SleepDent

O.K.. You have severe sleep apnea. You have given CPAP your best shot. Used every mask on the face of the earth. Tried several machines. Been coached by the best sleep staff. Just can't do it. Where do you go from here? Well, using the CPAP standard for efficacy, oral appliances have been rated at about 30% successful. Not very promising. Is that the end of the story? I think not. Here is a practical guide to turn failure into success: 1. Optimize your nasal patency(ability to breath through your nose). See an ENT for a complete evaluation. Control that chronic sinusitis. Control that allergic rhinitis. Consider turbinate reductions and septoplasty, if indicated. Good nasal patency can significantly improve the success rates for oral appliance therapy. 2. Don't let the perfect become the enemy of the good. Currently, there is no consensus among the dental sleep medicine community on what efficacy standard should be applied to oral sleep apnea appliances. There are several standards in wide usage. Let's consider the LEAST stringent standard. This states that an oral appliance is successful if it reduces the AHI at least 50% to an AHI below 20 with a total abolition of symptoms. Using this less stringent standard, a well-regarded study by Dr. Hoekema shows a success rate of 69% in treating severe OSA. In all fairness, this study used ideal conditions and would probably not be realistic for normal clinical practice, so maybe the success rate would be 55-60% in the real world. What does that get you? Well, you would sleep well at night and you would feel alert during the day. In terms of medical outcomes, it is unclear if getting the AHI slightly under twenty would be sufficient to take heart attack, stroke, and increased mortality off the table. It might or it might not. Not a settled issue. 3. Consider combination therapy. People who are CPAP intolerant but for whom oral appliances can not control the OSA adequately, can often find success by combining the two. Most notably, there is the Tap-Pap CS system. This combines a TAP OSA appliance with nasal pillows. The oral appliance lowers the necessary CPAP pressure at least marginally and sometimes substantially. The device is secured by the teeth and there are no external straps. Mask leakage is nil and mouth leakage can be controlled by an intraoral mouth shield. Works pretty well in terms of comfort and acceptability. But the most exciting fact is that the combination device is MORE powerful than CPAP alone. The treatment AHI is usually as good as CPAP or BETTER! Good luck and a restful night's sleep to you. Arthur B. Luisi, Jr. D.M.D. The Naples Center for Dental Sleep Medicine. Practice partner, dental sleep medicine, NCH Healthcare system. Practice partner, dental sleep medicine, The Millenium Physician Group.

I think that it is important for the reduction of unwanted smells in oral appliances to make ABSOLUTELY sure that it dries out completely between uses. I would try to dry it as completely as possible after use and then let it dry with the (completely dry) case open to the air. Arthur B. Luisi, jr., D.M.D.

Well, one of the contraindication to oral appliance therapy is a painful TMJ. Confronted with that, I would do a full TMJ work-up and take measures to take your TMJs back to a healthy state before contemplating OAT. If we could not get you there, I would not try OAT. I would agree with Dr. Demko, that a device like the Tap or Somnodent with discluder would be helpful in moving the forces away from the joint and decreasing the pressure from the muscles. Of those two, I prefer the Tap because the center attachment allows the TMJs to free-float and self adjust the pressure between them. Arthur B. Luisi, Jr., D.M.D., The Naples Center for Dental Sleep Medicine.

Actually I have seen oral appliances correct OSA to normal as per CPAP standard and still allow a soft "purr" of snoring. Not often, but I have seen it. Typically, these patients can have a little attention to better nasal patency and the snoring will go away. Arthur B. Luisi, Jr., D.M.D. The Naples Center for Dental Sleep Medicine. Practice partner, dental sleep medicine, NCH Healthcare System. Practice partner, dental sleep medicine, The Millenium Physician Group.

When you say that oral appliances can control sleep apnea in only 30% of patients with severe OSA what efficacy standard are you applying? Arthur B. Luisi, Jr., D.M.D.

Actually, no, I have not evaluated the content of the product, because I do not consider myself competent to judge such things. Let me be absolutely clear about the circumstances here. I had no knowledge of ProDentClean until literature was provided to me by Airway Management with my new Taps. Airway Management now officially sanctions ProDentClean for all their products. In the interest of full disclosure, I have had a long and close association with Airway Management, primarily as an unpaid consultant to evaluate their products. However, I have no financial interest in the company. what-so-ever. Dr. Keith Thornton, the founder of the company, did personally mentor me at the start of my career, when formal education in dental sleep medicine was very limited. In my opinion, Dr. Thornton is one of the best sleep dentists there ever was and a man of the highest character. I value his judgement on the merits of the product. In my opinion, Airway Management has always been very responsible in presenting safe products to the public. So, if they say it is O.K., that's good enough for me. Maybe I am naive, but there you have it. Never-the-less, I take this forum very seriously, and try to be fair and balanced and not to let my personal relationships cloud my judgement. I do also know that Dr. Morgan, the founder of ProDentClean, enjoys a good reputation within the profession. Arthur B. Luisi, Jr., D.M.D.

One thing that you could try is a specialized type of mask called a Tap-Pap CS. It is secured by an intraoral sleep apnea appliance on the teeth and does not involve extraoral masks or straps except for nasal pillows. Arthur B. Luisi, Jr., D.M.D.

Really great story and great job telling it. I think that patients should understand that they need to be proactive and take control of their treatment. Don't accept negativity and inadequate counsel from your health care practitioners. Go on line. Educate yourself. Read the forums. Get second and third opinions when necessary. Don't give up until you get treated. Too much is at stake for you and your family. Arthur B. Luisi, Jr.,D.M.D.

It is possible for an oral appliance to resolve the apneas and hypopneas without resolving the snoring. If that is the case, you would be considered successfully treated in a medical sense, although, from a social sense, the people in your household would still be suffering with the noise. There is no way to be sure without having a sleep study(home sleep study or sleep lab study) with the appliance in place.. Feeling better is not sufficient proof in and of itself. There can be a placebo effect. Arthur B. Luisi, Jr. D.M.D.

You make some very valuable points here. There is no "typical" sleep apnea patient. They come in all shapes, sizes, and ages. This patient does not fit the typical stereotype in that he was thin, fit, and apparently healthy. Keep an open mind when you are diagnosed, even if you are not the typical patient(older, male, overweight). It could save your life. Arthur B. Luisi, Jr.,D.M.D.