Sleep Apnea


Snoring is a common problem, which affects 60% of men and 40% of women over the age of 40. The sound of snoring in some people has been measured at 90 decibels – a loudness that would require earplugs in the industrial workplace. This has affected the quality of sleep of many a bed partner causing them to seek refuge in a separate room. Benign snoring is non-obstructive, and is in most cases, the uvula fluttering in response to rapid airflow, like a flag flapping in a stiff wind.

Obstructive snoring results from a partial airway closure and/or a narrow airway. According to Bernoulli’s Principle, A decrease in the size of the lumen causes an increase in velocity of air, resulting in a decrease in pressure, sucking in the compliant airway walls and facilitating obstruction. So when you fall asleep your muscles relax, including those that control the tongue and soft tissues in your throat which leads to your tongue dropping back into your throat and the sagging of the soft tissues in the palate and throat.

Nasal obstructions can also cause turbulent airflow which leads to further turbulence in the airflow reaching the back of the throat and worsening the obstruction. Incoming air then makes the tissue at the rear roof of the mouth (the soft palate), the flap of skin hanging from the palate (uvula) and the throat vibrate – a sound we know as snoring.

The more obstructions, the more turbulence which results in more suction on the tonsils, adenoids, fat tissue in the throat, swollen nasal membranes, soft palate and the tongue. This can lead to a serious medical condition called Obstructive Sleep Apnea.

Snoring can be a symptom of a serious medical condition that can be life threatening. Obstructive sleep apnea affects more than 20 million Americans and can lead to hypertension, heart attack, stroke, depression, muscle pain, fibromyalgia, morning headaches, and excessive daytime sleepiness. Most people with mild sleep apnea are aware that they snore and feel overtired or fatigued but are unaware of potentially serious medical problems which may exist.

Snoring Treatment

Diagnostic Testing for OSA

Polysomnogram or PSG is the gold standard for diagnosing sleep apnea. It involves spending the night at a sleep clinic while your heart rate, blood oxygen level, breathing and EEG are measured. The diagnosis of OSA is then made by a trained physician. Increasingly there have been significant technological advancements for home sleep studies (HST) that can be done in your own bedroom.

In patients with a high pre-test likelihood of moderate to severe OSA, HST is comparable to in-laboratory PSG. HST tends to underestimate severity of OSA compared to in-laboratory PSG but has similar likelihood ratios for detecting the presence of OSA. HST is used only to look for obstructive sleep apnea.

Only 4-5 channels of physiologic data regarding respiration are obtained, as opposed to 14 channels during in-lab polysomnography. We work closely with several of the leading sleep clinics in the Seattle area

Our clinic uses the MediByte HST for screening and titration of the effectiveness of your appliance. This saves you from having to do extra overnight PSG studies and allows us to test the oral appliance at multiple positions as necessary.

Treatments for Snoring and OSA

Self Care

Weight gain is a significant cause of snoring and sleep apnea as fat tissue are deposited into the tissue of the throat. Therefore a weight reduction program can lessen or eliminate Snoring and OSA.When you sleep on your back the tongue and soft palate due to gravity will sag into the back of the throat. Snoring and OSA is usually improved by sleeping on your side.Many medications, especially relaxants can decrease muscle tone within the tongue and pharyngeal muscles which leads to increased apnea. Alcohol in the evenings also causes decreased muscle tone within the tongue, soft palate, and pharynx.Maxillary dental night-guards have been shown to increase OSA by as much as 50 %.   Since patients with apnea also have increased Bruxism or teeth grinding episodes the nightguard may be contributing to the cause of the problem. Special night-guards can be made that do not increase the apnea. This can be verified with a home sleep study such as we use at our office.


This has been the gold standard for the treatment of OSA. It utilizes a mask that fits over the face and is connected to a machine by a long tube which then blows air through the nose into the throat. The influx of air keeps the throat from collapsing during sleep and allows the patient to breathe freely without worry of episodes of non-breathing. This is an extremely effective treatment but while CPAP is highly successful when used properly, many patients have trouble complying with its use.

Some studies have shown that only 23% – 45% of patients are successful with the CPAP method. Unfortunately, CPAP is difficult because the device requires the use of a mask over the nose and mouth, and must be worn each night and can be a cause of claustrophobia, face breakouts from the straps, eye, sinus and nasal irritation, mouth dryness, runny nose, sore throat and gastric bloating. Additionally, many people find the aesthetics of being a “jet-pilot” less than desirable and can also find being tethered by the hose to the machine impedes their sleep comfort. This results in many people who use CPAP and wear it for 4 hours or less per night.

Oral Appliance Therapy

Oral appliances that treat snoring and obstructive sleep apnea are small devices that are worn in the mouth, similar to orthodontic retainers or sports mouth guards. These appliances help prevent the collapse of the tongue and soft tissues in the back of the throat; keeping the airway open during sleep and promoting adequate air intake.

Currently there are approximately 70 different oral appliances available, so it important that your dental sleep specialist be familiar with the pros and cons of different appliances. Oral appliances may be used alone or in combination with other means of treating OSA, including general health and weight management, surgery or CPAP. Studies have shown that oral sleep appliances can be as effective as CPAP at reducing cardiac risk factors associated with OSA.

Potential drawbacks of oral sleep appliances are that they can increase headaches, neck pain, TMJ pain and dysfunction and cause tooth and bite shifting. When the lower jaw sits in a different position during sleep, there is a risk of creating discomfort in the Temporomandibular joint or “T.M.J.” and can lead to irreversible bite changes. Jaw exercises and bite repositioning therapy can help to minimize these changes. Our clinic which specializes in the treatment of disorders within the jaw and bite is ideally suited for providing oral sleep appliance and expertly managing their potential side effects.

Oral Sleep Appliance treatment program

A thorough clinical evaluation is done which includes review of your PSG (Please bring a copy of your PSG to your appointment).A Craniofacial cone beam CT will be done which allows us to visualize your teeth, your jaw joints and jaw position, and a 3-dimensional view of your airway. Typically a second CT is done at a bite position which approximates the position of the oral sleep appliance. We then measure for improvement in airway volume as that can be a sign that treatment with an oral sleep appliance will be effective. Our CT machine is the only lay-down cone beam CT machine in the northwest. Only a lay-down CT machine can visualize your airway in the sleep position. Our NewTom CT machine was also designed to minimize radiation exposure so that it uses about 10% of the radiation of a typical hospital head CT.Models of your teeth and bite records of the jaw position are taken.Insertion of your new appliance is done approximately 3 weeks later. In addition jaw exercises and often a bite-repositioning appliance is given to decrease potential side effects of bite change and jaw discomfort. Titration of the appliance for comfort and effectiveness is done.A Home sleep study is done to verify effectiveness.Once effectiveness has been verified you will be referred back to your sleep physician for a follow-up.

Dr. Pehling is an expert in the treatment of jaw disorders, therefore unlike many other providers of oral sleep appliances, Dr. Pehling is able to address any problems with your jaw and bite should they come up.

OSA Surgery

  • Tracheotomy During a tracheotomy, a surgeon cuts an opening into the windpipe and then inserts a tube into the opening to be used for breathing only during the sleeping hours. Patients will be able to breathe and speak normally during the daytime. A tracheotomy is reserved for severe cases of sleep apnea that cannot be adequately treated with other modalities.
  • Uvulopalatopharyngoplasty (UPPP) During the UPPP procedure, a surgeon cuts away the soft tissue at the back of the throat and palate in order to minimize the risk of the airway collapsing during sleep. The tonsils and part of the uvula will be extracted also. UPPP is done rarely today because of the significant risks and side effects from the procedure.
  • Laser Assisted Uvuloplasty – LAUP The laser assisted UP procedure, or LAUP, uses the same principles as the UPPP, but uses a laser to remove uvula, throat and palate tissue. Unfortunately, the LAUP has not been shown to be very effective for treating OSA.
  • Somnoplasty Somnoplasty can be used to tighten and reduce soft palate tissue, turbinates and the base of tongue. The advantage to this procedure is that it has much fewer side effects than other surgical procedures. Dr. Pehling has found that this procedure in combination with oral sleep appliance therapy can be effective in severe or refractive OSA patients.
  • Tonsillectomy and adenoidectomy During a tonsillectomy and adenoidectomy, a surgeon will remove the tonsils and adenoids, creating more space for airflow and reducing the opportunity for tissue collapse. This procedure is often recommended for children with sleep apnea or heavy snoring problems. Orthodontic widening of the maxilla in young children not only increases the oral airway but can significantly enlarge the nasal airway. This procedure can also be used in conjunction with oral sleep appliance therapy.
  • Bimaxillary Advancement During a bimaxillary advancement an oral surgeon will surgically move the maxilla and mandible forward (much like an oral appliance) decreasing the possibility of a collapsed airway. The enlarged mouth also reduces the chance that the tongue will interfere with correct breathing. This is the most useful surgical procedure and can give 100% relief. Successful oral appliance therapy can predict success of bimaxillary advancement. This procedure is often combined with GGA procedure.
  • Genioglossus and Hyoid advancement (GGA) A surgeon uses GGA procedure to pull the tongue muscles forward and prevent the collapse of the airway. By tightening the front tendon in the tongue, the procedure decreases the chance that the tongue will collapse and inhibit breathing. GGA involves an incision inside the mouth, and the creation of an avenue in the bone that is used to pull the front tendons forward. The result is an enlarged space between the rear of the tongue and the patient’s airway. GGA is often recommended as a supplemental procedure used in addition to another procedure or oral appliance.
Dr. Pehling works closely with several ENT physicians and oral maxillofacial surgeons. We also find that a combination of surgery and oral appliances can be effective treatment for OSA.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) occurs when the soft tissue in a person’s throat repeatedly collapses and blocks the airway during sleep. These obstructions in breathing typically last between 10-30 seconds, but can persist for a minute or longer. These pauses can happen hundreds of times a night, leading to abrupt reductions in blood oxygen levels.

The brain alerts the body to its lack of oxygen, causing a brief arousal from sleep that restores normal breathing. This results in a fragmented quality of sleep that often leads to excessive daytime sleepiness. Most people with OSA snore loudly and frequently, with periods of silence when airflow is reduced or blocked and then make choking, snorting or gasping sounds when their airway reopens.

Imagine how rested and relaxed you would be, if while awake, you held your breathe for 30-60 seconds twenty times in an hour (which a moderate sleep apneic will do). Sleep apnea is a very common sleep disorder. More than 18 million Americans suffer from the condition and it is a major risk factor for not only excessive daytime sleepiness but also the conditions listed below.

Health Risks of Sleep Apnea

  • Hypertension
  • Heart attack
  • Stroke
  • Depression
  • Muscle pain
  • Fibromyalgia
  • Cardiac arrhythmia
  • Inefficient metabolism
  • Loss of short term memory
  • Weight gain
  • Gastric reflux
  • High blood pressure
  • Diabetes
  • Severe anxiety
  • Memory and concentration impairment
  • Intellectual deterioration
  • Mood swings/temperamental behavior
  • Insomnia
  • Impotence