Oral Appliances: Let's Correct This Understanding

[roster]

Many think the probability of success of an oral appliance is inversely related to the severity of OSA. It is common to read here (I have posted it myself) that oral appliances might work for mild to moderate OSA and are very unlikely to work for severe OSA.

Go read this article:

Most literature states that oral appliance treatment of OSA should be reserved for mild to moderate cases.1-3 Our findings4,5 are that it is not the severity of OSA that predicts the success of oral appliance treatment, but the site of closure (velopharynx—high, oropharynx—mid, and hypopharynx—low).
................. Oral appliances need not be reserved for mild to moderate OSA cases.

http://www.sleepreviewmag.com/issues/ar ... -10_11.asp

Or this one:

Mandible advancing oral appliance seems not to be effective in reducing the AHI value in mild cases. However, it seems to be especially effective in reducing the apnea/hypopnea index in moderate and even certain severe OSA patients.
http://iadr.confex.com/iadr/papf09/webp ... 26401.html

"It's not the severity, it is the anatomy."

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.

[jnk]

I think that article expresses what many dentists, such as that one, would like to believe.

Although, if dentists would bring their prices down, I think it would be great if EVERY OSA sufferer got an oral device as a matter of course in between the diagnostic study and the titration. That way every patient could be titrated with the oral device in place to see what it did for them. The oral device could help to keep the patient's mouth closed to make nasal masks and pillows more successful, and the pressure might even be lower with the oral device in place, too.

But I think we are several studies away from getting anywhere near showing that a lot of severe-sleep-apnea patients would likely do well using an oral device alone, regardless of anatomy.

You always have great posts, Rooster.

[roster]

I would be careful about something to force the mouth closed. Sometimes, while asleep, we open our mouths to breathe because we need the additional oxygen. A patient might have breathing problems from forcing the mouth closed that will not show up in oximetry studies or CPAP software details. These problems might show up in expensive in-lab PSG sleep architecture details but it could be very hard to tie them to the forced mouth closure.

Unfortunately, our population has highly prevalent allergies and other congestion issues. Breathing through the mouth might be a good backup plan many nights for many people.

[jnk]

I would be careful about something to force the mouth closed. Sometimes, while asleep, we open our mouths to breathe because we need the additional oxygen. A patient might have breathing problems from forcing the mouth closed that will not show up in oximetry studies or CPAP software details. These problems might show up in expensive in-lab PSG sleep architecture details but it could be very hard to tie them to the forced mouth closure.

Unfortunately, our population has highly prevalent allergies and other congestion issues. Breathing through the mouth might be a good backup plan many nights for many people.

My oral appliance holds my jaw in place, but I can still breathe through my lips without popping my teeth out of the appliance. I can easily pop my teeth out of the appliance with very little effort, too, if necessary. What I was referring to was the ability of an oral device to keep the jaw from dropping open inadvertently.

I have severe allergy issues, myself.

I have occasionally opened my lips for a sigh or a cough during therapy. And my appliance actually holds my jaw slightly open as well as forward, allowing breathing through the mouth just fine while using a ffm.

I just think that keeping the jaw from dropping is a good thing with most masks, even the ffms.

[WearyOne]

That's interesting. When I first started cpap, I contacted a local dentist who specializes in these things for a consultation. The first question I was asked on the phone was the severity of my OSA, she stated because they usually don't work well if the apnea is severe (mine's not). Maybe things have changed, though, as that was a little over two years ago.

Pam

[jnk]

Maybe things have changed

Nope. Things are the same, regardless of that dentist's case study.

According to the AASM on August 3, 2009:

"An oral appliance is an alternative treatment option for people with mild or moderate OSA; people with severe OSA should be treated with CPAP."--http://sleepeducation.blogspot.com/2009 ... -best.html

[rws]

I gave up on my $1200 oral appliance several years ago. However, once I removed the bottom section with a pair of wire snips, I had the perfect upper mouth guard for preventative teeth grinding. Basically, for sleep apnea, it was a failure, at least for me.

Rick

[roster]

I gave up on my $1200 oral appliance several years ago. However, once I removed the bottom section with a pair of wire snips, I had the perfect upper mouth guard for preventative teeth grinding. Basically, for sleep apnea, it was a failure, at least for me.

Rick

I don't mind anything you want to say in this thread, but do you realize the OP is about how to determine up front whether an oral appliance might be effective? That an appliance was or was not effective for a certain person is off the topic. Unless, for example, someone says they have a severe case and an oral appliance treats it perfectly. Or for another example, someone says they have a very mild case and an oral appliance was not able to improve it at all.

OK, have at it now.

[rws]

[quote="rooster"]
I don't mind anything you want to say in this thread, but do you realize the OP is about how to determine up front whether an oral appliance might be effective? That an appliance was or was not effective for a certain person is off the topic. [quote]


Sorry, didn't mean to ruffle your feathers. I'll follow you lead in future posts, strictly on topic, as always.

[jnk]

I'll follow you lead in future posts, strictly on topic, as always.

I love this place!

I only hope we have been able to correct that dentist's understanding, like Rooster asked us to do.

[roster]

On the few days in this joint when no one slaps me around, I always go home feeling disappointed.

Thanks for letting me hang out in your joint Johnny G!

[BioPAP man]

... Before obtaining a MAD an easy test can be conducted to see if an oral appliance would be benificial. First try to replicate snoring sound with the throat only. Second, start advancing the mandable forward while generating the natural snoring sound. if you are a candidate for a MAD, then at a certain protrusion the snoring will become quiet and perhaps eventually go away all togather. One also can perform variations of vertical titration in combination vith protrusion to predetermine optimal results. I use this technique all the time, and had it proven clinically. try it.

[-SWS]

... Before obtaining a MAD an easy test can be conducted to see if an oral appliance would be benificial. First try to replicate snoring sound with the throat only. Second, start advancing the mandable forward while generating the natural snoring sound. if you are a candidate for a MAD, then at a certain protrusion the snoring will become quiet and perhaps eventually go away all togather. One also can perform variations of vertical titration in combination vith protrusion to predetermine optimal results. I use this technique all the time, and had it proven clinically. try it.

Well, I tried that test and found it useful.

My results: Extremely easy to simulate snore in ordinary mandible position; much less-severe snore tendency with my mandible advanced. Unfortunately it was still extremely easy for me to simulate a much lighter snore with my mandible advanced.

My conclusion: A Mandibular Advancement Device (MAD) would probably lessen the severity of my obstructive SDB. However, a MAD would probably be unsuitable as sole treatment method for my obstructive apnea. Some patients finding high CPAP pressure intolerable may be able to reduce therapeutic pressure to tolerable levels if CPAP and MAD are used in conjunction. Similarly, some CompSAS patients may be able to avoid pressure toxicity levels by employing CPAP and MAD together. And in some anatomical cases, a MAD is well-documented as a viable alternative to CPAP.

That was a great test, BioPAP man!

[millich]

... Before obtaining a MAD an easy test can be conducted to see if an oral appliance would be benificial. First try to replicate snoring sound with the throat only. Second, start advancing the mandable forward while generating the natural snoring sound. if you are a candidate for a MAD, then at a certain protrusion the snoring will become quiet and perhaps eventually go away all togather. ....

Yes, this is the test I used to determine that a MAD would treat my snoring. I talked my dentist into making me one and never had a sleep study to confirm that it was working. Judging from my symptoms, I think it's obvious that while it reduced my snoring, it didn't significantly reduce my AHI.

Note: If you go the route of a mandibular device, you REALLY should have a follow-up sleep study to determine it's effectiveness.

Rooster - I hope this was on-topic enough for your stringent standards!

[-SWS]

Note: If you go the route of a mandibular device, you REALLY should have a follow-up sleep study to determine it's effectiveness.

I would posit that these three practical indicators can suffice in lieu of that sleep study: 1) a marked improvement in perceived quality of sleep, 2) a marked improvement in daytime cognition, and 3) satisfactory SpO2 scores during a simple nocturnal oximetry test.