10 sec apneas on ResScan?

[jnk]

. . . There are some members who use both CPAP and MAD. jnk comes to mind. . . .

For me, Velbor comes to mind.

Here is where I now am on my use of MAD, just to keep you up-to-date on me, Rooster.

I used MAD with my CPAP faithfully for about a year and a half. I used the MAD to keep my mouth shut while I used my nasal pillows.

The MAD kept my lower jaw forward enough that it took about 20 minutes for my teeth to align naturally the next morning. No problem after that 20 minutes. Then one morning after I had taken out my MAD but before my teeth had aligned, stupid me, I thought about something and absentmindedly moved my jaw sideways. There was a small pop. First non-profanity thought through my head was, "Bad move." Ouch!

My jaw hurt for about three days. During that time, I figured I shouldn't sleep with the MAD. Funny thing is that as soon as I put my LT on my head and the machine came on, I found that I automatically moved my own jaw forward without the MAD, like one of Pavlov's dogs, or something. And I found I had trained myself to keep my mouth shut without the MAD in place.

So, long story longer, I now sleep with the MAD in my drawer instead of in my mouth. My AHI is the same. I did use it a few nights to make sure I still could without reactivating the jaw pain, and it went OK. But now that I don't need it anymore, I don't use it.

jeff

[roster]

I found that I automatically moved my own jaw forward without the MAD, like one of Pavlov's dogs, or something. And I found I had trained myself to keep my mouth shut without the MAD in place.

That is the highest level of success for a MAD.

"Pull a man's jaw forward and he will breathe for one night. Teach him to pull the jaw forward and he will breathe for life."

[rada]

Thanks for sharing those stories about MAD. My own MAD story is thus far only of administrative delay as follows. My medical insurance (BCBS PPO for State of Maryland employees) should cover MAD 100% when I have letter of medical necessity (that I now have) and the prosthodontist is in-network. Unfortunately, none of the in-network prosthodontists is certified with the American Board of Dental Sleep Medicine. I finally determined through discussions with the receptionists of the 8 in-network prosthodontists' receptionists who have offices within 30 miles of my house that 2 of them supposedly have experience with MAD and file medical claims: Dr. Mohammed Warshanna and Dr. Michael Wright. I had an appointment set Feb. 26 with Dr. Warshanna but an hour before my appointment his office phoned me and said that on further exploration into my insurance his office realized
• we had miscommunicated and
• he does not do MAD and does not file medical claims.
So I made the appointment for Mar 2 with Dr. Wright and confirmed repeatedly on the phone with the receptionist that Dr. Wright does MAD and files medical claims. When I got to Dr. Wright's office yesterday I was told that
• I would have to pay up-front $2,000 for 'two visits plus one device',
• they do not file a medical claim (or maybe they do), and
• they don't think that Dr. Wright is in-network for BCBS.
So I asked for a reprieve and returned home defeated with the tentative plan to call my insurance company tomorrow and to try other prosthodontists' offices.
After reading JNK's story of wearing something a few times and then having trained himself to keep his jaw forward and mouth closed, I am also thinking now of another alternative. For $40 I could buy something online that I fit myself (see, for instance, http://www.snorban.com). It has the disadvantage of not being continually adjustable but maybe it's worth a try. I'd be comfortable to pay $140 and get the self-adjustable device from http://www.prosnore.com/prosnore2.html. Many other alternatives exist, such as the $65 noizeless (see http://www.nosnorezone.com). What do you suggest I do as regards MAD?
It's 3 a.m. and I'm tired. I had a nap from 8 p.m. till midnite (tried my full face mask for a change and felt okay but had terrible SpO2 -- often in low 80%). But I realize that I should search the cpaptalk site further before asking questions that might have been already answered. I have searched online a little further now at cpaptalk.com. Some of what I found includes:
• a two-node thread called "Oral Appliance Therapy" from a month ago in which JNK commented on the oral appliance.
• the Dec 2009 thread called "my oral appliance experience".
• the October 2009 thread "Dental Appliance (Mandibular Advancement Device)".
• in the Oct 2009 thread titled "Oral Appliances: Let's Correct This Understanding", I found this: "But unless insurance covers an oral appliance, I'd suggest borrowing, or buying an oximeter, a good digital recorder, and buying a $5 walmart boil and bite mouth protector, and seeing if the noise and the numbers suggest you will respond. If so, the next step makes sense. If not, I'd stick with cpap."
That last one led to http://www.walmart.com but all I found was $20 mouth guards that did not seem to be moldable. I want to pick-up my new eye glasses at Walmart this morning anyhow (they arrived on Monday). My tentative plan is to 1) look while at Walmart for mouthguards and 2) call my insurance.
I apologize for not addressing the tracheotomy topic that Roster raised -- I have thought about that too. I should read more but I'm not ready for something like that yet. Since I am a base-of-tongue cancer survivor (dying from the treatment), I am familiar with tracheotomies and feeding tubes, as ways of bypassing the oral cavity.
By the way, in reading one of the other threads on oral appliances, I came across again the topic of on-topic discussion. I realize that asking about oral appliances in a thread called 10-sec apneas is off-topic. I have, at times,
• gone to other threads to post questions or comments that were topic-relevant and
• have started threads on new topics
However, our discussion has assumed for me a certain timely and personal character that might not be best served my posting this message about MAD to some older thread about MAD and leaving nothing at this thread.
Thank you,
Roy

[roster]

I have to go out and see some customers today - they are complaining that I phone every day but they miss my handsome face (and my paying for lunch).

Definitely interested in continuing the discussion as some of your experience with obtaining a MAD parallels my ongoing pursuit of a MAD.

Will return to this thread soon.

[jnk]

I believe that greed among dentists is killing the MAD market. When people find out it costs $2000.00 for $1.00 worth of plastic, they lose interest fast.

If it was me, I would call every dentist's office within a 200 mile radius (concentrating on the rural dentists) and ask if they talk price over the phone for you to pay cash out of pocket for their cheapest MAD. If the dentist knows how to take impressions of teeth and mark a point in your jaw movement, he or she has all the skill necessary for the 20 minutes it should take to set you up for a good fit of the nonadjustable kind of MAD. Maybe no dentist will "bite" at that offer, but it might be fun, and the right guy with a small practice wanting a little experience off the record may offer to do it for practically nothing. Don't bother paying the big bucks for one of the highly adjustable MADs until you know one will work for you, I say.

jeff

[rada]

I called my insurance provider this morning and learned this:
For my plan BCBS for my device which is HCPCS code E0485 and following diagnosis code of ICD9 327.24, BCBS reimburses for in-network provider 100% of allowed benefit, with no deductible, and no co-pay (this is part of my durable medical equipment coverage). For out-of-network provider, the reimbursement is 80% and has $200 deductible.
In-network provider (dental or medical) should submit claim. Evidently Dr. Wright's office is trying to cover any risk from his side by getting my cash up-front. These dental appliances are relatively new for dental offices, and they may be uncertain as to how to proceed. If I have to submit claim and provider is in-network, then BCBS will directly reimburse the provider and not me, but this has advantage to me in sense that provider is obligated to take what is covered and to reimburse me appropriately.
Typically I might have first consultation that I should confirm whether is free or whether the office will bill as a medical consultation for which I would pay my normal $25 co-pay.
When I go to my prosthodontist, I might want to ask for his credentials, experience, and pointers to treated patients. I should get clear information about how many visits would be part of the treatment and what would be done in those visits.
I will double-check the list of in-network prosthodontists at http://www.bcbs.com and will re-call some of them soon. I went to bcbs.com as my insurance company told me to do. After half an hour of searching I could only find options to find either MDs or to declare my BCBS dental plan and so I recalled BCBS. I was now directed to enter bcbs site as guest but give my code of MYY. Lo and behold the list is very different from what I found in January. Now instead of 8 doctors in Maryland most within about 30 miles of my house and some within 5 miles, I get only 2 prostodontists and they are both in Virginia and approximately 50 miles from my house:
• Sadr, Lida DDS, Prostodontics; 44031 Ashburn Shopping Plz Ste 131; Ashburn,VA 20147; 703-858-3456; 42.5 Miles
• Prasanna, Mysore K, DDS; Prostodontics; 1455 Old Bridge Rd Ste 205; Woodbridge,VA 22192; 703-494-2226
The customer service representative at BCBS who I am reached via 1-800-225-0131 confirmed that this was all that could be obtained from the web site. She did note that I might get further information by calling the number for provider locating at 1-800-810-2583. So I called that number and was given these doctors who are within 10 miles of my house:
• stanley mcgee, 109 Frederick Road, Baltimore, MD 410-744-7610
• jaime brahim, 650 West Baltimore St, Suite 1401, phone 410-706-6195
• henry williams, 3701 Eastern Ave., Baltimore, phone 410-327-7639
None of those doctors were on my list from January 2010 nor on the web site!!!
I have an appointment next Wed. with my sleep specialist and wanted to try this oral appliance prior to seeing her. At this time, that trial seems no longer very likely to happen prior to seeing her. I will try later today perhaps to buy an appliance online of some sort or first go to a sports store and get a mouth guard.
Allow me to digress on two topics: my time and CPAPtalk results.
As regards my time, I should be a busy professional. I have been and remain a full-time professor. I earned a M.D. and Ph.D. 35 years ago. I have a 11-yo son and 14-yo daughter, do investing, love to take walks and work in the garden, ... . I do not envision myself spending my entire day every day for the remainder of my life chasing my OSA. Nevertheless, the OSA has become such an obstacle to my health that I feel obligated to pursue this path in order to come to some level of peace with my OSA and its treatment. At the moment, I am going to be late for meeting a PhD student (who, by the way, I am going to discuss the possibility of doing artificial intelligence research on sleep apnea data available from http://www.physionet.org).
On the second topic of CPAPtalk results, I might add that last night I learned a little something further. I had been testing the modified prone half swastika positions but consistently in the last part of my sleep and consistently found 2% lowered SpO2. Last night I tried the prone position in the first hour of sleep and then moved to supine and again SpO2 was 2% higher for me when supine. I also noted my pulse was about 20% higher in the prone position. I had started another thread a couple weeks ago called 'position and respirator' but for now post this here.
Got to go.
Cheers,
Roy

[roster]

A few comments:

1. Dental practices are not used to dealing with health insurance policies. They typically deal with dental insurance policies which are much simpler. Typically the policies have a simple schedule of what they pay, often less than one page long. This is very different from health insurance policies which often have booklets nearing 100 pages which are open to interpretation. This may be why dentists want their payment up front from the patient. It is a common practice at this point in time. These guys have to stay in business and support their families like the rest of us do.

2. I agree with Jeff’s advice about a cheap device as a trial if you are having to pay out of pocket. I would not want to pay $2000 and find the device was no help or I could not tolerate it.

3. If your insurance will pay, then go for one of the two top devices on the market. These are:
SomnoDent MAS http://www.somnomed.com/SomnoDent_sup__ ... uide_.aspx

and
TAP 3 http://www.dentalartslab.com/tap-3-thor ... positioner

All other factors being equal, I would prefer the TAP3 because it has a longer history and is more popular. But the SomnoDent may be just as good.

4. Don’t disregard the skill and the experience of the dentist in fitting these devices. A poorly fitted device can be miserable. I would choose someone with considerable experience and good references.

5. Prices around $2000 are about market. We have a local guy who will do a TAP3 for $1400. Similar to Jeff’s comments, this is a young aggressive guy who is trying to build a name for himself as the apnea appliance man. I am 100% certain he will gradually adjust his price to market level over the next several years.

6. This is neither here nor there and I am not insulted if it is ignored (or assualted) but Jeff’s comments about greed are irrelevant. Whomever I deal with on a financial transaction, it never concerns me whether they are greedy or not and I would not easily be able to judge that in any case. What concerns me is what price I can negotiate with them and what value I will receive in turn. You get outside of that and your emotions will have you making bad economic decisions. (Besides what Jeff is describing is just the way our system of markets is supposed to work and eventually the price settles to a lower point if the product performs well. You are seeing this in the CPAP market the last few years as quality improves, features are added and prices fall.)

I understand you have other obligations, but your posts are appreciated. This is especially true in my case as I eventually intend to try a MAD.

[jnk]

A few comments:

. . .

This is neither here nor there and I am not insulted if it is ignored (or assualted) but Jeff’s comments about greed are irrelevant. Whomever I deal with on a financial transaction, it never concerns me whether they are greedy or not and I would not easily be able to judge that in any case. What concerns me is what price I can negotiate with them and what value I will receive in turn. You get outside of that and your emotions will have you making bad economic decisions. (Besides what Jeff is describing is just the way our system of markets is supposed to work and eventually the price settles to a lower point if the product performs well. You are seeing this in the CPAP market the last few years as quality improves, features are added and prices fall.) . . .

All good points, Rooster.

My point about greed was that if prices were lower, I believe more people would try them and the dentists would make MORE money, not less.

I think it would be great if EVERY OSA patient tried a MAD, myself. And I like that mine is in my drawer for if power went out for an extended time and I needed to do something to stay alive.

It is my belief that until MAD gets more market share, more dentists should be doing what you describe the young dentist doing in your area, keeping price low to get more customers and to increase public acceptance of it. Then everyone can make more money in the long run.

I agree, though, that market forces should make that happen on its own, once someone figures out the market and has a good model for exploiting it. I just don't think that has happened yet.

Good post, Rooster, as usual.

jeff

[roster]

I think it would be great if EVERY OSA patient tried a MAD, myself. And I like that mine is in my drawer for if power went out for an extended time and I needed to do something to stay alive.

It is my belief that until MAD gets more market share, more dentists should be doing what you describe the young dentist doing in your area, keeping price low to get more customers and to increase public acceptance of it. Then everyone can make more money in the long run.

jeff

Agree to all those points.

Further, this young dentist told me that to keep their state dental licenses they have to have 10 hours of continuing education every year. He does 100 hours per year and budgets this in for every year and believes he will continue to do this throughout his career. However he had statistics from the state which show that over 90% of the dentists only do the minimum 10 hours per year. You can speculate about why this is.

He also told me that most dentists don’t want the hassle of learning and dealing with MADs. If I am correct that more than 50% of the population either has or will develop SDB and MADs become more popular, dentists may have to start doing them to remain competitive. Competition is what gives us good prices, good services and good products. Not governments and not good moral intentions. (Apologies to my Pastor and buddy)

I agree, though, that market forces should make that happen on its own, once someone figures out the market and has a good model for exploiting it.

In free markets it is typically not the “greedy” who are able to do this. They eventually end up screwing themselves. Wall Street has an old saying about investors, “Bulls make money, bears make money and pigs get slaughtered.”

I just don't think that has happened yet.

It does take time and in heavily regulated businesses it can take great amounts of time.

Should an oral appliance have to be approved by the FDA? IMO, hell no. Let us and our dentists and the equipment manufacturers figure out what works and what doesn’t. That is what we are doing anyway.

Personally I would love to purchase a Somnofit device, http://www.oscimedsa.com/anti_snoring_a ... fit_device , for U.S. $166 (rada you should consider this as a good cheap one) but I have to get someone in Frankfurt or Canada to purchase it and forward it to me. Why should our federal government have the power to stop me from purchasing this excellent inexpensive devise? FDA, get out of my face!

[rada]

I called the 5 dental offices on my new list this afternoon. Four answered that they do not do MAD. With the fifth I was only able to leave a message, but information I have gathered about that practice also suggests the answer will be no. That leaves me batting zero with finding an in-network dentist to fit the device for me. Accordingly, I am into the self-fitting strategy. Based on the advice from the October 2009 thread at CPAPtalk, I went tonight to Walmart to buy a mouthguard. My Walmart had mouthguards ranging in price from $1 to $4 but nothing that covered upper and lower teeth or had a hinge. I bought two 'football mouth guards' (each doing only the upper teeth) for $1 each. Maybe somehow filling my mouth with those would do something (such as, choke me). I then drove to a store called 'Sports Authority' which had a dozen different types of mouthguards ranging in price from $5 to $25. I bought a $20 mouthguard called the "Gel Nano" that includes in the blurb "when fitted and worn correctly, positions the lower jaw down and forward and the tongue up onto the roof of the mouth which may increase strength and athletic performance." I am debating now whether to
• try the $1 ones tonight,
• try the $20 one tonight, and/or
• order online something targeting specifically sleep problems.
The 'specifically for sleep ones' on my list include:
• noizeless (see http://www.nosnorezone.com) $65
• http://www.prosnore.com $120
• http://www.oscimedsa.com/anti_snoring_a ... fit_device (suggested by Roster) for $166
Roster, thank you for the pointers to top quality dentist fitted devices and to a quality patient fitted device.
Roy

[roster]

http://www.oscimedsa.com/anti_snoring_a ... fit_device (suggested by Roster) for $166
Roster, thank you for the pointers to top quality dentist fitted devices and to a quality patient fitted device.
Roy

If you have success getting one of these without traveling to Canada or Europe, please let me know. It is not FDA approved in USA and I have been unable to find a supplier who will ship one to me. I have close friends in Europe but hate to impose on them to purchase the device and forward to me.

[chicagocard]

Hi- I'm kind of late to the discussion but I wanted to add my story. Here goes: Blue Cross/Blue Shield approved me for E0486 - oral appliance. The dentist required payment up front. It was $361 for an exam and evaluation and $3,200 for Somnodent! This is in addition to $390 of x-rays. I am waiting to see how much BC/BS will cover. I get the Somnodent this afternoon.

[JohnBFisher]

Hi- I'm kind of late to the discussion but I wanted to add my story. Here goes: Blue Cross/Blue Shield approved me for E0486 - oral appliance. The dentist required payment up front. It was $361 for an exam and evaluation and $3,200 for Somnodent! This is in addition to $390 of x-rays. I am waiting to see how much BC/BS will cover. I get the Somnodent this afternoon.

Well, I sure hope it works for you. It's not for everyone. But for some people with a lower level of apneas (a lower AHI value) it could just be the ticket. It assumes your problem is due to a collapse of the airway that moving the jaw forward will help. It often does.

So, here's hoping it goes well for you. I would be interested in hearing how well it works for you.

[roster]

But for some people with a lower level of apneas (a lower AHI value) it could just be the ticket.

John, Read the OP and links in this thread and tell us what you think. Thanks.

-> viewtopic.php?f=1&t=44181&st=0&sk=t&sd= ... 7s+correct

[JohnBFisher]

... John, Read the OP and links in this thread and tell us what you think. Thanks.

-> viewtopic.php?f=1&t=44181&st=0&sk=t&sd= ... 7s+correct

I don't think we're in a disagreement. I thought (though I might have edited it out) that I noted it depended on the physical features that cause the obstruction. That often correlates to a severity - but not always. I definitely agree with your summation in your post:

But don't forget, the portion of patients who can effectively be treated by oral appliances seems to be quite low. For now, CPAP remains the number one therapy for the patient population in general.

Still, for those few for whom it works, it is definitely easier to pack and use than xPAP therapy.

And while I wish the poster well, I don't hold a great deal of hope that it will "solve" his problem. But I'm not his doctor / dentist. I do not know his circumstances. As I note, it might just be the ticket. Or it might be an expensive paper weight.