Causes

• Excessive alcohol intake or certain sleeping medications: that cause throat muscles to over relax during sleep.
• Inadequate neck: back and throat muscle tone and weakness.
• Nasal obstruction: as a result of transitory health conditions like colds, sinusitis or hay fever. Other anatomical abnormalities such as nasal polyps, septum deviation, inflamed tonsils.
• Skeletal malocclusions: patients with maxillary prognathism (inadequate development of the lower jaw that causes the upper maxilla to be overpronated) This malocclusion is known as skeletal type II and it is associated with numerous posture, respiratory and dental problems.
• Swelling: soft palate (soft tissue at the back of the roof of your mouth) abnormalities. Other inflammatory diseases such as laryngitis or swollen throat.
• Obesity: having a higher than normal Body Mass Index (BMI) has been associated as a risk factor for snoring and OSA, as the increased amount of tissue produces extra pressure over the airway and breathing passages.
• Smoking: causes inflammation of the throat and contributes to narrow the airway.

Diagnosis

As the majority of sleep disorders, snoring is usually diagnosed by the patient’s partner or relatives. Although it might be loud and uncomfortable for others, it can remain unnoticed for the patient.  There is a lack of accepted clear guidelines about diagnosing snoring in the current scientific literature. However, the International Classification of Sleep Disorders consider a patient as snorer when:

• There is a report of sonorous breathing during sleep reported by the patient or their bed partner.
• The patient does not have sleep disorders associated with the snoring (the cause remains unknown).
• There is an absence of another sleep-related respiratory disorder.

Primary snoring should be diagnosed by a sleep physician and not a dentist, as it is often accompanied by OSA, and misdiagnosis can have severe implications for patients. However, dental practitioners can help in diagnosing snoring based on findings during the oral examination. Relying on a few tests, the dentist will look at the anatomical disposition of the patient’s mandible in relation to the upper maxillae, the joint function and the permeability of the airway. The dentist will also inspect the patient’s history, including their bed partner when possible as well as evaluate anatomical conditions and clinical signs that suggest snoring or OSA, and will make referrals if further analysis is needed.

Some of the further exams you could be referred to are:

Extraoral X-Rays that show the morphology and orientation of the facial skeleton.

Nasal function tests.

Allergy diagnosis.

Sleep endoscopy and pharyngeal manometry are more specialised tests to make a topographical diagnosis of the upper respiratory tract and differentiate snoring from more severe sleep respiratory disorders like OSA.

Polysomnography: is a more specialised test and the gold standard to further investigations of the respiratory tract and its related sleep disorders.

Sleep studies: performed overnight, in a specialised laboratory to monitor and assess the extent of snoring and how it affects the quality of sleep. It is used primarily to diagnose OSA.

Due to its multifactorial causes, snoring should be diagnosed and managed by a multidisciplinary team. General practitioners, otolaryngologists (specialist in ear, nose and throat), dentists and dental practitioners specialised in OSA and sleep disorders management can be part of the team that will help you manage your snoring problem.

Treatment

Snoring and OSA treatment can be divided into four categories:

Lifestyle modifications: weight loss, regular exercise, cessation of smoking or frequent excessive alcohol consumption, sleep position training.

Medications: nasal and throat spray to unblock air passages should be used under medical supervision.

Nasal appliances: strips or nasal dilators that open nasal passages, oral or dental splints that block or decrease airflow coming through the mouth and encourage nasal breathing, or move the lower jaw forward to prevent obstruction of the airway.

Oral appliances: reduce the frequency and intensity of snoring, improve quality of sleep and life. These should be used when more conservative lifestyle changes fail in reducing snoring. Custom made dental appliances have proven to be more effective than over the counter ones.

Surgery: mainly minimally invasive procedures designed to remove anatomical blocks causing airway blockages such as a deviated septum, enlarged tonsils or soft palate tissue. 

References

• Barewal, R. M., & Hagen, C. C. (2014). Management of snoring and obstructive sleep apnea with mandibular repositioning appliances: a prosthodontic approach. Dental clinics of North America, 58(1), 159–180. https://doi.org/10.1016/j.cden.2013.09.010
• Hoffstein V. (2007). Review of oral appliances for the treatment of sleep-disordered breathing. Sleep & breathing = Schlaf & Atmung, 11(1), 1–22. https://doi.org/10.1007/s11325-006-0084-8
• Ramar, K., Dort, L. C., Katz, S. G., Lettieri, C. J., Harrod, C. G., Thomas, S. M., & Chervin, R. D. (2015). Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 11(7), 773–827. https://doi.org/10.5664/jcsm.4858
• Sleep apnoea association of New Zealand (2020). A general overview of sleep apnoea. Retrieved from http://www.sleepapnoeanz.org.nz/overview.shtml
• Stuck, B. A., & Hofauer, B. (2018). The Diagnosis and Treatment of Snoring in Adults. Deutsches Arzteblatt international, 116(48), 817–824. https://doi.org/10.3238/arztebl.2019.0817
• Southern cross medical library (2017). Snoring-causes, treatment, surgery. Retrieved from: https://www.southerncross.co.nz/group/medical-library/snoring-causes-treatment-surgery