Oral appliance user -- should i go to cpap??

[nineteencats]

Thanks for your replies and yes I did have a sleep study done. After which my Dr. informed me I had 80 + interruptions and my oxygen level dropped below 80% several times. Don't remember exact numbers but as I told him, the numbers didn't mean much to me just WHAT CAN WE DO TO FIX IT???? He suggested that the oral appl. would work in about 75% of the cases and cpap 100%. Thinking the mouthpiece to be the lesser of the two evils that is what I opted for. As I said earlier not getting the hoped for results I now wonder if I should have went with the machine. Not being a severe case, my pressure setting is "8", I hoped the mouthpiece would work. Am I expecting too much too soon? I was really looking forward to not feeling beat all the time and was truly relieved with the diagnosis, thinking yeah I may feel like doing something again. One call to the Doc and I can have a RX for cpap Thanks to all Steve

Sorry to go off-topic here, everyone, but this reminds me of something that I've found confusing for the longest time. Steve says he's got 80+ interruptions (is that per hour or the whole night?), which he's saying is "not a severe case." Yet I had 24 interruptions during 4 hours of sleep and a 6.5 AHI, which my doctor pronounced "moderate apnea." I've seen others posting much higher numbers than mine and getting a diagnosis of "mild" apnea. What gives? Is there another factor that dictates severity, that I'm not aware of?

[RogerSC]

When I asked about hem, my sleep doctor said that dental/oral devices were effective in about 30% of cases. That's a much lower figure than you were quoted. That would (and did) send me to a cpap machine.

[49er]

Sorry to go off-topic here, everyone, but this reminds me of something that I've found confusing for the longest time. Steve says he's got 80+ interruptions (is that per hour or the whole night?), which he's saying is "not a severe case." Yet I had 24 interruptions during 4 hours of sleep and a 6.5 AHI, which my doctor pronounced "moderate apnea." I've seen others posting much higher numbers than mine and getting a diagnosis of "mild" apnea. What gives? Is there another factor that dictates severity, that I'm not aware of?

Hi,

In a previous post, he said that was for the night which comes out to 15.5 per hour if I am not misremembering

If you have an AHI of 6.5, that is considered mild apnea as anything between an AHI of 5 and 15 obstructive apneas or hypopneas is considered on the mild scale.

Moderate is 15-30 and anything above that is considered to be severe.

49er

[49er]

When I asked about hem, my sleep doctor said that dental/oral devices were effective in about 30% of cases. That's a much lower figure than you were quoted. That would (and did) send me to a cpap machine.

Hi Roger,

I am wondering what he is basing that on.

Not that I am an expert but as one who has explored this option due to what I feel is current intolerance to sleeping on the machine, I think the effectiveness first depends on the device used.

According to the sleep medicine dentist who posts on the other board, the TAP seems to be the most effective device according to research. And if anyone thinks he has an agenda, I recall a post by someone who ran a sleep lab at a military hospital? who pretty much said the same thing.

This sleep medicine dentist has said the effectiveness rates for people with mild apnea are 75%, for moderate 60% and for severe, 40%. He said those statistics are based on either getting the AHI below 5 or a reduction of the AHI by 50%.

So on that basis, Steve would have a good chance of having success on an applicance since his apnea is around 15. Anyone else is taking a bigger risk in my opinion.

However, if someone has tried like heck to make cpap work and can't, some treatment is better than nothing in my opinion.

49er

[TheUglyTruth]

This sleep medicine dentist has said the effectiveness rates for people with mild apnea are 75%, for moderate 60% and for severe, 40%. He said those statistics are based on either getting the AHI below 5 or a reduction of the AHI by 50%.

So on that basis, Steve would have a good chance of having success on an applicance since his apnea is around 15. Anyone else is taking a bigger risk in my opinion.


49er

The scientific evidence contradicts your shallow pronouncements:

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

and

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."

Capiche?

[zoocrewphoto]

I suspect the person was considering his sleep apnea to bot be severe as he follows that by stating his pressure is only 8. Some people assume that a lower pressure needed means less severe, but how much pressure you need is not an indicator of how severe your apnea is.

Also, ahi is important, but so is the level of oxygen deprivation. For example, if your apneas are very long, they will be more severe and cause more oxygen deprivation than more frequent, but shorter events. So, both need to be considered.

[49er]

Ugly Truth,

Is it really necessary to insult people with your responses such as using the term "shallow responses"? Whatever happened to disagreeing respectfully?

That sleep medicine dentist is quoting research that differs from what you are referencing. Believe it or not, reasonable people can disagree without being insulting.

In quickly glancing at your link, it was based on a case study and it looks like another very small sample size of around 28 in 2007. I confess I haven't thoroughly read it but most studies like that would be considered way too small of a sample and only preliminary.

I will have to doublecheck myself but I think the sleep medicine dentist is referencing research that is lot more recent and involves more people.

Anyway, it doesn't seem to be as cut and dried as you think it is which is another reason why you shouldn't be insulting people. And even if you were completely right and I was wrong, it is still not right to insult people for no reason.

49er

[TheUglyTruth]

Anyway, I will take a lot at what you have referenced as it might be helpful to many people like myself who thought that dental appliance wouldn't work for their apnea.

You are becoming deeper.

The word on dental appliances that you and many others spread here is potentially hurting CPAP-adverse patients by discouraging them from trying appliances.

My intent was to sting you. To be sure you get the message.

I fight for the sake of "my" patients.

CPAP remains the first line of treatment.

[Dr. Rathjen]

As a dentist who successfully uses an oral appliance for my own sleep apnea and also treats sleep apnea patients, I would like to state very clearly that CPAP therapy is the Gold Standard by which all other treatment modalities should be judged. In our office we strongly advise patients to consider/try a CPAP machine. If you can’t or won’t comply with CPAP treatment then you really only have three other choices. 1) Don’t do anything and suffer the associated health problems. 2) Opt for a surgical correction which is typically not a long term solution and can have a rather difficult recovery phase (think adult tonsillectomy). The majority of otolaryngologists won’t even do these procedures any longer and they seem to be falling out of favor. 3) Treat your sleep apnea with an oral appliance.

Some TMD or TMJ patients can be treated with oral appliances. I am also a TMD patient. A complete exam is necessary to determine this.

If we can agree to the above then let me play devil’s advocate to some of the comments already posted:

1) I have used a TAP III appliance and I do not recommend them because a sore tongue tip can occur when the tongue is restricted in its ability to move forward by the mechanical system that joins the two dental arches.
a. One of the main ways to open the airway is to move the tongue forward. There are other well-designed appliances will allow the tongue to move forward unobstructed.
2) If you can’t tolerate a CPAP (the Gold Standard) then the next best alternative is an oral appliance which isn’t 100% effective in every case.
a. For any other disease or medical condition would you forego treatment because it wasn’t 100% effective or it couldn’t guarantee a “cure”? Is not some improvement better than none? Remember: I’m not telling you that this treatment is better than CPAP. I’m telling you it’s better than no CPAP and the research data is there to prove it.
3) No dentist can tell you that your insurance company will pay for anything unless a prior authorization is done first. If your primary reason for choosing a treatment is whether insurance will pay for it then ask that a prior authorization be done. Remember that insurance companies are not there to help you- they are interested in making money. I caution my patients against allowing an administrative policy at the insurance company to dictate treatment. Sometimes this means paying “out of pocket” for the dental appliance with no insurance reimbursement. Armed with that information you can then make an informed decision about proceeding with the oral appliance.
4) Oral sleep apnea appliances must be titrated (adjusted) to the point of maximum effectiveness and then verified by another sleep test. Most dentists verify this titration by a home sleep test before referring the patient back to the sleep center for followup.
Finally I want to encourage any patient who suffers from sleep apnea to learn all they can about the health repercussions. It is much more than simply a snoring problem.

[jnk]

I agree that mutual respect is important for online forums. And everywhere else. It is difficult when emotion, although commendable in all discussions involving life-and-death treatments, goes so far as to override acceptance of the fact that there will be serious differences in opinion on matters as unstudied as oral appliances.

The reason I personally consider them unstudied is that there are such divergent views on the word "success" in discussions and "studies" of oral appliances for OSA.

At one end of the spectrum, if an appliance prevents one apnea, or reduces one apnea to a hypopnea, somebody somewhere may call that a form of "success." After all, it reduced the night's total by one apnea! Although that may be significant statistically, if reproducable, it is not medically significant for anybody unless it makes someone with an AHI of 5.0 now have an AHI of 4.9. Even then, it wouldn't matter in the grand scheme of things. Still, studies that are little more than glorified advertising for oral appliances continue to speak of 50% of people being helped or speak of 50% effectiveness. But that is highly misleading if 50% of the people have more events or the same number of events and 50% have only a FEW less events wearing the device. Without a clearcut, defined, accepted definition of "success," all those claims and numbers are more than meaningless--they are deadly.

In my opinion.

Most non-PAP treatments (with a few exceptions) "help" approximately 50% of the people who regularly use the treatment to reduce their AHI by about 50%. That is a broad rule of thumb that researchers have found to be the case with everything from oral appliances to one-way nose bandaids. All of those treatments are useful for a certain subset of patients who cannot, or will not, use PAP therapy. But they cannot be considered useful first-line treatments until there is a scientifically verified way to discern which patients will benefit and by how much. That truth should not stifle innovation. But it should stifle unverified, exaggerated claims aimed at people who are just looking for a reason not to try the gold-standard treatment for OSA first before giving up and moving on to less-effective approaches.

In my opinion.

And hey, I'm wrong a lot.

I do have an oral appliance. I used it until I could get a machine and then have used it in conjunction with PAP therapy, not as a long-term substitute for it.

[TheUglyTruth]

If you can’t or won’t comply with CPAP treatment then you really only have three other choices. 1) Don’t do anything and suffer the associated health problems. 2) Opt for a surgical correction which is typically not a long term solution and can have a rather difficult recovery phase (think adult tonsillectomy). The majority of otolaryngologists won’t even do these procedures any longer and they seem to be falling out of favor. 3) Treat your sleep apnea with an oral appliance.

You have forgotten positional therapy (non-supine sleeping) which reduces severity in about 50% of cases.

I have used a TAP III appliance and I do not recommend them because a sore tongue tip can occur when the tongue is restricted in its ability to move forward by the mechanical system that joins the two dental arches.

Of course not allowing the tongue to move forward tends to worsen obstructive sleep apnea and conversely, encouraging the tongue to move forward tends to reduce the severity of apnea.

Just a couple of years ago, one of the appliance suppliers was looking into a design for their MAD that "encouraged" the tongue to move forward. Do you know anything about this?

Can you say which current designs are best for "forward tongue placement"?

Thank you,

[jnk]

. . . positional therapy . . .

And the nose-bandaid thingies. And playing the Aborigine tube thingie.

[SleepingUgly]

I have used a TAP III appliance and I do not recommend them because a sore tongue tip can occur when the tongue is restricted in its ability to move forward by the mechanical system that joins the two dental arches.

I assume this is a temporary condition that would remit when the appliance was discontinued (if need be), correct?

One of the main ways to open the airway is to move the tongue forward. There are other well-designed appliances will allow the tongue to move forward unobstructed.

If you don't recommend the TAP, what device(s) do you recommend?

[zoocrewphoto]

You have forgotten positional therapy (non-supine sleeping) which reduces severity in about 50% of cases.

Thank you,

Has the definition of success been changed to actually mean that the patient is no longer in danger of health problems?

Most non-cpap treatments have a different defnition of success. As in, they define success as a 50% reduction of apneas. That means that unless the person has an untreated ahi of 10 or less, they will still be suffering from sleep apnea enough to require treatment.

I have an ahi of 79. So, successful treatment, defined by the people selling dental devices would be an ahi of 40. That would still leave me in the severe category. Hardly successful. We NEED to tell people this so that they can make a truly education decision. People being faced with cpap tend to want anything else but cpap. So, tell them something is successful, and they will go with it, blissfully unaware that they are still in a dangerous health situation.

Positional sleep therapy is not as useful as many thing. When I sleep in bed (without a cpap machine), I have bad sleep apnea. I'm rarely aware of it. But prop me up in a chair, or even with a bunch of pillows, and I snore and gasp so bad that I hear it myself. The sleep study doesn't test people sitting up, yet we tend to tell people to try sleeping upright if the power is out, or they are taking a quick nap. That can be dangerous advice, giving people the illusion that they are okay when they are not.

[DHosehead]

I found all an oral appliance did was mess up my bite PERMANENTLY while not fully fixing the problem. And 1/2 a problem is still a problem. CPAP solved my problem.

When I started on an oral appliance, I thought the only option was it or surgery. I wish I had visited a sleep doctor sooner, had a sleep study and been put on CPAP at least a few months sooner. It would have helped me avoid all the mess oral appliances did to my mouth. I tried, PureSleep, The Ultimate Stop Snoring Solution, a couple other cheaper versions that are basically the same as the others. And even made my own by fusing together single sports mouth pieces and using dual mouth pieces too. It's all the same, just pushing the lower jaw forward. And none of it fixes the problem fully. It's like a band-aid for a cut that needs stitches. CPAP was a winner from me after night 2 of the sleep study when they let me try it for the first time.

I'd recommend people avoid the oral appliances. See a sleep doctor first. If they find you should have CPAP, get it.