Snoring & Sleep Apnea

Snoring, a very prevalent breathing disorder, is often associated with Obstructive Sleep Apnea (OSA), which affects millions and is associated with higher risk of Stroke and Heart Attack. OSA occurs when breathing stops for ten seconds or more during sleep or is reduced such that blood oxygen saturation drops, placing significant strain on your heart and cardiovascular system. This prevents air from reaching your lungs and deprives your body of oxygen. One of the most undiagnosed disorders known to mankind, OSA is easily treated once a diagnosis is established. Committed to helping you maintain restful, health-promoting sleep, Dr. Viviano has provided Airway Orthotics for the management of Snoring and Sleep Apnea since 1997. A strong commitment to patient follow-up helps insure you not only understand your current treatment but are also made aware of new progresses in sleep therapy and treatment options as they become available. This approach combined with a customized care plan consistently achieves a significantly higher rate of treatment compliance, thereby reducing the risk of stroke, heart attack, and other sleep-related illness, contributing to a healthier lifestyle for our sleep patients.


Signs and Symptoms

Sleep apnea is difficult to diagnose during wakefulness, as the individual with the condition is asleep while it is occurring. A bed partner or family member can help by bringing their observations to the person exhibiting signs of sleep apnea.

A common sign of sleep apnea is snoring, caused by soft tissue vibration associated with air passing through the airway. The pauses in breath that characterize sleep apnea are often followed by a snoring or choking sound as the person forces air through a constricted or collapsed airway. It is important to note that snoring is not a definite indicator of sleep apnea and can occur apart from the condition.

A symptom that an individual with sleep apnea is likely to recognize is fighting daytime sleepiness. Because air intake is compromised in untreated cases of sleep apnea, the brain and vital organs are unable to get oxygen, diminishing the quality of sleep and reducing restfulness. A person with undiagnosed sleep apnea may find themselves especially tired during quiet periods of the day, while driving and other times of low activity.

Other symptoms of sleep apnea include a dry throat after waking, morning headaches, trouble concentrating, irritability or depression, and need to urinate multiple times during sleep. An individual should consult his or her doctor if a sleep condition is suspected.


Why Me?

sleep apnea has the prevalence of Asthma and Diabetes combined and affects more than 43 million Americans. Overweight individuals are often affected by obstructive sleep apnea as the excess tissue weighs heavily on the airway, causing it to collapse. According to the National Heart Lung and Blood Institute, more than half of people with sleep apnea are overweight. The condition is also more common in males than females, among those with a family history including sleep apnea, with increased age, and among patients with diabetes as well as smokers.

An individual may also be susceptible to obstructive sleep apnea due to an inherited small airway. Allergies and other medical conditions can also cause features along the airway that restrict the flow of oxygen.

In women, sleep apnea may occur during pregnancy and following menopause. In children, the inflamed tissue of tonsillitis can block the airway and cause sleep apnea.  



Sleep apnea can deteriorate an individual's quality of life by causing daytime sleepiness and contributing to depression, poor job performance, increased risk of accidents and increased chances of additional health risks such as diabetes, heart disease, stroke and high blood pressure. Snoring sounds can also affect family and loved ones of an individual with sleep apnea by interrupting the quality of sleep of those around them.



Sleep apnea often goes undiagnosed, as the person experiencing the condition is asleep when the majority of symptoms occur. Doctors cannot positively diagnose sleep apnea during routine visits as an individual must be sleeping for the main indicators to be present. Typically, it is the family or friends of a person with sleep apnea who notice symptoms, such as choking sounds and pauses in breath during sleep, and can report it to the individual.

If a patient suspects sleep apnea, a doctor can check for some secondary symptoms of the condition, such as swollen or inflamed airway soft tissues. A doctor may also be interested in a patient's family history, as a family history of sleep apnea is a strong indicator of the condition. The patient is also likely to be experiencing daytime fatigue due to poor quality sleep.

An overnight sleep study, performed by professionals through a polysomnogram (PSG), measures a number of factors including brain function, eye movement, heart rhythm and respiratory airflow in order to diagnose sleep disorders like sleep apnea. A person with clinically significant sleep apnea will demonstrate blood oxygen desaturation of three to four percent or more, and apneas, or pauses in breathing, of at least ten seconds at a rate of five or more episodes per hour.


Treatment Options

Sleep apnea is usually manageable through one or more treatment options, including lifestyle changes, CPAP, Airway Orthotics or Surgery. Treatment of sleep apnea can greatly increase happiness, restfulness and health of an individual with sleep apnea and those around them. An individual should work with his or her doctor to find a treatment plan that is effective and comfortable. The goal is to restore ease to breathing during sleep and to alleviate associated symptoms such as excessive daytime tiredness and snoring.

Lifestyle changes: in some cases, the problem is mild enough that it can be managed through weight loss, altering sleep position and/or moderation of alcohol intake, certain medications and smoking. A person with sleep apnea may want to avoid gaining weight as weight gain can worsen the condition, while losing weight may improve sleep apnea. If an individual using CPAP or an Airway Orthotic to manage sleep apnea experiences a change in weight, they will often require adjustments to their device, highlighting the importance of follow-up appointments. 

CPAP (Continuous Positive Airway Pressure): in severe cases, delivering continuous positive air pressure through a face or nose mask and a CPAP device is required.   This device keeps the airway open by exerting air pressure in the mouth, throat and airway. A constant stream of low-pressure air is blown into the throat via a mask worn over the mouth and nose or more typically just the nose. The air presses the walls of the airway open, preventing collapse or blockage of the breathing passage.

Surgery: in some cases, surgery may eliminate or improve the severity. Surgical solutions to sleep apnea seek to increase the size of the airway by removing or shrinking tissue or to support the lining of the throat to prevent the collapse that occurs with muscle relaxation. Physically removing the tissue with surgery is one procedure that may be appropriate. A series of shots to shrink excess tissue may also be effective, or the airway may be supported by a piece of stiff plastic inserted under the tissue. A doctor evaluating the cause of an individual's sleep apnea condition can only determine the procedure most appropriate for a patient.

Airway Orthotic: a custom made Airway Orthotic (oral appliance) can provide relief by advancing the jaw during sleep. This expands the airway, and prevents the tongue from falling back and blocking the airway. There are a number of custom-fitted Orthotics that can be made by a dentist trained in sleep apnea. 


Importance of Early Detection

Snoring has been known to progress to Sleep Apnea (Progressive Snorers Disease) and Sleep Apnea has been known to progress in severity (due to tissue damage) if left untreated. Untreated Sleep Apnea is associated with Heart Attack, Stroke, Pulmonary Hypertension, High Blood Pressure, Cardio-vascular Diseases, Depression, Anxiety, Memory Problems, Headaches, Weight Gain, Sexual Dysfunction, Motor Vehicle Accidents and Job Impairment.

A consultation appointment can help you start on your journey to a good nights sleep. If you suffer from Loud Snoring, Morning Headaches, Restless Sleep or Daytime Fatigue call for a consultation appointment today.




Q: Is there a Fee for the consult?

A: Yes, Dr. Viviano will be spending approximately 60 minutes with you at the consultation. He will conduct a thorough intra and extra oral examination to establish that you are a candidate for oral appliance therapy and he will review with you his exam findings, the results of your baseline sleep study findings, exactly what is happening in your airway to create the problem and all of the treatment options available for you as per the american academy of dental sleep medicine and the american academy of sleep medicine guidelines. This examination/consult appointment is typically covered by your dental insurance plan.

Q: How much does the appliance cost?

A: Fees for the appliance vary depending on the type of appliance; trial, Over-the-counter temporary or custom made. These fees range from approximately $500 to $3,000.

Q: How many appointments will it take?

A:Should you decide to proceed with an Oral Appliance we will require a Physician direction (prescription) to do so. At the first appointment we take impressions (analogue or digital) and a bite registration. Approximately 2-3 weeks later, Dr. Viviano will deliver the appliance and provide you with instructions on use and care of the appliance.The first milestone is to become accustomed to wearing the appliance throughout your sleep period (usually a couple of weeks). The appliance is then adjusted over several appointments to establish which jaw position optimally manages your sleep symptoms as evaluated by questionnaire. Once we deam the appliance to be optimally calibrated we conduct a Home Sleep Study to Objectively evaluate appliance effectiveness.Once we are pleased with the results or we establish the results are as good as is currently achievable we send a report along with a copy of the Home Sleep Test to the referring physician. This entire process usually takes 6 to 12 weeks

Q: Why do I have to go for a Sleep Study to get an appliance?

A: Sleep Apnea is a serious medical disorder with the potential for severe consequences when mismanaged. Currently, the only method we have for a physician to establish an accurate diagnosis involves an overnight sleep study.

Q: Why can’t I just get an appliance to deal with my snoring?

A:Before making a snoring appliance, we must first ensure there is no underlying sleep apnea. Many snoring patients have sleep apnea but are not aware of this fact because they do not necessarily exhibit other symptoms such as daytime sleepiness. making a snoring appliance without considering the presence of sleep apnea could result in creating a “silent apneic”, leaving the patient “snore free” but medically compromised due to the unresolved sleep apnea.

Q: Why doesn’t OHIP cover sleep apnea appliances?

A: Unfortunately, this is purely a fiscal decision. there are many other countries that have socialized medicine such as France and Swedan that do cover oral appliance therapy. In fact, even the USA Medicare system covers Oral Appliance Therapy for the management of sleep apnea.

Q: Will Dental Insurance cover them?

A: Snoring and sleep apnea are medical disorders, and as such, dental insurance does not cover them.

Q: How do I find out if my Medical Insurance will cover them?

A:Our office can send a pre-determination request to your medical insurance. to do so we will need a copy of your baseline sleep study and a Physician Direction (prescription) to fabricate an oral appliance for your sleep apnea. This is usually done after the initial consultation so we can establish which appliance you would be proceeding with.

Q: I only snore on my back!

A:for some patients, the problem is purely positional and resolves when you avoid sleeping on your back. inexpensive Positional aides are available to help you avoid back sleep. However, an overnight sleep study is necessary in order to confirm this issue.

Q: My insurance won’t pay for an Oral Appliance!

A:Insurance policies vary greatly and are dependant on decisions made by your plan administration. Coverage, or lack of coverage in no way speaks to whether or not an appliance is appropriate for you.

Q: My Physician said Oral Appliances don’t work!

A: According to the most current American academy of sleep medicine Guidelines, oral appliances are considered “first line therapy” for snoring, and a “Standard of care” for any severity of sleep apnea should the patient not tolerate cpap, or if they simply prefer an orAl appliance over cpap. download guidelines

Q: My Physician said Oral Appliances will ruin my jaw!

A: nothing is free of side effects. however, over 30 years of literature evidence does not support this statement. Side effects associated with wearing an oral appliance are mostly short lived and upfront while you are first becoming accustomed to wearing your appliance. Over the long term, the only meaningful side effect is changes in the bite, which interestingly, is also associated with wearing a CPAP mask.

Q: I heard that Oral Appliances cause TMJ!

A: over 30 years of literature evidence does not support this statement.

Q: I heard that Oral Appliances will ruin your teeth!

A:The oral appliance engages the teeth and repositions the jaw in a slightly forward position. a proper dental examination to determine health of the teeth and restorations is necessary prior to placing an oral appliance. If the dentition and supporting bone and soft tissues are helthy, the appliance will do no harm.

Q: My Physician said he doesn’t believe in them!

A: Although the Medical guidelines are very clear as to the role oral appliances can play in the management of sleep apnea, Unfortunately, there is still a great deal of myth and bias in the medical feild regarding this role. My suggestion is to consider what the medical guidelines state as they would be the most evidence based and free of bias opinion available to you. Download guidelines