Snoring and sleep-disordered breathing (SDB) affects millions of Americans, both adults and children.1-2 The signs and symptoms are the results of a partial or complete collapse of the upper airway during sleep.3 The structures involved in treatment protocol include the floor of the mouth, soft palate, uvula, and the base of the tongue.4 The goal of the treatment is to decrease the amount of blockage of the upper airway.5
As part of a team, dentists are in a great position to help screen and treat problems with airway health management such as sleep apnea and SDB. Assisting patients to improve their sleep can profoundly improve their health, quality of life, and even their loved ones’ well-being.
Health Concerns
Obstructive sleep apnea (OSA) is defined by the American Academy of Sleep Medicine as a recurrent collapse of the upper airway during sleep, resulting in total (apnea) or partial (hypopnea) reduction in airflow. Changes in the mechanical physiology of respiration during sleep, including marked relaxation of upper airway muscles, result in the doubling of total upper airway resistance compared to wakefulness. The upper airway includes the portion of the respiratory system between the lips and proximal trachea. Multiple sites of potential obstruction within the upper airway include the retropalatal and retroglossal areas.
LightWalker®
• LightWalker lasers are designed for dental perfectionists and all forward-thinking professionals who wish to upgrade their daily dental experience with new treatment possibilities that only the latest laser technology can offer.
• LightWalker’s patented quantum square pulse mode represents a significant technological advancement, improving the laser’s interaction with dental tissues for optimized patient comfort, speed, and clinical results.
• Typical treatment procedures with LightWalker are fast, easy to perform, and feature less pain and shorter healing times for patients.
Fotona
(888) 550-4113 | fotona.com
A multitude of short- and long-term health issues can arise from SDB. The gold standard for the treatment of sleep apnea is the continuous positive airway pressure (CPAP) device, followed by oral appliance therapy. Dental health professionals have found that after many years of providing dental sleep medicine, many patients cannot attain the level of health that they need with just one treatment modality. Also, compliance issues arise with both of these modalities as time goes on.
Without a drug-induced sleep endoscopy procedure, it is very difficult to locate the exact location of airway collapse in obstructive SDB. The protocolwhich starts with neodymium YAG laser and follows with erbium YAG laser, considers this by addressing most of the areas involved in concentric collapse (floor of the mouth , soft palate and uvula and back of the tongue).6
Research by Michael Friedman, MD, has shown that 75% of obstruction is caused by the tongue and 25% is palate, etc.7
NightLase Treatment
Tongue position is also important. As the genioglossus muscle lower fibers protrude the tongue, the geniohyoid muscle brings the hyoid bone superiorly and anteriorly towards the mandible, and this dilates the airway and aids in respiration. The digastric muscle elevates the hyoid bone. Addressing the floor of the mouth with the NightLase treatment protocol helps with tongue position.
NightLase is a dual-wavelength laser system by Fotona. NightLase snoring and apnea treatment results in improved nasal breathing, which has numerous benefits. NightLase reduces the effects of sleep apnea and decreases the amplitude of snoring by means of a gentle, laser-induced tightening effect caused by the contraction of collagen in the oral mucosa tissue.
Now, let’s compare mouth breathing with nasal breathing. Nasal breathing has many documented health benefits related to daytime airway and sleep. Because of mouth breathing muscles, orofacial functions tend to adapt to a disordered breathing pattern. Nasal breathing filters out irritants, smooths airflow, enables improved blood and gas transfer in the lungs, and helps support optimal orofacial development. Therefore, patients who are not sleeping, breathing, and chewing properly cannot be completely healthy. Retraining of the oral and facial muscles can help enable better sleep and breathing.8,9
The LightWalker Laser
Of the commercially available hard and soft tissue lasers, only the LightWalker combines 2 proven wavelengths; Nd:YAG and Er:YAG. These wavelengths have unrivaled power and precise pulse control resulting in high efficacy levels for a wide range of procedures. With this advanced level of performance comes significant patient comfort. The following procedure has been developed to take advantage of these attributes.
Prior to the CPAP device for the treatment of SDB was the introduction of mandibular advancement devices (MAD). Compliance with both of these treatment modalities shows a reduction over time and with significant side effects. Now, NightLase therapy protocol is a unique approach to treatment when using the Fotona LightWalker dental laser with its proprietary protocol and handpieces. Another positive benefit is the 24-hour-a-day improvement in nasal breathing that occurs versus CPAP and MAD.
How does it work exactly? NightLase uses the photothermal capabilities of the LightWalker laser to convert and initiate the formation of new and more elastic collagen.10 The target mucosal tissues are the oropharynx, soft palate and uvula, back of the tongue, and the floor of the mouth. The proprietary “Smooth Mode” pulse characteristics create a non-ablative heat generation or “Heat Shock” that initiates the conversion of existing collagen to more elastic and organized forms and also initiates neocollagenesis, which is the creation of new collagen in the fibroblast cells.10 The effect of the laser energy as it penetrates (by transmission) deeper into the tissues, is a low-level photobiomodulation that directly affects the fibroblast cells and has been found to stimulate protein production from quiescent cells.11,12
This process results in a visible elevation of the soft palate and uvula and the tightening of the oropharyngeal tissues, resulting in an improvement in the upper airway volume. Following the NightLase protocol, users are able to tighten up the facia and mucosa over a number of muscles. These include palatoglossus, palatopharyngeus, levator veli palatini, and tensor veli palatini. For the soft palate, palatoglossus, and palatopharyngeus muscles, their fixed hard origins are at the hard palate. When they are tightened up with laser energy, they will move toward the hard palate.
When the soft palate shrinks from the laser energy, it will shrink upward and forward to the hard palate opening up the nasopharyngeal airway and reducing snoring. The palatopharyngeus muscle that is attached to the soft palate also moves upward and forward with the contraction of the soft palate. Some believe that the palatopharyngeus muscle has a role in upper airway dilation.
When users tighten up the palatoglossus muscle, the posterior part of the tongue will elevate upward and slightly forward to the hard palate to improve the oropharyngeal airway, the posterior tongue posture, and seal the mouth-to-pharynx air passage. As a result of all these actions, the nose-to-pharynx air passage will be enlarged, and the mouth-to-pharynx air passage will be reduced.
Given all of this, NightLase treatment helps patients to sleep better and breathe better through their noses. However, suppose the nasal cavity and airways are small and inadequate due to an underdeveloped maxilla and premaxilla. In that case, over time, the body will lower the tongue posture to occupy the lower arch in order to reopen the mouth-to-pharynx air passage for better air supply.13
Dental health professionals feel the NightLase treatment for patients with restricted maxilla and nasal cavities will need more frequent touch-up treatments. Patient adherence to myofunctional exercises on proper swallowing is also essential to prevent long-term relapse. In some cases, lingual frenectomies are also indicated to facilitate correct swallowing and correct tongue posture at rest and should always be evaluated as part of our clinical exam.
Appliances couple nicely with NightLase. Jaw development treatments such as advanced lightwire functionals (ALFs), daytime-nighttime appliances, and other functional appliances will work well with the NightLase treatment.14 The jaw development with these functional appliances has been shown to increase the bony opening of the nasal cavity. There’s an article on the addition of ALFs to other treatment regimens in the 2009 International Journal of Orthodontics documenting the nasal cavity improvement on posteroanterior cephalometric radiographs.15
Putting It All Together
The NightLase protocol has many promising values. It will help patients with breathing issues and craniofacial pain. Tightening up the levator veli palatini and tensor veli palatini with laser energy through the soft palate helps to open up the eustachian tube and reduces the pressure in the middle ear, which may affect some forms of tinnitus. Diaphragmatic nasal breathing is essential, as is tongue position to help patients maintain their health.
Clinical Results of NightLase
NightLase therapy is indicated for cases when the patient has been diagnosed with chronic snoring, upper airway resistance syndrome, or mild to moderate sleep apnea who either cannot or chooses not to wear a MAD or CPAP device. The results can be seen in 2 cases ( Figures 1a-cand Figs. 2a-b). It can also be used in cotherapy with devices and represents a less invasive alternative to current surgical, chemical, or radiosurgical options that may require hospitalization, general anesthesia, or soft tissue removal.
NightLase has a significant success rate in producing a positive change in sleep patterns. Research published by Miracki et al in the Journal of the Laser and Health Academy showed that NightLase can reduce and attenuate snoring and provide an effective noninvasive modality to lessen the effects of OSA.6
As with any treatment, there are potential risks with laser treatment. However, the risks are minimal and certainly less than alternative therapies if the protocol is followed correctly. NightLase therapy is not a permanent alteration and lasts anywhere from 6 to 12 months and is easily touched up at follow-up appointments.14
In 2013, a pilot study was completed that addressed snoring with only 12 patients. A 12-month follow-up showed a 30% to 90% reduction in snoring tone and volume. The lower percentages were smokers, obese patients, and patients with severe OSA. Follow-up studies with polysomnography using a home sleep test are in process, as are pharyngometer studies. Both of which have shown significant positive changes in the early results.15
A recently published pilot research study by Lee et al in Dental, Oral and Craniofacial Research touching on nonablative laser procedures showed that through colorized 3D CT imaging, there were positive volumetric changes after NightLase treatment. This study has helped support the clinical results. The study authors have follow-up studies with 3D CT scans, polysomnography, and a larger group of patients currently in process.
Dental health professionals consider NightLase to be another tool in the treatment toolbox providing more options and the possibility of better results when used in combination with MADs and CPAP devices for patients that may not get adequate improvements from only one therapy. NightLase also serves as interim therapy for children, adolescents, and teenagers while undergoing craniofacial development to enlarge their airways.
Using the modern and minimally invasive NightLase therapy, the dental community can now offer patients health improvements that reach beyond restorative and rehabilitative dentistry.
Financial disclosure:The author has no financial interest in the products mentioned in this article.
References
1. A report of the National Commission on Sleep Disorders Research (1995) Wake Up America: A National Sleep Alert. Washington, D.C.: U. S. Government Printing Office.
2. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217-1239. doi:10.1164/rccm.2109080
3. Lattimore JD, Celermajer DS, Wilcox I. Obstructive sleep apnea and cardiovascular disease. J Am Coll Cardiol. 2003;41(9):1429-1437. doi:10.1016/s0735-1097(03)00184-0
4. Courey MS, Fomin D, Smith T, Huang S, Sanders D, Reinisch L. Histologic and physiologic effects of electrocautery, CO2 laser, and radiofrequency injury in the porcine soft palate. Laryngoscope. 1999;109(8):1316-1319. doi:10.1097/00005537-199908000-00025
5. Fomin D, Nicola E, Oliver C, et al. Collagen type analysis in the soft palate after surgical intervention with CO(2) laser and radiofrequency ablation. Photomed Laser Surg. 2007;25(5):449-454. doi:10.1089/pho.2006.2085
6. Miracki K, Vizintin Z. Nonsurgical minimally invasive Er:YAG laser snoring treatment. J LA&HA. 2013:2013(1):36-41.
7. Vanderveken OM. Drug-induced sleep endoscopy (DISE) for non-CPAP treatment selection in patients with sleep-disordered breathing. Sleep Breath. 2013;17(1):13-14. doi:10.1007/s11325-012-0671-9
8.Mersch J. Eustachian tube dysfunction. MedicineNet. July 12, 2019. https://www.medicinenet.com/eustachian_tube_problems/article.htm
9. Valcheva Z, Arnautska H, Dimova M, Ivanova G, Atanasova I. The role of mouth breathing on dentition development and formation. J of IMAB. 2018;24(1):1878-1882. doi:10.5272/jimab.2018241.1878
10. Liu H, Dang Y, Wang Z, Chai X, Ren Q. Laser induced collagen remodeling: a comparative study in vivo on mouse model. Lasers Surg Med. 2008;40(1):13-19. doi:10.1002/lsm.20587
11. Lee CYS, Lee CCY. Evaluation of a non-ablative Er: YAG laser procedure to increase the oropharyngeal airway volume: A pilot study. Dent Oral Craniofac Res. 2015;1(3):56-59. doi:10.15761/DOCR.1000113
12. Spock C, Metelitsa AI, Kaufman J, Green JB. Lasers and light sources to activate fibroblasts. Cosmet Dermotol. 2012;25(1):27-33
13. Recinto C, Efthemeou T, Boffelli PT, Navalta JW. Effects of nasal or oral breathing on anaerobic power output and metabolic responses. Int J Exerc Sci. 2017;10(4):506-514.
14. Delz E, The ALF (advanced lightwire functional appliance) creating facial beauty and balance. Int J Orthod Milwaukee. 2009;20(2):23-27.
15. Shiffman HS, Lukac M. NightLase: minimally invasive laser-assisted uvulopalatoplasty. Journal of the Laser and Health Academy. J LA&HA.2008;2018(1):39-44.
