Just as nasal breathing is critically important to any OSA/UARS patient who attempts PAP therapy, care should be taken to monitor nasal health in patients using oral appliance therapy (OAT). Every effort must be made to promote smooth nasal airflow and any nasal congestion issues must be aggressively treated, particularly nonallergic rhinitis. Different combinations of medication, nasal sprays, and nasal or sinus rinses may be required to take control of both allergic and nonallergic rhinitis.
A note on rhinitis:
Nonallergic rhinitis has symptoms that come and go year-round, which may include:
- Stuffy nose
- Runny nose
- Mucus (phlegm) in the throat (postnasal drip)
Nonallergic rhinitis doesn’t usually cause itchy nose, eyes or throat — symptoms associated with allergies such as hay fever. There are a number of things known to trigger nonallergic rhinitis — some resulting in short-lived symptoms while others cause chronic problems. Nonallergic rhinitis triggers can include local and environmental irritants, such as OAT or PAP therapy.
Beyond treatment of congestion, there is also the nasal dilator approach that assumes nasal breathing can be further improved even when no congestion is present. In two prior posts, I delved into many aspects of nasal dilator strip (NDS) therapy describing our prior research as well as current application tips. In these posts I expressed my strong enthusiasm for the use of NDS therapy in patients using PAP therapy. Additionally, the marketplace often serves as its own form of evidence as many people today regularly use NDS therapy because they are happy with their results.
With OAT, NDS therapy is equally important as the dynamics of the dental device assume normal nasal airflow – if not enhanced nasal airflow. Unfortunately, many sleep professionals give nasal strips a bad rap. Some have gone so far as to declare that nasal strips only function as a placebo when used as a sleep breathing aid.1,2 Two additional review articles were released recently, one of which only looked at objective data and again declared limited to no value from NDS therapy.3 The second review looked at the effect of nasal strips on the internal nasal valve and declared the device has some degree of efficacy. This was without commenting on its use in sleep breathing disorders, however, as their selection of research articles excluded patients with sleep apnea or metrics of sleep quality.4 One final study of immense interest looked at the objective effects of NDS therapy on changes in the internal nasal airspace and documented significant anatomical enlargement, and they proved their point by using a placebo device for comparison.5
Putting all this research together we come up with an obvious paradox. On the one hand, there are many who still believe that NDS therapy is a placebo. On the other hand, there are both objective and subjective signs that NDS improves nasal patency and nasal airflow. How do we reconcile this seemingly conflictual information? The answer is quite simple, but it has never been researched. If patients report breathing better and sleeping better as they did in our randomized controlled trial of NDS therapy,6 the most obvious explanation would be that the improved nasal patency improved sleep breathing sufficiently to make a difference in the quality of sleep. Why then has this crucial point not been conclusively demonstrated in past research studies? Again, the answer is simple: no one has conducted an randomized controlled study to actually measure the subtle change in breathing likely to be consistent with the findings and reports of patients who insist they sleep better with NDS therapy.
This lack of objective information on changes in sleep breathing events with NDS therapy is likely explained by two problems in past research studies. First, and most obviously, all of the studies conducted to date have never described any potential impact of NDS on flow limitation breathing events. Instead, they only discuss apneas and hypopneas, which suggests these researchers never measured flow limitation events (aka RERAs). A second plausible barrier would be that the sensors we use to measure breathing events in sleep-disordered breathing patients are simply not refined enough to detect any changes that may lead to enhanced breathing and sleep quality. This second problem of course would be very difficult to sort out until a more sophisticated technology (possibly something like pneumotachography) were implemented to measure NDS effects.
Going forward, research must be conducted to address either or both of these potential barriers, because in all likelihood either or both will demonstrate the clinical effects of NDS therapy and therefore corroborate their value to patients. For all we know, the effect might prove to be something more unexpected in which the breathing change is barely noticeable, but instead we will find sleep EEG waveform changes at some level, which would then corroborate improved objective sleep quality to match patients’ description of self-reported improvements in sleep quality.
Regardless of how, when, and where such research is conducted, NDS therapy is very likely to prove to be an essential component of the OAT paradigm for reasons potentially more important than for the PAP paradigm. In OAT, the entire focus is on expanding the airway in the back of the throat. Undoubtedly, such changes will improve nasal airflow, but the dentist must still take in account areas of practice not necessarily covered by dentistry. While nasal hygiene is a must for sleep doctors prescribing PAP therapy, dentists must develop a similar attitude in managing OAT patients. Depending upon prescribing practices for dentists in different states, a consistent and reliable tool would be recommendations for patients to use NDS therapy.
When I used OAT for during a four-year stretch (1998-2002), I wore a nasal strip virtually every night with it, regardless of the fact I had also been using a vigorous nasal hygiene program involving sinus rinses, saline washes, and nasal steroids. I had also undergone septoplasty a year earlier for a deviated septum, and yet with all these steps, I still found the combination of OAT and NDS therapy the most optimal. To this day, when I am prescribing OAT for my patients, I strongly encourage them to use NDS therapy as well.
Amaro AC, Duarte FH, Jallad RS, Bronstein MD, Redline S, Lorenzi-Filho G. The use of nasal dilator strips as a placebo for trials evaluating continuous positive airway pressure. Clinics (Sao Paulo). 2012;67(5):469-74.
Yagihara F, Lorenzi-Filho G, Santos-Silva R. Nasal Dilator Strip Is An Effective Placebo Intervention For Severe Obstructive Sleep Apnea. J Clin Sleep Medicine (accepted manuscript).
Camacho M, Malu OO, Kram YA, Nigam G, Riaz M, Song SA, Tolisano AM, Kushida CA. Nasal Dilators (Breathe Right Strips and NoZovent) for Snoring and OSA: A Systematic Review and Meta-Analysis. Pulm Med. 2016;2016:4841310. doi: 10.1155/2016/4841310. Epub 2016 Dec 13.
Kiyohara N, Badger C, Tjoa T, Wong B. A Comparison of Over-the-Counter Mechanical Nasal Dilators: A Systematic Review. JAMA Facial Plast Surg. 2016 Sep 1;18(5):385-9. doi: 10.1001/jamafacial.2016.0291. Review.
Bishop CA, Johnson SM, Wall MB, Janiczek RL, Shanga G, Wise RG, Newbould RD, Murphy PS. Laryngoscope. Magnetic resonance imaging reveals the complementary effects of decongestant and Breathe Right Nasal Strips on internal nasal anatomy. 2016 Oct;126(10):2205-11. doi: 10.1002/lary.25906. Epub 2016 Feb 10.
Krakow B, Melendrez D, Sisley B, Warner TD, Krakow J, Leahigh L, Lee S. Nasal dilator strip therapy for chronic sleep-maintenance insomnia and symptoms of sleep-disordered breathing: a randomized controlled trial. Sleep Breath. 2006 Mar;10(1):16-28
About the author
Dr Barry Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr. Krakow started in sleep research in 1988 and helped pioneer innovative therapies for chronic nightmare patients. Since 1995, he has practiced sleep medicine full-time and currently operates Maimonides Sleep Arts & Sciences, Ltd., a private sleep medical center specializing in the treatment of sleep disorders such as insomnia and sleep apnea in mental health patients. He is also principal investigator of the Sleep & Human Health Institute, a non-profit research center that focuses on the complex interplay between physiological and psychological sleep disorders.