SleepDent

Dr. Demko, I absolutely agree with SusanR. That is an EXCELLENT posting on oral appliances. Clear. Fair. Factual. I strongly urge all patients on this forum to take the time to read it. Arthur B. Luisi, Jr.,D.M.D.

Dr. Demko, your statement that oral appliances are more effective in patients who needed CPAP pressure lower than 13 surprises me. I have always been under the impression that there was no known correlation between the level of CPAP treatment pressure in cm's H2O and the success rate of oral appliances. Could you offer some research data on this topic? Arthur B. Luisi, Jr.,D.M.D.

As Dr. Demko said, the list of officially certified dentists is extremely limited at this time. There are not nearly enough to cover the current needs of patients in the USA. There are a much larger number of dentists who do have sufficient experience to be effective, but are not certified. I think a good way to find them is to ask for a recommendation from your sleep physician or the head of your local sleep disorders testing lab. They have typically established a relationship with local dentists experienced in dental sleep medicine and can give you the name(s). Arthur B. Luisi, Jr., D.M.D.

As you stated, Hoekema's study(2004) showed an excellent response to oral appliance therapy. It proves that, with top notch technique, properly selected patients, and a better than average titration protocol, much better results CAN be achieved with oral appliance therapy than is being achieved currently in the United States with dentists who, in general, are fairly poorly trained in dental sleep medicine. So, just because the dentists are currently not up to this level of quality, does that mean that we have to accept mediocrity and blame the technology when most of the fault lies with the practitioners. I hope not, for the sake of the patients. Arthur B. Luisi, Jr., D.M.D.

I would add that, if you feel that your bite is off, you should stop using the OTC appliance immediately before any further damage is done. If the problem is in the very early stages, your teeth and bite might return to normal over time. Lets hope so. If not, you will need to seek dental care for a correction. Arthur B. Luisi, Jr.,D.M.D.

A few more thoughts on treatment standards. The CPAP standard is an AHI reduced to less than 5("normal" people can have a few apneas per hour) and total abolition of symptoms. Let's say that a patient who had a pre-treatment AHI of 20 and was quite symptomatic is reduced by an oral appliance down to an AHI of 9 with a total abolition of symptoms. Would you consider that successful treatment? I would. Long-term cohort mortality studies show increased mortality in OSA patients with an AHI above 20. Let's say that a severe OSA patient has a pre-treatment AHI of 50 and an OA cuts that down to 15 with a total abolition of symptoms. Would you consider that successful treatment? I would. The point is that physicians feel that they must titrate the AHI down to below five for success with CPAP and usually they can do so. Remember that oral appliances are a different mode of treatment than CPAP. Do they have to be titrated down to below AHI of 5 to be successful. Possibly not. TO BE DETERMINED. Arthur B. Luisi, Jr.,D.M.D.

It is true that the standard Tap and DreamTap do open the bite somewhat more than some other appliances. This is a matter of millimeters and the majority of patients can accommodate. The upside of this is that the mouth can be kept from falling open during sleep, which increases efficacy while still allowing some space for air exchange to accommodate mouth breathers. Both the Tap and the DreamTap can optionally ordered with the bite more closed than the standard design and the manufacturer is in the process of offering new hook designs that will allow the bite to be further closed, if desired. So the problem is being addressed. Arthur B. Luisi, Jr., D.M.D.

The study quoted in my last post is as follows: A Method of Studying Adaptive Changes of the Oropharynx to Variation in Mandibular Position in Patients With Obstructive Sleep Apnea. J. Oral Rehabil. 1996 Oct.23(10):699-711. Test: 6 subjects moved their mandibles to maximum protrusive position. Then fluoroscopic imaging was done as the subjects opened their mandibles in maximum protrusive position. Jaw opening resulted in synchronous posterior movement of both tongue and soft palate, with subsequent narrowing of oropharyngeal airspace. Recommendation: It is suggested that, where artificial mandibular advancement with dental devices is considered beneficial, jaw OPENING should be kept to a minimum. The point that I am making is that a large number of the MADs on the market, perhaps a majority, Do allow the mandible to fall open in the name of "comfort", this will cause a significant loss of efficacy that both the prescribing dentists and the patients are not informed is going to happen. All MADs are NOT created equal. Arthur B. Luisi, Jr., D.M.D.

If one references the 2015 joint study by the AADSM and the AASM on oral appliances, as I read it, there is no statistical difference in many of the medical outcomes of CPAP vs. OAs with the notable exception of Oxygenation levels(big win for CPAP) and AHI(big win for CPAP). The question that has to be raised is the following: Is it fair and proper to apply CPAP standards to OAs when evaluating them? I believe that that is still an open question. OAs are not CPAP Lite, they are a different mode of treatment alltogether. A huge difference is that the entire oral appliance experience is much less intense than CPAP and for that reason people's bodies react significantly differently too it. This must be taken into account and is not. As I understand it, the AADSM does not have an official standard for acceptable efficacy for an oral appliance at this time and do not think that it is necessarily correct to just use the CPAP standard. Arthur B. Luisi, Jr., D.M.D.

Well, O.K., point made. However, In my practice, I track the results with my appliances very carefully with sleep studies with the oral appliance in place. I am VERY insistent that the patients get these and over the twelve years that I have placed Taps, the results have tracked that of the Hoekema study pretty closely. I know other dentists that have told me that their results have also come close to the Hoekema study long term, too. So I am fairly confident that these appliance can exceed the 50% success level by a pretty significant margin. I do not say this because I am acting as an agent for Airway Management. And I do use a selection of other appliances when indicated so that I am not a one trick pony. The point that I am making is that we should not get comfortable with a 50% success rate. I think that, with more research, and by weeding out some of the weaker members of that over 100 population of oral appliances, we CAN do better than that for the patients. Arthur B. Luisi, Jr.,D.M.D.