SleepDent

I am a dentist working in dental sleep medicine. Unfortunately, there is no way to adequately address your question without the benefit of having examined you and knowing your full history. All that I can do is suggest some possible avenues for discussion between you and your health care providers. Actually, the Tap is usually one of the better choices for people with a history of bruxing. Obviously, your dispensing dentist must have evaluated your tmj status prior to placing the device. This is often tricky, at best. You just have to make a determination if the joint is healthy enough at that present time to deal with the device and sometimes you guess wrong. We all do. If I am concerned, I will sometimes order a course of head and jaw muscle message therapy by a specially trained LMT prior to placing the device as well as using some special bite guards. I try to calm down the muscles enough so that they will accept the appliance without fighting back too much. Undoubtedly, your dentist has determined your total range of protrusive movement. He may need to adjust where you are in that range, either less, or ironically, sometimes more, so that you will get better treatment, have less apnea, and brux less. But hang in there, be patient, work with your dentist, and it will most likely work out. Your certainly have the right to request an A.M. Aligner. One comes with every Tap and your dentist certainly can get you one. Good luck to you! Arthur B. Luisi, Jr.,D.M.D.

I think that both patients and sleep dentists tend to underestimate the importance of chronic nasal congestion in reducing the efficacy of oral appliances. I always try to get patients to go the ENTs to optimize their nasal patency prior to oral appliance therapy. After that, they need to understand that they have to use their medications and other things RELIGIOUSLY to keep that air flowing through the nose. and at the first sign of increased nasal trouble, back to the ENT should they go. Arthur B. Luisi, Jr., D.M.D.

I am a dentist working in dental sleep medicine. Indeed, sleep apnea can be a progressive disorder. But the picture is more complex than that. It can get better or worse over time depending on how many factors interact. You know that losing weight can make it better. In some people, improving their nasal patency with medications or surgery can make it better. The normal aging process, which makes your tissues looser and more distended tends to make it worse. CPAP and oral appliances can actually improve things by resolving some of the inflammation in your throat caused by the trauma of snoring vibrations. So the picture is complex. The good news is that CPAP can generally be adjusted enough to successfully treat people for a lifetime. Arthur B. Luisi. Jr, D.M.D.

Well, the obvious question now is,"How does she feel?" Is she sleeping soundly at night? Does she wake up feeling refreshed? Any morning "brain fog"? How is her energy during the day? If all the answers are good and she isn't snoring and she had mild sleep apnea to begin with, you can pretty much deduce that she is home free enough in the current state. Arthur B. Luisi, Jr, D.M.D.

Well, sometimes you just have to sit back and try to think it through. You are now more tired than before. What is the only factor that changed--- the presence of CPAP. Certainly logic would point to that as a possible cause. Remember, when you are asleep, sometimes things that happen on a subconscious level have an effect that you are not aware of. An example of this is restless leg syndrome. A person's legs move, sometimes fairly violently, when they are asleep. On a conscious level they don't notice anything except that they wake up tired. You should discuss the situation with your health care professionals. Sometimes you can't be sure unless you test things out. If you use an oral appliance and wake up more rested than with or without the CPAP, it is the right solution. If you don't feel any better than before treatment, maybe the medications were good enough. You and your doctors can figure it out together. Arthur B. Luisi, Jr., D.M.D.

I am a dentist working in dental sleep medicine. Since you have mild sleep apnea, I am surprised that you were not offered oral appliances as an alternative choice, if you have your own natural teeth in reasonably good shape. They tend to work quite well for your level of OSA. Let's face it, for many people, especially people with a very sensitive nervous system, CPAP is a pretty intense experience to have while you are trying to sleep. The anecdotal experience from my office is that it is so intense that it disturbs the sleep of some mild OSA patients more than it helps them. An oral appliance is a much gentler experience. No noise, no compressed air to breathe against, no masks, no straps, no hoses. It can definitely make a more peaceful night's sleep for mild patients, in some cases. Arthur B. Luisi, Jr., D.M.D.

This post is based on a review article in The Journal of Dental Sleep Medicine. Volume:02 Number:04 10/10/2015. To start the discussion I am going post a quote from that article. I will then react to any comments or questions, should they be forthcoming. "Standard treatment remains continuous positive airway pressure which is highly efficacious but has well-recognized limitations, with suboptimal patient acceptance and adherence rates, which in turn obviates the desired health benefits. The leading alternative device treatment is oral appliances.-------------------------.Despite discrepancies in effficacy(apnea-hypopnea index(AHI) reduction) between CPAP and oral appliances, randomized trials show similar improvements in health outcomes between treatments, including sleepiness, quality of life, driving performance, and blood pressure. Similar results in terms of health outcomes suggests that, although the two treatments differ in efficacy and treatment usage profiles, these result in similar over-all effectiveness." Authors: Kate Sutherland, PHD., Craig L. Phillips,PHD., Peter A. Cistulli, M.D., PHD. Any comments? Arthur B. Luisi, Jr., D.M.D.

Well, Airway Management specifies that bites to guide construction of Taps be set typically at 60% of maximum protrusive position, which would typically be well forward of the typical "habitual closing" position and would make the device capable of reaching maximum protrusive position for the vast majority of people. Never-the-less, it is up to the dentist to be skilled enough to compensate for that. Best practice is to use a George gauge to determine maximum protrusive position ahead of time, so that the Tap can be built forward enough to make that position attainable. It is easy to do. One problem with the EMA and also with the Silentnite appliance, which are somewhat similar in construction is that the bases are made of only one thin layer of material. The upside to this is that the appliances are very thin and comfortable for people who are bulk averse. The down side is that there really is very little thickness for adjustment and unless the dental work is pretty minimal, adjusting the bases is tougher than on other appliances with thicker bases. Everything is always a trade off. Another problem with the EMA is that the adjustment straps tend to stretch and break over time, creating an ongoing maintenance problem. Other devices, like the Somnodent, the Taps, the Micro2, and others have sturdier, more trouble free adjustment mechanisms. Arthur B. Luisi, Jr., D.M.D.

Sounds reasonable enough. Things will get sorted out in due time. Arthur B. Luisi, Jr.,D.M.D.

I absolutely agree. Ideally, an ENT who works with obstructive sleep apnea and understands oral appliances should evaluate each patient prior to doing the oral appliance and do what procedures are necessary in support of the appliance. The procedures should be finished and healed before placing the appliance. I said ideally because the area in which I work is in the stone age with respect to OAT and I am so far out in front of the sleep physicians and ENTs that it is a real struggle to get everyone to do the right thing, but I do the best that I can. Arthur B. Luisi, Jr., D.M.D.