BGailDemko140

To date there is no scientific study that shows use of a morning repositioner helps to minimize tooth and jaw movement. There is a study being funded at the University of British Columbia to see if use of a morning aligner decreases morning side-effects. They are also looking at whether patients actually use the repositioner. Orthodontists argue that use of an morning realigner puts increased forces on the teeth and may actually do damage. We just don't know. That is why a scientific study is required. Like Dr. Luisi, I always give patients a morning realigner and encourage its use. Some people use if every morning, others never use it. I like to believe that use of a morning realigner makes a difference, but 'belief' has no place in medicine.

Effectiveness of an oral appliance is normally based on the action of moving the bottom jaw forward; they all work the same. A patient continuing with treatment is based on many things. Comfort is # 1 and the fit of the appliance is #2. Studies published as recently as December of last year show that half of the people who get an oral appliance stop using it in the first year...and these appliances were custom fitted by a dentist. Oral appliance therapy is not for everyone!!!! It works half as well as CPAP (but more patients use it all night) and has side effects. As to F.D.A. clearance, the FDA's job is to protect the public from dangerous therapies. All devices cleared (this includes the custom fitted devices use by Dr. Luisi) must be made of materials safe to be used in the mouth (no cancer producing materials, etc.) and must prove they are essentially equivalent to a device previously found to be safe for use. Even the custom made devices used by dentists do not have to 'prove' they work, only that they are safe. All devices have side-effects and very few studies show that one appliance is safer or more effective than another. Efficacy rates only apply to scientific studies and cannot be generalized to a real life situation. In one study an appliance my be effective in treating sleep apnea in 25 % of the patients and in another study as effective as 50%. Thus data must be analyzed for the quality of the study, the people being studied (were they all young or old or overweight) and then compared to the quality of other studies. People who do not understand evidence based medicine often believe that numbers from a single study are to be taken as a fact, not as an indication of a certain outcome.

TAP 3 and Dream TAP open the distance between the top and bottom teeth more than most appliances. This can make it difficult for you to close your lips around the device during sleep when the muscles are relaxed. Some appliances (Herbst, Printed nylon, and others) can be designed to keep your teeth almost in contact so that an open mouth at night is not a problem. Any qualified dentist should be able to offer many different styles of appliance based on your muscle tone, lip closure and the anatomy of your mouth. This is why the FDA has more than 100 devices cleared for treating sleep apnea. Strong evidence, comparing one oral appliance design to another, has shown no difference between how well they work , but there are differences in comfort, size and side-effects depending on the design.

An oral appliance that is inadequately fitted can leave the teeth sore each morning. A mouthpiece fitted by a qualified dentist can be adjusted to prevent sore teeth. Those of us who do a great deal of oral appliance therapy try to have the back teeth do most of the work of supporting the appliance and minimize forces on the front teeth because those teeth have minimal root support. Propping your head up changes the way your throat might collapse as does a chin strap; this explains the success of mattress makers who advertise that snoring can be reduced by sleeping in a bed that can lift your head. Snoring occurs in a large part of the population and does not necessarily indicate sleep apnea. On the other hand, there are many people who have the only complaint of snoring and do not feel tired but, when tested, turn out to have severe sleep apnea. I would recommend you speak with your doctor and see if testing finds sleep apnea or only snoring.

Do you have any citations to support this? There is no scientific paper that supports a connection between grinding teeth / clenching teeth and sleep apnea. In fact, grinding is known to be most common in children and young adults and less in older individuals. The exactly opposite of the population with sleep apnea. Nor is there any published study that supports the need for massage therapy or any other muscle relaxants in most patients. Also, the major area of throat blockage is behind the soft palate and not the tongue. It is very simplistic to say that oral appliances protect against tongue blockage.

Nasal CPAP masks often put pressure on the root area of the upper front teeth. Research has shown that there can actually be tooth movement with some mask styles. Talk to your mask fitting people and see if nasal pillows would work.

I must post a comment on side-effects with oral appliances (OAs). As Dr. Luisi stated, these devices put significant force on the teeth because they all began life as orthodontic appliances in the 1970’s (based on a device actually invented in 1909). That being said, all OAs, regardless of who makes them, have the possibility of moving teeth and actually moving the entire lower jaw. What we do know is that people with advanced gum disease and resulting bone loss will rapidly see tooth movement (and even lose teeth). Those who undergo orthodontic therapy after the age of 21 have a 99% change of developing tooth movement with the use of an OA. It occurs least in those with a healthy dentition and never had orthodontic therapy.

Long term studies, looking at patients who have used an OA for more than 10 years, find that the side-effects of OAs increase with the time used. Those using an OA for 10 years had much more tooth movement than those using it for 2 years. Patients who used the OA all night long had more tooth movement than those who used it for 4 hours/ night.

Dr. Luisi is correct that a qualified dentist (www.aadsm.org/dentistqualified.aspx) can help choose an OA that can limit forces on individually weakened teeth or spread the forces out over all the teeth. This should help limit tooth movement and unwanted side-effects. A qualified dentist can also monitor changes in your jaw alignment and warn you that there might be problems since the majority of people do not feel any problem until it is very advanced.

My favorite treatment regimen in those who use CPAP for 4 hours each night is for them to use CPAP for the time they can and then switch to their OA for the rest of the night. This get a patient treated all night long and limits the side-effects of either treatment.

Updated research on the effectiveness of mandibular advancement oral appliances (OAs) is always forthcoming and there is a journal that prints nothing but articles about this form of treatment. The success rate of oral appliances sits consistently at about 50%. That means that half the people who get an OA respond as well to the OA as others do to CPAP. Interestingly, 20% get better, but would not be considered to have controlled their sleep apnea by their sleep physician. A solid 25% do not improve and a few even get worse. After 20 years of research as to who will be effectively treated with an OA, we still cannot predict who that will be. Since we do not know who will respond to an OA and who will not, all people who get an oral appliance MUST return to see their sleep physician and most of these need to have actual sleep testing to make sure the OA is working.

On thing that does make physicians happy, and dentists too, is that the average nightly use of an OA is 6 hours/ night and the average use of CPAP closer to 4 hours / night. That means that people who are only partially treated with an OA, but use it all night may have the same medical improvement as someone who uses CPAP for 2-3 hours per night. All treatments used for the entire sleep time work better than a treatment used only part of the night.

All surgical approaches are less effective long term than CPAP and OAs. Even double jaw surgery (MMA advancement) will eventually fail. CPAP is the only treatment that does not fail with long term treatment.

Jaw expansion is a form of treatment that has been studies in children who have narrow upper jaws. In children, the upper jaw is actually in two halves (right and left) until the age of 15 or so. By adulthood the two halves fuse into a solid piece. This means that palatal expansion (the medical term for this procedure) can be done with no muss and no fuss in young children by pediatric dentists or orthodontists. It is normally done as part of overall orthodontic therapy. In adults, this treatment requires a surgical procedure to cut the fused bone apart to allow expansion and must be followed by orthodontic therapy so you won’t have a huge space between your upper front middle two teeth. This is not to be confused with maxillomandibular (that means both the upper and lower jaw… in Latin) surgery in which a surgeon moves both jaws forward. All published studies on this topic have been done ONLY!!! on people who had skeletal deficiencies leaving them with abnormal bone structure. Single case studies have been published in which an adult has been successfully treated, but a case study is often an unusual finding. As to your request about providers in British Columbia, the biggest research team in oral appliances and sleep apnea is at the dental school at UBC in Vancouver. Dr. Fernanda Almeida and Benjamin Pliska are two of the most famous.

Oral appliance therapy is best done with a dentist trained in the field. The American Board of Dental Sleep Medicine (www.ABDSM.org) oversees a rigorous examination and submission of completed cases (with sleep studies before and after) and has a list of qualified dentists in the US and Canada. While the list is quite limited at the moment, more than 100 dentist have already signed up to take the next exam.

Important data to know about oral appliance therapy is that they do not always work. Unlike CPAP which can open the entire collapsible airway (4" in women and 5" in men), oral appliance are site specific. Since your physician does not know where your blockage is, there is no way to predict if oral appliance therapy will be successful; this can be a very expensive trial and error adventure. Medical insurance will often cover the cost of an oral appliance if you have been diagnosed by a physician with sleep apnea. There are many rules that are unique to each insurance company. An example is that Medicare requires that you have a sleep study that is no more than 1 year old at the time of oral appliance therapy. Seems as if dentist have to follow the rules laid down for CPAP companies.

Oral appliances are more effective in patients with mild to moderate sleep apnea, who are of normal weight and who needed CPAP pressure lower than 13.

Side effects are related to the fact that the oral appliances in use belong to a class of orthodontic devices developed over 100 year ago to permanently move forward small lower jaws in children. Where the children had to wear the device 24 hours / day for 5 years, patients with sleep apnea only have to use the appliance during sleep. While some patients can have permanent jaw movement (I guess this is good if you have a small lower jaw), many dentist have developed various ways that can help you maintain normal jaw position. Switching between CPAP and oral appliance use could be one way of limiting side-effects.