SleepDent

You are spot on in all respects. For this reason I try to be extremely even handed and fair in my comments. I also try to state things as fact only if they are scientifically supportable by reputable studies. Of course, I am, not perfect and I fall short sometimes. Dr. Luisi

Let me clarify my previous statement. The vast majority of people on CPAP have been able to adjust to it and are benefiting from it. However, a significant minority are struggling with it or have abandoned treatment. For practices that focus on CPAP alone the danger is that, if patients don't make it on CPAP, they will be forever lost to treatment and will end up sick or dead. If all modalities are not discussed and considered on day one and tried in an orderly sequence, the patient can end up dispirited and untreated. It was never my intention to suggest that anyone abandon any treatment that is working for them. And, yes, I do recommend to some of my patients that they would be better off with CPAP than oral appliances. Arthur B. Luisi, Jr., D.M.D.

I would agree that each of our perspectives is necessarily affected by our own personal experiences and we need to be aware of that. One thing that I have seen is that the compliance rates for both CPAP and oral appliances appear to be somewhat dependent on the quality and quantity of the support provided by the organization that provided the service. I agree that I am aware of practices and organizations that do have very high rates of compliance for the CPAPs they place. I am also aware of organizations with dismal records and the same for oral appliances. Patients are best served when all their options are presented to them in a candid, complete, and honest way. Each option should be presented with equal enthusiasm and the presenter should try very hard to be knowledgeable about all the options and to not let his individual preferences influence his presentation. Arthur B. Luisi, Jr., D.M.D.

I think that this is becoming increasingly debatable. See my post on this forum: CPAP vs, Oral Appliances-- Is CPAP Still The Gold Standard. I think that CPAP has been considered the Gold Standard because the air pressure can be set at a point that will adequately control OSA in almost every patient. In that sense it is almost infallible. Oral appliances can not adequately control OSA in every patient and the treatment AHIs tend to be a bit higher than CPAP. However, as one of my earliest patients said to me, it doesn't matter how good a treatment is if you can't stand it enough to use it. In the real world compliance issues with CPAP make it suboptimal or useless for a large percentage of patients regardless of potential effectiveness. In that sense it is NOT a Gold Standard and other treatments, such as oral appliances, must be found. Arthur B. Luisi, Jr., D.M.D.

Unfortunately, you are so very right about the actual situation in the real world. I will use my own situation as an example. There are sleep physicians in my own area whom I have conferred with, have briefed extensively on the pros and cons of oral appliance therapy, and who have seen the oral appliances succeed on their patients verified by objective testing, who STILL act willfully ignorant about oral appliance therapy because it does not benefit them directly financially and disrupts the smooth patient flow that they have with CPAP. This is very wrong, but there is nothing I can do about, except to go on these forums to educate people. People need to go on these forums and use other resources on the internet to become knowledgeable enough to make sure that their treatment is being done in their best interest. Arthur B. Luisi, Jr. D.M.D.

You are welcome, as always. There is certainly a lot of misinformation out there. Arthur B. Luisi, Jr., D.M.D.

I think that I can give you some general sense of who might be a good candidate for oral sleep apnea appliances. Oral appliances have a much higher success rate for mild to moderate OSA than for severe OSA. Remember, though, that about 80% of the patients are in the mild to moderate category. You need to have fairly good teeth: 1. no less than eight good teeth in both the upper and lower arch. I find that there are some circumstances where you can get by with a few less than that. 2. The teeth must have good bone support and no or very little mobility(movement under pressure). The patient must have good gum(periodontal) health or periodontal disease that has been successfully treated. 3. Good quality dental implants are acceptable. 4. Patient can not have a severe intraoral gag reflex. 5. The patient can not have major levels of sinusitis with post nasal drip. 6. The patient should have fair to good levels of nasal patency(openness to air flow). 7. The patient can not have claustrophobia with respect to intraoral appliances. 8. The patient should not have active TMJ dysfunction. Condition of TMJs needs to be fairly good, but not perfect. As to success rate, if you took a general average of what happens to any patient in the USA who walks into a dentist's office, it has been quoted at 50%. I think that is probably pretty accurate. Please keep in mind, however, that the success rate could potentially be significantly better, IF the dentists in this country were not so poorly trained in dental sleep medicine on average, IF the very best quality and designs of oral appliances were always used, and IF the dentists used the very best protocols currently available for fitting, adjusting, and testing the appliances. A very skilled dental sleep medicine dentist using top appliances can also have significant levels of success with severe sleep apnea and I would not automatically write severe patients off as untreatable. Arthur B. Luisi, Jr., D.M.D.

I am a dentist working in dental sleep medicine. The question that I would ask is whether or not you and your doctor have explored the possibility of substituting an oral sleep apnea appliance for the CPAP machine. I have placed hundreds of them and many people are comfortable the first night out. Most people can make the adjustment and be comfortable within ONE week. Really. When I read about these titanic and protracted struggles with the machines, I really am at a loss as to what to think. Now oral sleep apnea appliances are not for everyone, but I have to think that they would be a much easier way out for many people who are struggling with their treatment. Arthur B. Luisi, Jr., D.M.D.

Well, if by this you mean that you were below 90% only 21 seconds all night, that would meet my definition of "very brief". This is a very important point, however, and I would suggest that you discuss it with your health care providers to make sure that you are reading the report correctly. Arthur B. Luisi, Jr., D.M.D.

Well, since you are using a dental appliance, I must assume that you have obstructive sleep apnea and not central sleep apnea, because an oral appliance is not effective against central sleep apnea. Obstructive sleep apnea, as the name implies, is caused by blockages in various areas of you respiratory system. In order for the heart to be implicated, you would need to have central sleep apnea or mixed sleep apnea(obstructive and central apnea mixed). However, poor circulation can contribute to low oxygenation, so some medical consultation concerning your heart rate would seem like a sensible move. Theoretically, you never want your SpO2 below 90% at night. However, sleep physicians also assess how long you are below 90% at night. If it is very brief, they might call it trivial hypoxemia and not make an issue of it. You need to ask your doctor to assess where you fall in the spectrum. Arthur B. Luisi, Jr., D.M.D.