eight criteria by which the article was selected as the winner, including study design and presentation and analysis of data, Dr. Goodday points to the final one, “potential clinical impact” as being the most meaningful.

“This criterion reflects the successful outcomes of the surgery we perform and the positive effect it has on obstructive sleep apnea,” says Dr. Goodday. “It shows what we can do as dentists and surgeons to improve people’s health and their lives.”