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I will offer you my advice but you may not like it. If you want your dental appliance to work you must learn patience, learn to communicate with your sleep dentist, and accept that there may be many appointments with him before you are sleeping great. It just is what it is. Same for a CPAP.
I have some patients that I just cant help because they want an instant remedy. They prefer to just take a pill and fall asleep. Wake up and take a pill to get through the day. They switch to a CPAP and get frustrated because turning on the power and putting on the mask is not instantly working. The truth is sometimes life is not that simple.
First you need to think in terms of your just now starting treatment. A dental device that is not fitting well is not helping you. Now that it is fitting you can begin treatment. So you need to forget the past few weeks and move forward from here. Just like the air can be turned higher or lower with a CPAP the same is true for a dental appliance. Your appliance will needed to be adjusted SLOWLY over the next few weeks and maybe a month or two until the base of your tongue does not fall into your throat. You have proven to yourself that you clench and grind your teeth. If the appliance is not adjusted SLOWLY you will have tension in your muscles again. The reality is your muscles may not let the appliance bring your jaw forward enough. This is why I have an in house massage therapist work on all my patients several times over the first few weeks. The muscles may need help letting go. You may need to consider massage/physical therapy/ chiropractic therapy to help your muscles relax. Or switch to a CPAP. But your clenching and grinding will still be a problem because its not being treated.
You may also have some cortisol/stress/adrenal gland issues to deal with. The dental appliance or CPAP may fix the apnea issue and you still don't sleep very well. Your airway is open. Its no longer the problem. But your hormones are all out of balance.
So my advice is patience and go see your doctor and talk to him.
Dr Tony
My experience is really just hearing from years of patients all kind of different ways they have tried to solve the same problem. And some of the ways make me a little nervous. Cajun ingenuity with duct tape and gorilla glue is not always a good thing! LOL. And some of the ways are pretty smart.
The soft foam football mouth guards are the least abrasive to the gums. They fit on both top and bottom jaws. Usually have a lip protector that you have to cut off. Channels are placed between the top and bottom to let air flow in and out. I would not have thought the channels would let enough air flow for the CPAP to work but I guess it dos. The soft foam is also the least supportive of the jaws which is why I don't like it for sports unless its the only option because of braces and it not really a hard contact sport. But for denture patients with CPAPs it works for a couple of my patients. Most however prefer a more stiff mouth guard like Wiredgeorge wears.
Ron, I appreciate you didn't really ask for my advice. So not trying to change your mind on anything either.
If your going to try a mouth guard start with a soft one. Its the opposite of what I recommend when you have teeth. When you dont have teeth the mouth guard os totally resting on your gums. If the mouth guard is made of a hard material you may end up with some nasty sore spots over time. Be ready to try different mouth guards until you find the one that works the best. If you get a small sore spot on your gums please stop wearing the guard until it heals. Warm salt water a few times a day is still a good remedy. Them trim out the guard where the sore spot is with a dremal tool or hot knife. Whatever works. I have seen these small sore spots turn into angry ugly ulcers if you ignore them for a long time. If the guard just can't be made to fit very comfortably try a different on.
Sorry for the unsolicited advice. Just trying to help.
Call them now. The inside of the appliance needs to be opened up a little bit and probably on the deep inside part where the edges of your teeth fit. Teeth can take some pressure before they start to hurt. Every time you bite down you are compressing the teeth into the bone and pushing them out. Its the normal part of chewing. The ligaments give and stretch. But if you keep them stretched long enough they say OUCH! If you have a pain response, even a very small one, that causes the release of the stress hormone cortisol. This hormone also wakes you up in the morning. So the pain in your teeth plus the anxiety of the appliance not fitting is causing a stress event that is releasing cortisol and thats why you can't sleep. Not much to do but bring it in and let them grind it out a little bit. This is common with the type of appliance you have. Its made of the same acrylic they make dentures with. Think about how many times dentures need to be adjusted when you first get them. The material shrinks as it hardens. So the lab tech has to allow for that shrinkage or the appliance is too tight in spots. This is not easy to do. So expect to adjust the inside a few times until it fits perfect. Easy to adjust. Just give your dentist a call and show him which teeth hurt.
Your snoring may be due to inflammation of your soft palate as well as the base of your tongue falling into your throat. If you have chronic sinus issues that can affect the soft palate. The appliance wont fix that. I tell all my patients that I will get their tonque out of their throat and if that solves all their problems then great. If they still have some snoring issues then they see my medical director who is an ENT and sleep specialist. In the spring time almost all my patients get an evaluation form both of us because of seasonal allergies. Start with a home sleep study to see if the apnea is under control and also look closely at the hypopnea score.
In Denver Dr Gary Radz is a fantastic cosmetic and sleep dentist. I know him very well and he will take great care of you. His website is http://www.downtowndenverdentist.com/ This may be his cosmetic site and not his sleep apnea treatment site. But they are the same contact number so no worries.
There are 5-6 appliances on the market that are uniquely different and probably a 100 designs to choose from. Sometimes insurance and particularly Medicare dictates which appliances dentists offer. I certainly don't offer my patient a 100 choices. I usually show them 3-4 different types based on the size of their mouth, condition of their teeth, if they sleep with their mouth open, how much they clench and grind, etc.
We adjust our patients appliances for them. Yes it means several appointments but it allows me to talk directly to our patients so I can monitor how they are sleeping. And how much advancement in the appliance so I can also manage their TMJ and muscle issues. I strongly suggest you go see your dentist and let his office adjust it for you. At least the first couple of times.
Don't get discouraged. Some of my patients take a little more effort to get to a great night sleep too! TMJ is almost always caused by sleep apnea. Not 100% of the time. But the vast majority. Once your sleep apnea is under control your TMJ problems should also start to get better.
Fell free to ask me any other questions you may have. And keep us posted on how your doing. Your not the only one out there in this same situation. So your questions and comments also help a lot of other patients.
Well I guess your referring to me so I will offer what advice I have.
First this is a Herbst style appliance. It is not my first choice for appliances. Didn't say it didn't work. just not my first choice for some of the reasons you listed. The Micro2 and the Narval are my two favorites. www.micro2sleepdevice.com/ www.resmed.com/us/en/consumer/products/dental/narval.htm
The advancement arm can be uncomfortable in some positions. Which is why I don't like this appliance. Its bulky like you say. And the screws tend to come loose.
You may make excess saliva but you should not drool on your pillow. The arms can sometimes rub against your paratoid glands on your cheeks. These glands make a lot of saliva and if your stimulating them you will make too much. But your lips should be closed when your in REM sleep. You may be opened too wide. Your dentist can grind down the thickness of the appliance to close your lips together but its often easier to make a new appliance.
Your tongue should fit into your palate at night. If the appliance is too bulky you may not have enough room for your tongue. The Narval is the thinnest appliance on the market and the Micro@ does not cover the tongue side of your teeth. This gives extra room for the tongue to move forward.
If you clench and grind your teeth, which it sounds like you do since you have a bite splint, this may not be the best appliance for you. This is not to say it can't be adjust so it fits perfectly. It has to be hard to support the metal arms and somewhat bulky. But not to the point where it hurts to wear it. That defeats the purpose. Have your dentist reduce its bulk and back up the arms so your not so forward. Wear it a few days and see if the pain goes away.
Sorry I don't have simple solutions. And yes this appliance can work for you. Sounds like it just needs some adjusting.
You have asked several great questions. So please be patients as the answers will be separate to read.
What part of Arkansas do you live? I can see if I know of a great sleep dentist close by.
How can an appliance have better results in an end to end position rather than 3,4,5 or even 6mm advancement out? It would seem that further advancement would always mean further area behind the tongue? The more is better rule does not always apply. The appliance simply brings the lower jaw forward until the base of the tongue is no longer blocking the throat at all. Fo some patients this is an edge to edge and for some the jaw must be brought out quite a bit more. Don't get hung up on the numbers as everyone is different. Once the tongue is out of the throat bringing the appliance further forward is not accomplishing anything and may start to cause the muscles around the throat to stretch too far and change the shape of the opening of the throat.
How can you have a worse AHI with further advancement than you did without an appliance in at all?? I have had an in home sleep study and I had a higher score with advancement than end to end. Two thoughts here. First you could be stretching the muscles too far and narrowing the opening of the throat. Usually you begin to have teeth and muscle soreness before you get this far out. But I have had some cases referred to me without pain that were not getting better. Lower jaw was wayyyyyyyy out there each time. I brought the jaw back according to where her muscles were not overly stretched and the AHI dropped. Or the higher AHI could have nothing to do with jaw position and could be a lowering of AI but a significant raising of HI. You always have to look at these number separately and not focus just on single AHI. Every spring I have patients that were doing fine all winter, No snoring. Sleeping great. AHI below 5. Then I get a call and they are snoring again. We do a new sleep study. Their total APNEA INDEX went from 4 to 1. Its actually better. But their HYPOPNEA INDEX went from 10 to 40. SO their AHI is worse but their APNEA count is better. Their appliance still has their tongue forward enough. But their nose is clogged. Springtime allergies. So I suggest you look at the AI and HI index, and the total A and H count. Then also look at the snoring count. Also positional. You may have slept on your back more for one test. The total time on your back is also a factor. So yeah I see this quite a lot. But its not always worse. And its not always the throat. You have to take all factors into consideration and often multiple doctors to get everything back on track.
Lets say you get an appliance and you don't change the position on it for 3 months, have you seen in your practice people getting better results after months of treatment rather than at the initial start of it? If so, why is that? See this a a lot as well. Has to do with the inflammation and clenching of the teeth caused by sleep apnea. Well actually the cortisol release caused by sleep apnea. Once the apnea is under control the inflammation in the body decreases. We take photos of all our patients throats when we start treatment. Always red and angry looking. About 3 months later the tissue has shrunk and looks normal. But this just opens the throat a little. Some. But not much. The bigger issue is the muscles are relaxing as the apnea gets better. So the tongue can advance further. This is why we have an in house massage therapist that works on every patient. We get results in 2-4 weeks as opposed to 3 months.
So sorry for long answer. But you asked some great questions that deserved to be answered.
I am normally not a fan of boil and bite dental appliances of any kind. If you have no muscle or joint issues these appliances can work well. But if you do have any tendencies to have muscle or teeth pain and you do not have the appliance soft enough and bite into it with even force on both sides it will hold your jaw slightly crooked. This can make teeth and muscle pain much worse. Or create pain that was not there to start with.
But I also respect that these boil and bite appliances are very inexpensive and easy to purchase. And if you listen to wiredgeorge he molded the appliance just right. Even the idea of buying more than one in case the first one does not come out right is a great idea.
We make a few boil and bite appliances each year for patients. Its all they can afford so I have them bring the boil and bite in and we fit it for them at no charge. Its not hard to do and my assistant is a master of making them.
If you are honest with yourself and have no teeth or muscle sensitivity nothing wrong with trying a boil and bite. If you do have some sensitivity as your dentist if he can help you fit it to your mouth. May not charge you anything if your a great patient or very little. If you have a lot of sensitivity or migraine headaches consider asking your dentist to help right from the start. If you dont have a dentist find one that treats sleep apnea or even a sports dentist. A sports dentist that makes custom mouth guards for sports teams will have no problems fitting you with a boil and bite. I am the dentist for our local hockey team so my assistant has made hundreds of mouth guards over the past 5 years. She is amazing at making them is no time. Better than me. Just dont tell her I said that!:)
Athena1965, I am not sure what I doing to be considered more compassionate than the next doctor. But thank you all the same. The over the counter guards do have to possibility of working great for you. Just be careful it does not start to cause muscle spasms in your head, neck, and upper back. We do not have a problem getting medical insurance to pay for dental appliances. But there is a very strict protocol that you and your sleep dentist must follow. Quite a bit of paperwork. If your medical doctor is willing to sign a prescription that a dental device is your best option then your insurance will probably pay for it after pre-authorization. Just make sure you have all your documents correct.
