SleepDent

You are so welcome!

Yes, I think that it would be reasonable to have the status of your airway re-checked. By definition, the Myasthenia issue gives you unusually poor tissue tone. In that respect, you are in a non-standard situation and you can't take for granted that your reactions to treatment are going to be typical. Your best bet is to expect the unexpected and be happy when it doesn't happen. Dr. Luisi

Hi! This is Doctor Luisi speaking. I hope you don't mind if I jump in a little bit. Common sense would tell me that someone with Myasthenia Gravis could, indeed have some trouble with oral appliances. I would think that, since CPAP is the more passive type of treatment, it might be a better choice for someone in your position, but that is just speculation on my part. Dr. Luisi

Hi! This is Dr. Luisi. Statistically most OSA patients are in the mild to moderate range(about 80%). This would mean that their AHI is in the 6-30 range. Therefore about 20% are severe. This would mean that their AHI is in the over 30 range. Severes with AHIs in the 45, 50, 65 range are fairly common in my practice. An AHI of 80 is on the high side, but by no means record-breaking. I personally have heard of at least two patients with AHIs in the 130 range. An AHI of below 4 is considered to be "normal". That is to say "normal" people can have a few apneas an hour. Never-the-less, you really have to consider whether a patient is still symptomatic. If your AHI is down to 2 and you are still tired, you have to try to get it even lower. Some people have no AHI and are just snoring and feel tired. In these patients, you have to eliminate the snoring to make them feel better. Dr. Luisi

Your point is well taken. Basically, in 2015 the AASM and the AADSM had a big joint conference on oral appliance therapy. They went through all the test data for medical outcomes in all categories for both CPAP and oral appliances. The outcome was that, for all medical outcomes, there was no statistical difference between CPAP and oral appliances with the exception of oxygenation levels, where CPAP showed a significant superiority to oral appliances. Admittedly, this is confusing. Does not jive with our current model of the pathogenisis of OSA. I can not give you a definitive answer, but I do have a theory. From my own experience with CPAP patients my sense of it is that the problem with CPAP is that it is just too intense for people to sleep with comfortably. From the mechanical point of view, it eliminates apneas and hypopneas quite efficiently, thus improving oxygenation. On the other hand it also tends to disrupt the patients sleep with noise, mask leaks, strap pressure on the face, unpleasant sensation of air pressure in the airway, etc. The oral appliance is just a gentler experience. I think that the slightly lesser treatment efficacy of oral appliances may be offset by less overall disruption in the patients sleep, giving a better over-all experience for many people. This is the best I can do, we are struggling to understand it, just like you are. Dr. Luisi

Thank you NiceSilverBison1316! Your TAP3 Elite is a great appliance, the most effective that currently exists. Be very careful about what cleaning agent you are using. What you said sounds non-standard for a TAP. It could shorten its lifetime. AirWay Management that makes the TAP now sanctions a new cleaning agent, Prodentclean. See: www.Prodentclean.com. The dental sleep medicine community is no longer sure that it is useful or correct to compare CPAP AHIs directly to oral appliance AHIs. These are two different modes of treatment. We shouldn't think of them as CPAP and CPAP lite. I asked for a declaratory letter from the American Academy of Dental Sleep Medicine and they stated that there are no generally accepted AHI numbers to judge oral appliance therapy by at this time, but it is probably neither correct nor practical to use the classic standards used for CPAP. Now, I know this is going to be controversial with this community and I might set off a firestorm, but bring it on. Dr. Luisi

Well, you certainly have a highly experienced sleep dentist. I know of his reputation, which is beyond reproach. Actually, I have never heard of the Panthera at all. It must be new or not a big seller. Personally, I think it is very important that the appliance have credible third-party, peer-reviewed independent efficacy test data available for you in writing. Many do not have that and i would stay away from them. The TMJ disorder is significant and I am sure that Dr. Parker will address that prior to your appliance. Dr. Luisi

Well, I am going to give you another point of view. I think that the DreamTap is an excellent choice for people who grind, especially laterally. The upper and lower DreamTap trays are attached at the center and there is a center wire bar. The device moves smoothly side to side on the bar through a very long lateral range, thus protecting the TMJs. The DreamTap is also of very sturdy construction that stands up to grinding, but is not a heavy, bulky horse like the Suad. I would call the lack of bulk good on the DreamTap, but not superb like the Narval or Micro2. Most people can tolerate this level of bulk though. Personally I would not recommend the Micro2 for a lateral bruxer like you because it has only 3 mm of lateral movement which could strain the TMJs on a side-to-side bruxer. The Micro2 would probably be strong enough to hold up against a regular clencher who does not brux from side to side. The DreamTap is also available with an optional Thermacryl lining that can be re-done any time you dental work changes. In all fairness, the thermacryl lining does need to be replaced yearly. The Dreamtap does come also with soft TL lining which is permanent. Dr. Luisi

The answer to your first question is, definitely, yes. Almost my entire practice consists of people who have tried CPAP, found themselves intolerant, and went on to the oral appliance and found success. It is my entire stock in trade. If you asked me what percentage of people came directly to me without first attempting CPAP, I would quesstimate it at no more than 15 per cent. The MyTap would not be reimbursable by medical insurance at this time because it does not fully meet their standards, primarily in terms of durability. They usually expect at least three year durability and the MyTAP doesn't have it. The regular TAP3 and DreamTap would meet it, but they are much more expensive, maybe in the $1400-$2800 range depending on dentist and area of the country. They might be partially reimbursable through Blue Cross depending on your policy and the dentist must be skilled at making medical claims because there is a very strict protocol that must be followed in terms of documentation and sequencing that must be followed to the letter. Dr. Luisi

Hi again GBerger, The online boil and bite appliances are meant only to treat snoring and (maybe) the lowest end OSA. Your condition is far too severe for them to give you meaningful relief. The fact that you got even a brief positive response is encouraging. I think that you might benefit from trying a MyTAP device from Airway Management. It is highly effective against severe OSA and relatively inexpensive. I am talking about somewhere between $400 to $650 dollars. It has to be fitted and managed by a dentist trained in dental sleep medicine. If you use the "Find-A-Dentist" feature on their website, www.tapintosleep.com, you should able to find a suitable dentist near you. The device is not particularly strong and would probably last only one year or at most two, but it is good enough so that you could find out if an oral sleep apnea appliance could work for you. Dr. Luisi