What’s the best Anti-Snoring Device? (Sleep-expert reviews top 13 criteria)

What’s the best Anti-Snoring Device? (Sleep-expert reviews top 13 criteria)

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What’s the best Anti-Snoring Device?

The best anti-snoring device is only prescribed after you’ve been screened for Obstructive Sleep Apnoea / Apnea (OSA).

The best one:

  • Stops your snoring
  • Costs you the least money (because it isn’t a false economy)
  • Creates the least side-effects (and helps you sleep and breathe at the same time)

So, if you’re wondering what’s the best anti-snoring device then read this independent (no advertisements or affiliate links!) sleep-industry expert review.

Despite the lack of prior screening for sleep apnoea, anti-snoring devices (Mandibular Advancement Devices – MADs) or ‘gumshields for snoring’ are big business on the internet and in the pharmacy.

Indeed, the NHS ↗ website makes reference to MADs but fails to differentiate between custom-made and Over-the-Counter (OTC) snore-stoppers!

Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I teach UK dentists how to help their patients stop snoring; sleep and breathe at the same time.

Many of my customers find their work so rewarding they devote their practice to it. I’m a sleep-industry insider with a quarter of a century of sleep medicine experience.

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Are you a dentist interested in prescribing anti-snoring devices?

We help you to help your patients to stop snoring (and stay indemnified).

So, the challenge as a hasty snorer is:

How to choose one that actually works?!

Snoring aids and cures are increasingly popular as we recognise the impact poor sleep has upon our health, daytime functioning and work performance.

A news article “Ten Snoring Cures” reviewed 10 ‘cures’ available in the UK. The journalist tried to stop his own snoring, with chin straps, sprays, pillows and ‘gumshields’, aka anti-snoring devices.

He had little success and concluded his review by quoting a snoring expert, Consultant Respiratory Physician, Dr Tom McKay, from Edinburgh Royal Infirmary Sleep Centre, UK, as saying:

Good to know:

Snorer.com is independent. We don’t sell anti-snoring devices, chin straps or whatever! And we don’t benefit from affiliate deals.

A note about mouth opening and nasal breathing:

If you have difficulty breathing through your nose, address this before you consider an oral appliance. Consult your GP if the issue persists.

While an oral appliance should not stop you breathing through your mouth, it will certainly present a restriction.

Nasal breathing is ideal. Read more about this in my post about snore-relief products available without prescription.

‘Sprays don’t have any great effect although nasal steroids have a small role if you’ve got nasal congestion. It can help to lose weight or avoid alcohol last thing at night or to sleep lying on your side. Various forms of gumshield are reasonably successful – maybe 50 or 60 per cent.’

So, its a reasonable question to ask….

Which Anti-Snoring Devices really work?

‘Gumshields for snoring’ could more accurately be described as mandibular advancement devices (MADs). They are also known as intra-oral devices, mandibular repositioning devices (MRDs) or even sometimes mandibular advancement splints (MAS) !

But there are essentially just two categories:

  Over-the-Counter (OTC) ‘gumshields’
  Prescription, Custom-Made Dental Appliances

In this updated for 2019 review, I examine how both categories of anti-snoring device measure up against my Top 13 criteria for choice (see call out box) to determine which ones really work, and if they’re safe and effective.

And the best bit?

Each section concludes with my verdict and there’s a free bonus at the end!

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If you are looking for impartial advice about snoring from an expert in the field, the highly respected Adrian Zacher should be your go to. We applaud Adrian’s work, to raise awareness about the health implications of snoring, and the importance of prescription, custom-made devices for long-term success.

Lucie Ash Director Somnowell Snorer.com September 7, 2018

CAUTION: Snoring may be a symptom of Obstructive Sleep Apnoea / Apnea (OSA)

Snoring may be a symptom of obstructive sleep apnoea/apnea (OSA).

Without first being screened for OSA your purchase of an OTC anti-snoring device, could harm you and if you snore because you have undiagnosed Obstructive Sleep Apnoea (OSA) the OTC gadget delays effective (and free on the NHS!) treatment that will prolong your healthy life.

Get signposted to the most appropriate professional (it’s free!)

The professional will screen you for OSA and decide if you’re ‘just’ a snorer or if your snoring needs investigating.

Your GP may be able to help you – but they may not know much about sleep apnoea as sleep is not part of core medical training. We provide expert written GP Guidelines to help.

In the UK, you can also find sleep-trained dentists who can screen you and recognise Obstructive Sleep Apnoea/Apnea (OSA) symptoms2, make custom anti-snoring devices for snorers, without a prior medical diagnosis, or if they suspect OSA refer you on for further investigation.

Oral appliance therapy is considered a second-line option for OSA (which means that PAP is first-line [the first treatment option] and only after PAP failure would an oral appliance for OSA be considered).

Learn more about dental appliances for sleep apnoea.

Clinical evidence (proof) that the MAD works

No. 1. Clinical evidence (proof) that the Anti-Snoring Device works

What does 'clinical evidence' actually mean?
Medical and dental experts review medical devices (clinical research) to establish if they work. Their research produces data and information which can be thought of as ‘proof’ that something does or does not work, and how well it works in certain circumstances. The evidence they create is also judged for quality.

Judging Anti-Snoring device (MAD) research quality

When selecting an anti-snoring device, it’s important to look at this clinical evidence. To judge the quality of a mandibular advancement device’s (MAD’s) clinical research evidence, you need to look past the headlines claiming “Clinical research– tick”.

What was the outcome of the research?!

Typical patient-centred measures of outcome

Measurement of what patients perceive as important effects from wearing an MAD typically include:

  • Partner reported snoring (derrr… a no-brainer!)
  • Daytime sleepiness
  • Quality of life
  • Adherence (long-term use)
  • Device preference
Gumshields for snoring
Gumshields or ‘Boil-and-Bite’ anti-snoring devices, have been clinically researched head-to-head against custom-made, prescription, adjustable anti-snoring devices and found to be lacking.

Our results suggest that the thermoplastic device cannot be recommended as a therapeutic option nor can it be used as a screening tool to find good candidates for mandibular advancement therapy.3

…patients overwhelmingly found the ready-made MRD difficult to tolerate…4

…96% of patients reported minor adverse events, which related predominantly to discomfort.4 [referring to a study by Dr. Tim Quinnell 5

Prescription, custom made MADs
Today, clinical research has established that custom made MADs are first-line therapy (the default first option) for snoring and mild obstructive sleep apnoea / apnea.

MAD research now focuses on:

Predictors of satisfactory outcome before purchase (who will benefit and why) and which type of custom made MAD is most effective for a given genotype (which MAD is best for YOU as opposed to a vanilla approach).

Expert’s verdict on clinical evidence for MADs
It is not enough to say that an MAD has been clinically researched. Such research may have proved the MAD didn’t work!

A positive outcome from clinical research can be thought of as a ‘guarantee’ of sorts.

My advice is to do your homework (grab the Bonus Mouthpiece Guide at the end) and be guided by a sleep-trained dentist. You can find one on via our Links new window page.

[Note: Below is an advanced topic about typical MAD research metrics. So, if you’re new to clinical evidence, feel free to skip this tip].

Typical Mandibular Advancement Device (MAD) research quality metrics include:
  • Total sample size (the ‘N’ or number of patients who used the device)
  • Could they tolerate it in their mouth (known as tolerance)
  • How many hours they used it for each night (known as compliance)
  • How many nights they used it for per week (part of the compliance metric)
  • Partner reporting of cessation of snoring
  • Perceived sleepiness before and after use
  • Before and during use blood oxygenation level
  • Before and during use AHI (apnoea hypopnea index – an index used to indicate the severity of sleep apnea. The number of apnea and hypopnea events per hour of sleep)
  • Whether a placebo was used with a control group
  • Whether patients crossed over to a different therapy / device
  • Whether the researchers and/or patients were ‘blind’ (who was aware which device was a placebo or an actual MAD?)
  • Has the research been published in a high profile and peer-reviewed journal? (This means other experts in the field judge it for quality)

No. 2. Anti-Snoring Device costs

OTC gumshields and ‘treatments’ might appear cheaper than custom-made, prescription appliances & dentist fees, BUT…

Are they a false economy?

Why use a dentist to get an Anti-Snoring Device (MAD)?

Financially, its tempting to cut out the dentist.

After all, a large part of the cost to you when purchasing a mandibular advancement device, is their clinical time.

The device fees vary, but what are you paying for?

Dentists know about teeth, gums and jaw-joints
That is what they do.

While Dentistry may initially seem expensive, the risks of not using an expert are considerable. Remember, you are relying on the anti-snoring device to hold open your airway while you sleep. Think carefully before you choose.

Some dentists are specially trained in snoring and sleep apnoea / apnea, known as sleep-related breathing disorders (SRBD) and work closely with medics. Dentists with a special interest in sleep, can help you find the correct balance of benefits versus side-effects.

If you have certain medical conditions, or grind your teeth, you might break an OTC ‘gumshield’ whilst you’re asleep. When you are asleep you cannot spit out pieces of a broken gadget. You could INHALE or SWALLOW pieces.

You can find sleep-trained dentists on our Links page. In the UK, look for the British Society of Dental Sleep Medicine.

Expert's verdict on whether to cut out the dentist
Don’t do it.

The terrifying thought of bits of MAD breaking off and being inhaled while you sleep, should surely make you realise you need to see a sleep-trained dentist and use a prescribed custom-made, adjustable anti-snoring appliance, made to quality standards.

In case you’re wondering, I’m not a dentist.

Anti-snoring device (mandibular advancement device - MAD)

Example of a custom-made Mandibular Advancement Device (MAD). Image above used with permission from SomnoMed.

Mandibular Advancement Device (MAD) made from metal

Example of a custom-made Mandibular Advancement Device (MAD). Image above used with permission from SomnoWell.

When it's time to stop:

Get signposted (free) to the right professional. Saving you time and helping to alleviate pressure on GP practices

over the counter: anti-snoring devices

Tired of the sleepiness and the snoring?

Then read our free, definitive step-by-step how to stop snoring Guide.

This comprehensive Guide walks you through self-help, signposting, screening, professional assessment and diagnosis, the three categories of prescription treatment, follow-up and rounds off with a substantial FAQ.

No. 3. Comfort and bulk of Anti-Snoring Devices (MAD)

An MAD that is so uncomfortable to wear, soon ends up being thrown across the bedroom or just left in the bathroom at bedtime…

Both the design and clinical expertise in how an anti-snoring device is supplied, directly impacts your likelihood of successfully wearing it (and therefore whether it stops your snoring) – particularly during the first two weeks of use.

This is when most people who aren’t going to get on with them, quit. It might seem obvious:

but if you don’t wear it – it doesn’t work.

OTC gumshields for snoring (Boil-and-Bite)
Generally OTC gumshields for snoring are “one-size-fits-all”.

They have to be bulkier in size to adapt to your teeth than custom-made devices. This would mean it feels like you are squeezing a tennis ball into your mouth – Oh, and then you’re expected to sleep!

Custom-made MADs
A sleep-trained dentist will ensure that your MAD fits properly and doesn’t hurt.

They will also ensure you know how to put the device into your mouth and get it out again.

Expert's verdict on comfort and bulk
As a general rule, custom-made anti-snoring devices are less bulky than ‘gumshields’.

Due to the lack of accuracy of the ‘fit’ and one-size-fits-all approach of gumshields, they may be too large, too small or take up so much room in your mouth you can’t close your lips and you find yourself dribbling attractively!

Warning! Is this the best anti-snoring device for you? UK expert review

No. 4. Will an Anti-Snoring Device (MAD) damage my teeth and gums?

You wear these things in your mouth.
What impact will it have?

Gumshields for snoring (So called 'instant anti-snoring devices')
Its quite possible that a gumshield will place excessive load upon an individual tooth/teeth.

Over time your teeth will move. It will hurt.

And you will either stop wearing the mandibular advancement device and accept the financial loss (good luck trying to get a refund on a used product), or under duress from your partner and family, continue wearing it and risk losing the tooth or an expensive crown/cap/bridge.

Prescription, custom-made MADs
Prescription Mandibular Advancement Devices on the other hand, can be designed to avoid certain teeth if they are identified as at risk.

An expert sleep-trained dentist can help identify (and save that tooth) if it could not withstand the lateral loading required.

A dental technician would ‘block out’ the identified tooth and not include it in the custom-made device.

Expert's verdict on risk to your teeth and gums

All anti-snoring devices will aggravate your oral hygiene. 

However, a sleep-trained dentist would ensure BEFORE you had an MAD, that your hygiene and oral condition (teeth, gums and jaw-joints) were satisfactory before you began to use it.

Try to keep the device as clean as possible. Use your toothbrush and toothpaste on it each morning. Don’t use chlorine based denture cleaners on gumshield based devices – it makes them hard and brittle (unusable) rapidly. Instead, use a baby bottle sterilising fluid (follow the manufacturer’s instructions).

Brush and floss your teeth carefully and consider using a chlorhexidine mouthwash. If you spit blood when you clean your teeth consult a dentist/hygienist.

‘Boil-and-Bite’ devices will flex when worn and over time, this will procline (tilt forwards) your lower incisors and retrocline (tilt backwards) your upper incisors.

Certain custom-made anti-snoring devices are designed to avoid this tooth tilting movements.

Consult your sleep-trained dentist.

No. 5. Will an Anti-Snoring Device damage my jaw-joints?

Jaw pain is truly horrible and once you have a jaw pain problem it persists.

All types of mandibular advancement device (MAD) work by moving your lower jaw forwards, and the amount it does this to be effective, and not hurt too much, is specific to you.

Gumshields for snoring
Some gumshields for snoring are only adjustable in large increments, while others you have to fit the device – rather than the device actually fit you (again you may lose your money).
Custom-made MADs
Custom made, adjustable, prescription MADs really win when considering your jaw joint. In fact, it’s possible, with some of the custom made ones to start off wearing it with no (or very little) change in your jaw position.

While of course it won’t initially prevent snoring in this position, the dentist will gradually advance your jaw until you stop snoring over a matter of weeks or perhaps even longer (this is known as titration). This gives you, your device (and your jaw joint) time to get accustomed.

Which means you STOP SNORING!

And don’t permanently harm yourself. Yay!

Expert's verdict on jaw-joint risk
Your sleep-trained dentist will screen you for sleep apnoea, assess your teeth, gums and examine your jaw joints.

They will take X-rays and put things right beforehand if necessary. If it doesn’t look like its a good idea, they’ll suggest:

  • You DON’T have one,
  • Explain why,
  • And direct you to appropriate help.

If everything is OK, they’ll monitor the effect the MAD is having upon your teeth, gums, jaw joint and snoring.

If your jaw joint isn’t healthy before you start using an anti-snoring device then it may cause irreversible harm. (The exception is when a specialist sleep and jaw joint pain [Temporo-Mandibular Joint Dysfunction or TMD] dentist prescribes a device for BOTH issues.)

A sleep-trained dentist would know what to avoid and ensure you did not experience premature posterior contact (see call out box) that would damage your jaw-joint.

Premature posterior contact

This gets a bit technical.

A common problem particular to ‘gumshields’ occurs when the device is adjusted forwards known as ‘protrusion’ (you might do this in an attempt to increase the effect – and stop the snoring noise). The upper and lower parts of the device may then come into contact on just your back teeth.

This acts like a ‘bit’ for a horse – it gives you something to chew on. It ‘gags’ open the bite (keeps your jaws more open than they should be) and this uneven bite places enormous load on your jaw joints.

It would be even worse for your jaw joint, if this was on one side only, and as you close your mouth, your jaw has to ‘rotate’ around this ‘premature contact’. What the above means, is that your jaw has to move in unnatural ways.

This hurts. And if you use the device in this position (because you’re trying to appease your partner) you will irreversibly damage your jaw joint.

No. 6. Retention /  Fit of your Anti-Snoring Device (MAD)

How well your anti-snoring device fits, is known in dental terminology as ‘retention’.

But retention has two meanings in Dental Sleep Medicine (DSM is the term for MADs used to help with sleep-related breathing disorders, including snoring and OSA).

The first meaning is how well it keeps hold of your teeth, or to put it another way, how well it ‘clips on’ or stays in place. 

Most MAD designs rely upon its ability to ‘clip’ into place to then be able to hold your jaw forwards – and stop you snoring.

The second DSM interpretation of ‘retention’ relates to the MAD’s ability to hold open your airway, retain it in a forward position, and prevent you from snoring.

So, the right amount of retention (or fit) is essential for it to work.

Over-the-Counter ‘gumshield’ vendors make their money by relying on you being too lazy to seek a refund when it doesn’t work.

Read my review of ways they separate you from your money. ↗

Gumshields and retention
This is unavoidably technical. So, feel free to skip to my verdict.

Due to the necessary choice of thermo-plastic (it softens and becomes adaptable to you, when heated in boiling water) material used in ‘boil and bite’ devices, getting and keeping the right degree of retention, for the long-term is nigh on impossible.

The material ‘wants’ to go back to its original shape as it cools down, which is technically due to both the elastic memory and elastic recovery of the material. There’s more about the material used in the Lifespan or ‘Cost per wear’ section below.

Custom-made MADs
Custom-made dental devices for snoring are made for you (on prescription) from raw materials by a registered dental technician. While the materials used vary, they usually only become thermoplastic (soften when warmed up) when heated over 100 deg C.

On the other hand, ‘Customised fit‘ devices are the ‘Boil-and-Bite’ gumshield type of MAD (and I know you know water boils at 100 deg. C!).

Expert's verdict on retention of Anti-Snoring Devices
Boil-and-Bite gumshields for snoring as a general rule, cannot provide good retention.

Without good retention or ‘clip’ to your teeth, gumshields will not stop you snoring. End.

No. 7. Can I adjust the position of my Anti-Snoring Device (MAD)?

The ability to adjust the forward position of your jaw (adjust the protrusion to prevent snoring) impacts upon both comfort and how well it works.

The optimum position is unique to you. It has to be just far enough forward to prevent you from snoring, yet not so far forward, it hurts your jaw joints.

Fixed devices (sometimes called ‘monobloc’ devices) take an arbitrary approach to the forward position of your lower jaw. This primitive design (exhibited by both over-the-counter gumshields and some old tech custom-made ones) is likely to be less than ideal for comfort and effect.

Gumshields for snoring
For the MAD to prevent snoring it must prevent your mouth from falling open.

You should NOT need a chinstrap in addition to your anti-snoring device. If a chin straps is suggested then:

You need a different MAD.

If you’re trying to ensure you breathe through your nose and stop your mouth falling open, then read Chinstraps for snoring? Safe, Effective or Dangerous? [new window]. In my chin strap review, I examine if they have a role for snoring and obstructive sleep apnea (OSA).

If you can only breathe through your mouth and/or sometimes struggle to breathe through your nose, then consult your GP and seek an ENT assessment.

Custom-made, adjustable MADs
Custom-made, adjustable MADs are inherently adjustable (the clues in the name!)

The important thing to understand about adjustable MADs relates to their range of movement, and:

  • Whether this is sufficient
  • Whether it dictates a hard to tolerate initial position

The most modern custom-made adjustable MADs have between 8-10mm range of movement. If more is needed – you will most likely need a remake (more money).

Expert's verdict on ability to adjust the protrusion
Clearly, fixed or monobloc devices fail this test 🙂 A new anti-snoring device would need to be made if the jaw position was incorrect. Adjustable anti-snoring devices need to have sufficient range of motion to coincide with your jaw range of motion – or you must start in a forward jaw position, which may impact your ability to get along with the MAD initially.

No. 8. Life-span or ‘cost-per-wear’ of your Anti-Snoring Device

To ensure your purchase of an anti-snoring device (MAD) is not a waste of money or a false-economy, you have to consider:

  • Its outright price (don’t forget the clinical fees) and VAT (if its for snoring)
  • Its length of useful life

Amongst other things…

Gumshields for snoring
A material that softens in boiling water called ‘Ethylene Vinyl Acetate (EVA) or EVA’ is commonly used in gumshield type anti-snoring devices.

  • This material absorbs saliva from your mouth (and also any cleaning chemicals that may then leak back out into your mouth overnight – nice).
  • They are damaged if you grind your teeth because the material is soft and elastic.
  • Their typical lifespan is 6 months to 1.5 years before the EVA constructed gumshield becomes too smelly and unpleasant to use.
  • They also distort and place high lateral loads on your front teeth – making them very sore in the morning.
Custom-made Anti-Snoring Devices
Some early design variants of custom-made anti-snoring devices, are also made from EVA ‘blow down’ or vacuum formed blanks of CE marked material by a registered dental technician.

However, most are typically made from a type of denture acrylic (polymethylmethacrylate) or ‘PMMA’, and as such are stronger and less likely to absorb saliva than EVA materials. Some new variants are made from a type of ‘Nylon’ (polyamide) and are very strong in thin section (see Comfort and bulk above). This means they will last longer and therefore the ‘cost per wear’ may be reduced.

In the UK, it is also possible to obtain a custom-made anti-snoring device manufactured entirely from metal (known as ‘Chrome’ = Cobalt chrome wiki link: http://en.wikipedia.org/wiki/Cobalt-chrome new window ) While this type of manufacture may cost more (they are more time consuming to make) the material cross-section is extremely thin (fractions of a millimetre are possible) making the bulk in your mouth minimal (see comfort and bulk above). Additionally, the metal device does not absorb saliva or cleaning agents.

The downside is that any adjustment of ‘fit’ of metal devices may be problematic and over time the clasps (bits that wrap around your teeth to hold [retain – remember that?] the device in your mouth) may ‘relax’ and need adjusting.

Expert's verdict on lifespan of MADs
Broadly speaking its a sliding scale of cost versus lifespan.

The high-end devices using nylon or chrome are thinner and less bulky but are also difficult (if not impossible) to adjust. This does not mean to say its a problem, they just have to be perfectly made.

So, if its not – then it needs to be remade: Do not accept a poor fitting custom made anti-snoring device.

No. 9. Control of mouth opening (Does the MAD do it?)

When using a mandibular advancement device (MAD) it is essential that your mouth does not fall open for effective snoring relief, which if permitted would make your airway narrower than it would be without a mandibular advancement device!

It should not be necessary to resort to a chin strap to control this. Yes, I’ve been over this point in point 6 Retention above, but…

Why does vertical opening matter?

The lower jaw rotates backwards as it opens which further narrows your airway and makes snoring worse (or if you have sleep apnoea / apnea may increase the severity and duration of apnoeaic episodes).

If your jaw is protruded with a mandibular advancement device (MAD) and your jaw falls open your airway may be narrower than without using an MAD.

See the three X-ray diagrams below, to understand why vertical opening with an MAD should be avoided. The red dots highlight how the airway increases / decreases with protrusion and vertical opening.

Images courtesy of Dr Ulrich Huebers DDS.

The diagram (below left) shows the size of the airway in your throat without a mandibular advancement device (MAD).

The diagram (below centre) shows the ideal situation. The mandibular advancement device advances the jaw and opens the airway in your throat.

The third diagram (below right) shows how the airway becomes narrower with both protrusion and vertical opening. Disaster.

rest position before a mandibular advancement device
Mandibular Advancement Device (MAD) with NO vertical opening in protrusion
mandibular advancement device
Gumshields and custom-made MADs
Both categories of MAD (Boil-and-Bite gumshield and custom-made MADs) can fail when examined against this important test metric.

  • Jaw advancement must increase as the mouth opens (protrusion must increase proportionally [to maintain the same effect] if vertical opening occurs).
  • Less protrusion correlates with:
    1. Less side-effects (including less risk of tooth movement and jaw pain)
    2. Increased tolerance and improved long-term compliance.

An interincisal opening (the distance measured between the upper and lower front teeth) of more than 5 mm has been associated with lower patient adherence (long-term use), perhaps as a result of discomfort.6

Expert's verdict on mouth opening

Minimal vertical opening (as in just sufficient to permit the lower jaw to advance without the upper and lower teeth hitting each other) should routinely be considered ideal. More than this may be necessary in selected cases where:

  • the tongue is large
  • the jaw is small

However, opening beyond 5mm (measured between the incisors) is uncomfortable, inhibits lip closure and detrimentally impacts long-term use. A design principle for MADs is control of vertical opening (note my previous comment about not needing a chin strap).

Finally, consider your sleep position. Avoid sleeping on your back and ensure that your neck is inline with your body. Choose a supportive pillow. Learn more about positional therapy and anti-snore pillows.

No. 10. Ability to move side-to-side (lateral movement)

It might seem obvious, but unless the MAD is worn, it cannot stop your snoring.

As such, it must be comfortable to use. Part of this comfort equation is the MAD not creating a ‘trapped’ sensation.

This may occur when the lower jaw is unable to move from side-to-side.

Gumshields and custom-made MADs
Some MADs (both custom-made and ‘Boil-and-Bite’) exhibit the capability to move laterally (side to side) while some do not. My viewpoint is that you should look for one that does permit movement.
Expert's verdict on lateral movement
If you grind your teeth (brux) then this will significantly impact the life-expectancy of your MAD. In fact, you may work harden metal components necessitating their earlier replacement, than would otherwise be expected.

Finally, while it is perhaps a contentious area, if you routinely ‘brux’, then an anti-snoring device that does not permit side-to-side (lateral) movement may actually disrupt your sleep. One theory suggests that this is because your attempts to move are hindered.

The opposing theory suggests you will no longer brux when your apnea is resolved. The jury is out.

No. 11. Does the Anti-Snoring Device mechanism invade your tongue-space?

Ever had a filling or a crown? You may recall how you were very conscious of it. You probably explored it with your tongue and it felt alien. Every anti-snoring device will feel huge in your mouth when you start to use it.

Consequently, less is more!

 

Less physical presence in your mouth, squashing your tongue, enhances your ability to initially accept it and keep using it – and stop snoring…

The concept behind an MAD is to advance the jaw, and in turn, move the tongue forwards and away from the back of your throat.

This increases your airway dimensions and improves tissue tone, which stops you snoring.

So, when an MAD is too bulky, it squashes your tongue. Which is self-defeating.

Gumshields and tongue space
Typically, gumshields are bulky and squash your tongue. They may even have rough or sharp edges which may cause tongue ulcers.

Technically, this may occur with ‘gumshields’ at the junction between two materials, typically with devices that have a hard-outer shell and a softer thermoplastic liner, or when they are crudely ‘adjusted’ with home equipment i.e. scissors!

Prescription, custom-made MADs

Construction

Some primitive custom MADs are bulky and invade tongue space. Materials technology is continually improving, and thinner cross-section devices are now appearing on the market using laser sintered polyamide (a type of nylon).

While traditionally manufactured metal (known as ‘chrome’) devices are available. These may be expensive to make (as they are labour intensive) and may necessitate plastic and metal combined devices, which builds in failure points (because dissimilar materials exhibit different mechanical properties).

Placement of the adjustment mechanism

The placement of adjustment mechanisms in the tongue space is uncomfortable and counter-productive (see concept note above in introduction to this point). Some early custom MADs used orthodontic screw mechanisms in the palate or inside the lower jaw (lingually).

A sleep-trained dentist will guide you when you choose. To get informed for that conversation download our free, evidence-based How to Choose a Mouthpiece Guide. new window

Expert’s verdict on tongue space invasion
If you can’t wear your MAD, then its pointless having it. Consequently, comfort has to be a pivotal deciding factor when selecting one.

Anything placed where your tongue can contact it, is a negative. Remember less is more, when it comes to MAD design.

No. 12. Easy to Keep Clean (Extend useful life, hygiene)

Consult your dentist and the MAD manufacturer’s instructions on how to clean your MAD.

I would suggest that broadly speaking you should (every time you remove it in the morning) use a toothbrush and toothpaste on the device before/after cleaning your teeth. Floss if you have the enthusiasm and discipline… and consider using a chlorhexidine mouthwash too.

Having worked in this industry for longer than I care to remember, I know that MADs must be:

  • Easy to keep clean
  • Not absorb cleaning fluid or saliva
  • Ideally not have intricate mechanisms to retain food and bacteria
  • Be entirely made of one material

Bacterial biofilm (a slimy film of infectious microbes) will form on the device. It’s important to pay extra attention to your oral hygiene (and keep the MAD clean with a toothbrush immediately you remove it in the morning).

Gumshields for snoring
These materials absorb saliva (and cleaning fluids) so bacteria are drawn into the material itself – not just on the surface. Ewww.
Prescription, Custom MADs
The use of materials with better properties, more suited to long-term use in your mouth, should have less detrimental impact. You will of course need to keep them clean and remove the biofilm – and keep your teeth and gums really clean.

See a dental hygienist if you need assistance keeping on top of this. Its an investment.

Expert’s verdict
Prescription, custom-made MADs utilise materials that are better-suited to long-term use. They are inherently easier to clean and keep clean. This is vital when you consider the number of people who have gum disease (gingivitis) whose condition would be aggravated by an MAD, perhaps to such an extent that they risked losing a tooth.

Top Tip

If you are lucky enough to have a marble bathroom, make sure that the MAD cleaning fluid does NOT splash out (powder or granule type cleaning products are commonly a type of acid that permanently damages marble). Ideally, clean your MAD elsewhere! (Voice of experience! Customer reported the above to me when I ran Zacher Sleep Appliances).

No. 13. Side-effects of Anti-Snoring Devices (Mandibular Advancement Devices)

There’s always a down-side!

Or in ‘English’:

“You don’t get nowt for nowt”

side-effect
The most common side-effect from Anti-Snoring Devices (MADs)
The most common initial side-effect from using anti-snoring devices is related to saliva. Some people find they dribble while wearing the device during the first few weeks of use. Others may find they have a dry mouth.
The next most common side-effect is jaw ache
This is normally transient and may arise during the ‘titration’ period (where the device is adjusted to gradually advance your lower jaw and stop you snoring).

If this occurs, the correct advice is to speak with your dental clinician. It normally resolves itself but do not suffer in silence.

Longer term, changes in the position of your teeth may occur
This is due to the weight of your lower jaw (think gravity) and the muscles attached to it combining to attempt return of your jaw to its normal position. These forces are all transferred to your teeth and their roots.

This is why even the most wonderful anti-snoring devices are NOT suitable for children – because they would act like an orthodontic device and move their teeth in uncontrolled ways (exceptionally an orthodontist may prescribe an anti-snoring device for certain children with particular needs).

Expert's verdict on side-effects
It is really important to keep things in perspective: Not snoring, breathing and sleeping at the same time or perhaps minor tooth movement?

However, as I have highlighted throughout this review all anti-snoring devices have side-effects.

A sleep-trained dentist would screen you for sleep apnoea, help you stop snoring and minimise (and if necessary correct) any side-effects. They also carry professional indemnity insurance and use prescription anti-snoring devices made to quality standards by registered dental technicians.

FREE BONUS

Download our free, NHS England’s Information Standard accredited, evidence-based, expert-written and jargon-decoded Guide

(that’s a mouthful!):

> How to Choose a ‘Mouthpiece’ to Stop Snoring

You’ll learn about your options and be able to make more informed choices.

No registration is required.

All our Guides, including our award-winning snoring and sleep apnoea overview guide are free on:

google play books logo

If you prefer you can grab the guides on Amazon Kindle (who sometimes insist on a minimum 99p fee).

 Amazon Kindle

If you snore and self-help isn’t cutting it then don’t self-diagnose.

Get signposted to the most appropriate professional to help you. Its free, evidence-based and a simple way to find out if snoring is actually a symptom of sleep apnoea.

NHS England's Information Standard UK
top-selling anti-snoring devices

Summary

This review has examined the best anti-snoring devices, both Over-the-Counter and custom-made, against my top 13 criteria, to help you choose an anti-snoring device that works, and is safe and effective.

My final verdict is that while a ‘boil-and-bite’ gumshield may prevent snoring for a short while (if you fit the gadget) they are ultimately a false economy and won’t work for long (if at all).

Longer-term, if you were to persevere with a ‘gumshield’ for snoring, it would:

  • Create unpleasant and sometimes permanent, unmanaged dental side-effects
  • Potentially irreversibly damage your jaw-joints
  • And it delays potential OSA diagnosis and effective treatment

In conclusion, clinical research3 has established that ‘boil-and-bite’ gumshields are not valid as either a trial or treatment device.

But this is not a definitive guide to OTC anti-snoring device manufacturers’ claims. This is.

The real question

The real question is:

Why do you snore?

My advice is to:

  • Get signposted to the most appropriate professional
  • Get screened for sleep apnoea before you dive into any treatment and learn why you snore

And then you will know how to stop.

Here’s the next step:

Found this useful?

Write a review below, and let me know.

Anti snore pillows seem ideal.

But do they work? Read my review.

1 - 5 out of 5, where 5/5 is the best and 1/5 is the worst


Reviews

Mrs P
Really interesting stuff!
May 24, 2018
    

Really helpful when I was worried about my OH’s snoring. Gave me info on what to worry about. Next stop the GP.


We applaud Adrian’s work
Snorer.com
September 7, 2018
    

If you are looking for impartial advice about snoring from an expert in the field, the highly respected Adrian Zacher should be your go to. We applaud Adrian’s work, to raise awareness about the health implications of snoring, and the importance of prescription, custom-made devices for long-term success.

Expert reviews and ‘How-to’ Guides related to Anti-Snoring Devices:

Here are some more expert reviews about anti-snoring devices, snoring and sleep apnoea / apnea products, cures and aids!

Personally, I hate instant snoring cures as the balance of benefit to risk is generally against you.

Glossary

Anti-Snoring Device – generally considered a product worn in your mouth to stop you snoring.

Boil-and-Bite – a type of gumshield for snoring that may be adapted to you by softening the material in boiling water. See OTC below.

Custom-made – a bespoke device made exclusively for you by a registered dental technician, working to prescription, using CE marked materials. In Europe working to the Medical Devices Directive  administered in the UK by the Medicines and Healthcare Products Regulatory Authority (MHRA).

DSM Dental Sleep Medicine – the management of sleep-related breathing disorders using dental devices.

Gumshield for snoring – see ‘Boil-and-Bite’ above.

Information Standard – NHS England’s Information Standard. Organisations that join The Information Standard are showing their commitment to producing good quality, evidence-based health and care information.

MAD Mandibular Advancement Device – Jaw advancing device, worn at night while asleep to hold forward the lower jaw to stop snoring and prevent obstructive sleep apnoea / apnea.

MAS Mandibular Advancement Splint – See ‘MAD’.

MRD Mandibular Repositioning Device – See ‘MAD’.

OSA Obstructive Sleep Apnoea – (also spelt apnea) When an individual is unable to sleep and breathe at the same time. Visually, a repetitive pattern of breathing interruptions (apnoeas) occurring while the individual sleeps, due to a physical obstruction in the airway.

OTC – Over-the-Counter product sold over the pharmacy counter or on-line without prescription, medical or dental assessment and without a review of medical/dental history.

Signposting – Is the medical term for directing people to the most appropriate professional to help them based upon their answers to some high-level questions.

Sleep-trained Dentist – A dentist that has undergone special interest training in sleep. As such they are able to obtain professional indemnity insurance.

TMD – Temporo-Mandibular Joint Dysfunction. Jaw-ache or pain, due to abnormal or impaired movement.

References

  1. Snoring cures success ‘exaggerated’ http://news.bbc.co.uk/2/hi/health/1701735.stm new window [accessed 16th Oct 2016]
  2. Stradling, J. and Dookun, R. 2009, Snoring and the role of the GDP: British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol, British Dental Journal, 206, 307 – 312. Available here: http://www.nature.com/bdj/journal/v206/n6/abs/sj.bdj.2009.214.html new window [accessed 12 April 2017]
  3. Vanderveken OM, Devolder A, Marklund M, et al, 2008. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med; 178: 197–202. Available here: http://www.atsjournals.org/doi/abs/10.1164/rccm.200701-114OC#.V9ukcFT_rio new window [accessed 12 April 2017]
  4. Ready-Made Versus Custom-Made Mandibular Repositioning Devices in Sleep Apnea: A Randomized Clinical Trial, Johal A, Haria P, Manek S, Joury E, Riha R. Ready-Made Versus Custom-Made Mandibular Repositioning Devices in Sleep Apnea: A Randomized Clinical Trial. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2017;13(2):175-182. doi:10.5664/jcsm.6440. Available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263072/ new window [accessed 18th June 2018]
  5. A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO). Quinnell TG, Bennett M, Jordan J, Clutterbuck-James AL, Davies MG, Smith IE, Oscroft N, Pittman MA, Cameron M, Chadwick R, Morrell MJ, Glover MJ, Fox-Rushby JA, Sharples LD. Thorax. 2014 Oct; 69(10):938-45. Available here: http://thorax.bmj.com/content/68/Suppl_3/A4.1  new window [accessed 18th June 2018]
  6. Pitsis AJ, Darendeliler MA, Gotsopoulos H, et al: Effect of vertical dimension on efficacy of oral appliance therapy in obstructive sleep apnea. Am J Respir Crit Care Med 166:860, 2002. Available here: https://www.ncbi.nlm.nih.gov/pubmed/12231498  new window [accessed 18th June 2018]

Created by Adrian Zacher | Page last updated 2nd Dec 2019

How to prescribe oral appliances for snoring (Ultimate Guide 2019)

How to prescribe oral appliances for snoring (Ultimate Guide 2019)

Healthcare
Professional
information 

HOW TO PRESCRIBE ORAL APPLIANCES FOR SNORING

The Ultimate Guide

By Adrian Zacher

2019 edition


This Ultimate Guide for dentists, will show you exactly how and when to prescribe oral appliances for snoring patients. Supplemented with multiple real-life examples, downloads, videos, photos of impressions and 13 intra-oral images.

It could equally be titled ‘When to prescribe…” as there’s a right and a wrong time to prescribe a Mandibular Repositioning Appliance (the technical name).

The best part? If you’re a UK dentist, I will show you how to prescribe oral appliances for snorers without a prior medical diagnosis (and stay indemnified).

Sound good? Let’s dive right in…

Snorer.com
Rated 5/5 based on 16 customer reviews
How to prescribe oral appliances for snoring and sleep apnoea / apnea

Peer review and about the Author

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Looking into snoring solutions can be an intimidating process, with so many different options and treatments available. The How to prescribe oral appliances for snoring: Ultimate guide provides in-depth, impartial advice, looking at all the options available, so the practitioner can offer the best service. Well done!

Lucy Ash (Director at Somnowell. Ltd) An excellent resource for both, snorers and healthcare professionals. October 10, 2018

Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I teach UK dentists how to help their patients stop snoring; sleep and breathe at the same time.

Many of my customers find their work so rewarding they devote their practice to it. I’m a sleep-industry insider with a quarter of a century of sleep medicine experience.

Google Scholar

Click to jump to each chapter:

CHAPTER 1

Finding suitable patients: referrals, screening, recognition and diagnosis

CHAPTER 2

Dental clinical signs and symptoms of sleep-related breathing disorders

CHAPTER 3

Can I prescribe oral appliances for snoring / sleep apnoea?

CHAPTER 4

What training do I need? How to judge quality dental sleep education

CHAPTER 5

What does the lab need?

CHAPTER 6

How to choose the ‘best’ oral appliance for snoring?

CHAPTER 7

Titration, follow-up, your duty of care

CHAPTER 8

FAQs, tools and resources

Before we begin… is this you?

A patient has asked me about an Anti-Snoring Device…

STOP.
Unless you’re sleep-trained do NOT prescribe an anti-snoring device.

  • You’re not insured (both the Dental Defence Union and Dental Protection Ltd. have position statements on this)
  • You may delay your patient’s diagnosis by inadvertently disguising their symptoms: snoring may be a symptom of obstructive sleep apnoea (OSA) and the first-line therapy for OSA is not an oral appliance

I’ve received a referral (patient has sleep apnoea): Now what?

STOP.

While you’re medico-legally ‘OK’ to prescribe an anti-snoring device (the patient has a medical diagnosis and has been referred to you for oral appliance therapy) ask yourself:

Do you feel sufficiently informed to treat?” 

Intrigued? Read on…

CHAPTER 1:

 

Finding suitable patients


Starting right now, I’ll show you how to find enough patients, to make a fulfilling business from helping snorers.

Beginning with networking, referrals and building your credibility, we then navigate how to accelerate the process through screening and recognition (I will also cover diagnosis).

Finding snorers who need help

Finding patients

Helping someone stop snoring, I’m sure you’d agree, is a great aim. Happily, the market for oral appliance therapy for snoring (i.e. prescription, custom-made anti-snoring devices) continues to grow.

Indeed, 20% growth in European unit sales (2017) was reported by one of the few listed companies1 that provide such details.

So, its perhaps surprising then, that in my experience, dentists get very excited, train how to prescribe oral appliances for snorers… and then….

Nothing.

Nothing at all.

If you’re reading this, then maybe you have a snorer in mind (you or your other half perhaps?).

Well you’ve found one snorer, so how hard can it be, to find some more?

After all, it seems just about everyone snores…2

40% of the UK population regularly snore

Perhaps a slight exaggeration to say EVERYONE snores, however, in a telephone interview of 4972 people (UK population sample, aged 15 -100 yrs) 40% reported snoring regularly and 3.8% reported breathing pauses during sleep. BMJ, 1997; 314:860 (Ref. 2)

Yet, dentists once sleep-trained either:

  • Don’t know how to find these snorers
  • Or perhaps it’s just too darn hard (or slow) to make a real go of it

Why is that?

(Don’t worry – I will tell you why – and how to get snorers knocking on your door).

How to receive referrals of snorers?

Dentists around the world are facilitators in sleep medicine. They facilitate provision of a therapy for a sleep and respiratory condition:

  • Snoring (and Obstructive Sleep Apnoea / Apnea).

The choice of treatment (in this case a mandibular repositioning appliance or MRA) is not made by them.

Which is not such an alien situation as it may at first appear…

For instance:

You may as part of your oral health assessment (with training) suspect the patient has an oral tumour and proceed to refer them for expert assessment, diagnosis and a treatment plan.

Perhaps you’re involved in the long-term management of the patient?

Treatment for snoring or OSA follows diagnosis, and the diagnosis of obstructive sleep apnoea / apnea (OSA) is the exclusive preserve of the Consultant Respiratory Physician (after amongst other things an overnight sleep study) – but we’ll get to that in a moment.

It might seem obvious but to receive referrals, you need to be known to the referrer!

JARGON ALERT!

Oral Appliance, Device, Mouthpiece, ‘Gumshield’, Splint…
MRA (Mandibular Repositioning Appliance)
MAS (Mandibular Advancement Splint)
MAD (Mandibular Advancement Device)
MRD (Mandibular Repositioning Device)

These are different names (acronyms) for the same thing: an oral appliance which holds the lower jaw forwards to improve breathing while asleep.

JARGON ALERT!

A sleep study is an overnight test that (while the patient sleeps) includes measurements of oxygen saturation, body position and the amount of effort required to breathe.

Treatment for snoring follows screening for sleep apnoea

When can dentists treat snorers?

Snoring may be a symptom of OSA, in which case the sleep-trained dentist is faced with a situation that is more or less delineated by this extract from the American Academy of Sleep Medicine’s Clinical Guideline3 (yes, OK, this is a US Guideline but it’s broadly similar to what’s found in other parts of the world and it makes my point clearly enough):

The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment.

This is an ideal time to define obstructive sleep apnoea:

What is Obstructive Sleep Apnoea?

Obstructive sleep apnoea (OSA) is a condition where breathing repeatedly stops during sleep4, because the upper airway behind the tongue, has narrowed or collapsed. Sufferers commonly snore.

What are the symptoms of Obstructive Sleep Apnea Syndrome?

Obstructive sleep apnoea syndrome (OSAS) gives rise to unexplained daytime sleepiness as the dominant symptom. Sufferers experience major adverse physiological changes, due to the recurrent asphyxia and micro-arousals that fragment their sleep.5

Other symptoms include:

  • Reduced vigilance
  • Difficulty concentrating
  • Poor at work, home and driving6 performance
  • Snoring

OSAS fragments someone’s sleep to such an extent that they’re unaccountably drowsy and tired when they should be wide-awake.7

How to differentiate between snoring and OSA?

This is the crux of the issue.

Differentiating between OSA sufferers who snore (who would benefit and most likely comply with a Positive Airway Pressure or PAP device) and ‘simple’ benign snorers, who would be most appropriate for an oral appliance is what sleep units ‘do’.

You need to leave this to the professionals in the sleep unit. (Unless you’re a dentist in the UK – we’ll get to how this works later).

JARGON ALERT!

PAP = Positive Airway Pressure therapy.

This is the best option for severe obstructive sleep apnoea (OSA).

Learn more about PAP therapy with this ‘How to choose: PAP therapy‘ ↗ Guide

If you want to understand where MRAs fit with the other treatment options (PAP, soft and hard tissue surgery) for snoring and sleep apnoea, then check out this video from our KnowSleep™ Academy for dentists. ↗:

Snoring or OSA?

How to get referrals from the Sleep Unit, ENT and MaxFac departments?

Active networking is not for everyone.

However, as a sleep-trained dentist wishing to receive referrals, you will need to network with:

  • Your local sleep unit
  • The ENT department
  • The Oro-maxillofacial department
Receiving referrals from the sleep unit, MaxFac dept, ENT

The departments in your local hospital (listed above) need to be aware of your existence and training, for you to receive referrals of patients, in the following circumstances:

  • When snoring patients do not merit treatment with PAP therapy or sleep apnoea patients have refused or failed with it
  • ENT approaches have not been successful or require concurrent oral appliance therapy
  • Oro-maxillofacial surgery is not considered appropriate
Treatment options

It certainly won’t hurt to write to them, yup, good ol’ snail mail.

Also, make sure you attend any continuing education events the units may run, join the available professional societies and go to the national sleep conferences (I can see a joke here – but I’m not going there)

There’s no way around it:

It will take some time and effort.

This rather passive, ‘wait and see’ approach as to when you can prescribe an oral appliance for snoring, is globally applicable – with one unique exception (in the United Kingdom):

Which I hinted at earlier and can now reveal…

How to screen and recognise obstructive sleep apnoea (OSA)

Sleep-trained dentists in the UK, using the British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol8, may screen and recognise obstructive sleep apnoea (OSA) symptoms (and refer for further investigation).

What this means:

You can train to identify snorers who can be treated safely with oral appliances, without a prior medical diagnosis.

Which is a globally unique situation (to the best of my knowledge).

Screening for obstructive sleep apnoea?

Dentists screen for oral conditions every day.

Call it an ‘oral health assessment’ if you like, whether you’re screening for gingivitis, caries or an oral tumour… screening for a condition is simply looking for the warning signs, while it’s in its infancy.

The idea of course, is that a condition in its early stages may be more easily treated or managed.

Warning signs of sleep apnoea

Can I screen for obstructive sleep apnoea?

Screening for OSA is no different to the screening (sorry oral health assessment) that you do routinely.

The conversation begins by adding the important question:

Do you snore?

to your medical history questionnaire. If you ask this question, then I’m sure you will be amazed how many snorers you discover – and how many want to talk to YOU about their condition.

Sleep-trained dentists may recognise (and I use the word ‘recognise’ intentionally) symptoms of obstructive sleep apnoea, including:

  • Daytime sleepiness
  • Obesity
  • A partner witnessing breathing interruptions during sleep
  • Awakenings due to gasping or choking fits
  • Frequent night awakenings to urinate
  • Need to sleep sitting up
  • Snoring

It’s important to note that UK sleep-trained dentists are not diagnosing.

They are assessing according to an agreed, published protocol and acting within the bounds of their professional indemnity insurance9, 10 (which is kind of important!).

Unless you’re a sleep-trained dentist in the UK, you need to refer EVERYONE to their GP (primary care physician – PCP) for the doctor to decide who should be referred for a sleep study after which the most appropriate treatment can be discussed. You might well see the patient again for the fitting of an oral appliance.

The Association of Respiratory Technology and Physiology (ARTP) Standards of Care document, cites the British Society of Dental Sleep Medicine’s pre-treatment screening protocol (as published in the BDJ May 2009, by Prof. John Stradling FRCP and Dr Roy Dookun BDS).

These two documents make up the ‘rules of the game’ for UK sleep-trained dentists.

We’ll get into this some more later (Chapter 4 – What training do I need?).

The benefits of dental screening and recognition of sleep apnoea

OK, so you can’t immediately prescribe an oral appliance for snoring.

But the snorer you refer to their GP (or Primary Care Physician if you prefer) effectively becomes your ‘sales person’. The patients you push through the system the right way, then help to reinforce your networking.

The sleep unit medics will think:

“Here is a responsible, informed professional – lets send our patients to them.”

Tick.

Diagnosis of snoring and / or obstructive sleep apnoea (OSA)

As I said in the paragraph ‘Screening and Recognition’ above, the diagnosis of OSA and what is known as ‘simple’, ‘benign’ or ‘anti-social’ snoring is not something a dentist can do.

Here’s the pertinent extract from Dental Protection Ltd’s position statement (a UK-based professional indemnity insurer):

The diagnosis and treatment of OSA, other sleep disturbances or snoring conditions does not fall within the definition of the practise of dentistry and therefore falls outside the scope of assistance normally provided by Dental Protection. However, dentists can have an important role in the screening of patients for signs and symptoms which may predict the presence of OSA.

Consequently, determining that your patient ‘just’ snores and prescribing an oral appliance for snoring, is likely to get you into ‘hot water’.

And it would comprehensively obliterate any credibility you’ve built up, with all your networking and screening efforts.

Don't just prescribe for snoring

Sleep-Related Breathing Disorders: The Dentist’s Role

There is an expectation that patients see their GP at a frequency, based upon their age and needs.

For example, a new mother would perhaps see their GP regularly (say once a week – a month), whereas young adults perhaps less so (once every few years – or only as necessary). And so on.

Dentists on the other hand, generally see their patients (and look in their mouths) at defined and comparatively frequent intervals.10 i.e. more than 3 months and no more than 24 months apart.

Dental intervals

As such, dentists are ideally placed to play 4 critical roles12:

Treating adults with oral devices for snoring  Treating adults with oral devices for snoring and mild to moderate OSA to slow the progression of the disease
Identifying patients at risk (both children and adults) by looking at their upper airways on a regular basis  Identifying patients at risk (both children and adults) by looking at their upper airways on a regular basis
Treating children with rapid maxillary expansion and avoiding deleterious orthodontic treatments  Treating children with rapid maxillary expansion and avoiding deleterious orthodontic treatments
Recognising the need for bimaxillary osteotomy among young adults with a need for maxillofacial correction  Recognising the need for bimaxillary osteotomy among young adults with a need for maxillofacial correction

Top tip: Sleep-related breathing disorders: Dentists are ideally placed to play 4 critical roles.

So, as a UK dentist with dental-sleep medicine training, YOU can become a valued member of the sleep patient care team.

You just need to find patients…

Have signposted snorers making appointments with you.

Have signposted snorers come to you

CHAPTER 2:

 

What are the dental clinical signs and symptoms of sleep-related breathing disorders?


Picture yourself:

You’re screening performing an oral health assessment and you start to wonder:

“What are the dental signs and symptoms of sleep-related breathing disorders?”

Well, lets have some real-life examples:

What are the dental clinical signs and symptoms of sleep apnoea?

What are the dental clinical signs & symptoms of sleep-related breathing disorders (SRBD)?

Let’s have some examples. You may come across these dental clinical signs and symptoms of possible Sleep-Related Breathing Disorders (SRBD).

Including:

Scalloped tongue  Tongue crenulations (scalloped borders) suggesting perhaps both bruxism and that the patient is regularly pushing the tongue forwards against the teeth to open their oral airway.

Scalloped tongue

open-bite relationship of the opposing teeth may result from tongue posturing  The development of an anterior or lateral open-bite relationship may result from tongue posturing.

Sleep bruxism   Sleep bruxism may develop or increase (see point 1 above)

Gastroesophageal reflux  Dimpling of the cusps and lingual surfaces of the teeth may be an indicator of related gastroesophageal reflux. Reflux may occur due to  ‘pumping’ efforts to breathe bringing up stomach acid.

Incisor damage from stomach acid - perhaps from gastro-oesophageal reflux
Dentinal pooling a symptom of sleep apnoea?

temporomandibular joint (TMJ) dysfunction symptoms  The development of:

  • Orofacial pain
  • Temporomandibular joint (TMJ) dysfunction symptoms
  • Masticatory muscle fatigue noted on awakening
  • Morning headache

These can be related to the positioning of the mandible to open a person’s airway or bruxing after a sleep apnoeaic episode.

large uvula, or a narrow or tongue-obstructed airway  During the evaluation of the oropharynx, prominent tonsils, a large uvula, or a narrow or tongue-obstructed airway may be noted.

The patient’s age may also contribute to loss of tone of the pharyngeal muscles.

mouth breathing while sleeping  Evidence of mouth breathing while sleeping may take the form of drying of the surface of the gingiva.

  Halitosis

What should I do if I suspect the patient has sleep apnoea?

If your suspicions are aroused, then refer the patient to their GP (in writing) for further investigation. Or if you’re in the UK and you’re a sleep-trained dentist, you should screen for OSA and its comorbidities.

And if you look down a patient’s throat and see this – what does it tell you?

This patient has had a UVPPP (sometimes its written UPPP). This acronym stands for ‘uvulopalatopharynogplasty’ and this is the ENT surgery solution for problem snoring.

Read more about surgery for snoring.

CHAPTER 3:

Can I prescribe an oral appliance for snoring?


Now (at last) we can answer your question:

“Can I prescribe an oral appliance for snoring?”

And this is absolutely about WHEN as a dentist you can prescribe.

Time to put the sickle scaler down.

Can I prescribe an oral appliance for snoring?

When to prescribe oral appliances for snoring?

It really is the million-dollar question! So, let’s start positively.

You can prescribe an oral appliance for snoring when:

  The patient has been diagnosed by a sleep unit and referred to you for an oral appliance for snoring or obstructive sleep apnoea.

  You’re a UK sleep-trained dentist, who has screened for OSA, and is satisfied the snorer is a candidate for oral appliance therapy.

Now back to reality with a bump…

If either of the above 2 conditions are not satisfied, then you cannot prescribe an oral appliance for snoring.

Sorry, I don’t make the rules. (Err… Except I did have a hand in making the rules in the UK… but that’s another story).

Onwards…

Case selection

In situation case selection above, the patient has been deemed suitable (from a medical perspective) for an oral appliance for snoring / obstructive sleep apnoea (OSA) and referred to you.

This is now a double prescription situation.

Allow me to explain:

The Consultant Physician has prescribed oral appliance therapy, and YOU as the dentist prescribe which mandibular repositioning appliance (if you consider it dentally appropriate) the patient gets to take home.

JARGON ALERT!

Oral Appliance Therapy is the term for prescription, custom-made medical devices that reposition the mandible to aid breathing while the user is asleep.

JARGON ALERT!

Mandibular Repositioning Appliance, Mouthguard, Device, Mouthpiece, ‘Gumshield’…
MRA (Mandibular Repositioning Appliance)
MAS (Mandibular Advancement Splint)
MAD (Mandibular Advancement Device)

These are different names (acronyms) for the same thing: an oral appliance that repositions the lower jaw to improve breathing while asleep.

Bottom line:

It is down to you as a dentist, to determine if the patient is suitable from your dental, clinical perspective – and then to select the most appropriate oral appliance.

But not like the example shown below:

Unsuitable patient lower impression

Example of an unsuitable patient (lower impression)

Poor case selection upper dental impression

Example of an unsuitable patient (upper impression)
[and yes both impressions are from the SAME patient]

What’s wrong with the above case?

  • Insufficient teeth per arch
  • Of the remaining standing teeth, they are unevenly distributed around the arch
  • Only incisors remaining on the mandible – retaining the MRA and therefore the jaw will be difficult (is this time to consider implants?)

If an oral appliance for snoring were to be prescribed – it would likely prejudice the remaining teeth.

CHAPTER 4:

 

What training do I need to prescribe an oral appliance for snoring?


The Financial Conduct Authority defines independence for financial advisers, and uses wonderful terms like:

“non-independent advice”

My point is, that any rational person seeks a whole-of-market view, and treats ‘one brand sales spiel’ with a degree of caution.

Selecting dental sleep medicine training, is exactly the same.

What training do I need to prescribe oral appliances for snoring?

Training to prescribe oral appliances for snoring: What’s required?

Staying with my financial adviser analogy a moment longer, the ‘tied’ financial adviser is, in dental sleep medicine terms:

The ‘one oral appliance for snoring dental lab‘ provided course.

Such a course provides you with:

Insufficient knowledge  Insufficient knowledge of a broad range of oral appliances for snoring. Just like any other medical device, mandibular repositioning appliances have indications and contra-indications. There is no ideal or ‘best’ device. It all depends upon the patient.

Risk exposure  Professional indemnity insurance risk. Why would you use anything other than an insurer approved way to screen and recognise snorers that are safe to treat with oral appliances (without a prior medical diagnosis)? When selecting education, look out for the British Society of Dental Sleep Medicine’s pre-treatment screening protocol.

What constitutes appropriate dental sleep medicine training?

Happily, in the UK we don’t have to guess what constitutes appropriate dental sleep medicine training. We simply refer to the Association for Respiratory Technology and Physiology’s (ARTP) defined training course content:

Click to read: ARTP - content of courses / documented training should include:

1.7.1 Content
The content of courses/documented training should include:

  • Basic knowledge of sleep physiology/architecture
  • Pathophysiology of relevant sleep disorders (including the parasomnias and dyssomnias which in addition to OSA, are causes of excessive daytime sleepiness)
  • Sleep disordered breathing, OSA, OSAHS
  • Biomechanics of MRD therapy
  • Screening for the signs and symptoms of OSA, patient evaluation and assessment
  • Potential side effects of MRD therapy (short and long term)
  • Varieties of appliance design and manufacture
  • Appliance adjustment and patient follow up/recall
  • The dental practitioner must also be aware of the range of non-dental appliance interventions (both medical and surgical) available for patient treatment as well as an appreciation of the medical co-morbidities associated with OSA, an appreciation of the dangers of excessive daytime sleepiness (EDS), the assessment of EDS and the importance of taking a full and accurate medical and OSA history.

The identification of snoring/OSA predisposing factors needs to be discussed with the patient and along with appliance assessment factors which must also be taken into consideration as these may influence the design of device to be prescribed or even the decision to provide a mandibular repositioning device at all.

Cut to the chase: training to do what again?

Training that means you are confident with the below list:

  • You must be sufficiently informed about a range of oral appliances for snoring: their indications and contra-indications
  • You’re into lifestyle advice, i.e. stop smoking, quit alcohol, lose weight etc.
  • You (or a dental nurse perhaps?) need to record (and monitor for changes) the patient’s:
    • Blood pressure
    • Height
    • Weight
    • Neck circumference
  • You will ideally have examples of different MRA to demonstrate to the patient
  • You must explain the risks and benefits: and it’s a good idea to provide this advice in writing
  • You must ensure you have valid informed consent (grab an example PDF in Downloads)
  • You need to explain the possible side-effects and keep master casts to identify tooth movement – and communicate signs of this immediately to the patient
  • You have a duty of care to follow-up snorers and sleep apnoeaics alike (as their condition may change over time)

Here are the pertinent lines re: different designs of oral appliance from the same document (they use the acronym MRD – mandibular repositioning device):

1.5 Equipment
There are a variety of custom manufactured MRD designs available. Some designs may be deemed more appropriate for the individual patient after assessment.

1.7.1 ……………. The identification of snoring/OSA predisposing factors needs to be discussed with the patient and along with appliance assessment factors which must also be taken into consideration as these may influence the design of device to be prescribed or even the decision to provide a mandibular repositioning device at all.

Which means (if you undertake independent training and use the BSDSM protocol) you’ll stay on the right side of the professional indemnity insurers’ position statements.

How the professional indemnity insurers position statements help you

Fortunately, the Dental Defence Union8 and Dental Protection Ltd.9 have issued position statements (and of course other insurers will refer to these as the industries benchmarks).

I say ‘fortunately’ because we’re not guessing.

The position statements and ARTP Standards of Care make it crystal clear WHAT constitutes appropriate dental sleep medicine training and what does not.

Here’s the deal:

  • Seek comprehensive courses, independent of manufacturer bias – that make you aware of the wide array of oral appliances (and their indications and contra-indications)
  • Screen using the British Society of Dental Sleep Medicine’s protocol or frankly you’re asking for trouble.

Of course, it would be rude at this point not to highlight our KnowSleep™ Academy for dentists, on-demand video courses (that naturally do all of the above):

CHAPTER 5:

What does the lab need to make an oral appliance for snoring?


You might be wondering:

  • "What impressions does the lab need?"
  • "What bite registration is required?
  • "Errr... How do I record a protrusive bite?"
  • "How many teeth are required?"

Fear not.

What information does the lab need to make an oral appliance for snoring?

Lab requirements

Or to put it another way:

What do good, bad (and plain ugly) impressions look like?

The examples below, illustrate what impressions and the typical protrusive bite registration, should look like. Consult the dental lab (of course) for specifics for each mandibular repositioning appliance you consider. 

The impressions shown below are not fictitious. 

Good dental impression for an oral appliance for snoring

'Good' dental impression for an oral appliance for snoring

 

Bad dental impression for an oral appliance for snoring

'Bad' dental impression for an oral appliance for snoring. (If you look closely you will see a BSDSM standing order mandate!)

Ugly dental impression for an oral appliance for snoring

'Ugly' dental impression for an oral appliance for snoring

 

What impression material should I use for a mandibular repositioning appliance (MRA)?

Unless your alginate impressions are cast up within the hour, my advice is to use upper and lower fine detail silicone or polyvinysiloxane impressions of all the patient’s teeth. Use a special tray if required.

> Why include ALL teeth in the dental impression for an MRA?

It's advisable to include the 8s if present, as regardless of whether they are included in the final device, including them aids the lab avoid interference on protrusion and lateral excursions.

> What about sulcal extension?

Pay close attention to the sulcal extension where the device mechanism is to be situated.

What bite registration is needed for a mandibular repositioning appliance?

A protrusive bite registration.

Typically between 50% and 80% of the patient’s maximum protrusion (it may be useful to work back from 100%).

Your protrusive bite registration dictates your choice of oral appliance: Don't have an oral appliance in mind.

How to record the protrusive bite?

The George Gauge video below (click on it bottom right to go full screen) shows you more about how to take a protrusive bite registration with a product called a George Gauge (you can get these from MRA labs).

[YouTube video used with permission from Great Lakes Orthodontics - who I have no commercial connection with.]

How many teeth are required for a mandibular repositioning appliance?

8 teeth per arch (minimum) is a good starting point. However, just as important (if not more so) as the number of teeth, is the arrangement of the remaining teeth:

  • You need teeth where you intend to have the titration mechanism
  • If there are few molars - incisor sensitivity and ultimately proclined / retroclined incisors will result

So that wraps up general lab requirements. Talk to your lab - they may have their preferences and these may vary for a particular device.

Which brings me neatly to how you choose the 'best' oral appliance for your patient:

CHAPTER 6:

 

How to choose the 'best' oral appliance for snoring?


We've covered How?, When? and What? now we'll look at Which?

Which oral appliance for snoring is 'best'? 

When the patient is:

Class II?, Class III? A heavy bruxist? Has edge-to-edge incisors? Has a heavily restored dentition?

Do you mean to say the 'best' oral appliance can't cope?

How to choose the best oral appliance for snoring?

Which oral appliance for snoring do I prescribe?

There's a lot of marketing guff about this or that oral appliance for snoring being the 'best' one.

The 'best' oral appliance for your patient is of course, the one indicated and not contra-indicated.

I've written it before and I will write it again:

"There is no ideal (read 'best') oral appliance"

Here are some examples of what I mean:

Class II, steep condylar angle, step between lower 3 and 4

Situation
Mr X snores. He does not have OSA (referred to you by the local sleep unit), his BMI is 30 but he is otherwise healthy. He is late 30's, fully dentate, with reasonable oral hygiene and no perio. No evidence of TMD. He is Class II skeletal (mandibular retrognathia) with an acute condylar angle and a 'step' between lower 3 and 4. As he protrudes his OVD markedly increases.

Observations

  • An oral appliance that crowds his already cramped tongue is contra-indicated.
  • As the patient protrudes, an adjustment mechanism between the incisors, may no longer connect
  • Gross (and intolerable) vertical opening may develop due to the high condylar angle
  • The posterior parts of the oral appliance may impact upon one another
The heavy bruxist

Situation
Mr S snores. He has moderate OSA and is PAP non-compliant (referred to you by the local sleep unit). He sleeps supine (on his back). He is mid 40's, was a rugby player in his youth and now his BMI is 35 despite exercise. You suspect it relates more to muscle bulk and not so much fat. Neck circumference is 20 inches.

He bruxes and exerts terrific forces on his MRA (which he swears by). He has however found the metal components BREAK. And he has on occasion woken up with the broken part in his mouth.

What do you do?

Observations
Metal components will be work-hardened by his bruxing.

Perhaps consider an MRA where metal components are not subjected to his bruxing forces. Ensure it permits limited lateral movement or be prepared to swap out the metal components at frequent intervals.

Consider offering advice re positional therapy.

Class III or 'edge-to-edge' incisors

Situation

Miss G snores. She does not have OSA (referred to you by the local sleep unit), and she is otherwise healthy. She is mid 30's, fully dentate, with reasonable oral hygiene and no perio condition. BMI 35. No evidence of TMD. She is Class I skeletal. She has a 'firm' incisor relationship (edge-to-edge) i.e. nil overjet / overbite.

Which MRA do you consider is indicated?

Observations
Consider an MRA that neither contacts the labial aspect of the maxillary incisors or lingual aspect of the mandibular incisors to limit and ideally prevent incisor tilting.

Heavily restored dentition

Situation
Mrs B snores. She is a new patient. She does not have OSA (referred to you by the local sleep unit), and she is otherwise healthy. She is mid 50's, fully dentate, with reasonable oral hygiene and no perio condition. BMI 35. No evidence of TMD. She is Class I skeletal. Her incisors have veneers and her molars have bridgework that do not raise immediate concerns.

Which MRA do you consider is indicated?

Observation
Consider perhaps an MRA that is less dependent upon dental retention for its effect.

Here are two examples (and there are many more) of oral appliances for snoring with entirely different protrusive mechanisms.

While they both protrude the lower jaw, they have different indications and contra-indications, range of movement, side-effects and frankly costs!

Which one is 'best!' Hah!

Oral appliance for snoring and sleep apnoea
Oral appliance for snoring

Why does this matter?

Knowledge of a range of MRAs is vital for you to prescribe the most appropriate for your patient. It gives them the best chance of it working and should minimise side-effects.

Finally, I refer you to the 'ARTP Standards of Care for MRDs' document we discussed earlier:

The particular part about:

"...possessing knowledge of a range of oral appliances".

Sadly, time and again, I've witnessed dentists and patients struggling with patently the wrong type of MRA.

 

  • The well-intentioned but misinformed dentist is at a loss. They have nothing else to offer the patient because the 'one trick pony' lab they usually rely on, only sells the 'best' oral appliance.
  • The lab does not have the indicated oral appliance in their portfolio - i.e. they believe their own hype - and are contractually bound NOT to carry competing (shouldn't that be complementary?) appliances.

How to select the 'best' oral appliance for your snoring patient

Earlier I wrote:

"Your protrusive bite registration dictates your choice of oral appliance: Don't have an oral appliance in mind."

To elaborate:

The 'protrusive bite' informs your decision-making process, when it comes to selecting the indicated oral appliance for your snoring patient.

Buckle up, this gets a little complicated

The objective at this point, is to stay within the adjustment 'window' of the mandibular repositioning appliance:

Which is not as simple as it may at first appear...

Let me give you an example:

Assume the (new to MRA) patient's range of protrusive movement is ~15mm, then consider these points:

  1. Typical MRA protrusive range is 8-10mm (if more is required then you're into a remake)
  2. You might think therefore that an initial protrusive bite that is 5-8mm ahead of centric has you covered
  3. You know that patient acceptance, during the critical first two weeks of use, may be impaired by an excessive initial protrusion

Now factor in these points:

  1. With MRA use, the total protrusive range of motion may well increase: Patients don't normally go around protruding their mandible - their perception of 100% protrusion may well be inaccurate.
  2. Posterior interference on protrusion: If your initial protrusive bite and final effective (titrated) bite positions are widely divergent, the occlusal surfaces of the upper and lower appliances will require adjustment, typically over the most posterior molars (also bear in mind that gross vertical opening is associated with lower acceptance rates)
  3. The MRA mechanism does not connect any more: At the limit of MRA protrusion, upper and lower appliances of the 'hook and screw mechanism between the incisors' type MRA, may no longer connect.

I did say it was a little complicated.

Moving past the bite registration, what factors influence oral appliance selection?

What to consider when selecting the 'best' oral appliance for snoring?

Below is a non-exhaustive list. We've discussed the first two points, above:

  • Range of oral appliance motion (starting from nil protrusion to enhance acceptance rates)
  • Protrusion necessary (how much the patient can protrude - the maximum tolerable)
  • Lateral movement (necessity for it?)
  • Bruxism (damage to the MRA verging on destruction in a week or less. Or if they brux and the MRA does not permit lateral movement, the MRA may cause an arousal or the patient may simply not wear it).
  • Bulk - less is more
  • Lip seal - aesthetic considerations and to promote nasal breathing (less vertical opening is associated with higher acceptance and compliance)
  • Tongue space invasion - acceptance and frankly effect!
  • Incisor contact = incisor sensitivity and proclined  / retroclined incisors over time
  • Placement of the adjustment mechanism - you need there to be teeth where you want to put the mechanism.
  • Material choice (galvanic reaction, different expansion rates of the materials its made from = cracks and remakes, absorption of saliva and cleaning fluids)
  • Dexterity of the patient (can they actually adjust it themselves?)
  • Control - do you want the patient to be able to adjust it themselves?! Note: an aggressive (read desperate) rate of adjustment of protrusion, WILL aggravate the patient's TMJs and extend the time it takes to stop snoring

Phew!

Anything else I should look out for?

Yes.

Here are the contra-indications:

What are the contra-indications for an oral appliance for snoring?

Here's another long list to consider. Does the patient have any of these 'red flags'?:

  • Inadequate oral hygiene
  • Poor periodontal condition
  • Insufficient teeth per jaw
  • Edentulous mandible (some - but not many - MRA designs can be made for edentulous maxillas)
  • TMJ locking or other apparent dysfunction
  • Inability to protrude more than 5mm from resting jaw position
  • Mandibular ‘free end saddles’
  • Missing teeth where you would place the titration mechanism
  • Short crown height, or ‘pyramid’ shape / under erupted teeth
  • Extensive bridgework
  • Incompetent or restricted nasal airway
  • Severe ‘gag’ reaction
  • Unmotivated patient
  • Partner motivation for simple snoring (as in they're not really bothered about the noise themselves)

The presence of these 'red flags' does not mean an MRA is out the window. It does mean you need to select the most appropriate oral appliance to prescribe.

Which brings me full circle to:

There is no 'best' oral appliance.

The oral appliance has arrived from the lab: Now what?

Once the patient is comfortably inserting (and removing) the MRA themselves, its time to revisit your discussion about seeing them again.

Its important to point out, that for an oral appliance to stop someone snoring, they're going to need support and encouragement. The first 2 weeks set the pattern for the future.

When do you plan to see them again?

Or perhaps, when should you see them again?

And what's this about your 'Duty of Care'?

Top tip: 'Play' around with a new oral appliance for snoring BEFORE you see the patient. To work out the adjustments (and know which way up it should be!)

CHAPTER 7:

Titration protocols, follow-up, duty of care


Snorers may need motivating to wear their oral appliance (because it won't work immediately) and most patients find that it takes time to become accustomed to its presence.

While those with OSA must be followed up rigorously.

What does this actually look like?

Titration protocols, follow-up, duty of care for oral appliances for snoring

What does Subjective and Objective titration mean?

Adjusting the oral appliance's protrusive position to stop snoring and overcome sleep apnoea, is known as 'titration'.

Titration comes in two forms:

subjective titration  Subjective

objective titration  Objective

Subjective titration

Subjective titration means adjustment ceases when the wearer decides (perhaps with the kind assistance of their partner). No further protrusion is required.

Here's a suggested schedule of follow-up appointments for the benign snorer:
  • 3 days from fit a phone call "How has it been...?"
  • 7 days from fit an ease, adjust 2mm forwards maximum, reassure
  • 3 days later another call "Any improvement?"
  • 14 days from fit: adjust 2mm forwards maximum (look for posterior interference)
  • Repeat until either snoring ceases or no further protrusion can be tolerated.

Should the patient experience TMJ issues the patient should be instructed to immediately cease wearing the device. Refer them to a TMD expert. An aggressive (impatient) rate of titration WILL bring on TMJ issues in just about anyone.

But what if they're sleep apnoeaic?

That's when things get a little more scientific:

Objective titration

Objective titration is when evidence of effect is used, to inform adjustment of protrusion. The patient begins by becoming accustomed to wearing the oral appliance. They then titrate subjectively (see above) and at this point they have a sleep study to see if the MRA is providing effective therapy for their sleep apnoea.

Then a cycle of increased protrusion and repeat sleep studies occurs. Protrusion would cease when one (or more) of these things happen:

  • The MRA is deemed objectively effective (great!)
  • The physiological limit is reached (not so great)
  • Or patient tolerance to the position dictates (tilt!)

Communicate with the patient's GP and the sleep unit

Write and say thanks for the referral. Advise of your intended treatment plan, your review schedule and ask about repeat sleep studies. Ask about supine sleep position (observed by sleep study) as positional therapy combined with an MRA, can be an effective way to control OSA.

Follow-up and your Duty of Care

As a trained member of the sleep-patient care team, you have a duty of care for both the snorer and the sleep apnoeic patient.

This means you need to monitor the patient for a change in their condition - and not just in their mouth. You need to get the patient reassessed with a view to an alternative or adjunctive therapy. The examples below explain further:

The snorer may:

  • Start snoring again - and no further protrusion is tolerable
  • Become hypersomolent (by your assessment informed by the Epworth Sleepiness Scale [see Key sleep terms])
  • Experience other OSA symptoms
  • Be diagnosed with a comorbidity
  • Not improve with increased protrusion

For the diagnosed OSA patient referred to you for prescription of an oral appliance:

Before commencing use they:

  • May not be dentally suitable for prescription of an oral appliance
  • May consider the risk / benefit analysis (of oral appliance therapy) unacceptable
  • They may also find the cost of treatment unacceptable

After commencing use:

  • May inadequately respond to protrusion when measured objectively or subjectively
  • They may discontinue use and / or fail to attend

The diagnosed OSA patient in the situations above needs to revisit the sleep unit. You need to write to the GP and communicate what has (or hasn't) happened.

Longer-term follow-up

Longer-term, tooth movement WILL occur. There is no point in dressing this up.

How important is that tooth movement?

Well that's another thing:

The pictures above are after 21 months of nightly use of an oral appliance for snoring, the patient's occlusion now appears as an anterior crossbite with an anterior displacement of approximately 2.5mm. These post-treatment photos were taken after three weeks of non-use.

Keeping tooth movement in perspective

It is vital to keep tooth movement, as a result of mandibular repositioning appliance wear, in perspective.

As dental professionals we may be shocked at undesired orthodontic tooth movement. But you may be hard-pressed to extract the effective oral appliance from the patient on the grounds of a tilted incisor!

Points to note here:

  • Post-wear exercises e.g. chewing gum in the shower can help the mandible to return to its 'normal' position.
  • The patient had minimal (if any) overbite before MRA use: an overbite is considered 'protective'.

Your Duty of Care to both snorers and sleep apnoeaic patients

As a trained member of the sleep patient care team you have a duty of care. Not just to recognise when to treat or refer new patients.

Certainly, you understand the necessity for follow-up of OSA patients, but its important to identify when an MRA is:

  • No longer effectively treating the (apparently benign) snorer
  • The patient has reached their physiological or maximum tolerable protrusion. Their condition as changed: for example with age, weight gain and lifestyle changes etc.

These patients need your help.

They need you to recognise the change in them (that they may not see themselves) and refer them for further investigation at a sleep unit.

CHAPTER 8:

 

FAQs and resources


This Guide wraps up with an FAQs and resources section.

Have a question that isn't answered in our FAQ? Then let us know! contact@snorer.com

If we don't know the answer - we'll find out if at all possible! - And also add it to the list:

FAQ, Key sleep terms & Downloads re oral appliances for snoring

FAQs

Repositioning or Advancing the mandible?
MRAs aid breathing while the patient sleeps, through anterior repositioning of the lower jaw. There is also an optimum vertical opening.
Is it really: Airway versus Occlusion?
Yes and No.

Yes, long-term use of MRAs will result in occlusal change.

Tooth movement is more likely when:

  • MRAs do not fully utilise the canines and molars (these may be more resistant to movement induced by lateral load)
  • The number and distribution of teeth is less than ideal
  • The MRA design loads the incisors (this will result in retroclined maxillary incisors and proclined mandibular incisors)

Factors that protect against and may limit tooth movement include:

  • Post-wear exercises
  • An overbite (edge-to-edge incisors are prone to incisor tilting)
  • MRA designs that limit the load applied to the incisors
My patient has sleep apnoea and is struggling with PAP - when can I make an oral appliance for them?
When the referring Physician decides. In this circumstance, communicate with the GP and the sleep unit. Explain what is happening, your concerns (i.e. they may use an OTC product) and offer your assistance.
What is patient compliance like with an oral appliance for snoring?
Compared to what? Generally speaking, patients that use prescription custom, adjustable MRAs, use them every night, insert them as they go to sleep and wear them until they wake up.

However, for the sleep apnoeaic patient, the MRA may be less effective (measured using overnight SpO2 saturation) yet used more frequently than PAP therapy (both more hours and more nights a week).

Which therapy is better?

Are MRAs adjustable by the patient, in terms of mandibular advancement?
Yes. While MRA designs vary, patients will find a way.

Further, you may wish to retain control of adjustment (see titration).

Patients may adjust the position in error (typically rapidly increase protrusion) and create TMJ issues that prevent use until the joint has recovered. Ultimately delaying effective therapy.

Should GDPs ask about sleep routinely?
By now you see there is a role (and therapy) ideally suited to the General Dental Practitioner.

It is your choice: do you want to help your patients in this way?

Anti-snoring devices may be categorised as 'luxury items' and your lab may charge VAT
Consult HMRC for the latest guidance.

HMRC (the UK's tax man) considers products for snoring, luxury items and demands 20% VAT.

For patients with diagnosed OSA an MRA is zero rated. You may reclaim 'input VAT'.

'Loose' lower incisors? Has the patient been wearing an OTC anti-snoring device?
OTC oral appliances will damage the patient.

Problems include:

  • Delayed diagnosis and effective therapy
  • Pain
  • Tooth movement or loss due to excessive and uncontrolled lateral loads
  • Posterior open bite
  • Development of a reverse incisor relationship
  • Development of a protruded mandibular posture
Maximum protrusion = maximum effect, right?
If only life was that simple!

The "Law of Diminishing Returns" applies to MRA titration: initially lateral loads are perhaps low (with minimal side-effects) and the effect increases linearly.

However, beyond a patient-defined protrusion, lateral loads significantly increase for non-linear gains in efficacy.

Still further protrusion may cause pain, significant dental side-effects and less effect.

Key sleep terms

  • OSA – Obstructive Sleep Apnoea
  • OSAS – Obstructive Sleep Apnoea Syndrome
  • ESS – Epworth Sleepiness Scale. Patient completed subjective assessment of sleepiness in specified circumstances
  • AHI – Apnoea Hypopnea Index. Index of sleep apnoea severity combining apnoeas and hypopneas:
    • 5–15/hr = mild;
    • 15–30/hr = moderate;
    • and > 30/h = severe
  • MRA – Mandibular Repositioning Appliance
  • PAP – Positive Airway Pressure
  • UPPP/LAUP – UvuloPalatoPharyngoPlasty – Laser Assisted UvuloPlasty

Downloads

PDF

  • Download: Example of an Informed Consent document as a PDF
  • Download: Management of sleep apnoea and snoring, suggested guidelines for General Practitioners and other interested medical professionals. As a PDF.

Now, it's your turn:

Did this Ultimate Guide help?

  • Are you inspired?
  • Concerned?
  • Awake?!

Let me know by leaving a quick comment below right now (scroll down).

Comment or write a review about prescribing oral appliances for snoring

References

Click to view the References
  1. SomnoMed 2017 Annual Report. [Accessed 9th Oct 2018]. Available here: https://somnomed.com/wp-content/uploads/2017/10/SomnMed-Annual-Report-FY17-FINAL-ASX.pdf 
  2. Ohayon Maurice M, Guilleminault Christian, Priest Robert G, Caulet Malijai. Snoring and breathing pauses during sleep: telephone interview survey of a United Kingdom population sample BMJ 1997;314 :860 [Accessed 21 Sept 2018] Available here: https://www.bmj.com/content/314/7084/860.short
  3. Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. (2009). Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine, 5(3), 263–276. [Accessed 19th Sept 2018] Available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699173/
  4. Remmers JE, deGroot WJ, Sauerland EK, Anch AM. Pathogenesis of upper airway occlusion during sleep. J Appl Physiol 1978;44:931-8. [Accessed 20th Sept 2018] Available here: https://www.physiology.org/doi/abs/10.1152/jappl.1978.44.6.931
  5. Issa FG,.Sullivan CE. The immediate effects of nasal continuous positive airway pressure treatment on sleep pattern in patients with obstructive sleep apnea syndrome. Electroencephalog Clin Neurophysiol 1986;63:10-7. [Accessed 20th Sept 2018] Available here: https://www.ncbi.nlm.nih.gov/pubmed/2416530
  6. Stradling J. Driving and obstructive sleep apnoea Thorax 2008;63:481-483. [Accessed 20th Sept 2018] Available here: https://thorax.bmj.com/content/63/6/481
  7. Guilleminault C, Tilkian A, Dement WC. The sleep apnea syndromes. Ann Rev Med 1976;27:465-84. [Accessed 20th Sept 2018] Available here: https://www.annualreviews.org/doi/abs/10.1146/annurev.me.27.020176.002341?journalCode=med
  8. Snoring and the role of the GDP: British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol. British Dental Journal, BDJ volume 206, pages 307–312 (28 March 2009) Available here: https://www.nature.com/articles/sj.bdj.2009.214 ↗ [Accessed 19th Sept 2018]
  9. Dental Defence Union position statement re snoring treatment. Available here: https://www.theddu.com/press-centre/press-releases/snoring-treatment ↗ [Accessed 19th Sept 2018]
  10. Dental Protection Ltd. Position statement: https://www.dentalprotection.org/uk/articles/snoring-and-obstructive-sleep-apnoea-syndrome ↗ [Accessed 19th Sept 2018]
  11. NICE. Dental checks: intervals between oral health reviews. Available here:  https://www.nice.org.uk/guidance/CG19 ↗ [Accessed 28th Sept 2018]
  12. Sleep-disordered Breathing, Adrian Zacher & Michael McDevitt, Carranza's Clinical Periodontology - E-Book: Expert Consult: Online, Elsevier Health Sciences, 2017. Accessible here: https://www.elsevier.com/books/carranzas-clinical-periodontology/newman/978-0-323-18824-1  ↗ [accessed 24th May 2018]

Snorer.me Signposting™ is a CE marked, Clinical Decision Support System, Software as a Medical Device. The Manufacturer is Snorer.com Ltd.

Created by Adrian Zacher and Emma Easton. All rights reserved.

Last updated 22nd Mar 2019.

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How to stop snoring (The definitive, step-by-step Guide 2019)

How to stop snoring (The definitive, step-by-step Guide 2019)

HOW TO STOP SNORING:

The Definitive Guide

By Adrian Zacher

2019 edition


Nobody wants to snore. So when it’s time to stop, this step-by-step, evidence-based, definitive guide will tell you exactly how. And if your snoring is actually a symptom of sleep apnoea – we’ve got you covered.

Bottom line: If you will work with the same types of medical and dental professionals that you already trust to care for you, you will:

  • Quickly and permanently stop snoring
  • Have sleep apnoea diagnosed or dismissed as the cause of your snoring
  • Wake up rested and happy with your better half next to you in bed

Here’s how:

How to stop snoring: The definitive step-by-step Guide
Snorer.com
Rated 5/5 based on 16 customer reviews
Video transcript
In this video I’ll tell you how to stop snoring – permanently.

But I should warn you:

There’s nothing here about things you spray up your nose or boil in a pan in the kitchen…

I’m Adrian Zacher founder of Snorer.com and for 25 years I’ve helped people stop snoring and get treatment for sleep apnoea.
In this video, I’ll walk you STEP BY STEP

back to quiet nights and alert days.

Keep watching and I’ll explain the 5 steps involved.

Oh and don’t worry about taking notes because I’ve put together a free download for you. I will give you the link ——————-at the end.
[Snorer.com url and whizzy effects]
Now, it seems everyone finds snoring funny

Unless they have to listen to it every night.

There’s a really important caution here: If you (or your partner?) are drowsy when you should be awake see your GP immediately. Drowsiness may be a symptom of sleep apnoea.

Sleep what? Keep watching – I will explain.

With that let’s jump straight in with step 1. The 6 self-help ways to stop snoring.

The 6 self-help ways to stop snoring are known as lifestyle changes:

Number1: If you’re overweight, try to lose weight. We get fat inwards as well as outwards and weight around your neck reduces the diameter of your airway. When your airway gets narrower, air you breathe has to travel faster and this makes the walls of your airway vibrate (in other words it makes you snore).

Number 2: Avoid evening alcohol. Yes I know that drinking alcohol in the evening is exactly when you want to drink it.

Alcohol super relaxes your throat – which makes it floppy and prone to vibrate (and you snore). – so you have to choose.

Number 3: Stop smoking. Yup the same old message.
Smoking inflames the tissues of your throat which makes your airway narrower, so you snore for the same reason I have covered already.

Number 4: Get off your back! Gravity pulls your tongue backwards and narrows your airway. Your mouth may also fall open and as it does so your jaw moves downwards and backwards and this also narrows your airway. And no, a chin strap is NOT the answer (here’s why).

Number 5: Keep your nose clear. If you can’t breathe through your nose you have to breathe through your mouth. When your mouth opens it moves downwards and backwards – narrowing the airway in your throat. Ditto point 4. Additionally, some people find that dairy products make them ‘stuffy’. Think about alternatives perhaps.

Number 6: Avoid sedative medication i.e. sleeping pills and painkillers (See your GP for alternatives).

Now it’s time for Step 2

Signposting.

Signposting works like this: You answer some questions online and the signposting tool directs you to the right type of professional to help.
If you have symptoms of sleep apnoea and/or other related health issues you will be directed to your GP.

If not you will be directed to a sleep-trained dentist.

Now seems an ideal time to outline what obstructive sleep apnoea is.

Obstructive sleep apnoea (OSA) is when your breathing is disrupted while you are asleep.
The airway in your throat repeatedly narrows and not enough air gets to your lungs despite
continued efforts to breathe. Sufferers snore and may be drowsy in the day because they must wake up to breathe.

Because the urge to sleep is irresistible this may be disastrous should you fall asleep when driving or a similar activity.

From here we go on to Step 3 screening for obstructive sleep apnoea.

Screening is essential and where over the counter products fail.

The professional screening you now has 3 options:

Option 1: Referral to a sleep unit for a home sleep apnoea test (I will show you what this looks like in a minute)

Option 2: Lifestyle change & local management – this is the self-help we discussed at the beginning

Option 3: Prescription custom-made dental appliance. Two important points here. These are prescription devices and are NOT the gumshield things you might see online or in the pharmacy. Secondly the gumshield gadgets are NOT valid as a way to see if a real dental appliance will work. Again, there’s more about this in the free download.

On to Step 4 – Sleep testing and diagnosis.
You’d only need a home sleep apnoea test if screening raised concerns.
So now assume you’ve been offered an appointment at the sleep unit for further investigation.

If you’re diagnosed with obstructive sleep apnoea syndrome (OSAS):
• First-line therapy is Positive Airway Pressure therapy (PAP)
• Second-line therapy is a prescription, custom-made dental appliance
• Surgery is usually only considered appropriate to enhance the use of PAP and MRS

Here we go then with Step 5 – Treatment options

Lets have a look a these things

First-line therapy, meaning the most appropriate option for snoring as recommended by NICE is an intra-oral device: a custom-made dental appliance. Here’s one (the sleep-trained dentist would prescribe what is indicated for you – there are many to choose from so be guided by the expert)

First-line therapy for obstructive sleep apnoea is Positive airway pressure or PAP therapy. That’s when you’d wear this to sleep every night. It pumps air (not oxygen) in via this mask. The pressured air keeps your airway open and you get the best night’s sleep you’ve had in years. Oh and you don’t snore wearing this!

Treatment for sleep apnoea is transformational. Patients report feeling 10 years younger.

Of course, some people cannot adjust to or don’t use PAP therapy long-term. This is when the dental appliance may be considered as a second-line option (the next best thing).

Now, let’s talk about surgery. Surgery may seem appealing as perhaps a ‘quick fix’. However, surgery on its own is rarely effective.

Soft tissue surgery for snoring aims to improve the airway in your throat to improve the effect of an oral appliance.

Whereas hard tissue surgery which will change the way you look, aims to entirely eliminate the need for other therapies.

Bariatric surgery may exceptionally be considered when your health and quality of life are impacted by obesity.

Let’s sum up with some simple Do’s and Don’ts:

Do something about snoring. You don’t have to live with the ridicule and social consequences.

Do use our free signposting tool

Don’t ignore drowsiness.

Here’s the link I promised to the free signposting tool and the download.

Don’t forget to subscribe and like this video or share it with someone you know!

Sleep well!

Peer review and about the Author

default image

Emeritus Professor of Respiratory Medicine, John Stradling MD FRCP

This is a very comprehensive manual for those interested in understanding why they snore and what to do about it. Adrian Zacher has many years of experience in this field. Take time to read it carefully as there is a great deal of information to digest. Armed with this information one should be able to make informed choices as to what to do about snoring and possible sleep apnoea.

Prof. John Stradling How to stop snoring guide.

Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I teach UK dentists how to help their patients stop snoring; sleep and breathe at the same time.

Many of my customers find their work so rewarding they devote their practice to it. I’m a sleep-industry insider with a quarter of a century of sleep medicine experience.

Google Scholar

Contents

Click an icon to jump to each chapter.

CHAPTER 1

Self-help ways to stop snoring & signposting to treatment options

CHAPTER 2

Assessment and screening for Obstructive Sleep Apnoea (OSA)

CHAPTER 3

Sleep testing and diagnosis

CHAPTER 4

Prescription ways to stop snoring and treat sleep apnoea

CHAPTER 5

Follow-up of snoring and sleep apnoea patients

CHAPTER 6

Comprehensive snoring and sleep apnoea FAQs

CHAPTER 1:

 

Self-help ways to stop snoring & signposting to treatment options


If you snore, have been told you stop breathing while asleep, and are sleepy during the day consult your GP or Primary Care Physician immediately. Being drowsy needs medical attention.

If you’re not drowsy, here are 6 lifestyle changes to consider, as the first attempts to stop snoring.

Then we’ll introduce Snorer.me Signposting™ – which is a new, free, CE-marked software tool to connect you with the most appropriate medical or dental professional.

Signposting the treatment routes for snoring and sleep apnoea

6 self-help ways to stop snoring

Here are 6 self-help ways to stop snoring:

Lose weight to stop snoring  Lose weight.

Stop drinking alcohol in the evening to stop snoring  Avoid evening alcohol.

Stop smoking to stop snoring  Stop smoking.

Get off your back to stop snoring  Get off your back!

Breathe through your nose to stop snoring  Keep your nose clear. Consider avoiding dairy products if they make you ‘stuffy’.

Avoid sedative medication to stop snoring  Avoid sedative medication. Consult your GP for alternatives.

Download this PDF with additional methods to stop snoring self-help ways to stop snoring

 

Here are 6 self-help ways to stop snoring. These are known as lifestyle changes:

Lose weight to stop snoring  If you’re overweight, try to lose weight. We get fat inwards as well as outwards and weight around your neck reduces the diameter of your airway. If the airway in your throat gets narrower, the air you breathe has to travel faster and this makes the walls of your airway vibrate (in other words it makes you snore).

Stop drinking alcohol in the evening to stop snoring  Avoid evening alcohol. Alcohol super relaxes your throat – which makes it floppy and prone to vibrate (and you snore). I know that drinking alcohol in the evening is exactly when you want to drink it – so you have to choose.

Stop smoking to stop snoring  Stop smoking. Smoking inflames the tissues of your throat which makes your airway narrower, so you snore.

Get off your back to stop snoring  Get off your back! Gravity pulls your tongue backwards and narrows your airway. Your mouth may also fall open and as it does so your jaw moves downwards and backwards and this also narrows your airway. And no, a chin strap is NOT the answer (here’s why).

Breathe through your nose to stop snoring  Keep your nose clear. If you can’t breathe through your nose you have to breathe through your mouth. When your mouth opens it moves downwards and backwards – narrowing the airway in your throat. Ditto point 4. Additionally, some people find that dairy products make them ‘stuffy’. Consider alternatives?

Avoid sedative medication to stop snoring  Avoid sedative medication i.e. sleeping pills and painkillers (Consult your GP for alternatives if you have a diagnosed condition that necessitates their use).

Download this PDF with additional methods to stop snoring self-help ways to stop snoring

 

Does Your Partner Snore?

This free Guide is for you:

Free Guide for the partner or family member of a snorer

Remember why you’re trying to stop snoring?

To:

  • Maintain intimacy with your partner
  • Share hotel rooms
  • Stay over at friends
  • Fly long-haul without complaint
  • Wake up without a sore throat / dry mouth
  • Avoid ridicule

Two problems with self-help to stop snoring:

  • It often doesn’t work.
  • It doesn’t give you a diagnosis of sleep apnoea or no sleep apnoea (spelt ‘apnea’ in the US).

If self-help isn’t helping, you need to see the most appropriate healthcare professional to get a real diagnosis.

That is the purpose of Snorer.me Signposting™. It is a self-help tool that provides free information to direct you to the right professional to get the help you need.

Carry on guessing?

Signposting is about providing free, valid information, regarding available services and options… and pointing out the right ‘road’….

You can either carry on guessing if your snoring is a symptom of sleep apnoea or you can use Snorer.me Signposting™.

We think you’re here because you want definite answers. Snorer.me Signposting™ is your first step to definitively answering how to stop snoring.

The Oxford English dictionary defines signposting as:

A sign giving information such as direction and distance...”

In medicine, signposting is about providing free, valid information, about available services and options… and pointing out the right ‘road’….

The image above illustrates one of the questionnaires used inside Snorer.me Signposting™.

Snorer.me Signposting™ works like this:

Signposting first step  You answer 25 questions on-line.

Signposting second step  Your GP (additionally a UK sleep-trained dentist) then uses your answers to rapidly screen1 you for sleep apnoea, and determine if you need further investigation (a sleep study).

Signposting third step  If you don’t need a sleep study, then you can be prescribed a custom-made, anti-snoring device.

What happens next?

Whichever way signposting directs you, the healthcare professional will screen you for sleep apnoea (spelt ‘apnea’ in the US) next.

Chapter 2 explains how and why:

CHAPTER 2:

 

Assessment of snoring and screening for obstructive sleep apnoea


Assessment and screening occur when a healthcare professional checks to see if your snoring needs further investigation – for example by conducting a sleep study.

There’s an advantage to early detection (i.e. you “nip it in the bud“), and we’re getting ever closer to definitively knowing how to stop snoring.

Assessment and screening for sleep apnoea

Step 1. Assessing and screening for sleep apnoea symptoms

What is Obstructive Sleep Apnoea / Apnea (OSA)?

What is Obstructive Sleep Apnoea (OSA)?

Obstructive sleep apnoea (OSA) is when your breathing is disrupted while you are asleep. The airway in your throat repeatedly narrows and not enough air gets to your lungs despite continued effort. Sufferers typically snore and may be drowsy in the day, because they must wake up to breathe. 

When snoring is a problem, please consult your GP (Primary Care Physician – we use ‘GP’ throughout this Guide), additionally a sleep-trained dentist (in the UK) can help. More about these professionals later.

Your GP has your medical history to hand and they want you to be well.

However, we’re all aware that GPs are extremely time-poor. Therefore, to make better use of their clinical time, you may be asked to complete an assessment form in your own time – and to return for another appointment.

 

So your options are:

1. Fill in the forms and return to your GP

Your GP will screen you for sleep apnoea and determine if you need further investigation.

Your GP may not know much about sleep. Help them by downloading our GP Guidelines ↗ (send the document to your GP before your appointment to give them time to read it).

1. Fill in the forms and return to your GP

Your GP will use the information on the form to screen you for obstructive sleep apnoea (OSA) and other related conditions, and determine if you need further investigation in a sleep unit or perhaps by referring you to an ENT (Ear, Nose and Throat) department.

Your GP may be clued in about snoring, but equally, they may not be. Currently, sleep medicine in the UK and elsewhere, is not part of core medical training.

We’d suggest you download our GP Guidelines ↗ and send them to your GP before your appointment (to give them time to read it).

2. Waste your money on OTC (over-the-counter) snoring cures, aids and mouthguards

Naturally, it’s tempting to go for the ‘quick fix’ and buy ‘instant’ snoring remedies. That’s why we review them.

So, learn how to compare OTC mouthguards and custom-made dental devices ↗ and find out if chinstraps for snoring ↗ are dangerous, or safe and effective, amongst other reviews.

How to find a GP in the UK?

If you’re in the UK and don’t have a GP you can find one here:

https://www.nhs.uk/Service-Search/GP/LocationSearch/4 find a GP 2

If you know country specific web addresses for how to access secondary care services – please let us know so we can add them here to help others. Thanks.

Punch in your location (PRO TIP: It works better with a place name rather than postcode).

Take your pick:

Find GP services in the UK

Outside the UK?

If you’re outside the UK, finding a GP may depend on how your healthcare expenses are paid for.

In the USA, if your care is paid for by an insurance company, you should check their website to see which ones are listed.

If you’re covered by Medicare use this link to find a doctor:

https://www.medicare.gov/physiciancompare/

Step 2. Consult your GP

Return to your GP with your completed assessment forms (ideally you did these with the help of your partner – they may have a different perspective…).

Now, the outcome of your GP appointment may go 1 of 3 ways:

Option 1: Referral to a sleep unit

Your GP may suspect you’re suffering from sleep apnoea (find out more about sleep apnoea (OSA) in the FAQ) and refers you to a sleep unit.

Ask someone else to take you to the appointment, as you might be told by the doctor that you cannot legally drive yourself home.

Important:

Keep hold of your referral paperwork and if you’re in England, visit the NHS e-referral website:  https://www.nhs.uk/using-the-nhs/nhs-services/hospitals/nhs-e-referral-service/e-referral service3

Option 1: Referral to a sleep unit

After reviewing your assessment forms, consulting your medical history and perhaps a physical examination; your GP may suspect that you’re suffering from obstructive sleep apnoea (find out more about OSA in the FAQ) or something else that is making you drowsy (as well as snore) and considers further investigation necessary.

They may then refer you to a sleep unit for further investigation.

If you often experience daytime drowsiness when driving, ask someone else to take you to the appointment, as you might be told by the doctor that you cannot legally drive yourself home.

Important:

Keep hold of your referral paperwork and if you’re in England, visit the NHS e-referral website: e-referral service3

You will need your:

  1. booking reference (first page)
  2. year of birth

and the (automatically generated) password to login (that’s on the last page of the print-out your GP gave you).

TIP: Compare waiting times. If you are prepared to travel for a consultation, you may find you can be seen sooner.

If you’re in Scotland the GP will make a referral for you and the Hospital will contact you with an appointment. Similar electronic patient referral management systems are being rolled out around the world. As we learn of them we will add them here. Let us know.

NHS e-referral service

Option 2: Lifestyle change & local management

If your GP does not suspect obstructive sleep apnoea (OSA) they may suggest you try to stop snoring naturally with lifestyle changes (e.g. lose weight if you’re overweight, stop smoking (if you do), quit the evening alcohol, get off your back when sleeping, exercise…).

Option 3: Dental appliance for snoring

If your GP does not suspect obstructive sleep apnoea: they may consider your snoring to be ‘benign’, they may offer lifestyle advice (as Outcome 2), and suggest you consult a sleep-trained dentist with a view to a prescription dental appliance or ‘mouthpiece’.

This type of dental appliance is known as a custom-made mandibular repositioning splint (MRS).

Grab this ↗ free, evidence-based Guide about how to choose a ‘mouthpiece’ to stop snoring.

The NHS will not fix snoring*

Bad news?

Only option 1 above (Referral) involves NHS treatment.

* In exceptional circumstances some ‘benign’ snorers (i.e. not sleepy) may dependent on the availability of local expertise and budget, be offered a hospital dental laboratory manufactured oral appliance.

Options 2 and 3 require you to take action yourself.

So, now you’re wondering:

How can I stop snoring?

If you’re given Option 2 (lifestyle change) or 3 (dental appliance for snoring), the good news is that you’re unlikely to have sleep apnoea symptoms.

Hang on:

Don’t go and feed the ‘circling sharks’ by buying an over-the-counter ‘cure’.

There’s very good evidence 4 that custom-made, adjustable dental appliances for snoring (aka mandibular repositioning splints) will help with anti-social snoring. Below are two examples (there are many more to choose from). The images below are used with permission from SomnoMed UK Ltd. and Somnowell (UK) Ltd. respectively.

Custom-made, adjustable dental devices for snoring
Custom-made, adjustable dental devices for snoring

Clinical research5 has established that custom-made dental appliances are NOT the same as over-the-counter ‘gumshields’ or other mechanisms, and neither are they valid as a trial of whether a custom-made dental appliance will work.

So, be sure to bookmark my independent review of the top 13 criteria for choice of ‘gumshield’, so you can come back to it later.

Otherwise its time for…

CHAPTER 3:

Diagnosis of obstructive sleep apnoea


Assume you’ve been offered an appointment at the sleep unit for further investigation.

When you’re diagnosed, you know if your ‘snoring’ is actually sleep apnoea and how bad it is.

Soon, you will sleep better – and more quietly.

Medical diagnosis of sleep apnoea

Snoring and Sleep Apnoea happen for a reason

An investigation into the cause of your ‘snoring’ is called an assessment.

Together with an overnight sleep study, the specialist respiratory medicine physician may come to a diagnosis.

When you have a diagnosis, the doctor will determine what is the most appropriate treatment, and this (finally and definitively) answers your question:

How to stop snoring?

It’s a “cause-and-effect” relationship, while the ’cause’ is unknown; until you’re diagnosed, the ‘effect’ is the all too familiar, loud snoring problem….

An investigation into the cause of ‘snoring’ is called an assessment. This typically includes an overnight sleep study and a review of your medical history.

All of which helps the specialist respiratory medicine physician come to a diagnosis.

When you have a diagnosis, the doctor will determine what is the most appropriate treatment, and this (finally and definitively) answers your question:

How to stop snoring?

How to know if your snoring is actually sleep apnoea?

Click the tab headings for the 3 steps.

You will be invited to attend the Hospital sleep unit for basic assessments including height and weight measurements, your medical history and a review of your GP referral letter.

It’s not a bad idea to take a copy of your Snorer.me Signposting™ printout with you as well (just in case its been mislaid).

Some time later, you will be invited to the sleep unit again (should a sleep study be considered appropriate).

Home Sleep Apnoea Testing (HSAT) is, in the UK and USA, the default way to examine your sleep quality and quantity. Home Sleep Apnoea Testing is testing of your sleep at home, in your own bed. Learn more about home sleep apnoea testing new window

You will be loaned some sleep apnoea test equipment, to put on over your pyjamas, before you go to sleep. The sleep physiologist will show you how to use it. The sleep-test equipment records (amongst other things) your snoring, how much oxygen there is in your blood and how much of the night you sleep on your back.

Stowood sleep study equipmentImage used with permission from Stowood Scientific Instruments Ltd ↗

In the morning when you wake up, turn it off, repackage it and return it promptly to the sleep unit. The data it has captured is then downloaded and analysed by a skilled sleep physiologist. They will ‘score’ your sleep study and create a report to accompany your medical history.

The sleep doctor will then review your scored sleep study, sleep physiologist’s report, your medical history and assessment forms. If possible, and if there is sufficient data, they will then diagnose your sleep condition and severity.

You will be sent a letter inviting you to attend the sleep unit offices to review your diagnosis with the Sleep Doctor. They will discuss the ramifications of their diagnosis, and their proposed course of action.

They may also offer lifestyle advice.

My advice is to listen. These medical professionals are experts and they’re motivated to provide you with the best care, factoring in your health, occupation and lifestyle.

Once again, its not a bad idea to take a copy of your Snorer.me Signposting™ printout with you as well.

Diagnosed with obstructive sleep apnoea syndrome (OSAS)?

If you’re diagnosed with obstructive sleep apnoea syndrome (OSAS):

  • First-line therapy is Positive Airway Pressure therapy (PAP)
  • Second-line therapy is a prescription, mouthpiece. Known as a
    custom-made mandibular repositioning splint (MRS)
  • Surgery is usually only considered appropriate to enhance the use of PAP and MRS

If you are not diagnosed with obstructive sleep apnoea syndrome then the healthcare system of the country you live in, determines what help if any they may provide.

  • In the UK, then routinely there is no NHS help available. Sometimes sleep units may have an informal network of dentists that can help you obtain a custom-made anti-snoring device as a private, fee-paying patient.
  • Not in the UK, then you should discuss what options exist with your sleep doctor. In the US and in some EU countries your healthcare system may contribute to the cost of treatment.

Now, it’s time for treatments for snoring and sleep apnoea:

If you’re diagnosed with obstructive sleep apnoea syndrome (OSAS):

  • First-line therapy is Positive Airway Pressure therapy (PAP)
  • Second-line therapy is a prescription, custom-made mandibular repositioning splint (MRS)
  • Surgery is usually only considered appropriate to enhance the use of PAP and MRS

Chapter 4 (coming up in a moment) explains more about these treatment options.

Not diagnosed with Obstructive Sleep Apnoea Syndrome (OSAS)?

If you are not diagnosed with obstructive sleep apnoea syndrome of a severity that merits treatment with Positive Airway Pressure therapy (PAP) then the healthcare system of the country you live in, determines whether prescription mandibular repositioning splints (MRS) are a funded therapy:

  • If you’re in the UK, then you will most likely be told no NHS help is available. That said, sleep units often have an informal network of dentists that may help you as a private, fee-paying patient.
  • If you’re not in the UK, then you should discuss what options exist with your sleep doctor. In the US and in some EU countries your healthcare system may contribute to the cost of treatment.

Now, it’s time for treatments for snoring and sleep apnoea:

First-line and second-line therapies

Initial and preferred therapy is known as ‘first-line’ and the backup option as ‘second-line’.

CHAPTER 4:

 

Ways to stop snoring and treat sleep apnoea


Treatment follows diagnosis.

In this chapter we’ll introduce the various prescription ways to stop snoring and treat obstructive sleep apnoea.

The choice of treatment (made by your Doctor) is the definitive answer to your next question:

What are the ways to stop snoring?

Treatment for snoring and sleep apnoea permanently

3 ways to stop snoring and treat sleep apnoea

The 3 prescription ways to stop snoring and treat sleep apnoea are:

  1. Dental appliances known as Mandibular Repositioning Splints (MRS)
  2. Positive Airway Pressure (PAP)
  3. Surgery (both soft and hard tissue in the nasal and respiratory airway) and exceptionally bariatric (stomach surgery to reduce your weight)

Your sleep Doctor will determine which way is most appropriate for you.

Additionally, if you’re in the UK your sleep-trained dentist may offer you a prescription, custom-made MRS if you do not require further investigation in a sleep unit.

There are essentially 3 prescription ways to stop snoring and treat obstructive sleep apnoea syndrome (OSAS):

  1. Dental appliances known as Mandibular Repositioning Splints (MRS)
  2. Positive Airway Pressure (PAP)
  3. Surgery (both soft and hard tissue in the nasal and respiratory airway) and exceptionally bariatric (stomach surgery to reduce weight)

Your sleep Doctor will determine which category of therapy is most appropriate for you.

Additionally, if you’re in the UK your sleep-trained dentist may offer you a prescription, custom-made MRS if you do not require further investigation in a sleep unit.

 Mandibular Repositioning Splints (MRS)

How do dental appliances for snoring and sleep apnoea work?

Mandibular repositioning splints work by holding your jaw forwards.

  1. They keep your tongue away from the back of your throat
  2. They tension your soft palate

You must wear the MRS (while you sleep) for it to work.

There’s much more here about dental appliances for sleep apnoea.

Dental appliances for snoring and sleep apnoea (known as Mandibular repositioning splints or MRS) keep your airway open by holding your jaw forwards (repositioning it).

This does two things:

  1. Keeps your tongue away from the back of your throat
  2. Tensions your soft palate

The effect of an MRS is similar to that of the anaesthetist’s hands with an unconscious patient. The dental appliance moves the jaw forwards (and in turn the tongue) to open your airway and help you breathe.

They do not cure snoring. They are a therapy that must be worn (while you sleep) for it to work.

There’s much more here about dental appliances for sleep apnoea.

How do dental appliances (mandibular repositioning splints) work?
Mandibular repositioning splints mechanically open the airway in your throat

What happens next?

The sleep-trained dentist will check to see if a dental appliance is right for you.

If appropriate they will take moulds of your mouth and send these to a dental lab for your dental appliance to be made.

When the dentist fits the appliance they will teach you how to insert and remove it.

You will need to visit the dentist again at regular intervals.

The sleep-trained dentist will assess your suitability (from a dental perspective) for an oral appliance.

Factors include ability to protrude your lower jaw more than 5mm, oral hygiene, jaw-joint health, number and distribution of teeth.

If an oral appliance is prescribed they will take impressions of both your jaws (moulds of your mouth) and a bite registration in a forward posture (how your jaws meet when you close your mouth and push your chin forward).

This information is then sent to a specialist dental laboratory for the dental technician to make your oral appliance. When it is fitted you will learn how to insert, remove and perhaps how to adjust it. You will be requested to visit the dentist again in a week to two weeks, and again at regular intervals.

How to choose a 'Mouthpiece' (MRS) Anti-Snoring Device?

Co-author: Adrian Zacher MBA
Co-author: Dr Roy Dookun BDS, MFGDP (UK), MGDSRCS (ENG), FFGDP (UK), DIP DENT SED
Peer Reviewer: Dr Shouresh Charkhandeh DDS

In this NHS England’s Information Standard Accredited Guide, you’ll learn in jargon-free language:

  • What a ‘Mandibular Repositioning Splint’ is
  • How to choose the best stop snoring mouthpiece for you
  • What the sleep-trained dentist can do
  • How to compare over-the-counter with prescription anti-snoring devices

No signup is required.

No credit card.

Nothing at all in fact.

We do this to help – because we can.

Anti-Snoring Device Guide

Meet the co-authors

Adrian Zacher. Click for full profile [new tab]

Adrian Zacher MBA

Author and founder of Snorer.com, co-founder and former CEO of the British Society of Dental Sleep Medicine

Dr Roy Dookun BDS

Dr Roy Dookun BDS

Co-founder and former President of the British Society of Dental Sleep Medicine

Dr Shouresh Charkhandeh DDS Click for full profile [new tab]

Dr Shouresh Charkhandeh DDS

Award-winning Dental Sleep Medicine Dentist

 Positive Airway Pressure (PAP) therapy

What is PAP for sleep apnoea? And how does it work?

Positive Airway Pressure (PAP) therapy prevents your airway narrowing or collapsing while you sleep.

PAP works by pumping air into your nose (and or mouth) through a mask worn over your face.

A common misconception is that oxygen is pumped in. This is rarely the case.

Positive Airway Pressure (PAP) therapy for obstructive sleep apnoea (OSA) is a treatment that prevents your airway narrowing or collapsing while you sleep.

PAP works by pumping air into your nose (and or mouth) through a mask worn over your face.

PAP therapy is considered the ‘gold standard’ or reference therapy for obstructive sleep apnoea.

For those who can tolerate PAP (an arduous therapy) it’s absolutely transformative.

A common misconception is that oxygen is pumped in. This is rarely the case.

PAP therapy pneumatically splints open your airway while you sleep

The left-hand image illustrates airway narrowing on breathing in. The right-hand image illustrates how PAP prevents this.

What happens next?

Sleep apnoea treatment with Positive Airway Pressure therapy

  1. Have a PAP mask fitting and loan of an Automatic PAP
  2. Return to collect ‘your own’ PAP machine
  3. Return for a 3-month review and sleep test
  1. Have a PAP mask fitting and loan of an Automatic PAP
    After you receive your OSAS diagnosis, you usually have an appointment the same day, with a sleep unit nurse. At this appointment they will:

    – Provide an explanation of PAP therapy
    – Fit you with a PAP mask
    – Loan you an automatic PAP machine (an automatic PAP establishes over the following 2 weeks your specific PAP therapy pressure)
    – Supply you with support details

  2. Return to collect ‘your own’ PAP machine
    Approximately 2 weeks later, you return to the Hospital sleep unit and the data from your APAP machine is used to setup your treatment device. This is routinely a fixed or continuous pressure PAP machine.
  3. Return for a 3-month review and sleep test
    You will be sent a letter inviting you for a 3-month review and another sleep study using your PAP therapy. The idea is to determine both subjectively (how to do you feel?) and objectively (what does the sleep study data say?) if you are adequately treated and restored to normal function.

    You will meet with the sleep unit practitioner/nurse to review your latest sleep study data and see how you’re getting on with PAP therapy. This is the time to seek help with niggles with mask fit (if you haven’t already).

How to choose PAP therapy?

Co-author: Adrian Zacher MBA
Co-author: Dr Lizzie Hill PhD

In this 3-part NHS England’s Information Standard Accredited Guide, you’ll learn in jargon-decoded language:

  • How PAP therapy works
  • What to consider when selecting a ‘mask’
  • What ‘titration’, ‘ramping’ and ‘humidification’ mean… and more
  • Includes details of support groups and PAP user feedback

No signup is required. No credit card.
Nothing at all in fact.
We do this to help – because we can.

Snoring & Obstructive Sleep Apnoea Overview Guide

Meet the co-authors

Adrian Zacher. Click for full profile [new tab]

Adrian Zacher MBA

Author and founder of Snorer.com,
co-founder and former CEO of the British Society of Dental Sleep Medicine

Dr Lizzie Hill PhD Click for full profile [new tab]

Dr Lizzie Hill PhD

Dr Lizzie Hill PhD RPSGT EST. Clinical Sleep Physiologist (RCCP M-Level registered); Education Lead, British Sleep Society & President, European Society of Sleep Technologists.

 Surgery for snoring and obstructive sleep apnoea

Surgery for snoring aims to improve the airway in your throat
  1. Soft tissue surgery for snoring and sleep apnoea enhances the use of dental splints and Positive Airway Pressure therapy (PAP). 
  2. Hard tissue surgery will change the way you look. Hard tissue surgery aims to eliminate the need for other therapies (i.e. dental splints and PAP).
  3. Bariatric surgery may exceptionally be considered when your health and quality of life are impacted by obesity. 
  1. Soft tissue surgery for snoring and sleep apnoea is appropriate to enhance the use of dental splints and Positive Airway Pressure therapy (PAP). This includes surgery on the inside of your nose, soft palate and base of your tongue to remove physical obstructions and improve tissue tone.
  2. Hard tissue surgery will change the way you look. It moves the bones of your face. Hard tissue surgery aims to eliminate the need for other therapies (i.e. dental splints and PAP).
  3. Bariatric surgery may exceptionally be considered when your health and quality of life are impacted by obesity. Qualifying criteria varies – consult your doctor.
Uvulopalatopharyngoplasty (UPPP) surgery for snoring
Soft tissue surgery (UPPP)

Uvulopalatopharyngoplasty

Bi-maxillary osteotomy permanent treatment for sleep apnoea
Hard tissue (bone)

Bi-maxillary osteotomy.

What happens next?

Accuracy of the diagnosis is essential for surgery to provide a satisfactory result. Sleep nasendoscopy is sometimes performed to confirm the surgical site.

Read our free Surgical Guide ↗ for a jargon-decoded explanation of all the options.

Things to discuss, when considering surgery for snoring and sleep apnoea

Co-author: Adrian Zacher MBA
Co-author: Professor Bhik Kotecha FRCS
Co-author: Professor Iain Ormiston FRCS

In this NHS England’s Information Standard Accredited Guide, you’ll learn in jargon-free language:

  • About soft tissue, hard tissue and bariatric surgery
  • When surgery is considered appropriate
  • Includes ‘non-gory’ image explanations
  • Details of support groups

No signup is required.
No credit card.
Nothing at all in fact.
We do this to help – because we can.

Snoring & Obstructive Sleep Apnoea Overview Guide

Meet the co-authors

Adrian Zacher. Click for full profile [new tab]

Adrian Zacher MBA

Author and founder of Snorer.com, co-founder and former CEO of the British Society of Dental Sleep Medicine

Professor Bhik Kotecha Click for full profile [new tab]

Professor Bhik Kotecha MB, MPhil, FRCS (Ed, Eng, Orl), DLO

Professor Kotecha is the Clinical Lead for the Sleep Disorders Unit at the Royal National Throat, Nose & Ear Hospital, London.

Professor Iain Ormiston FRCS Click for full profile [new tab]

Professor Iain Ormiston BDS, LRCP, MRCS, FDSRCS, FCSHK, FHKAM, FRCS

Professor Ormiston is doubly qualified in medicine and dentistry holding dental and medical/surgical fellowships, FDSRCS, FRCS. He is also a Fellow of the Hong Kong Academy of Medicine.

Check out Chapter 5 (Follow-up) to appreciate what it should look like, and Chapter 6 our extensive (FAQs) section.

CHAPTER 5:

Follow-up of snoring and sleep apnoea patients


Follow-up for both snorers and those with OSA is essential.

Snoring may become sleep apnoea, and sleep apnoea may worsen or an initially successful therapy fail to control drowsiness in the long-term.

But what does follow-up look like?

What does it entail?

Follow-up of snoring and sleep apnoea treatment

Follow-up

If you’re struggling with therapy don’t give up. It’s quite common for people to need help:

  • Using an oral appliance? Go back to the dentist.
  • On PAP? Go back directly to the sleep unit.

Regrettably, snorers who are prescribed a dental appliance are NOT routinely followed-up to assess whether:

  1. It continues to provide satisfactory control of their snoring
  2. Or, if their snoring has developed into sleep apnoea

Follow-up by the dentist MUST include:

  • Assessment of perceived sleepiness or drowsiness
  • Ideally an annual home sleep apnoea test (HSAT) to determine if the appliance remains effective.

PAP therapy today, commonly incorporates monitoring technology, to track how much it’s used.

Annual follow-up is required to identify if sleepiness symptoms have returned.

Surgery for snoring. It’s vital that follow-up home sleep apnoea testing (HSAT) is performed for those who have undergone surgery for snoring.

Changes in weight, lifestyle (particularly evening alcohol consumption) may give rise to sleep apnoea symptoms that need investigating.

 

If you’re struggling with therapy do not give up. Help is available and it’s quite common for people to need help and time adjusting to routine use of an oral appliance or PAP device.

If you’re using an oral appliance go back to the dentist.

If you’re on PAP go back directly to the sleep unit.

The importance of follow-up for snoring and sleep apnoea therapy users cannot be overstated.

However, snorers who are prescribed a mandibular repositioning splint are commonly NOT followed-up to assess whether:

  1. Their mandibular repositioning splint continues to provide satisfactory control of their snoring
  2. Or, if their snoring has developed into sleep apnoea

What should follow-up of ‘snorers’ look like?

MRS therapy follow-up Mandibular Repositioning Splints (MRS) are typically prescribed for ‘benign’ snorers or those with less severe sleep apnoea.

Follow-up by the dentist MUST include assessment of perceived sleepiness or drowsiness and ideally an annual home sleep apnoea test (HSAT) performed to determine if the mandibular repositioning splint is effective.

Dental changes should be communicated to you by your dentist and your risk/benefit analysis reviewed.

PAP therapy follow-up PAP therapy today, commonly incorporates sophisticated monitoring technology, to follow how much it is used and how effective it is.

Less commonly remote ‘titration’ or adjustment of therapy pressure to optimise treatment may occur. This has an unfortunate tendency to get tied up in data access and use permissions.

Annual follow-up is required to identify if daytime drowsiness symptoms have returned – if so they need investigating.

Surgery for snoring follow-up Surgery for snoring. It is vital that follow-up home sleep apnoea testing (HSAT) is performed for those who have undergone surgery for snoring.

The ‘fire alarm’ of snoring has been removed. What if the far more serious fire of sleep apnoea develops?

Changes in weight, lifestyle (particularly evening alcohol consumption) may give rise to sleep apnoea symptoms that need investigating.

Driving or similar vigilance critical roles

When sleep apnoea treatment is effective and it’s used, driving may resume.

However, it’s the individual’s responsibility to ensure they remain fit to drive.

Vocational drivers and those in vigilance critical roles (i.e. pilots or train drivers) will be actively monitored to ensure the safety of others.

Should sleepiness / drowsiness symptoms return driving/flying must immediately cease. Contact your sleep unit. They will be keen to assist you.

The Sleep Apnoea Trust provide detailed guidance about driving here. ↗

When obstructive sleep apnoea syndrome treatment is effective (i.e. no more drowsiness when you should be awake) and most importantly the treatment is adequately used, driving may resume.

However, it is the individual’s responsibility to ensure they remain fit to drive.

It should be noted that if you are a vocational driver or perform some other vigilance critical role (i.e. a pilot or such like) then you will be actively monitored to ensure the safety of those around you.

Should sleepiness / drowsiness symptoms return you must immediately cease driving/flying and contact your sleep unit. They will be keen to assist you. 

The Sleep Apnoea Trust provide detailed guidance about driving here. ↗

Summing up follow-up and condition change

Beware: The snorer and partner are commonly exploited for profit:

  • Some custom dental appliance manufacturers may neglect to mention to dentists that without sleep training, they (the dentist) are not insured.
  • Over-the-counter (OTC) anti-snoring devices according to Which? are commonly sold with exaggerated claims.  They may also delay effective treatment of sleep apnoea. Check out this review new window of the silly claims gadget manufacturers make.

Finally, medical professionals may wish to reconsider suggesting a snoring patient use an OTC anti-snoring device as oral appliance therapy is the practice of dentistry and they would be personally liable for unfortunate dental consequences.

Snoring and sleep apnoea both change as we get older and/or our lifestyle changes: what works tonight, may not work tomorrow night.

Regrettably, nil follow-up and symptomatic treatment of ‘snoring’ without any, or perhaps inadequate assessment of sleep apnoea symptoms, is today encouraged or through regulatory inaction, effectively condoned.

Consequently, the snorer and partner are exploited for profit:

  • Some custom dental appliance manufacturers (with a short-term view) may neglect to mention to dentists who prescribe mandibular repositioning splint therapy, that without sleep training, the dentist is practising outside the bounds of both their expertise and professional indemnity insurance.
  • Over-the-counter (OTC) mandibular repositioning splints are commonly sold on-line and in the pharmacy as Class 1 (low-risk) devices. This is (in my assessment) irresponsible and typically delays effective treatment of sleep apnoea and its co-morbidities. Check out this exhaustive review new window about the silly claims the manufacturers make.

Finally, medical professionals may wish to reconsider condoning or suggesting a snoring patient use an over-the-counter gadget not least because they may find themselves personally liable for the harm such oral appliances can and do cause to teeth and jaw joints, but because oral appliance therapy is the practice of dentistry.

Snoring and sleep apnoea both change as we get older (and typically gain weight).

Our lifestyle may also change, so in summary:

What works tonight, may not work tomorrow night.

CHAPTER 6:

 

FAQs about how to stop snoring


We conclude with a snoring and sleep apnoea Frequently Asked Questions (FAQ) section.

Have a question that isn’t answered? Ask it below by commenting, if we don’t personally know the answer, we’ll find someone who does!

Please note we cannot give medical advice.

Snoring and sleep apnea FAQ

Snoring: a technical explanation

Assume a fixed volume of air travels into your lungs while you sleep (typically this is around 500 ml). If your airway narrows, the air must travel faster for the same volume, to enter your lungs in one breath. As the air speeds up, floppy airway walls move in-and-out and make the snoring noise.

Snoring FAQs ⤴

What does surgery offer for sleep apnoea?

Surgery may appear a ‘quick-fix’ solution. However, diagnosis and accurate identification of precisely WHERE the problem is, dictates the success or outcome of surgery, which in itself is challenging.

Surgery for sleep-related breathing disorders, is split by whether bone needs to be operated on. If not then ‘soft-tissue’ surgery, is intended to improve the effective use of other therapies (see above). In contrast, surgery on the bones of the face, is intended to eliminate the need for other therapies.

This is major surgery and it will change the way you look.

A final option is to bypass the collapsing area of the throat. This is known as a tracheotomy and it’s not normally considered, until everything else has failed. Grab the Surgery for snoring Guide.

Snoring FAQs ⤴

I would like to undergo surgery to stop my snoring…

Question continued:

I would like to undergo surgery to stop my snoring, I have been to my doctor regarding this and they referred me to a specialist, who gave me a machine to test for sleep apnoea.

The results came back fine (I don’t have sleep apnoea). Yet my snoring is so bad that it keeps my partner awake, and they already sleep with ear plugs. Not sure what else to do. Have tried sleep spray, strips, mouthguard etc.

Response:

We cannot give medical advice. However we can offer personal opinion on the UK situation: Consult your GP.

You will find that surgery for snoring without sleep apnoea (the machine the specialist sent you home with to test your sleep overnight) is NOT provided by the NHS. Which means that if you’re a suitable patient you would have to pay for surgery. Of course I do not know if you’re in the UK reading this!

We have 2 things to help you make a more informed decision:

  1. Things to discuss when considering surgery for snoring and sleep apnoea Guide
  2. How to stop snoring: The definitive, step-by-step Guide (2019)

Have you tried a custom-made oral appliance for snoring? These are fundamentally different to over-the-counter devices and (if you get the right one) will help most people. You can find more about them here

Finally, I suggest you contact the Hope2Sleep.co.uk ↗ forum on Facebook. ↗ It may help to discuss things there.

Snoring FAQs ⤴

How would I go about getting surgery and how much would it cost?

First you must be screened for obstructive sleep apnoea. Consult your GP (additionally if you’re in the UK a sleep-trained dentist) and heed their advice.

Three important things to note:

  1. Surgery is an option when all other options have failed.
  2. Surgery is usually only considered to improve the effect of PAP or an oral appliance.
  3. If your weight changes it will impact upon the success (or otherwise) of surgery.

If your GP considers it appropriate, you would be referred to the nearest ENT department or you can choose somewhere else if you wish. (the NHS Constitution gives you this choice).

At the ENT department they would assess you, examine your nose and throat and perhaps do a nasendoscopy or a sleep nasendoscopy in an attempt to identify where the snoring is coming from. Various surgical options exist but the difficulty is in identifying precisely where the problem is. It may be many areas.

Surgery is a private option. You could discuss the cost of this with the GP and then the ENT department.

Snoring FAQs ⤴

What is obstructive sleep apnoea?

Sleep apnoea can be thought of as the serious side of snoring. The problem is, without professional assessment its impossible to say if snoring is (or is not), a symptom of sleep apnoea.

Sleep apnoea may be observed as periods of silence between snores. The snorer’s chest and stomach continue to move up and down, but no air enters their lungs, until they wake up and breathe. As you can imagine, sleep apnoea eliminates deep, restorative sleep. If left undiagnosed and untreated, the sufferer will experience multiple short and long-term health consequences.

Ultimately, untreated sufferers will die sooner than would otherwise be expected. Sleep apnoea affects the individual in what is called apnoeaic episodes. These typically last 10 seconds and can be as long as 2 minutes at a time – they occur occasionally with most people who snore and this can be considered relatively normal.

However, most observers only notice the ‘tip of the iceberg’ and the condition may be far more serious. The severely affected individual will experience daytime symptoms that may be described as ‘a cross between jetlag and a hangover‘. The partner will notice the noise and occasional moments of silence – this is when the individual is not breathing!

Get a better understanding of snoring and sleep apnoea, by grabbing our free Overview Guide.

Snoring FAQs ⤴

Stop snoring: ‘Tips and Tricks’?

For some snorers a quick and easy solution to stop snoring, is to change sleep position get off your back). This may immediately reduce or stop the annoying noise: “TURN OVER!” might be something you’ve heard before…?

You may also have seen promotions for anti snore pillows? They aim to encourage you not to sleep on your back. Which is known as positional therapy. 

Sadly, changing sleep position alone, doesn’t cure snoring for everyone. This is because there are many reasons, with as many solutions, for why someone may snore each night. That’s why you need signposting and professional screening and assessment.

Snoring FAQs ⤴

Is snoring an act which absolutely cannot be controlled?

Yes. It is an unintentional and uncontrollable phenomenon. While the individual can lower certain risk-factors (see above), they can’t choose ‘not’ to snore. It would be like asking someone, not to breathe!

Snoring FAQs ⤴

Snoring risk factors

There are a number of risk-factors, some may be quickly and easily fixed… Others may not.

Lifestyle changes include:

  • maintaining your ideal weight,
  • not smoking,
  • reducing alcohol consumption (and not drinking that glass or two of wine/beer in the evening – which is exactly when you WANT to drink it – I know!)

These are useful things to work on. However, lifestyle changes take time and are not always effective even then.

For example, if your lower jaw is ‘set back’ in relation to your upper jaw, this may make your airway narrower and predispose you to snore. You may also snore if you have enlarged tonsils and adenoids – physical obstructions in your nose or throat – that limit the size of your airway. If you’re concerned about this, your GP is the first person to contact to seek a referral for an ENT assessment.

As we get older, it’s a fact of life that our body tissue becomes less elastic (we’re back to tone again) as we age. This ‘floppiness’, together with excess weight, is a contributory factor to why we snore.

Snoring FAQs ⤴

If we are more tired, do we snore while sleeping?

If we’re exceptionally tired, we may lose body tone more rapidly and more deeply, when we go to sleep, so yes if we’re prone to snore, this would mean we snored more loudly or frequently.

Snoring FAQs ⤴

Why do anything about snoring?

You mean apart from not being anti-social?!

Snoring may be a symptom of Obstructive Sleep Apnoea (OSA). OSA makes your heart race as the oxygen in your blood drops. This places strain on your heart and because after every stoppage of breathing, you start to wake up, you do not get a good nights sleep. This affects the way you feel and your behaviour the following day.

UARS is a milder version of this and can be thought of as in between snoring (mild interference in airflow) and obstructive sleep apnoea (when the airway is closed or obstructed).

Snoring FAQs ⤴

Why don’t we wake-up from our own snoring?

A classic warning sign of obstructive sleep apnoea is waking up and: …hearing the end of your own snore…

Typically, this would be as a result of what is known as an ‘apnoeaic episode’ or period of not breathing.

Typically, the sufferer doesn’t remember this. They take a breath and go back to sleep.

Its sounds like this:

Snoring…. Stop breathing… silence…. Partially awaken. [Gasp / cough / scratch / roll over.] Snoring… Stop breathing….silence Partially awaken.  [Gasp / cough / scratch / roll over.]

Repeat. All night.

However, most snorers do not wake themselves up, they just irritate those who are trying to sleep within earshot…

Snoring FAQs ⤴

When does snoring indicate a more serious problem?

If you snore loudly with occasional pauses in breathing, and you frequently wake up during the night, you may be suffering from sleep apnoea.

Ask your partner, or a member of your family to listen for signs of this disorder.

Sleep apnoea is periods when you stop breathing while you’re sleeping. These interruptions in your breathing, which can last 10 seconds or longer, occur when the muscles in your soft palate, uvula, tongue and tonsils relax during sleep.

This is the same process involved with normal snoring, but with sleep apnoea, the airway narrows so much that it closes. Your breathing stops, cutting off the flow of oxygen into your body and reducing the elimination of carbon dioxide (CO2) from the blood.

Your brain detects this rise in CO2 and briefly wakes you up, re-opening your airways and re-starting your breathing. This process can be repeated many times during the night.

Proper sleep can become impossible, resulting in severe fatigue and a decreased quality of life. Sleep apnoea in adults can increase the risk of serious health problems such as heart failure, because it deprives the sufferer of adequate levels of oxygen, making the heart work harder than normal.

Snoring FAQs ⤴

How can I tell if I snored last night?

Well, you could ask your long-suffering partner! But what if you don’t have a partner? (Or if they’re not in the same bed?). Well, if you wake up with a sore throat or perhaps a dry mouth, this probably means that yup, you were snoring.

To get slightly more scientific about it, you could buy a voice-activated dictaphone or if you have a smartphone, there are apps that may detect snoring.

A word of caution: Light from your phone at bedtime could interfere with falling and staying asleep.

Snoring FAQs ⤴

Why do some people snore so loudly?

Some people are born with certain traits and characteristics that pre-dispose them to be snorers, such as a heavy set lower jaw, a large neck circumference and a high body mass index (BMI).

Snoring FAQs ⤴

Why does alcohol make you snore more loudly?

Alcohol further relaxes the soft tissue in the throat and worsens any snoring noise created.

Snoring FAQs ⤴

My doctor doesn’t seem to listen or take me seriously?

Some people and some doctors, do not take anti-social snoring very seriously.

Question. Is treatment really necessary?

Answer. Both ends of the spectrum deserve treatment. Benign snoring can be far from benign. The social consequences can be extremely distressing, snoring may be a symptom of obstructive sleep apnoea and as such investigation for this possibility is reason enough to take what the patient reports seriously.

The misery of snoring to both the partner and the snorer is not worthy of the joke approach. We can help you inform your Doctor of the serious social consequences, and the economic and longer-term health benefits of the available treatment options.

Snoring FAQs ⤴

Should I visit a doctor about my snoring?

Your Doctor (General Medical Practitioner or Primary Care Physician) has access to your medical history. As such they will be able to make an informed decision about how appropriate the available treatment options are for you. They will want to know and discuss how your life (and that of your partner) is affected.

Snoring FAQs ⤴

What will the sleep or ENT consultant do?

Upon referral from a doctor, the hospital consultant will examine you and discuss all the treatment options with you.

There are many options available and not all are suitable for everyone. You may need to spend a night at the hospital and be examined while sleeping.

Snoring FAQs ⤴

What will the dentist do?

Upon referral from a Hospital Consultant the Dentist will examine the condition of your mouth and your oral hygiene. You must have good oral hygiene and be prepared to work hard to maintain it.

If you have periodontal problems or extensive crown and bridge work Sleep appliances may not a good idea. You must have sufficient good teeth in both jaws to hold the appliance in place.

Exceptionally in the UK, a sleep-trained dentist may screen your for sleep apnoea (and if they don’t recognise the need for further investigation into your sleep problem) offer you a mandibular repositioning splint without you having to be medically diagnosed beforehand. 

Snoring FAQs ⤴

Why not buy a mandibular repositioning splint on-line or at the local pharmacy)?

It’s essential that the presence or absence of obstructive sleep apnoea (OSA) is established before using any treatment or ‘cure’ for snoring. Why? Because some people with undiagnosed OSA (remember snoring may be a symptom of OSA), do not adequately respond to oral appliance therapy (the typical pharmacy bought stop snoring ‘cure’), and their underlying condition may continue to deteriorate, while their snoring noise is perhaps a little muffled, (but this is not a definitive guide to anti-snoring devices – this is.)

It would be a bit like turning off the fire alarm (the snoring) and ignoring the fire.

Snoring FAQs ⤴

Is sleep apnoea classed as a disability?

The Sleep Apnoea Trust Association 6 state: [new tab]

Untreated, obstructive sleep apnoea can be very disabling. But it is not a disability as the condition can be treated by a simple painless non-surgical approach available entirely free of charge on the NHS. For most patients, the treatment, using a CPAP machine, is wonderfully effective and dramatic. Many users experience a return to energy levels that they have not enjoyed for many years.

The main symptoms such as constant and excessive sleepiness, memory impairment, mood swings, irritability and

under performance at work are quickly eliminated. 2 Longer term benefits are still being intensively researched, but the 20% reduction in life expectancy 3, if not diagnosed and treated, is rapidly mitigated

The best treatment for OSA on the NHS is continuous positive airway pressure (CPAP). This involves wearing a mask over the nose (or nose and mouth) during sleep, connected to a quiet pump beside the bed. It supplies slightly pressurised air to keep the throat open. The mask allows the breathing to return to normal during sleep and usually ends the snoring! Many partners enjoy sleep that they have not experienced for even longer, as they are not disturbed by their partner’s snoring any more.

When successfully treated, any concerns about driving while sleepy disappear, and no driving restrictions are imposed by the DVLA.

Snoring FAQs ⤴

Do men snore more than women?

Yes. Snoring affects more men than women. However, a large neck circumference, fat deposits on the neck and a heavy set lower jaw predispose both sexes to snore.

As we get older our soft tissue loses some of its elasticity and this allows it to vibrate when the air (your breathing) passes – creating the snoring noise. After the menopause, women may snore just as much as men of a similar age.

Snoring FAQs ⤴

Do dental mouthguards work for sleep apnoea?

Yes, in selected cases. Over-the-Counter (OTC) gumshields for snoring are NOT the same thing as custom-made, adjustable prescription Mandibular Repositioning Splints (MRS).

There are a few important points to remember:

  • You should be screened for sleep apnoea BEFORE using any ‘mouthguard’
  • Clinical research has established that OTC gumshields are not valid as a trial or therapeutic device5

Adrian has examined how to choose the best anti-snoring device ↗ and also looked at the claims made by OTC dental devices ↗ for snoring manufacturers.

Grab our free Guide about how to choose a mouthpiece to stop snoring.

Snoring FAQs ⤴

What is the latest treatment for sleep apnoea?

The sleep apnoea treatment market is expanding rapidly (as are our waistlines – obesity being a compounding variable for sleep apnoea). The latest treatment today, will be superseded tomorrow.

As of June 2018, I have seen a novel CPAP launch that permits the use of ‘low-flow’ positive air pressure (high air pressure being a major cause of treatment non-use). Check them out Fresca Medical. 

Snoring FAQs ⤴

What works best to stop snoring?

There are many variables to consider and everyone is different.

That’s why a ‘One-Size-Fits-All’ approach will never work.

See your GP or a sleep-trained dentist and put this question to them IN CONTEXT. They will have access to your medical (and dental history) and be able to guide YOU individually to answer: “What works best to stop snoring?”

Snoring FAQs ⤴

Can snoring in children be indicative of a medical problem?

Children should not routinely snore each night: If they do, then consult your GP and seek an ENT assessment.

The ENT specialist will examine your child’s tonsils and adenoids, at the back of their throat. These can become swollen and make it hard for your child to breathe. Surgery permanently cures this.

If your child snores occasionally, perhaps because they have a cold or hayfever symptoms, then this should pass and it’s nothing to worry about.

Your GP is only human, and they may not know much about snoring and sleep apnoea. Print and take with you
the: GP Guidelines for Snoring and Sleep Apnoea.

Snoring FAQs ⤴

Are there societal or evolutionary ‘benefits’ from snoring?

An internet myth about snoring proposes we snore to warn off prowling predators: “I am sleeping here”, Cue caveman:

Grrr!

Or perhaps its a warning noise:

Do not disturb!“?

However, it’s more likely our early, grunting ancestors, didn’t snore at all! We started to snore, as we developed the ability to speak, perhaps due to a design compromise in our throat.

Our throat must be: Flexible enough to pass food to our stomach when we swallow (the wave like action of peristalsis).

Yet rigid enough not to collapse as we breathe These are contradictory requirements. If we contrast man with apes, their throat is more rigid (as they do not compromise their need to breathe, to be able to talk).

Snoring FAQs ⤴

Do you know someone who snores?

Share this with them. But first, put the noise to one side for a moment, have you observed periods of silence in between their snores? Are they sleepy when they should be awake?

The silence between snores is when they’re NOT BREATHING. Their chest and stomach rises and falls, as they make increasing efforts to breathe, yet no air enters their lungs.

They’re suffocating. Yes really!

Eventually, they come up from deeper sleep enough to cough, take a breath… and resume snoring.

Repeat. All night, every night.

They wouldn’t tolerate someone strangling them while awake – yet at night the snorer with untreated sleep apnoea – does it to themselves.

Learn how you might help them by reading our Partner’s Guide

Do you know someone who snores?

Other types of sleep and breathing issues

This page has focused on snoring and obstructive sleep apnoea (OSA), but you should know that there are other types of sleep and breathing issues (less common) where the ‘drive’ to breathe momentarily pauses.

A review of medical history, sleep study and an expert medical diagnosis is essential before starting any treatment because some people are made worse with regular PAP therapy.

If you are concerned about your own or someone else’s sleep or daytime alertness, I urge you to consult a sleep-trained professional. You would be helping them immensely.

Now, over to you

You’ve read it. Now, it’s time to act.

  • What will you do first?
  • Did this Guide help?

Or maybe you have a question? Let us know by leaving a quick comment below right now.

Thanks, Adrian & Emma.

Finally, we would like to thank Ed Grandi for his kind assistance with US specific information.

Thanks Ed👍 Here’s his blog ↗.

Comment or write a review about how you will stop snoring permanently
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Darren Umbers (Former Regional Director UK & Ireland, Philips Respironics)

Well done Adrian, anything that helps people find help and navigate the confusing terminology and landscape to better understand what they need to reclaim their days and nights is a win with me. There are both too many people not getting the help that they need, as well as too many people being mis-sold the help that they don’t need. I think that your guide will be a help to close the information inequality gap for many people.

Darren Umbers How to Stop Snoring (The Definitive Guide) October 25, 2018

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Mike McEwan, (Former VP Europe – ResMed)

An excellent overview and specific advice. Very useful.

Mike McEwan How to stop snoring Guide October 6, 2018

Add your review

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References

  1. Snoring and the role of the GDP: British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol. Stradling J. and Dookun R. BDJ Mar 2009 Available here: https://www.nature.com/articles/sj.bdj.2009.214 [accessed 25 Feb 2019]
  2. Find GP services: https://www.nhs.uk/Service-Search/GP/LocationSearch/4 ↗ [accessed 25 Feb 2019]
  3. NHS e-referral website. Available here: https://www.nhs.uk/using-the-nhs/nhs-services/hospitals/nhs-e-referral-service/ ↗ [accessed 29th March 2019] Updated to reflect new NHS URLs coming in July 2019
  4. Basyuni S, Barabas M, Quinnell T. An update on mandibular advancement devices for the treatment of obstructive sleep apnoea hypopnoea syndrome. Journal of Thoracic Disease. 2018;10(Suppl 1):S48-S56. doi:10.21037/jtd.2017.12.18. Available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803051/ ↗ [accessed 2nd Oct 2018]
  5. Vanderveken OM, Devolder A, Marklund M, et al, 2008. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med; 178: 197–202. Available here: http://www.atsjournals.org/doi/abs/10.1164/rccm.200701-114OC#.V9ukcFT_rio ↗ [accessed 12 April 2017]
  6. Is sleep apnoea a disability? Available here: http://www.sleep-apnoea-trust.org/sleep-apnoea-information-patients/sleep-apnoea-frequently-asked-questions/#obstructive-sleep-apnoea-osa-disability-equality-act-2010 ↗ [accessed 25 Feb 2019]

Our related expert reviews and ‘How-to’ Guides:

Here are some more high quality reviews about anti-snoring devices, snoring and sleep apnoea / apnea products, chin straps, pillows, cures and aids!

Signposting™ is a CE mark marked, Clinical Decision Support System, Software as a Medical Device. The Manufacturer is Snorer.com Ltd. registered with the UK Medicines and Healthcare Products Regulatory Authority.

CE marking is a certification mark that indicates conformity with health, safety, and environmental protection standards for products within the European Economic Area.

The signpost icon is made by Freepik from www.flaticon.comand is licensed by CC 3.0 BY

Page created by Adrian Zacher and Emma Easton. All rights reserved. Last updated 13th Nov 2019.

TURN OVER! You’re Snoring… Independent review of novel positional therapy device

TURN OVER! You’re Snoring… Independent review of novel positional therapy device

Snorer.com
Rated 5/5 based on 16 customer reviews

If you or your partner snore, then the words:

TURN OVER! – You’re Snoring… 

May be all too familiar!

Of course, the premise here is that the snorer (me!) will stop snoring in a different position (off their back most probably) and the offended, sleep disrupted partner, can then try to go back to sleep… 

Most people have heard of ways to help ‘train’ the snorer to get off their back (known as ‘Positional therapy’) including perhaps a tight fitting T-shirt with a tennis ball sewn into the back of it.

The idea being to make it uncomfortable to sleep this way (known as ‘supine’).

Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I teach UK dentists how to help their patients stop snoring; sleep and breathe at the same time.

Many of my customers find their work so rewarding they devote their practice to it. I’m a sleep-industry insider with a quarter of a century of sleep medicine experience.

Google Scholar

Good to know:

Snorer.com is independent. We don’t sell anti-snoring devices, chin straps or whatever! And we don’t benefit from affiliate deals.

Turn over - you're snoring!

Getting more serious

These approaches then develop slightly to include foam tubing or pillows strapped to the offending snorer’s back.

All these methods can help, but any change in sleep position throughout the night and over the course of time isn’t documented, and perhaps its not a lifelong solution:

So who knows what’s happening?

Certainly, the snorer’s partner may appreciate some noise reduction, but when they themselves are asleep – what’s going on?

Enter the new high-tech solutions and some more jargon (or when you know this device ‘buzz’ words) to explain:

  • Vibrotactile feedback: Essentially this means that when the device detects that the snorer is on their back it vibrates, just enough to encourage the snorer to turn over. You may know this, perhaps on your mobile/cellphone, as ‘Haptic feedback’.
  • Supine dependency: This is when the snorer either only snores when sleeping on their back, or that sleep apnoea is worsened when sleeping this way.

There are currently two competitors in this space and I was lucky enough to have the chance to try the NightShift device.

Point to note here: 

I don’t get paid for my thoughts and ramblings or get some other kickback.

Before I continue, its important to note that the NightShift device is a prescription medical device and that snoring may be a symptom of obstructive sleep apnoea (OSA).

If you are concerned about OSA you should consult your Doctor.

Now we have that out of the way, lets take a look at this thing:

Here’s a shot, I grabbed from the company leaflet:

NightShift device
Here it is on my hand (to give you some idea of scale).
NightShift on my hand for scale

My personal experience of positional therapy

I was impressed with the packaging and pleased to see how small the device was.

Hmmm….

The strap around the neck looks like it will throttle me – BUT – actually it contains two magnets to separate and release, right under my Adams apple. So if my wife gets annoyed with me… it separates.

The straps are actually quite comfortable, it just feels a bit strange the first few nights.

Note: The strap has loops (the manufacturer calls them retention bands) to slip the excess through. I mistakenly thought that mine had these loops missing, but they were at the end of the straps, over the magnets…

See the picture below (yes, its a bit small and hard to make out [its the ‘lump’ at the end] but it will become clearer in context below):

Neckstrap of NightShift device
You have to slide the loops along the strap, to limit the amount it can move.
See picture below:
slide the loops along

After getting the straps right, I turned it on…

Mistake!

Charge it first by plugging it into your computer with the micro USB lead that it comes with.

The next thing to do (which again I didn’t do the first night) is to head over to the manufacturer’s website (with the Nightshift device plugged in to your computer) and correct the time and date: www.nightshifttherapy.com

You need to have a current version of Java running on your PC for this to work. Get Java

So, did it work for me? Did I turn over?

Yes.

Put it this way, I use it every night.

I also use an oral appliance ‘mouthpiece’ and together the Nightshift controls my snoring and I feel better rested in the morning.

However, the first few nights of using it, I actually felt worse on waking as the device was making me turn over to sleep on my side. (At least it wasn’t my wife screaming at me “Turn over! You’re snoring….”)

This is to be expected I guess.

Now after a few weeks of using it, it must be changing my behaviour.

When I had it charged it lasted in excess of 3 nights. Its neat how when you turn it on, it vibrates to indicate how many nights of use it can provide.

I also like the delay in starting the vibrations for 15 minutes, so you can get to sleep before it starts working.

Did I turn over?

Have a look at the graph below and I will attempt to explain what they mean. 

This ‘3 day graph’ shows that my attempts to sleep ‘supine’ (on my back) have decreased considerably. I have deliberately spaced the nights chosen to give some idea of change.

The most recent data is the first graph. This shows improvement!

Look at the red line. This is when I was sleeping on my back and just following the line you can see I turned over like a good boy.

Now look at the second and third graphs and you will see I am sleeping less on my back, than I originally was.

It works!

There is the capability to record and display up to 12 months data, which I anticipate when I have been using it for some time, will prove valuable as there will be more data to work with.

Its interesting to see that it records how much I was snoring too… (click the image below to make it a bit bigger)

3 day detailed report

Who can help you stop snoring?

Get signposted (free) to the right professional

How to use the NightShift positional therapy device

Here’s a user instruction video placed on YouTube by the manufacturer.

I make no representations as to how useful or valid it is.

Night Shift – Using the Device

Conclusion

I think this is a fascinating area with real potential to manage sleep-related breathing disorders.

According to the manufacturer’s research 83% of participants had a 50% reduction in AHI (apnoea hypopnea index), 90% had > 35% reduction in AHI. The mean reduction across all participants was 69% and the median reduction was 79%.1

Combining an oral appliance with positional therapy appears to manage snoring and for those with supine dependent, mild to moderate obstructive sleep apnoea – reduce the incidence of apnoeaic episodes.

Its not clear to me, but I would imagine that it would also reduce the length of the apnoeaic episode too.

The take-away message seems to be:

‘Turn over and you will sleep better yourself 

Finally, a question occurred to me when thinking about this post and discussing my experience with the supplier:

  • Is the device really ‘training’ me to turn over?
  • What would happen if I stopped using it after a period of training?
  • Would I ‘forget’ and resume supine sleep?

The inventor Dan Levendowski was kind enough to let me know that yes it was training me – but continual use is advisable.

It just remains for me to add my thanks to Advanced Brain Monitoring and GDS Medtech for letting me try this product and review it.

Night Shift is CE marked and gained FDA clearance on the 3rd June 2014.

Here are some more independent reviews and how-to’s about snoring and sleep apnoea products, cures and aids:

Reference

The NightShift research paper, “Capability of a neck worn device to measure sleep/wake, airway position, and differentiate benign snoring from obstructive sleep apnea“, published in the Springer Journal in Feb 2015 http://link.springer.com/article/10.1007%2Fs10877-014-9569-3 new-window

Related:

NightShift crowdfunding page: https://www.indiegogo.com/project/preview/29da0980 new-window (now closed – Nov 2018)

Found this useful? Please take a moment and write a review:

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Created by Adrian Zacher Last updated 19th June 2019

Do Anti Snore Pillows work? (Sleep-Expert Review 2019)

Do Anti Snore Pillows work? (Sleep-Expert Review 2019)

Snorer.com
Rated 5/5 based on 16 customer reviews

Anti snore pillows: Do they work?

Anti snore pillows seem ideal: an easy and comfy way to return peace and quiet to your bedroom…

But:

Do they really stop you snoring? 

If you’re thinking of buying an anti snore pillow, then read this independent (no advertisements or affiliate links!) sleep-industry expert review.

I examine:

  • How anti snore pillows claim to work
  • What the clinical evidence tells us 
  • What the experts say
Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I teach UK dentists how to help their patients stop snoring; sleep and breathe at the same time.

Many of my customers find their work so rewarding they devote their practice to it. I’m a sleep-industry insider with a quarter of a century of sleep medicine experience.

Google Scholar

Tired of the sleepiness and the snoring?

Then read our free, definitive step-by-step how to stop snoring Guide.

This comprehensive Guide walks you through self-help, signposting, screening, professional assessment and diagnosis, the three categories of prescription treatment, follow-up and rounds off with a substantial FAQ.

CAUTION: Snoring may be a symptom of Obstructive Sleep Apnoea / Apnea (OSA)

Without first being screened for obstructive sleep apnoea (OSA) your purchase of an anti-snore pillow could be delaying your diagnosis and effective treatment (should your snoring be a symptom of OSA.)

A treatment that will prolong your healthy life!

Get signposted to the most appropriate professional (it’s free!)

The professional will screen you for OSA and decide if you’re ‘just’ a snorer or if your snoring needs investigating.

Your GP may be able to help you. Or if you live the UK, you can also find sleep-trained dentists who can screen you and recognise Obstructive Sleep Apnoea/Apnea (OSA) symptoms. These dentists can also provide you with a custom-made anti-snoring device.

Anti snore pillows (How they claim to work)

Various anti snore pillows are available, yet they share design similarities:

They’re either ‘door-wedge’ shaped or double-curved with the hollow being where you place your head.

In this independent review, I look past the marketing ‘hype’ and examine the science (if there is any) behind their claims:

sleep on your side Encouraging you to sleep on your side
better breathing by supporting your head and neck Encouraging better breathing by supporting your head and neck
better body alignment Encouraging better body alignment (whatever that is)

 

So we have 3 claims to review:

Anti Snore Pillows (What I'm not including in this review)

There’s another type of anti snore pillow that I’m not including in this review.

They’re the expensive (circa 300 USD) ‘high tech nudge’ pillows that don’t treat your snoring – they merely disturb your sleep in some way when a snore is detected. They wake you up enough to regain muscle tone in your throat.

Some manufacturers claim that after a while you will get used to this pillow movement and regain tone in your throat without waking up.

The jury is out on this.

No. 1. Anti Snore Pillows make you sleep on your side

Why? Why is sleeping on your side an aim? And how does that help stop snoring?

Think First Aid.

Are you familiar with the ‘Recovery Position’? Perhaps you should be!

This is when the unconscious individual is moved by a first-aider off their back into a semi-prone position known as the ‘Recovery Position’ to help them breathe.

We’ll come back to how this relates to snoring and anti snore pillows, later in this post (it’s called positional therapy).

Check out the video below about the Recovery Position by the St John’s Ambulance. It’s all about ensuring you can breathe when unconscious.

Here’s an authentic and less than favourable review of an anti snore pillow in the Huffington Post

The Recovery Position (YouTube video) by the St John’s Ambulance.

No.2. Anti Snore Pillows support your neck

According to the NHS ↗, the most common cause of neck pain is when your neck has become locked in an awkward position while sleeping.

But what’s neck pain got to do with snoring?

Allow me to explain:

If your pillow inadequately supports your neck while you sleep, and your head is on your shoulder. Then the airway in your twisted neck may become restricted.

And you guessed it:

You snore.

Anti snore pillow neck ache
So, there is merit in supporting your neck while you sleep:
  • From both a neck pain perspective
  • And if your current pillow could be improved upon, it seems reasonable it could improve your breathing while you sleep

But unless your pillow is truly terrible and you routinely wake-up with neck pain from a strange sleeping position;

I would not expect it to stop you snoring.

But what do the experts say?

What do the experts say about anti snore pillows?

Clinical experts research products or theories to establish if it does or doesn’t work. You can think of it as proof or as close as possible to ‘fact’.

There is good evidence that positional therapy i.e. training the individual NOT to sleep on their back (No. 1 in this review) can help stop snoring1.

What do the experts say about anti snore pillows?

No. 3. Anti Snore Pillows stop snoring by encouraging 'Better Body Alignment'

Encouraging better ‘body alignment’ (as in sleeping with your head and body straight and your neck not bent) would on the face of it seem reasonable.

Perhaps if you were to sleep with your neck at an acute angle (as I mentioned in my review of claim No. 2) then yes the airway in your throat would be restricted and it could make you snore.

However, marketing a pillow with a supposed anti snore feature being improved ‘body alignment’, is I think reaching a little.

Anti snore pillows are they the most effective positional therapy device?

The Real Question

So if positional therapy has some validity as a way to stop snoring, the real question is:

Are anti snore pillows the most effective positional therapy device?

And to answer that I will:

  • Look a little closer at positional therapy
  • Provide a rough cost/benefit analysis
  • Review what the experts advise

Unless your pillow is truly terrible, I would not expect a new one to stop you snoring.

Adrian Zacher MBA

Snoring & Sleep Apnoea Care Navigator

Positional therapy for snoring and sleep apnoea

Turn over you're snoring!

Positional therapy for snoring is ‘as old as the hills‘. Think tennis ball in the breast pocket of a t-shirt worn back to front.

Position dependent snoring1 is the technical name for when snoring either stops or lessens in different (not on your back) sleep positions.

Fortunately things have moved on some from tennis balls and anti snore pillows.

I’m not going to review the various high tech ways or my experience of them here.

Suffice to say positional therapy may be useful IN ADDITION to:

  • A prescription, custom-made anti-snoring device
  • Positive Airway Pressure therapy

To get either of these you’ll need to know what you’re trying to ‘fix’. As in not self-diagnose yourself.

Keep reading:

Sleeping prone or on your front with an anti snore pillow

My personal experience of an anti snore pillow

When I rolled over and tried to sleep prone (on my front) my wife reported that the part of the pillow designed to support my neck when I slept on my side, pushed against my throat.

It appeared to be collapsing my airway!

She said I was making some very strange noises…

However, I continue to use an orthopaedic neck support pillow (remarkably similar shape!) and wouldn’t used anything else. I’ve learnt not to sleep quite so flat on my face!

Are they worth the money?

Anti Snore Pillows (Cost/Benefit Analysis)

Are anti snore pillows worth the money?

From a financial perspective its hard to beat the tennis ball in the pocket of the t-shirt.

With anti snore pillows on the market from 5 GBP they may be worth a punt.

However, you need to be aware of these limitations:

  • The tennis ball or anti snore pillow might not be enough to stop the snorer sleeping on their back (they just ignore it)
  • You have no evidence of effect throughout the night (other than the lack of a partner’s elbow in the ribs!)

Anti Snore Pillow: Costs

Anti snore pillow prices online and in the shops range from as little as 5 GBP to 25 GBP.

As a first-line and relatively harmless way to stop snoring they probably make financial sense.

However (and it’s a big HOWEVER) if they don’t stop the snoring problem then you need to seek the advice of a professional.

Pretty much everything is going to cost more than a tennis ball or a stop snoring pillow, but if you’re serious about no longer snoring, then consult a professional. There are considerable drawbacks to self-diagnosis.

  • If you have mild to moderate obstructive sleep apnoea (OSA) and you’re using an oral appliance then some data to show you turned over and your sleep has improved might be worthwhile.
  • If you’re on an auto-titrating PAP then getting off your back may reduce pressure and make PAP more tolerable.

Are you trying to ‘cure the snore?‘ (Before you know what’s wrong?)

Trying to ‘cure the snore’ before you know why you snore – is like driving a car before you’ve passed your test.

Wrong

You might think you can drive – but you could be on the wrong side of the road!

Treatment (the ‘cure’ for the snore) follows diagnosis i.e. find out if your snoring is more than just anti-social before trying to ‘cure’ it – for this you need signposting.

What about anti-snoring devices?

If anti snore pillows aren’t helping then you might wonder what else is available. Enter anti snoring devices.

Anti-snoring devices are commonly oral appliances you wear in your mouth at night.

They work by holding your lower jaw in a more forward position. This keeps your tongue away from the back of your throat so you don’t snore.

What’s the best anti-snoring device?

Example of an anti-snoring device

Example of an anti-snoring device. Image courtesy of SomnoMed and used with permission.

What about surgery?

A long way from an anti snore pillow…

Surgery for snoring is divided into whether hard and soft tissue is involved.

Soft tissue surgery is intended to improve the effect of an anti-snoring device or PAP therapy (more about what PAP is in a moment).

Whereas hard tissue surgery (that changes the way you look) is intended to eliminate the need for any other treatment.

Learn more:

Radio-frequency ablation for snoring

Image representing a soft tissue operation: radio-frequency palatal surgery.

Image representing a hard tissue operation: bi-maxillary osteotomy (both jaws operated on).

What about CPAP?

There are pillows especially designed for PAP users. Keep reading:

CPAP stands for Continuous Positive Airway Pressure therapy. Today, it is referred to as just PAP.

PAP works by providing low pressure air (through a mask worn over your nose and sometimes both your nose and mouth) to the airway in your throat. This pneumatically holds open your airway.

While an arduous therapy, it is highly effective if snoring is actually a symptom of obstructive sleep apnoea (OSA).

Learn more:

Example of a full face PAP mask

Do’s

Don’ts

  • Don’t self-diagnose yourself as ‘just’ snoring
  • Don’t buy over-the-counter stop snoring gadgets
  • Don’t ignore drowsiness or sleepiness during your normal awake time (consult your GP)
  • Signposting to the right professional

    When self-help and pillows aren’t helping it’s time to get serious.

    Signposting is when you’re directed to the most appropriate expert to help you stop snoring.

    The expert professional (your GP, additionally if you’re in the UK a sleep-trained dentist2) will screen you for sleep apnoea and decide if you need further investigation i.e. a sleep study.

    If you don’t need a sleep study a custom-made anti-snoring device (available from the sleep-trained dentist) is the first way to stop snoring and treat mild to moderate OSA3.

    Oh and signposting is free.

    Signposting to the right professional to stop snoring

    Summary

    My final verdict is that anti snore pillows are a relatively low-cost way to try to stop snoring. But don’t get your hopes up.

    You need to be comfortable to sleep well, so find a pillow that helps you sleep comfortably on your side and supports your neck. Consider orthopaedic pillows in addition to the big headline grabbing brands.

    When snoring is a problem consult a professional. If you’re in the UK you can get signposted to the right type.

    Otherwise consult your primary care physician. They have your medical history and want you to be well (they’re not trying to sell you something!)

    A final note about high tech anti snore ‘nudge pillows’:

    I’d like to see the impact this type of anti snore pillow has on the individual’s sleep quality.

    They appear to me to be fragmenting sleep and preventing deep restorative sleep from occurring. I consider the onus upon the pillow manufacturers to substantiate their marketing claim.

    And I come back to the fact, that this is a ‘treatment’ before knowing why you snore: there has been no prior assessment or screening for sleep apnoea.

    Reviews

    We applaud Adrian’s work
    Snorer.com
    September 7, 2018
        

    If you are looking for impartial advice about snoring from an expert in the field, the highly respected Adrian Zacher should be your go to. We applaud Adrian’s work, to raise awareness about the health implications of snoring, and the importance of prescription, custom-made devices for long-term success.

    Found this useful?

    Let others know what you think.

    1 - 5 out of 5, where 5/5 is the best and 1/5 is the worst


    Here are some more high quality, independent sleep-expert reviews of anti-snoring devices, snoring and sleep apnoea / apnea products, cures and aids!

    Glossary

    Anti-Snoring Device – generally considered a product worn in your mouth to stop you snoring.

    Custom-made – a bespoke device made specifically for you by a registered dental technician, working to prescription, using CE marked materials. In Europe working to the Medical Devices Directive  administered in the UK by the Medicines and Healthcare Products Regulatory Authority (MHRA)new tab

    OSA Obstructive Sleep Apnoea – (also spelt apnea) When an individual is unable to sleep and breathe at the same time. Visually, a repetitive pattern of breathing interruptions (apnoeas) occurring while the individual sleeps, due to a physical obstruction in the airway.

    OTC – Over-the-Counter product sold over the pharmacy counter or on-line without prescription, medical or dental assessment and without a review of medical/dental history.

    Signposting – Is the medical term for directing people to the most appropriate professional to help them based upon their answers to some high-level questions.

    Sleep-trained Dentist – A dentist that has undergone special interest training in sleep. As such they are able to obtain professional indemnity insurance.

    References

    1. Benoist LB, Morong S, van Maanen JP, et al. Evaluation of position dependency in non-apneic snorers. Eur Arch Otohinolaryngol. 2013;271(1):189–94. https://link.springer.com/article/10.1007/s00405-013-2570-5  new window
    2. Stradling, J. and Dookun, R. 2009, Snoring and the role of the GDP: British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol, British Dental Journal, 206, 307 – 312. Available here: http://www.nature.com/bdj/journal/v206/n6/abs/sj.bdj.2009.214.html new window [accessed 12 April 2017]
    3. The American Academy of Sleep Medicine (AASM) has approved oral appliance therapy (OAT) as a first line treatment for patients diagnosed with mild to moderate OSA. https://www.sleepapnea.org/treat/sleep-apnea-treatment-options/ new window

    Created by Adrian Zacher | Page last updated 3rd June 2019

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