To introduce myself I am Dr Tony Soileau. I am the dental/clinical director for Louisiana Sleep Solutions and Dedicated sleep. You can see more about my practice at tonysoileau.com I have been treating sleep apnea for 18 years with dental appliances. I still treat patients four days a week in my private practice in Lafayette Louisiana. I just joined this sight so I am still learning the rules and how things work. I have read several posts and really like the questions and advice given to help solve the problem. If any of you have a dental appliance that you have questions about or you are considering getting one I am happy to give you the best advice I can share.
Dr Tony
Dr. Tony,
After greatly struggling with pap therapy, I made the decision to try a dental appliance only to find it was alot more uncomfortable than using my VPAP. What I found even more disconcerting was when I had my usual three hour wakeup and and had the need to take out the appliance yesterday (in spite of little advancement), my jaw already felt like is was greatly out of alignment. I went ahead and did the exercises to get the jaw back in place because I was too concerned about waiting until the morning. Not good for great sleep.
My advice to anyone considering a dental appliance is to buy a cheap appliance like Snore X to get a sense of sleeping with something in your mouth. Not a perfect simulation but definitely better than nothing.
Finally, I hope to god that you understand that just because someone stops snoring doesn't mean their AHI is at an acceptable level. I had a very hard time getting the dental assistant to understand that and found that very frustrating.
Very sorry to hear that you had to wake up in the middle of the night to relax your jaw muscles. And the dental assistant not knowing what "silent apnea" means should be a concern.
Lets start with the jaw issue. The way all dental appliances work is to bring your jaw forward so you cannot choke on your tongue at night. Apnea is choking as you all know. The problems caused by apnea is NOT the lack of air. Hold your breath for ten seconds over and over all day today. No bad consequences. Tha'ts because your brain knows you can breath again at any point. During a sleep choking (apnea) event the brain does not know when you will breath again. I promise I am getting to the jaw problem. Just keep reading. Because the brain does not know when you will breath again the fight or flight response kicks in. Cortisol surges through the body. And now the bad stuff starts to happen. One of the bad things is your breathing rate will greatly increase. Cortisol indirectly does this. So you will begin to "chest breathe" and not "belly breathe" To breathe with your chest you must lift your shoulders. Its how the body is designed. As you lift your shoulders you will brace your teeth together. This prolonged and repetitive clenching (and grinding) is known as TMJ dysfunction. The jaw muscles begin to stay tight and develop trigger points and lactic acid buildup. Its actually more complex but lets keep it simple. If the muscles are very tight and have been this way for a while you will become accustomed to biting this way even if it is not healthy. The dental appliance is now trying to bring your jaw forward where your jaw may be able to comfortably go while in the dental office. But at night the muscle tighten up and fight the appliance. That's what happening to you. In my practice we have a full time massage therapist specifically trained to relax the muscles of the head and neck using massage, acupressure, and yoga stretches. By getting the muscles free of trigger points, lactic acid, prostaglandins, and reprogramming the muscle memory (engrams) the muscles relax and lengthen. She sees each patient before I take my bite record for the appliance and at adjustment appointments Your options then become to reset the bite on your device, back up the device and advance slower, or see a massage therapist, physical therapist, or chiropractor to heal your muscles and rest your skeletal alignment. You probably need this even if the appliance was working perfectly. Sleep choking (apnea) cause a lot of TMJ problems. 95% of my patients with sleep apnea have TMJ issues to some extent. They just have not made the connection between the two. Your muscles will at some point adapt to the appliance. They just may need some help along the way.
As the the silent apnea situation the sleep dentist you are seeing will or should suggest a new home study at the 1-3 month mark of treatment to verify that the appliance is working. If I am using the Micro2 appliance I test at 1 month. Narval, Moses, Somnodent, or Respire Appliance I test at the 3 month mark.
Please let me know if this post helps or how I can communicate better. I am new here so I could use some feedback.
Dr Tony
Do you have any citations to support this? There is no scientific paper that supports a connection between grinding teeth / clenching teeth and sleep apnea. In fact, grinding is known to be most common in children and young adults and less in older individuals. The exactly opposite of the population with sleep apnea. Nor is there any published study that supports the need for massage therapy or any other muscle relaxants in most patients. Also, the major area of throat blockage is behind the soft palate and not the tongue. It is very simplistic to say that oral appliances protect against tongue blockage.
Your opinions are the frustrating part of treating sleep apnea. Everything is an argument or turf war when doctors discuss treatment. Have you talked to any chiropractors about diaphramatic breathing and the consequences of chest breathing? What about kinesiologist and sports trainers and and the cranio sacral relationship? Dentists wont study these things. Pulmonologist wont study TMJ. Cardiologist wont study body alignment. And no one talks to each other when everyone has valuable data to share. Just prefer to argue. While patients suffer. Sad.
Apnea is the cessation of breathing. Choking is NOT apnea, it is the brains reaction to the OSA. Otherwise central sleep apnea would be characterized by choking. A better understanding of the dynamics of sleep would benefit everyone involved here.
The problem caused by apnea is not the lack of air? Huh? That's the whole point of CPAP. As for the brains' not knowing when it will breath again, yeah, partially. The brain senses a low enough blood oxygen level that it wakes you from REM sleep and sleep paralysis to clear the obstruction. It's the last resort when it senses it is in danger of dying from asphyxiation.
Science is science, not a turf war. Regardless of the origin.
More is written about myofunctional therapy in the medical literature. Properly done studies with controls, controlling for confounders, etc. is the difference between proper care and supportive and alternate care.
We know that the relief of excessive tiredness with an oral appliance (CPAP too) is no better than with a placebo effect from well controlled studies; this is why looking at biomarkers such as blood pressure, natiuretic hormones, and mRNA is so critical in outcomes studies.
In looking at the studies of breathing, the most important part has to do with free nasal breathing. Other 'forms' of breathing, well known by singers, those who do yoga, etc, have nothing to do with how you breathe in your sleep when all control is based on the central nervous system and not voluntary muscles.
Lack of rigorous science means that imagination, belief and 'clinical experience' drive quasi-medical care and makes physicians wary of dealing with dentists who do not demand similar science from their sources.
BGD
Dr Soileau is correct! I went undiagnosed with OSA for 45 years because the doctors only said I had TMJ because I've always been thin. I'm currently 5'3" and weigh 106. The OSA was causing my TMJ problems. My AHI is 14.7 and 28 during REM. I have been grinding and clenching my teeth all my life while sleeping and it was all due to OSA. Since I have been using the CPAP my grinding and clenching as greatly decreased. Please do not dismiss what he is saying. He is correct! Since I have been grinding my entire life, I now have advanced osteoarthritis in my jaw and it is dislocated. I now have extreme pain and discomfort....all because doctors wouldn't think outside of the box. I'm looking into getting he oral appliance as it is not as restrictive. I can't go camping. Dr. Soileau, would an oral appliance work for me with an open lock jaw? Dislocated so I cannot open my mouth as wide as I should be able to.
Dr Soileau is correct! I went undiagnosed with OSA for 45 years because the doctors only said I had TMJ because I've always been thin. I'm currently 5'3" and weigh 106. The OSA was causing my TMJ problems. My AHI is 14.7 and 28 during REM. I have been grinding and clenching my teeth all my life while sleeping and it was all due to OSA. Since I have been using the CPAP my grinding and clenching as greatly decreased. Please do not dismiss what he is saying. He is correct! Since I have been grinding my entire life, I now have advanced osteoarthritis in my jaw and it is dislocated. I have extreme pain and discomfort....all because doctors wouldn't think outside of the box.
Hard to ask questions about somehing you don't have knowledge of. Why not spend a bit of time and tell us what dental appliances are and what their purpose is.
Fair question and I understand you may not know a lot about dental appliances.
How does the dental appliance work. Try to keep this simple so if I am over simplifying it I apologize. The issue with apnea (choking) is the throat is blocked by the tongue and sometimes the nose is blocked usually by thickening of the turbinates. A CPAP works by forcing air past the blocked points. A dental appliance works by bringing the lower jaw forward thereby keeping the tongue from blocking the throat. If the only blockage is the throat/tongue then a dental appliance will work well even with severe apnea levels of AHI50+. I practice in south Louisiana where all my patients have sinus problems. So most of my patients also see my medical director Dr Philip Noel who is an ENT and sleep specialist. He did a turbinate reduction on me. Took ten minutes. Insurance pays in Louisiana without preauth. No swelling, pain , or complications. Amazing how much better I breathe now.
What does the dental appliance not do. It cannot fix your nose. And even with a CPAP you need to breath in through your nose. Not your mouth. The nose filters, warms, and humidifies the air. This makes the oxygen transfer into the lung tissue easier.
The dental appliance will help TMJ issues but only after the muscles are relaxed. Trigger pints and lactic acid must be manually rubbed out.
If you view the dental appliance as one part of restoring your body back to its normal breathing and sleeping cycle and rhythm its an amazing option that works very well for what its only designed to do, keep the tongue out of your throat so you don't choke on it. The other parts need to be addressed separately. And the same is true for a CPAP or throat surgery.
Did this get us started on how a dental appliance works?
Dr Tony
Hi Dr. Tony,
Thanks for explaining how the different types of sleep apnea originate. I have a MAD, which, although I still snore like a freight train, has helped some with the actual apnea issue . I can tell when I wake at night by my breathing issues, that I'm still having a problem with the apnea, but not at the rate it was before. I'm at least not gasping much anymore, nor having suffocation dreams. The thing though, is that I am still having issues. I have sleep apnea whether my mouth is open or closed, or whether I'm breathing through my mouth or my nose, or whether my nose is stuffy or clear. Right now it's allergy season in the D.C. area, so I am really having an issue with my apnea and nasal breathing 24/7. I've tried using different things in conjunction with my MAD. Neck pillows, neck braces, chin straps, bed wedges - you name it.
Do you have any suggestions for people like myself, who have apnea problems whether they breathe from their nose or their mouth? Would any combination of these devices work better for these issues?
Appreciate any advice you can give.
Is a dental appliance similar to a football mouth guard? I was diagnosed with moderate OSA and have been on a Bipap for about a year. Therapy was a revelation but it was never explained WHAT was blocking my airway as I slept. I have been progressing even farther as I have become self-educated on what I can do to make therapy more effective and in the past week have begun wearing a fitted MMA mouthpiece to keep my lower jaw from going slack. This had not been an issue previously but my mouth was actually coming out of my mask as my jaw relaxed at night. I had typically had between 80-100 L/min but therapy was very effective if they stayed at the lower end of that range. Now the MMA mouth guard has gotten my leaks down to 11 L/min (last night and similar since starting this mouth guard business).
If I am not sure why I have OSA, what would be needed to determine the cause of blockage at night? Would a dental appliance be an answer if it was the tongue? I don't have issues with breathing through my nose...
In my practice 99% of my patients its the tongue being the major part of the problem. A sleep study does not show the location of the blockage. If you have any snoring its pretty much a given your tongue is the cause especially if you can breath well through both nostrils of your nose. For moderate AHI a dental appliance should always be considered often the first choice. Opinions will vary as to CPAP or dental appliance as first choice for moderate and severe AHI numbers.
Your treating doctor should spent a little more time explaining to you what sleep apnea is and options for treating it. The problem, at least here in Lafayette, is that the sleep docs are so busy and have never explained sleep apnea or HST/PSG study results they dont feel a need to. I guess that explains why this forum exists.
Dr Tony
I was diagnosed as just on the edge of mild to moderate sleep apnea. The first sleep team I had was pushing the CPAP machine on me so hard I really felt like I was in the CPAP patient factory. They even told me that the machine would cost me about $500. When my insurance company told me there should be no costs to me.
For this and many other reasons I want to get a new sleep team. When I saw the ENT doctor he thought that I would be a very good candidate for the dental appliance. Of course the biggest problem is my insurance company won't cover the dental appliance until I've been tortured for three months by the CPAP machine.
I'm getting my teeth fixed. I'm going to try one of those over the counter mouth guards. I have a friend who had a snoring problem. She's been using an over the counter mouth guard for quite a while. She doesn't seem to have any problems with it except occasionally she wakes up and it's across the room!
Thank you for being what I consider reasonable. And I wish more sleep teams were more compassionate. I frankly think there would be a lot more compliance with any therapy if that were the case.
Athena1965, I am not sure what I doing to be considered more compassionate than the next doctor. But thank you all the same. The over the counter guards do have to possibility of working great for you. Just be careful it does not start to cause muscle spasms in your head, neck, and upper back. We do not have a problem getting medical insurance to pay for dental appliances. But there is a very strict protocol that you and your sleep dentist must follow. Quite a bit of paperwork. If your medical doctor is willing to sign a prescription that a dental device is your best option then your insurance will probably pay for it after pre-authorization. Just make sure you have all your documents correct.
Hello Dr Tony,
I have been using a dental appliance to treat sleep apnea for just over a year now. While it has eliminated my snoring I do not believe it has done much, if anything, to eliminate the other symptoms of sleep apnea. Is there anything else I should be doing in addition to the mouthpiece?
I did not. After I received the bill for the visits, the first sleep study and the mouthpiece I decided that I couldn't afford to keep pursuing these experimental solutions and I am glad I did not. Within the first few months I do think it was working as I was sleeping through the night without waking, wasn't as drowsy during the day and not quite as irritable as usual.
However, when I started to experience the symptoms again I cranked the mouthpiece out farther and the symptoms went away only to return. Now it is out all the way and symptoms are returning in full. Example: I watch my kids during the day and cannot read even one book to them without dosing off. "Daddy you are asleep again!" Is a frequent complaint I hear.
I appreciate your concerns. Dental Appliances for sleep apnea have been around since the 1970s so they have pretty much passed the experimental stage a long time ago. Your dentist set the bite for the appliance where it keeps your jaw forward and keeps your tongue out of your throat. Unless the appliance is slipping or being adjusted in reverse the symptoms should not keep returning. If they are you must figure out why and adjust the appliance accordingly if it is a choking (sleep apnea) issue that is keeping you tired, go back to wearing a CPAP, or do nothing (strongly advice against this one). Sleep apnea causes a lot of TMJ symptoms especially tight and sore muscles. If your dentist suspects you are clenching and grinding he may have chosen to set the starting position for the appliance less forward than he normally would. This allows him to adjust the appliance forward slowly as the muscles relax and return to normal healthy length. I have an in office massage therapist work on all my patients just for this reason. Helps us get to the forward position of the jaw much faster. It may be that the appliance is working fine but you have other issues affecting your sleep. This would account for the on and off sleep your experiencing, I have patients that do just fine until they go back off shore, go on a trip, stay at the hunting camp for a weekend, etc. The different environment causes their sinuses to become congested and the back of their throat to swell. This can often be picked up as hypopneas on a sleep study. If you do a center PSG look for spontaneous arousals. These can often be pain responses that are fragmenting your sleep but the system does not know how to categorize them. Also you or your dentist may have advanced the appliance too far forward. This can cause tension on the muscles over a time period and cause you to experience non restful sleep. Simple solution is to back it up to the position when you had a a good night. Sorry I don't have specific answers. This is the best I can do with the information you have presented. If you can think of anything else please let me know.
I really appreciate your responses here. I should clarify that when I said experimental I was not referring to the effectiveness of the mouthpiece overall but the effect It has on me. My doctor lead me to believe that it may or may not work depending on the person. Also, he never had me try a mouthpiece, he said it was up to me weather to use the CPAP or mouthpiece.
As far as setting the mouthpiece I was told to start with it all the way back and bring it forward a little at a time until my symptoms diminished. I did this but each time the symptoms resurfaced I continued to move forward until I now have no room left.
I have noticed recently that it is getting harder to get my bite to go back into place in the morning with the realigner. Sometimes now I feel like I need to use it again during the day because, by dinner time, my jaw is spread apart again. Could this be, as you suggested, evidence that I have it too far forward? I think I will try to back it off a bit and try to move it slowly forward again in hopes to find a better sweet spot. Do you think this is a good idea?
Once again, thank you so much for your replies.
Yeah it does sound like it is moved too far out to be effective. Personally I adjust all my appliances instead of having the patient adjust them. Not that a patient can't do it. Its just turning a screw. Its more because sometimes my patients need me to monitor whats going wrong. I would suggest backing it up maybe all the way to the beginning. Not sure how far it is set initially. Then slowly bring it forward. Can I ask which appliance you are using? Will help give better advice how to adjust it.
The TAP is a good appliance. Been around for a long time. Its not my favorite design. The job of the appliance is to bring your jaw forward so your tongue does not fall into your throat. This means along with bringing the jaw forward there also needs to be room for your tongue inside your teeth for it to sit. The design of the TAP (not sure if you have the MyTap, TAP I, TAP II, or TAP III) has the advancement mechanism between your front teeth. By design this takes up some of the room for the tongue. I have found you have to bring patients out further than other appliances because of this. But I have to give it to TAP that they constantly work to improve their design. Back to your situation. My advice would be to start from the beginning. Turn the screw so it backs your jaw up to the starting point. Sleep a few night in this position and see how you do. After 2-3 nights if your not sleep well advance it one turn and then sleep 2-3 nights. Then decide if need to advance it again. For some patients the "sweet spot" is a very small window. Don't over shoot it. For some its quite big. Also look at other factors that may be contributing to either a good nights sleep or a bad one. If you are congested you may not breath as well. Yeah I know thats stating the obvious. But it also means don't advance it too much until your better. Try nose spray, vapor rub, or what ever works for you to clear your nose and chest. On a bad night did you sleep on your back? Thats a hard one to answer because your asleep so how would you know. But it is something to consider. Have you consulted your dentist about the issue? He should be available to help. And of course you can ask me as many questions as you like.
I am also a dentist working in dental sleep medicine. I have been doing it for over ten years. I must respectfully disagree with your assessment of the Tap line to some degree. Very credible third party peer reviewed efficacy tests have shown repeatedly that the Taps have the highest efficacy scores of any OSA appliance that currently exists. The fact that this is the best appliance to treat severe obstructive sleep apnea is undisputed. The Taps keep the mouth closed instead of letting it flop open, which has also been shown to increase efficacy. A great feature of the anterior central bearing design is that it is self-balancing. That is to say, that the force on the tmjs is automatically equalized. This greatly improves tmj comfort. The typical dorsal fin designs make it necessary to equalize the protrusion level in each side very carefully. The slightest mistake can cause tmj pain. The new DreamTap design shifts the advancement mechanism to the lower tray. This greatly increases room for the tongue, making it essentially equal to the other kinds of appliances. a.b.luisi,d.m.d.
Welcome and its great to have another dentist offer a different point of view. Thanks for sharing. And I really appreciate your enthusiasm for the TAP appliance. You even pulled some marketing points from their website. All good information. I have found in my practice I serve my patients best when I don't limit my patient's choices to one appliance. Each appliance has pros and cons. Even the TAP is not all perfect. And every patient is different. If you read the other post you will see that there is not one perfect CPAP mask that works for everyone. Just too many variables to put everyone in the same box.
Now, even though I do use the Tap for the majority of my patients, I am not a one trick pony. I recognize that individual humans do have enough variation that one size does not fit all. For instance, some people just can not stand the feeling of having their mouth held shut. It makes them claustrophobic. For others, the TAPs just feel too bulky, even though they are on the slim side. They may need something like an EMA. But, if I do use something else, I will tell the patient that they are sacrificing some efficacy for the other features and may not get as good a result. And if somebody has a favorite appliance and their sleep test with oral appliance in place showed good efficacy, I am happy to do a new one like it. But there is a serious issue here that needs to be addressed. Patients do not know that different appliance designs can and do have very different efficacy rates. Many manufacturers don't do the research to validate the effectiveness of their products, relying on an F.D.A. clearance, which is basically a sham. It is incumbent on every sleep dentist to do their due diligence to assure the efficacy of the appliances that they are presenting to the patients. I simply will not use any appliance not validated by good third party research, not matter how much merit I suspect that it may have. There is too much at stake for the patients. In all fairness the the patients, if a patient wants a design that you know has a lesser efficacy, they should be told that it is not the most effective out there and it should be compared to the best and let them decide if they want to take the chance on it. a.b.luisi,d.m.d.
I moved the appliance all the way back to the starting position. Since you mentioned discounting the bad night sleep when congested I noticed right away that I wasn't breathing all that well through one side of my nose. With that in the forefront of my mind I have stopped to notice that it seems like 100% of the time, night or day, I don't have unobstructed breathing on one side of my nose or the other. I saw an ENT specialist for an ear issue years ago and I remember him offhandedly mentioning that I have a deviated septum. I assumed because of how casually the ENT mentioned it that it wasn't a big deal but could this be worse than I'm assuming? Could it be the source of my problem? I probably should have mentioned this earlier but I am 6'0" 175lbs, I think not your typical sleep apnea patient.
At this point I haven't moved the mouthpiece forward from the start. I'm thinking I shouldn't mess with it until I get a resolution on this issue.
Once again thank you for your advice and Happy Thanksgiving to you and your family.
I am a dentist working in dental sleep medicine. As was mentioned previously, good nasal patency(being open) is critical to the success of an oral sleep apnea appliance. If you suspect that that the air exchange through your nose is not good, an easy test is to get some Afrin nasal spray and some Breathe Right nasal stips to see if that improves things temporarily. Often times things do improve enough so that you have a clue that it is time to see the ENT doctor. Of course, this is not a definitive test and you should never do anything mentioned in this forum without the express prior approval of your health care professionals. a.b.luisi.d.m.d.
It could be the major cause of your sleeping issues. Or it could be something as simple as enlarged turbinates. Actually just the membrane over the turbinates. Very easy for an ENT to reduce with cold laser.
I would suggest working with your dentist as you begin to advance the appliance forward again. Have you spoken to your dental office about the problems your having? What did they say if you did?
Hi Dr Tony, I have had impressions taken for a dental appliance, and I should be getting it next week. I'm curious about something you stated in a previous response - "The dental appliance will help TMJ issues but only after the muscles are relaxed". When I went for my exam (the day the impressions were done) my dentist determined I had TMJ. She recommended, but didn't require, that I get an appliance that I would wear during the day for several months to correct the TMJ. She said the sleep apnea dental appliance could make the TMJ worse. This TMJ appliance is not covered by insurance so I would have to pay the full cost of it out of pocket. I declined to do this, since my understanding is that there is no guarantee that the dental appliance will help with my sleep apnea. So rather than commit to treating the TMJ now, and since the TMJ is not bothering me, I thought I should first make sure the dental appliance works for the sleep apnea and then go from there. So I was wondering if you could go into a bit more detail about how the dental appliance (I assume you are referring to the sleep apnea dental appliance) will help TMJ issues, as that's not how it was explained to me by my dentist.
Also do you have any tips for a new user of the dental appliance?
Thank you in advance,
Thats a very good question and will take a lot to answer. So sorry for the long response. I am listing some of my videos that may help answer your questions as well if you would rather listen than read. They are only a couple of minutes long.
When you have sleep apnea its NOT the lack of air that causes the problem. If you hold your breath for ten seconds thats the same as an apnea event. You could hold your breath over and over all day and not have a health problem. And snorkeling where you hold your breath for prolong amounts of time under the water is actually healthy activity. So why does sleep apnea cause health problems and in this response cause TMJ dysfunction. Its not the lack of air. Its how the body responds to the lack of air. When your snorkeling your brian knows at any time you can go to the surface and take a breath. So the brain is calm. When you have a sleep apnea event the brain does not know when your going to breath again. So it panics! Big time. Remember the last time you choked on a piece of food? Think about how your body responded. Same thing. Your heart started racing. Your breathing rate rapidly increased or the attempt to breath rate increased. So you started to breath with your chest instead of your belly. To chest breath you must lift your shoulders. To continually lift your shoulders you must stiffen your neck. And to stiffen your neck you must clench your teeth. All this happens simultaneously. So each apnea event has the potential to cause TMJ dysfunction event. Decrease the apnea and you decrease the TMJ problems. But if you have already been clenching for so long and so hard your muscles may have shortening to the point where they stay tight all the time. You may not have headaches but you may have a lot of wear on your teeth. TMJ dysfunction has a lot of varied symptoms all related to over working the muscles of the head and neck. When you sleep appliance attempts to bring your jaw forward the muscles may not be used to lengthening this far. So they say OUCH! The sleep appliance did not cause the problem. It just making you aware of it. Ever have a sunburn and not know it until someone ot something toughed your skin? Burn was always there. You just didn't know it. My advice is to start slowly with the appliance advancement. It may mean you don't get great sleep for a few weeks. But your sleep will get better each night. And expect some setbacks. If you had a rough day your muscles may be tighter than usual. So they may not like your appliance. If so just have your dentist back it up a millimeter or two and start again. There is a position your jaw can be in where your tongue is not in your throat. This is true for everyone. Give your muscles the care they need to let your jaw get there comfortably. And you may need help from other than your dentist along the way. Massage therapy, chiropractic care, physical therapy, acupuncture, etc. All depends on how knotted up your muscles are.
Hope this is information you were looking for.If not just let me know and I will try to explain it better.
Dr Tony
Hello Dr Tony, First off thank you so much for your response to @UnassumingOrange. That explanation was very informative and comprehensive and makes so much sense! The info on the cortisol especially.
I have been referred to a sleep apne dentist with an appt in a couple weeks. I have been using my Phillips dreamstation for about 3-4 months now. The first few weeks I did well but after that I started swallowing air and cpap therapy has been hell ever since. I have both obstructive and central apnea. I take diamox and my dr has put me down to 5CM, I believe we started at 8, maybe a litter higher. I'm stable with the machine on and it's hard to say if it's the machine or diamox that is helping. I am still exhausted and can sleep for over 12 hours. I force myself awake and have recently started stimulants which honestly don't do much of anything. I feel immune to them if there is such a thing. I also have a circadian rhythm disorder with 2 failed attempts at sleep retraining. I'm suppose to take another melatonin profile this week but previously my melatonin release was 5-6am with a 5pm wake up time-not fun. I am also waking up and taking the mask off and not knowing it during the night. My doc explained the response of some type of uncomfortability during sleep. I also have a tendency to wake up about one hour after I go to sleep. Do you know why this would be?
My doc said that the oral appliance would stop the air from going to my stomach is this true? I didn't gather that from your explanation. I also have had adult orthodontics and wear Invisaligners 4 nights a week. The receptionist stated that normally those who've had adult orthodontics aren't candidates for a OA. Also as a child and young adult (I'm 31 now) I grinded my teeth severely when I slept. My jaw also had a tendency to come out of alignment and pop- for lack of a better word- out. I noticed this when I opened my mouth wide. I still feel my jaw isn't quite right and a dentist had mentioned at one time an issue with it that wasn't diagnosed or prevented as a child.
But my real question is what your thoughts on an oral appliance are for me? Thanks so much!!
I am a dentist working in dental sleep medicine. The fact that you have both obstructive and central sleep apnea is significant and can have a bearing on your treatment. Oral sleep apnea appliances treat only obstructive sleep apnea and not central sleep apnea. When oral sleep apnea appliances are placed into patients with both central and obstructive sleep apnea(called mixed sleep apnea), the interaction is complex and not totally predictable. The appliance could have a positive effect or it could accentuate the central sleep apnea, which might be dangerous for the patient. Any attempt to use an oral appliance should be made with extreme caution and be closely monitored via sleep studies with the oral appliance in place from the outset. a.b.luisi,d.m.d.
BeLovely, To answer your primary question I think an oral appliance is your next best step. You have tried a CPAP and its not working for you next step is oral appliance because if you have sleep apnea you need to do something to get air into your lungs.
Your what we call a combination case in my office meaning you have several issues all related to the apnea and a domino effect is happening. Combination cases can be frustrating for patients because they don't realize sometimes several issues have to all be treated before you sleep amazing each night. Getting air into your body is step one but may not be the only step. If you are waking up after 1 hour of sleep that is probably due to a pain response or cortisol. Your sleep study may give that answer. We tend to grind our teeth mostly in stage 2 of sleep. If your getting to stage 2 and then grinding hard enough to cause muscle spasms or pain that spikes cortisol and wakes you up. You also said you can sleep for 12 hours and still not feel rested. It may be that your making cortisol in very low levels or in spikes just enough to fragment your sleep. It sounds like your looking in the right place with melatonin pathway but you may need a full cell spectrum analysis to find where the break down is. It could be a problem with seratonin, B6, magnesium, GABA, and insulin. And 15 other hormones and neural precursors. So you may need and probably will need 2-3 doctors of different specialties working together to put your entire hormonal and circadian rhythm system back to its normal balance. This may take a few months to get just right. Don't get frustrated and be ready to try different treatments until everything is restored.
Dr Tony
Hi Dr Tony, I have sleep apnea and have moved from CPAP to an oral appliance. I tried several CPAP masks and they all worked to some extent, but I was never comfortable with them. The VA allowed me to switch to an oral appliance recently. They sent me to a local dentist that fitted me with a TAP 3. I had problems with excess saliva and jaw soreness initially, but am doing much better now. However, I recently had a home sleep apnea test that mentioned some residual sleep apnea. The VA is setting up an appointment with me to discuss what to do next. I don't want to go back to CPAP therapy. I want to make the oral appliance work. I read your complaint about the TAP appliances not having enough room for your tongue. I think that may be the case for me. It feels like my tongue is a little cramped. My dentist started me out with a fairly conservative setting, but I haven't moved it because my jaw still gets a little sore. I really love the oral appliance compared to CPAP, because of its simplicity. Would you suggest I move it forward on my own, or wait till my next appointment with my dentist. If I adjust it forward, I suspect I will have to have another sleep study to see if it is working better. What are your suggestions? I am on the border line between mild and medium sleep apnea.
