Not sure what a bite splint is so can't answer from that perspective but OSA treatment falls into two major fields, dental appliances and PAP. The place that did the sleep study very likely recommends ALL patients go in the direction they are comfortable prescribing. I bet the sleep study place that prescribed my BIPAP has likely NEVER prescribed an oral appliance. It probably wouldn't make much sense to go back to the prescribing sleep doc and talk this over as much as talking with your primary care physician and requesting a referral to a dentist who deals in oral appliances and just getting their take on your particular situation. Since whatever a bite splint is probably is not as common as OSA itself, you may not find a lot of first hand perspecitves so you had best let google be your friend and read all you can on this and remember that everything you read will come from a source familiar or associated with the two major OSA treatment directions and they will likely tout their own course of treatment. In the end your own common sense will be your best friend in this.
Hello I have an oral appliance for about 2 weeks now but I notice when I have it on I get a feeling in my throat as if it's tight it's very bothersome and keeps me up at night doesn't help me go to sleep due to the feeling of something in my throats please help
Its probably one of two possible problems. Both are easy to fix. Either the appliance is set too far forward and need to be adjusted backwards until your muscles adjust to it or the appliance itself is made too far into the back of your mouth and needs to be trimmed back. If I knew which appliance you have I could help you better.
Dr Tony
SomnoMed I never took out my wisdom teeth so I wonder if the appliance was made to fit longer due to the wisdom teeth being there
Could be. Yesterday I ha a patient that we delivered a MIcro2 appliance to last week. He was having same issues you are having. And he had his wisdom teeth on the top. The lab made the appliance cover the wisdom teeth and it was uncomfortable. I took 3 minutes to cut the appliance back to the first molars and problem solved.
Is a dental guard to stop teeth grinding the same as for apnea? A friend got one for teeth grinding and was told it might help her snoring but it has not helped that.
No. Not at all. A sleep appliance can help with TMJ issues. But a TMJ splint cannot position the lower jaw forward enough to help with apnea. And an upper TMJ splint can make sleep apnea a lot worse by positioning the tongue further back into the throat. Most dentists are still trained to make upper TMJ splints without testing for sleep apnea. When its the sleep apnea causing the TMJ the symptoms get progressively worse over time due to the upper TMJ splint,
Dr Tony
I would definitely agree with that. It is becoming increasingly obvious that sleep clenching/bruxing and TMJ problems are very strongly associated with obstructive sleep apnea. The association could be as high as 50% according to some studies that I have read. This knowledge has not yet filtered down into the general dental community. When dentists think bruxing/tmj, they should be thinking sleep apnea, too. Actually, even "simple" snoring without apneas is also very underestimated. Snoring alone puts the body under significant strain. We now know that elimination of snoring with oral appliances often results in better sleep and less daytime sleepiness for the patient(AND the bedpartner). We have thought that snoring alone would have negligible cardiac effects, but even that belief is being re-examined. a.b.luisi.d.m.d.
Hi Dr. Tony, I've been wearing a sleep apnea oral appliance for approximately 2 weeks. I have ringing in my ears that seems to have gotten worse since I started using the appliance and, also, I don't feel very rested. I have a thick tongue, seasonal allergies, chronic sinusitis, and mild sleep apnea related TMJ too. It's springtime so some of this is related to my allergies but could I be clenching with the oral appliance during the night thus causing the ringing in my ears? I had terribly plugged ears with lots of ringing when I was not using my CPAP machine prior to my using the oral appliance. I see my dentist again in 2 weeks. Please give me your opinion. Many thanks!!
PlacidSpringGreenTurtle3564 , I hear you on the seasonal allergies and chronic sinusitis. I have the same problem right now. I live and practice in south Louisiana. For us pollen season is horrible. I would strongly suggest you see an ENT. Ask him if a turbinate reduction might be just the thing for you. It will allow your sinuses to drain better and help you get "better air" because you will breath through your nose instead of your mouth. The job of the nose is to filter, warm, and humidify the air going into your lungs. The clean, warm and moist air travels into your blood easier than dry dirty air. I had a turbinate reduction done in Jan 2016. No pain or swelling. Took 10 minutes. Went right back to work. I have all my patients who are willing have an ENT consult at the same time I start treating them with an appliance. Greatly increases the patient's success rate.
The ringing in your ears could be congestion and wax build up or an infection of your ears. Or it could be your jaw joint is swollen and compressing your ear canal. I would have an ENT take a look at your ears at the same time he looks at your nose. Higher chance its the jaw joint. But let him look anyway. When we have sleep apnea we most often breath with our chest and not our diaphragm. When you breath with your chest you must lift your shoulders. This in turn tightens your neck muscles and stiffens the TMJ or jaw joint. This is common. If the muscles of your head, neck, and even upper back are tight your jaw cannot come comfortably forward. So you have a couple of option. Easiest is to back up the appliance and bring the jaw forward slowly over weeks to months. This will give the muscles a chance to relax and heal as the apnea is controlled. But this will delay getting your jaw to a point where your tongue is out of your throat and your sleeping like a baby. And often the knots and trigger points in your muscles wont go away just by treating the apnea. This is why I have an in house massage therapist that works on all my patients before we set the bite for the appliance. Really helps our patients get better faster. You should consider seeing a massage therapist that works on muscles inside the mouth to treat ringing ear or a physical therapist, chiropractor, acupuncturist, etc. If you had surgery on your knee you would expect to need physical therapy to get the knee joint strong, loose, and healthy again. When treating sleep apnea you have to look at the muscles and health of the joint the same way. Ask your dentist who he works with to treat the muscles of his sleep apnea patient. He should have someone to recommend or if he sees a lot of TMJ and sleep apnea patients he may have someone full time or that comes to his office.
Let me know how this goes for you.
Dr Tony
Actually, a visit to an ENT doctor might be in order in addition to the visit to your dentist. Poor nasal patency(poor breathing through the nose) can put a severe drag on an oral appliance and even cause it to fail. Since the ringing in the ears predated the oral appliance, that would also be a valid area of inquiry for an ENT. Since you are early on with the oral appliance, it is probably not adjusted to your sweet spot yet, so it wouldn't necessarily be working very well. You should certainly tell your dentist about your nasal problems and get his input on it. TMJ problems, in and of themselves, can cause ringing of the ears, and the oral appliance could conceivably have made it worse. The oral appliance could be causing two effects, one of which would make the ringing less severe and one that could make it worse. The condyle(ball joint) of your mandible sits very close to your inner ear. If your inner ear is already inflamed, pressure from the condyle on the inner ear as you brux could conceivably make the ringing worse. Often times your muscles do fight the oral appliance initially and bruxing can temporarily increase until the obstructive sleep apnea is under better control, at which time, the bruxing generally subsides. On the other hand, the mandibular protrusion caused by the appliance actually tends to pull the condyle further away from the inner ear, thus lessening the negative effects. It could go either way depending on what prevails. You have a lot to get sorted out here. a.b.luisi,d.m.d.
I got my mouth device in February and I'm still struggling to get used to it! It doesn't hurt, not too tight or doesn't fall out or anything like that. It's just so big! Once in a great while, I sleep through the night with it and I have no idea how but most nights, I can't. So I have to either take a sleeping pill or take it out and I don't like depending on sleeping pills and don't want to keep taking it every single night because I'm afraid my doctor is going to eventually take me off them. I read sleeping pills are only supposed to be on temporary basis. I don't understand. When I go to bed, I can fall asleep just fine but then I wake up once every hour until about the third hour then I have enough of it. I worry I'm not going to get enough sleep if I keep waking up every hour because eventually I won't be able to go back to sleep. I would put the clock away so I don't have to look at it as advised on many web pages for sleeping problems but I worry that I'm not getting enough sleep and what if that makes me unable to fall asleep when I worry about that? How can anyone possibly sleep through the night consistently with a big thing in their mouths? When I'm eating, even I don't have that much in my mouth. How do people get used to wearing an oral device and how do they sleep through the night with it in all night? It's very hard to relax in bed when I know I have it in. It's just not natural.
ReservedWhiteKangaroo6396 , It sounds like you don't have the right appliance for you. Sleep appliances are like running shoes, all look alike but don't fit everyone the same. For my patients with small mouths and/or very tight muscles the Narval or Micro2 is a nice choice. The Narval is the slimmest design on the market I know of. My patient's love them. But you can't reshape it very well so if your planning on having dental work plan to get another one after the dental work is complete or choose a different appliance. Ask your dentist which appliances he is comfortable using. He could have a better choice for you. Or if you have a lot of clenching and grinding your muscles may be very tight and addressing the TMJ issues may be your answer. But please don't just stop wearing it until you have another option. In my practice 1 out of 20 patients we end up with a different appliance from the one we started with. If Nike just doesn't fit you well then try Reebok!
Dr Tony
Hi ReservedWhiteKangaroo6396. I am a dentist working in dental sleep medicine. It would be helpful if you could tell me which oral appliance you are using. There are major differences in bulkiness between the various brands and if I knew the brand I would have a feel for how bulky it is. Bulkiness is also a very personal preference. Some people do very well with even the very bulky ones and others can't stand ones that are relatively slender. I could suggest two things. Depending on the appliance, it might be possible for your sleep dentist to trim it down somewhat so it doesn't feel so big in your mouth. Also, if you tell him about your problems, he may be able to help you select another type that is built smaller. You really don't know how sensitive a patient is going to be to bulk until after the appliance is placed unless a patient specifically mentions bulk as a concern. Patients have certainly complained to me from time to time that the appliance feels too big in their mouth and often you can replace it with a model that is much trimmer. That usually works. Personally, I don't place the really bulky types, even if they work well, because size and comfort is always a factor. a.b.luisi,d.m.d.
O.K., The Herbst appliance. The Herbst appliance is one of the more effective oral sleep appliances, but unfortunately, it is on the bulky side, in my opinion. The metal hinge hardware is somewhat heavy and the trays are pretty stout. Understand, the average person could cope, but a significant number of people could not. Maybe your dentist could at least thin the trays out for you. There are other choices that are a lot slimmer. Two advanced fourth generation appliances are the Narval and the Micro2. These are manufactured with computer aided milling and are light and strong. I think that the efficacy tests that I saw for the Narval were mediocre, but the ones for the Micro2 were pretty good, if not the best. The Silent Nite and the E.M.A. are pretty slim, too, but they are fragile and break comparatively easily in my view. Also, the Silent Nite and the E.M.A. are considered light duty, mostly for snoring and some low-end(very mild) obstructive sleep apnea. Their published efficacy tests are not particularly impressive, in my opinion. I think the Micro2 is a good choice for people who are very bulk averse. You might want to get your dentist's feeling about it. It is a relatively new product and he may not know about it. There is hope for you, though. a.b.luisi,d.m.d.
I remembered that I had another type of mouth guard to prevent grinding. It's only for the top teeth and much thinner and I had no trouble at all sleeping with it in. So I decided to try it for one night to see if I can tell the difference. While I can tell it's thinner and lighter, I still struggled with it in to go back to sleep! So I guess it's not the bulkiness or the size that's the problem. I don't know why I can't get back to sleep with my oral device. When I go to bed, I can fall asleep with it in just fine but it's hard to go back to sleep when I wake up. Once in a great while, I can go back to sleep with it in so I can't figure out what the difference is. I have tried sleeping without it just for a couple of nights and have had no trouble at all going back to sleep so I figured it was the oral device that's causing the problem. If it's not the bulkiness or the size then i don't know what it is.
Hi! Actually you are talking about a bite plane or night guard designed to combat nocturnal clenching and grinding. These are not designed the treat obstructive sleep apnea. An actual sleep apnea appliance works by holding your lower jaw a little protruded(forward of your top teeth) and this pulls your tongue away from your airway. The worst thing about it is that studies have shown that maxillary bite splints or planes can actually push your lower jaw BACKWARD, making the sleep apnea worse. I would not encourage you to use a bite plane to treat sleep apnea. Won't work. a.b.luisi,d.m.d.
Let me formally introduce myself. I am Arthur B. Luisi, Jr., D.M.D.. I am relatively new to this forum, but was a heavy contributor to the forum before this, www.apneasupport.org. The rules about presenting information appear to be more liberal on this forum so you may read my bio at www.naplescenterdentalsleepmedicine.com, if you so desire.a.b.luisi,d.m.d.
Hi, I have a couple of questions for Dr Tony...
My nose is blocking up when I lay down to sleep particularly if I am lying on my right side or back. It does not happen during the day when I'm up and about, only when I am lying down.
I have been using an oral appliance to treat my sleep apnea for a short while now and it seems to work perfectly on nights when my nose is not so blocked up. However, on the nights when the blockage is particularly severe I don't feel like I'm sleeping well at all.
I got a script for Dymista spray and have been using it as per the normal instructions (1 spray per nostril twice a day) for several days now. It does not seem to be having much of an effect.
I have used over the counter decongestant sprays in the past and whenever I have done so they work perfectly (instantaneous clearing of nasal airway) so I don't understand why Dymista isn't working out? Why does a decongestant work but not Dymista?
Is there something else I can try to get this blockage issue sorted? Anything more powerful than Dymista?
I have a badly deviated septum, which I know is contributing to this problem. I am planning on getting it fixed as soon as I can but whilst I wait I need some sort of solution to my constant nose blockage so that I can get some proper sleep!
Dymista is a combination of antihistamine and corticosteroid. Its great stuff if your problem requires a combination of antihistamine and corticosteroid. If your problem is excess mucous then it should work. But you may have a different problem. You may also have a problem with air, not mucus, being able to pass through. Try breath right strips or nose cones and see if that solves the problem. Simple and easy. If it does then a turbinate reduction may fix your problems without having to have your septum fixed. Let me know if this works. If not then we will figure something else.
Dr Tony
Hey Dr Tony -
You sound conversant in sleep appliances and I've been a bit frustrated getting solutions from my dentist. I've been diagnosed with sleep apnea (had a minor stroke a few years ago and I can't help but think SA may have been a contributing factor) and I've been using oral appliances since I realized I just couldn't manage the CPAP machine. I've got a Narval appliance - which is the most comfortable and easy to use I've ever had. The problem is that the posts keep popping out. When I fit the thing with the post size that give me the right jaw extension (#29) I must be grinding it off in the night. When I opt for a longer post I don't pop it out but it doesn't give me the relief I need. I'd rather not switch back to a more invasive appliance but I have no other options. Do you?
Thanks!
RM
Yeah I hear you! I wear the Narval too. And yes I have seen this problem with several patients. The problem your having most likely is that your grinding side to side at night and when you get way out to the side opposite the the bar thats popping off your clenching down enough to bend and flex the bar to the point there it pops off. So this is a muscle problem more than an appliance problem. The lab bill for the Narval is quite high so your dentist is probably not excited to make you a different appliance. But if your torquing your muscles this much you would have problems with other appliances too. You best option is to get the muscles under control. Have you done any kind of massage therapy, chiropractic, physical therapy for TMJ or upper back problems?
Would like to tell you a solution so the Naval would stay together even with extreme grinding but there just isn't one.
Tony
I'm looking into a dental appliance because I had little success with a Philips CPAP for OSA. I'm thinking of trying the apnea RX device to see what my patience level is and if I have better success before I go expensive. What devices would you recommend? I'm 6', 205 lbs, reasonably fit & healthy, 60. I've probably had apnea for 20 years, though I didn't test until last year. Thanks,
I am a dentist working in dental sleep medicine. I would not recommend any of the cheapie OTC or online available devices because the fit and level of efficacy is not sufficiently close to custom devices. However, there is a relatively inexpensive device called a MyTap that can be provided by sleep dentists in-office. It typically costs between $450-$600, depending on the office and is highly effective. It is also only made out of strong plastic and will only last about 1-1.5 years without breaking, but that is good enough for a tester. You can go to the Airway Management website "www.tapintosleep.com" to locate a provider in your area. Arthur B. Luisi, Jr.,D.M.D.
Hi Dr Tony, I'm currently using Provent nasal strips to treat my mild sleep apnea, but it usually causes my mouth to fall open in the night to breathe more easily, causing me to wake up with a dry mouth. I've had an increase in cavities recently and read that tooth decay is accelerated by mouth dryness. Do you know of an appropriate dental appliance that could help? I have a very small mouth/jaw/head and my doctor said the tongue likely is relaxing to block my airway.
When you ask for "appropriate" do you mean appliances in general or something specific like cost, size, fit, etc?
There are a lot of appliances on the market and every doctor has his favorite. I always first recommend getting whichever appliance works best in your doctors hands.
Let me know a little more about what your looking for or I can just list several appliances and their pros and cons.
Here to help.
Dr Tony
Definitely size and fit are more concerning since it's hard to tell from the online documentation when I read about features if there are ones that would just not work for a smaller mouth. I'm in the process of changing doctors/insurance so I'm hoping to find the best combination for me. A few oral appliance devices with pros and cons, size, whether they help with dry mouth, and are good enough for mild OSA would be perfect, thanks so much for the advice.
Dr. Tony,
Wow! Thank you for giving your time like this! I had posted this on the main page but was hoping you could help me with this question....
Hello! I am new to all this! I was diagnosed with moderate obstructive sleep apnea this year & decided on the Narval CC. My dentist encouraged me to try it out at home for a couple hours each night before I went to bed before officially using it overnight.
I have an issue where if I yawn/open my jaw wide, my lower tray lifts off my teeth. I can feel it snap off & then the tray is just there in my mouth.
The dentist had me show him; he says that this would not be an issue while I am actually sleeping as I will be resting & not be opening my jaw with enough force to lift the tray off. I am a mouth breather at night though & do wake up with my jaw hanging open sometimes! He pointed out that even if it did pop off, I would wake up & not choke on it etc. I have been afraid to try it though!
Does anyone else have this issue?!? Is this is known thing & okay to use? I called Resmed but they were not able to help me - they said they can't help on the clinical application side.
Thank you for any help! I keep looking at this expensive device & am so so tired but I'm anxious about trying it.
Yeah it does happen. Having the top and bottom parts connected is one down side to the Narval. Not saying its a bad appliance. I make a lot of them. Very thin and light. Cant break them. Good fit. But you are connected. Two ways of looking at fixing this problem your having. Change the appliance set up or change your breathing set up.
Lets start with breathing because that's your best option. You should be breathing through your nose and not your mouth when you breath IN. The nose cleans, warms, and humidifies the air. Breathing through your mouth skips this very important step. To get the most oxygen to transfer from the air and into your blood through your lung tissue the air must be warm, humid, and clean! Breathing in through you mouth works, but its OK air and not the GREAT air. I would have an ENT take a look at your nose to see how much air actually goes through. I am not talking about mucus, snot, and sinuses. I am talking about the size of air space through your nose. If the space is constricted and can be widened with antihistamines, steroids, or simple surgery then this is your best option. Even if the appliance fits great its still good to have your nose checked. If you breath through your nose you will not keep your mouth open or at least not as much.
To change the appliance set up you don't have many options with the Narval once its made. You can try putting longer bars to allow your jaw to stay in it longer. That is pretty much your only option with the Narval. The second best option would be to get into a different appliance. In my office if the an appliance is not working you give it back to me and I make you a different type. I don't charge patient or insurance twice. Please keep in mind that is my office policy and may not be your dentist's policy.
Hope this helps at least get you moving in the right direction. Please respond back if I can help some more.
Dr Tony
I wasn't able to use a CPAP as I found it very uncomfortable, so I decided to try the oral appliance. I am now on Day 3 of it, and although it's not uncomfortable to sleep with, I find myself unable to sleep. If I do fall asleep, I wake up constantly throughout the night. Is this because I have to 'get used to it?' As I mentioned, it's not because it's uncomfortable or that it hurts. I am so tired from not being able to sleep. I would very much like for the oral appliance to work, but am concerned about my not being able to sleep in the long term wearing it.
I am also getting used to an oral appliance, after trying CPAP therapy for a year. You didn't mention which one you have and that can make a big difference. I am currently using a TAP 3 oral appliance and it is a work in progress. Day 3 is definitely not long enough to get used to an oral appliance. I have been at it for over 5 months now and still haven't found my sweet spot, although I think I am getting closer. I never wore braces as a kid or dentures as an adult, so I am not used to having things in my mouth. Since I am a mouth breather, I have had difficulty with dry mouth when opening my mouth during apnea episodes. I have experienced some jaw pain when adjusting my lower jaw forward, but have been able to slowly advance it over time. After a while your jaw muscles seem to relax and sleeping comes easier. Good luck.
Thanks for your thoughts.
I don't know the name of the oral appliance I have. My problem isn't pain or discomfort. For some reason, I just can't sleep. I am allergic to nickel, and I am wondering if it is made with it, which may be the culprit, although if it is, so far it hasn't irritated my mouth. But as you say, 3 days isn't enough time anyway. Still, being awake for 3 nights does not make a happy or healthy person!!
Hi Dr Tony,
first off, thanks so much for this blog... the information is excellent! I have been diagnosed with mild/moderate sleep apnea (after a very poor sleep in my sleep study) I was recommended a somnomed advancement splint by my sleep Dr. After receiving it and sleeping with it for a week or so and still feeling tired/terrible and zombie like everyday I decided to adjust it myself as my sleep dentist only works 3 days a week and I was so busy. I did this for the next 3 weeks until it started working at 4.6mm of adjustments which was nearly the end of the device... I was feeling great everyday, sleep all night, never waking etc. 2 months later it just stopped working after 5 days or so I went to my dentist and he advised to wind it back which I did (just 0.1mm) and felt absolutely terrible (my sleep apnea symptoms are extreme) there is nearly no good days. So I contacted somnomed because there is no help/information about these devices anywhere and nobody understands them. I was seriously shocked to find this blog! thanks again. I was contacted back by somnomed advising me to advance the device more to which I did, around 1.1mm and it worked for another 2 weeks and stopped again. I had the device reset to its current position and and kept advancing, it never worked again and my jaw/neck got stiff and sore etc sleeps where terrible. After reading all your replies here, I wound it back to the starting position of the current reset and got myself a breath easy nasal strip. the fist night I slept really well all night, I cannot tell if its working as I have just developed a cold but I am not tired! so I was just wondering your thoughts? I use the somnomed classic device, I do think i still sleep with my mouth open with it sometimes? could my sleep study be underestimated severely? is there hope of the device working all the time?
sorry for all the question! thanks again for taking the time to answer these blog post. Ben
The key is to get the muscles, tongue (which is a muscle), and nose all working together. Once that is achieved you will breath normally and sleep great. This is if the only thing affecting your sleeping s lack of air. It kinda sounds like the appliance was not set far enough forward to begin with. This could be because your muscles would not let your jaw come forward to their relaxed length. When you brought the appliance back it relaxed the muscles but the sleep issues came back. When you brought it forward the sleep issues went away but the muscles started fighting the appliance. Eventually the muscles will let go. There is a comfortable spot for the appliance that also fixes the sleep issues. But you will have to slowly advance the appliance up to it or you will pass it up.
Dr Tony
Thanks for the reply Dr Tony, really appreciate it. I did advance far to quick i think. would 0.1mm every 2 days be too quick? What would you advise? Before i was doing 0.2mm everyday until i got it working. After it stopped working i would just do 0.6 over night and more the next night.. chasing that great sleep i had only experienced for 3 months of my life. Thanks for giving us your valuable time :)
What does your dentist suggest? Is he monitoring your appliance settings and how well your sleeping? Dr Tony
I dont see him now, i see my sleep physician who really has no idea about these device(appart from recommending them). My dentist did tell me to go out slow (think he said 1 turn per day) he explained this was the key to it and there was a sweet spot with these devices. I thought i had found it at 4.6mm then it stopped working. I am currently at 5.7mm and still having apneas. I will keep adjusting just much slower. The somnodent manager told me that in a small number of users the body corrects the tightness of the mucles to make them loose again and unfortunately this may be happening to me. I do have hope of it working again. Im moving to cpap in december. Thanks again for the replies, would be great for all of us to have a Dr like yourself!
