I Got a Dental Appliance

[ca_hosehead]

I got a Klearway dental appliance about two weeks ago.

For those of you not familiar with my back story, I have been on nightly CPAP for about two years. I have worked with multiple masks, chin straps, leak control, pressure adjustments, changing sleep position, all sorts of stuff to get good sleep, all with mixed results. I have been able to get numbers that most people would kill for, AHI consistently below 5, often with numbers in the 2-3 range.

Yet still I have OSA symptoms, morning headaches and feeling wiped out. I went through a phase where I monitored my sleep closely too see if the way I felt had any relation to my sleep or if it was the dreaded "something else" causing my symptoms. I found a close correlation between my sleep patterns and my symptoms.

It seems that when I have an breathing event I wake up. With even one breathing event my heart rate goes up and you can see me shake my head as I try to get air. Each apnea event is like a phone call in the middle of the night. My sleep cycles are wrecked.

I tried a series of gradual pressures increases over some months but I hit a comfort problem at around 15. I mostly stayed with a single pressure. Since the breathing events were so isolated the machine wasn't responding to them.

Rather than go for higher pressures (which probably would have required a bi-level) I decided to try a dental appliance.

I went to this web site:
http://www.aadsm.org

I chose someone who was Diplomate (Board Certified) in Dental Sleep Medicine. I had to drive to hell and gone to get to him, but it's worth the trip.

There are a lot of Dentists out there who sell dental appliances, almost everyone sells them as a sideline. You want someone who *specializes* in sleep apnea, who works on it all the time. This is really important. Don't skimp on this if you decide to go down this path. It's not easy to get it right, it's not just a matter of selling you an appliance and sending you on your way. If you can't find someone who is certified in your area, ask this question, "What dental appliance do you sell?" The answer should come back "We sell several, we select the one that is best for the patient." If they name a single device then keep looking.

I got an evaluation (cost $90). We discussed my sleep and he looked over my reports from my APAP and my sleep study. We talked over different appliances, and how they work. He examined my jaw, my bite and a number of other things. 1-2 hours overall.

I had some dental work to do so I got that taken care of and came back to be fitted for the appliance. The process took about 2 hours, they did impressions of the upper and lower teeth and tried several different jaw extensions to see which one gave me decent airflow and kept me comfortable. We looked over samples of a couple of appliances he thought I would do well with (Klearway and Somnmed). We selected the Klearway (Cost $1500)

None of this is covered by my insurance (ouch).

In about two weeks the appliance was in and we fitted it. We adjusted the fit and made sure it was right. Again about 2 hours. (no additional cost)

He instructed me to go without the CPAP, but that didn't go so well. After two years of nightly use I've become accustomed to the damn thing, I couldn't sleep without it. After many sleepless hours I turned down the floor pressure (I have an APAP) and put it back on. Wearing the two together worked pretty well, no mouth leaking that I can detect.

For those not familiar with dental appliances most of them are "mandibular advancement devices" which means they hold the jaw down a little and forward. The tongue and the front of the throat are attached to the jaw and move forward with it, opening the airway. Many are FDA approved (but most are FDA approved only for mild to moderate apnea.)

The one I got is pictured here:

http://www.klearway.com/

It's adjustable which is pretty important. You start with a mild level of jaw advancement and as the jaw gets used to it you move the jaw forward more and more. Too much starting out and it screws up your jaw, too little and you don't get much relief.

It's pretty comfortable to wear. I drooled like a mental patient the first night and for a few days after but two weeks in the drooling is almost gone. It keeps the mouth shut, but you can open a bit (enough to drink through a straw) and there are holes for airflow if you need to breathe through your mouth.

I'm definitely sleeping better. Before I started I was running the APAP at 15/15 and now I am running it at 8/15 and my AHI numbers are better. I only have isolated OSA events and the machine doesn't respond fast enough to really do anything. The machine does seem to be increasing pressure to meet snore events.

I have a long process of dialing in the appliance ahead. I was instructed not to advance it until I get my first follow-up which is Monday. He wants to check for soreness in the teeth or jaw or other problems, which I am not having. My bite does seem to be somewhat advanced, but that's not a big deal.

I'm going to stay with the dual therapy, at least for the time being. If I keep the floor pressure on the APAP low it will stay out of the way if the appliance is doing well and hopefully provide support if it's not. I also like being able to look at the numbers.

After a while (probably a long while) I may discontinue using the APAP if I can see that it isn't doing anything. I have the numbers that I can check from the APAP and a recording pulse-ox so I can monitor things pretty closely. I am well past the "I hate the hose" phase so using both indefinitely doesn't bother me.

The AHI numbers are about the same with the appliance and the new settings but I am seeing a lot more snores. The patterns overall are very different, it's like looking at someone else's report. I haven't done any deep analysis and if the appliance works well for me I won't bother.

As I move the jaw forward in very slow increments hopefully I'll get better and better sleep. I could use it.

[ozij]

Congratulations on finding something to help you sleep and feel better, ca_hosehead.

I was taken aback for a minute when I read this:

I have a long process of dialing in the appliance ahead.

What? They let you dial in your own setting on the appliance? Don't they know what grievous harm you can cause yourself of you set the pressure...sorry, I mean, if you set the dial too high???
Keep us posted!
O.

[MeToo]

Thank you for the informative post! I went a similar route with oral device, had to drive to another city for appointment w/ dentist, pay around $700 out of pocket, fight with insurer to pay the rest, and can't use the device. It makes me feel like it is causing my teeth to loosen. I can wear it for a couple of hours and then the pain wakes me and I can feel some instability in my teeth.
I went back to dentist and he sanded away where we thought the problem was, but same thing happened that night. So now it sits in my drawer! I look forward to perhaps giving this approach another shot but will first check to make sure my teeth (which otherwise have always been perfectly fine with no problems) and airway are suited for a device. As you say, going to a professional for whom this is a main focus of their practice is important. Otherwise they might not have enough experience in the nuances.

[SharkBait]

ca,

Sounds pretty cool and here's hoping you can ditch the machine...

My doctor discussed the oral device as an option, but he didn't have enough info as far as success rates to recommend it over CPAP or surgery.

Why don't you set your APAP to CPAP at a level 8, and perhaps begin weaning it down a 1/2 cm periodically until you get to where you can sleep without the machine? I'd think once you're around 4 you'd be able to jump to nothing fairly easily, and of course you're still getting AHI event reporting as well.

Good luck!

[packitin]

Of course, you're speaking with tongue in cheek, I assume.

[Mtnviewer]

Thanks for sharing your experience. I hope that you can keep reporting good progress.

I have not had great results from the Klearway for apnea relief and so finally decided that to help my fatigue, to retry PAP therapy and so now I use both. For me I find that I mainly need some way to really effectively keep my chin from dropping and mouth from completely opening when I sleep. This appliance can do that but others will likely do it too but for a lot less money. When my Klearway breaks or is unusable, I'll try a less expensive appliance. With it tied off, I still find too much movement allowed. The appliance's hold on the teeth also loosens up over time and too often but as I live too far away from the Klearway's inventors clinic, I just use my pliers to try to tighten it back up, nor do I want to pay the high Dr. fees for these extra visits. My appliance has also cracked but so far is still usable. A replacement was quoted at $800.

I've been using mine for 3 years now but have not found that the jaw advancement from normal, worth the minor benefit nor the side effects of tooth movement and changed bite. Also, I nor the Dr. could prove that my airway was being held open with it advanced. My Dr. (the inventor), has no sleep study referral privlages at the UBC hospital sleep disorders center that he is supposedly associated with and kept delaying me from trying to get a follow up sleep study to test the appliance's effectiveness. This went on for a year before I finally confronted him and found that he had no referral authority, and he admitted to me that the UBC sleep center recognizes him as "only a dentist", and he told me that I'd have to start from square one with a referral from my GP to get on the 13 month waiting list for a follow up study. Follow ups are not priorities and so are wait listed. Needless to say I was very disappointed with this information. The follow up study sadly for me was also deemed inconclusive by the sleep specialists, as not enough data was collected, which meant for me more time waiting for another study, give up, or work on finding a solution myself. I opted for the latter and have learned more from this forum than from all the Drs. etc..

I'm doing far better with PAP therapy (and still using the appliance to hold my jaw closed), than I ever did with just the appliance alone. Hopefully you'll also get at least that and or even better results. I look forward to hearing more of your experiences and learning more myself.

[OldLincoln]

I have pondered the oral device but wonder if it would cause a bite shift and lead to TMJ. You didn't mention TMJ but did the bite shift. What does you dentist say about it?

[Mtnviewer]

For me it was a 2.5 years since my last check up and I think that TMJ (Temporomandibular joint syndrome / disorder) was mentioned as a possible side effect. But perhaps it could be avoided before serious problems if assessed early enough? I only had mild discomfort the first few weeks in teeth, and my jaw joint. But then I also decided to end my appliance advancement at 6 mm's maximum, so perhaps for my jaw joint, that wasn't enough to cause problems, and thankfully not yet, if it's still to come.

[rested gal]

Jaw advancement dental devices can work well for some people.

If I were going to go that route, I'd definitely want to have a sleep study later with the device in place after it had been advanced to whatever was thought to be effective for me. I'd want to know for sure, via a full PSG study, that the device was treating my OSA well.

Hope you have comfortable success, ca_hosehead! Please keep us posted on how it goes for you.

[ca_hosehead]

I was taken aback for a minute when I read this:

I have a long process of dialing in the appliance ahead.

What? They let you dial in your own setting on the appliance? Don't they know what grievous harm you can cause yourself of you set the pressure...sorry, I mean, if you set the dial too high???
Keep us posted!
O.

They seem pretty relaxed about letting you turn that little adjusting screw on your own. For a chronic auto-titrator like myself it's a dream come true.

I'm going to get one of these(http://www.instructables.com/files/deri ... MEDIUM.jpg) and hook it up. I should be able to titrate my jaw into the next county. Woohoo!

[ca_hosehead]

Too address some comment in a batch:

>> It makes me feel like it is causing my teeth to loosen. I can wear it for a couple of hours and then the pain wakes me and I can feel some instability in my teeth.

I have no pain at all, and it doesn't seem to be putting any strain on my teeth. They don't feel "pulled" or uncomfortable at all. Getting it fitted right is really important.


>> My doctor discussed the oral device as an option, but he didn't have enough info as far as success rates to recommend it over CPAP or surgery.

I've never seen a success rate listed for these things. I've heard 50% for CPAP.

>> Why don't you set your APAP to CPAP at a level 8, and perhaps begin weaning it down a 1/2 cm periodically until you get to where you can sleep without the machine? I'd think once you're around 4 you'd be able to jump to nothing fairly easily, and of course you're still getting AHI event reporting as well.

Right now I know that the dental appliance isn't extended far enough. I am seeing a high snore rate which I didn't see before with only CPAP. A high snore rate means my airway is close to closing at those points. When I see the snore rate go down I'll know that it's doing a better job at holding the airway open and I'll think about backing off on the pressure.

>> For me I find that I mainly need some way to really effectively keep my chin from dropping and mouth from completely opening when I sleep.

The Klearway does hold the mouth mostly closed, but not all the way. You can open your mouth enough to drink through a straw. I would prefer that it hold my mouth all the way closed but I would think it might cause a comfort issue for a lot of people to have their lower jaw locked in place all night. I'm still wearing my CPAP "rig" which includes a chip strap so that is keeping my mouth closed. Opening my mouth even a little bit restricts the airway. I might try to tack the two parts of the Klearway together once I've got it fully adjusted. I tried Poli-grip strips and they worked OK but by morning they had morphed into some sort of genetically modified super-snot. Regular Poli-grip didn't work so well either and I had to throw the tube away when I almost used it to brush my teeth (whew!).

>> I have pondered the oral device but wonder if it would cause a bite shift and lead to TMJ. You didn't mention TMJ but did the bite shift. What does you dentist say about it?

We didn't talk about it specifically because I have never had trouble in that area. He does examine the jaw joint pretty extensively and I assume it is part of the ongoing monitoring. This Dentist also treats TMJ problems.

I don't think anyone should get one of these things unless they are willing to keep track of the follow-up visits. TMJ, tooth movement, bite changes, these are all things that you'll need to keep up with over the long haul.

It's not without side effects and several of them are things that will only manifest over the long term.

>> If I were going to go that route, I'd definitely want to have a sleep study later with the device in place after it had been advanced to whatever was thought to be effective for me. I'd want to know for sure, via a full PSG study, that the device was treating my OSA well.

Since I'm monitoring so closely with the APAP and the pulse-ox I don't know if I'll do that but if my strategy was to drop the hose altogether and switch to the dental appliance I think it would be dangerous and foolish to not get another sleep study once the appliance was dialed in. The equipment that I have is almost as good as the portable home sleep study that I got from my HMO, and in some ways better. But then again my level of home monitoring is the more the exception than the rule.

[rested gal]

If I were going to go that route, I'd definitely want to have a sleep study later with the device in place after it had been advanced to whatever was thought to be effective for me. I'd want to know for sure, via a full PSG study, that the device was treating my OSA well.

Since I'm monitoring so closely with the APAP and the pulse-ox I don't know if I'll do that but if my strategy was to drop the hose altogether and switch to the dental appliance I think it would be dangerous and foolish to not get another sleep study once the appliance was dialed in. The equipment that I have is almost as good as the portable home sleep study that I got from my HMO, and in some ways better. But then again my level of home monitoring is the more the exception than the rule.

Sounds like you're going about it in a smart, methodical way, ca_hosehead.

Good luck! Hope it works out fine for you!

[ca_hosehead]

>> This went on for a year before I finally confronted him and found that he had no referral authority, and he admitted to me that the UBC sleep center recognizes him as "only a dentist", and he told me that I'd have to start from square one with a referral from my GP to get on the 13 month waiting list for a follow up study.


(Pardon me while I climb up on this soap box)

<rant>

This brings up a point, something that really hurts us all when it comes to getting treatment. There is a distinct lack of an integrative approach by most practitioners. I think my apnea Dentist is very good, but he does have an anti-CPAP bias. And what's with this "only a Dentist" statement? By not allowing this "only a Dentist" to get sleep studies for his patients the medical establishment is making it harder to get good treatment with dental appliances.

CPAP is fairly new as medical treatments go. CPAP is often described as the "Gold Standard" for treatment but has a compliance rate of only 50%. If I was a Doctor that could only cure half of the people that were sent to me I'd be *constantly* looking to add additional options to my bag of tricks. A practitioner will usually stick to the tools that he is most familiar with. If you go to a Doctor you will get a CPAP, surgery or drugs. If you go to a Dentist you will get an appliance.

There are probably many people that would do well with both. If you want this kind of dual approach then chances are really good that you are on your own when it comes to managing your treatment.

And what about the treatments that are more "out there" than others like throat exercises or didgeridoo? We know that apnea has something to do with a loss of muscle tone in the throat and we also know that exercise improves muscle tone but just try to find a set of exercises that targets these muscles and a few good studies to support the workability of the exercises. I can't find it.

Practitioners need to take a more inclusive approach to apnea therapy. The problem is complex and the success rates of existing approaches are not good enough. Anyone working in the field should be conversant with treatments that fall outside their area of expertise and be able to integrate the therapies into an approach that will work for the patient in front of them.

</rant>

[ca_hosehead]

Got my first follow up visit at two weeks. I told him my jaw was riding forward some during the day. He said give it another two weeks to get used to it and then advance two 1/4 turns. We set up another follow up in a month.

Looks like this is going to be a long process. He seems to favor long periods of adjustment to let the soft tissues adapt. It makes sense to me but I am impatient. So far this thing seems to be working for me so I want to get to full relief.

I definitely sleep better with this thing. I have good nights and bad nights like before, but I am getting more good nights and the good nights are better than usual.

[georgepds]

Good luck on your appliance

I side sleep these days with my arm under my chin. I notice that my lower jaw is pushed forward when I do this so the lower teeth are almost parallel with the upper

Might be a poor man's way to get the effect of the appliance