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Dental Management Of Obstructive Sleep Apnea

[Editor's Note: I'm pleased to announce that Grant Ritchey has agreed to join SBM as a regular. He'll be writing about dental science and pseudoscience every four weeks on Sunday. (I swear, we'll get up to seven day a week publishing if it kills me—or the other bloggers.) Grant will be starting with science, but I'm sure he'll soon be discussing all the sorts of claims about dentistry and dental disease that are—how shall I put it?—less than science-based soon enough.]

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder in which the airway is partially or completely blocked during sleep. Although little or no air is flowing, the person continues to attempt to breathe. Typically, cessations in breathing last longer than 10 seconds per episode, but can last over a minute and usually occur multiple times during sleep. This can lead to poor sleep quality and precipitous drops in blood oxygenation levels over an extended period of time. This potentially life-threatening condition is frighteningly prevalent, especially in adults over 40, and it is estimated that 80-90% of OSA goes undiagnosed, further compounding the problem.

When a person experiences multiple apneic episodes during the night, the brain responds by alerting the body, resulting in increased efforts to breathe, gasping, and arousal from sleep. These frequent waking events, combined with lowered oxygen levels, can lead to the signs, symptoms, and sequelae of obstructive sleep apnea. Typically, OSA sufferers snore loudly, then are silent for 10-30 seconds as the airway is blocked. This is followed by choking, snorting, or gasping sounds when their airway reopens.

This illustration shows the relationship between the oro-pharyngeal structures and the airway:

oro-pharyngeal-structures

Signs and symptoms

According to the American Academy of Dental Sleep Medicine (AADSM) and others, the most common signs and symptoms of OSA are:

  • Unintentionally falling asleep during the day
  • General daytime sleepiness
  • Unrefreshed sleep
  • Fatigue
  • Insomnia
  • Waking from sleep with a choking sound or gasping for breath
  • Loud snoring
  • Bruxism (tooth grinding). This has been definitively shown in children; it is correlated in adults, but the literature is still inconclusive.

Prevalence

Data from the American Academy of Sleep Medicine (AASM) state:

  • OSA is most prevalent in middle aged and older individuals.
  • Approximately 2-5% of children exhibit OSA signs and symptoms, but it peaks at approximately 9% for girls and 7% for boys at around age 4 when the tonsils and adenoids are largest relative to head size.
  • Approximately 24% of men and 9% of women have obstructive sleep apnea.

As stated above, an estimated 80-90% of OSA remains undiagnosed. OSA in children is primarily due to enlarged tonsils and adenoids, which can impede air flow. As they mature, the tonsils and adenoids usually shrink in conjunction with the growth and development of the head and OSA rates plummet. In adults, sleep apnea is caused by other risk factors.

Risk factors

There are several risk factors that together or separately are predictive for sleep apnea. This list isn’t comprehensive, and a person may have several of these risk factors and not have OSA.

  • Overweight individuals
  • Men and women with large neck sizes (size 16-17 or larger)
  • Ethnic minorities
  • Children with enlarged tonsils and adenoids
  • Structural abnormalities of the head and neck (e.g. deviated septum)
  • Middle aged and older men; post-menopausal women
  • Smoking
  • People with a family history of OSA
  • People who suffer from allergies, rhinitis, and the like.

Diagnosis

The definitive diagnosis of obstructive sleep apnea is made on the basis of an overnight sleep study, monitored by a sleep technologist (when done in a sleep center) and interpreted by a sleep physician. The test, called a Polysomnogram, will chart a patient’s brain waves, heartbeat, and breathing during sleep. It also records arm and leg movements. Traditionally this has been in a sleep center (an “attended study”), but home sleep tests are becoming more common due to convenience and financial considerations. Of paramount importance is the total number of partial (hypopnea) or complete (apnea) cessation of breathing for greater than 10 seconds. Last, the sleep study will monitor the blood oxygen saturation level using a pulse oximeter.

Another thing a sleep physician will assess are any other medical considerations that may mimic or co-exist with OSA, including other sleep apneas (e.g. central sleep apnea, in which the cessation of breathing during sleep is due to a neurological problem, not an obstruction of the airway), medication side effects (many medications cause respiratory depression), substance abuse, or a mental illness (e.g. depression).

Once the sleep study is concluded, an index known as the Apnea Hypopnea Index (AHI), combined with the oxygen desaturation level, is created and a diagnosis is made. The number of apneas and hypopneas are averaged and a score is assigned. Roughly speaking, the classification is broken down as follows:

  • AHI < 5: Mild to no OSA
  • AHI 5-15: Mild OSA
  • AHI 15-30: Moderate OSA
  • AHI > 30: Severe OSA

Regarding oxygen saturation, at sea level normal waking blood oxygenation level is around 96-97%. This drops about 5% during sleep. Any blood oxygenation level under 90% is considered problematic; anything under 80% is considered severe.

Sequelae of obstructive sleep apnea

The following is a partial list of adverse effects of long-term OSA. When doctors start talking about the various issues associated with sleep apnea, it is tempting to assume that they think of OSA as a “One True Cause” of a plethora of illnesses. I assure you this isn’t the case. Just as a sedentary lifestyle can cause a breakdown in a wide ranging variety of body systems, so too can chronic hypoxia and interrupted sleep cycles. So please don’t read too much into it, but still appreciate the seriousness of the condition.

  • Increased heart rate – the lack of oxygen due to breathing cessation causes the heart to beat faster to supply oxygen to the body’s tissues.
  • Elevated blood pressure – the heart has to work harder to get oxygen to the tissues.
  • Increased risk of stroke and heart disease.
  • Impaired concentration and chronic drowsiness.
  • Reduced glucose tolerance and increased insulin resistance.
  • Mood changes, depression.
  • Disturbance of bed partner’s sleep cycle.
  • Erectile dysfunction.
  • Increased risk of motor vehicle accidents.

Treatment

After the proper diagnosis is made, OSA patients can be treated in various ways. The three broad classifications of treatment are:

PAP therapy: This has been the gold standard for treating OSA for over 30 years. PAP stands for “positive airway pressure” and it comes in many flavors, with the CPAP (continuous positive airway pressure) being the most popular and familiar. There are also BiPAP (bilevel positive airway pressure) and VPAP (variable positive airway pressure) machines, which deliver variable pressures of air. PAP therapy involves the delivery of pressurized air through a mask or nasal pillows in order to force the obstructed airway open to maintain adequate blood oxygenation throughout sleep. The advantages of PAP therapy are that there is a lot of good data attesting to its efficacy; the main disadvantage is that it is unwieldy and uncomfortable to wear and operate for most people.

Dental appliance therapy: Oral appliances can be used in many cases of mild to moderate OSA, and in severe cases where the patient is intolerant to PAP therapy. There are many makes and models of appliances, but the vast majority of them are variations on a theme in which upper and lower rigid mouthguards are worn which keep the mandible (lower jaw) postured forward in order to open the airway (see diagram below). I will discuss them in more depth later, but the main advantages of oral appliances are that they are more easily tolerated than PAP machines and are more convenient, especially when traveling. The disadvantages include they are not 100% effective, especially in more severe cases, and in some instances they can be uncomfortable to wear.

oral-appliance-airway

Surgery: Not used as often as the other two, there are different surgical techniques employed to open the airway. The most common is the uvulopalatopharyngoplasty (UPPP), in which excess tissue in the throat is removed, widening the airway space. Jokingly referred to as the “Roto-Rooter” approach, it is a fairly aggressive and uncomfortable procedure, and its success rate is marginal at best. Nasal surgeries to correct a deviated septum, genioplasty (tongue reduction), tracheostomy, orthognathic surgery (jaw advancement), and others are also employed. The main advantage of surgery is that it is permanent when successful, and the patient often doesn’t have to be married to a PAP machine or oral appliance for life. The disadvantages are obvious: surgeries are costly, can be risky, uncomfortable, and there is the potential of post-operative complications. Moreover, the efficacy and success rate for most surgeries pale in comparison to the other two alternatives, with the exception of the tracheostomy, which bypasses the obstruction altogether.

In children who are diagnosed with OSA, the removal of tonsils and/or adenoids is usually sufficient to treat the apnea. In the past tonsils and adenoids were usually removed only in cases of persistent infections, but fortunately pediatricians and otolaryngologists (ENTs) recognize the importance of managing children’s airways, even in the absence of infection.

Adjunctive therapies: There are other measures an OSA sufferer can take to help reduce the severity of their disease. In rare cases, the apnea may resolve completely after trying them. Among these therapies are losing weight, training oneself not to sleep on one’s back, medications for allergies, and others. One caveat is that there are many scam therapies out there that should be avoided: acupuncture, herbal remedies, and most of the other CAM therapies that promise to cure everything but don’t have any evidence to support their claims are foisted upon an unsuspecting public. Over the counter appliances are sold at retail stores, online, and on late night TV shows. They are usually marketed as “anti-snoring” devices because they cannot claim to treat an illness or disease, but don’t be fooled. Without a medical diagnosis and proper follow-up, it is impossible to determine if the person indeed has OSA, and if so, if the appliance is effective. Just because the snoring goes away, that doesn’t mean the apnea is gone. And no, I’m not a shill for Big Sleep. You get what you pay for.

More about dental management of obstructive sleep apnea

OK, now you’re a pseudo-expert on OSA, what the signs and symptoms are, how it’s diagnosed, and treatment options. Now I’d like to delve a little deeper into what “sleep dentists” do (note: sleep dentistry is only a special area of interest of some dentists, not a recognized specialty). Of course, as mentioned above, it all starts with a referral to a sleep center where a sleep study under the supervision of a physician is done and a diagnosis made. If the patient does not want to try PAP therapy, or if he or she has tried PAP therapy and found it to be intolerable, an oral appliance may be just what they need.

After an appropriate taking of a medical and dental history, an exam is performed to check for dental pathology or other issues. The polysomnogram is reviewed by the dentist, the patient is informed of the risks and benefits of treatment, and consent is given. The dentist will then take impressions of the upper and lower teeth, as well as registering the proposed initial jaw position so that the laboratory can properly fabricate the appliance. The models are then sent to the laboratory and are ready about 2-3 weeks later. When it returns, it is fitted properly to the patient and instructions are given. A follow-up study is performed (the patient is instructed to calibrate the appliance themselves, looking for silence and an improvement in fatigue), either at a sleep center or (as is more frequently happening) with a home sleep test to confirm that the appliance is effective. If it doesn’t resolve the apnea, the patient returns to the dental office for a reevaluation, and the appliance is adjusted to move the mandible further forward. At some point, a position is determined where the apnea is controlled and the patient is comfortable with the appliance.

I know what you’re thinking. What does that thing look like? The following illustration shows a representative appliance called a Somnodent (By way of disclosure, I have no financial interest in any product I discuss).

somnodent-oral-appliance

As you can see, this appliance fits over the upper and lower teeth. The “wings” on the lower appliance contact the upper extensions, which keep the lower jaw forward to maintain an open airway. There is a screw on each side that can be adjusted to bring the jaw further forward if necessary. After wearing the appliance for a while, the appliance is adjusted and calibrated, moving the jaw forward only as far as necessary to stop the apnea. Other proprietary appliances on the market have an adjustable “strut” connecting the upper and lower members, but the principle is the same for all of them.

Conclusion

Dentists can play a major role in the management of obstructive sleep apnea. We work in conjunction with sleep physicians and technicians to find the most successful means to control a patient’s OSA. Oral appliances have been shown to be very effective when used properly in the appropriate cases. They are not panaceas, however. In many cases, PAP therapy remains the treatment of choice. To learn more about OSA, follow the links given earlier in this post for the dental and medical sleep apnea organizations. In a recent podcast, I interviewed a prominent sleep dentist (Shameless Plug here), who goes into more detail than I was able to in this blog post.

Sweet dreams!



Dr. Grant Ritchey received his Bachelor’s degree in Human Biology from the University of Kansas in 1982, and his Doctor of Dental Surgery degree from the University of Oklahoma in 1986. He lives in Kansas City, is married, and has two grown daughters. Since 1986, he has maintained a general dental practice in Tonganoxie, Kansas, and was awarded a Fellowship in the Academy of General Dentistry in 1998. Currently, he is working toward his Master in Education degree from the University at Buffalo in the Science and the Public program, with an emphasis on the prevalence of alternative medical practices in dentistry. He is also the co-host of The Prism Podcast, a science-based podcast.

Posted in: Dentistry, Surgical Procedures

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42 thoughts on “Dental Management Of Obstructive Sleep Apnea

  1. Lulu says:

    Great post, Dr. Ritchey! I suffer from a disorder similar to sleep apnea called Upper Airway Resistance Syndrome, and I’ve been using an oral appliance to treat it for the last few years (I couldn’t tolerate CPAP at all).

    I recently switched dentists and when I told my new dentist about my oral appliance, he tried to discourage me from using it. He said that repositioning the lower jaw would weaken the muscles and cause TMJ and that even though he himself had sleep apnea, he refused to use any treatment for it. He went on a tear about how it could be cured with diet and exercise while I stared incredulously. When he finished, I responded that this was the lesser of two evils, either I end up with jaw muscle problems or return to sleeping for 12 hours a day and still falling asleep during the day and not having enough energy to go to the gym on a regular basis.

    Is there any evidence to support his claims, and if so, are they serious enough to consider a different treatment?

    1. DavidCT says:

      I am sure there is “evidence” to support his claims. There is evidence to support homeopathy after all. If you you were going to develop the problems he says you will, they would have been an issue long ago. Since you cannot depend on his advice for this issue, can you have confidence in any other recommendations he might have? I would not. I am a dentist by the way.

    2. WilliamLawrenceUtridge says:

      Diet and exercise can cure sleep apnea if caused by obesity and you can use diet and exercise to lose that weight. If the apnea is caused by something else, then diet and exercise are good ideas, but worthless for apnea.

      I once had my sleep and dreams prof describe the muscles that hold open the airway as “looking like strips of bacon” in extremely obese patients whose CPAP was primarily due to their obesity; they simply lacked the strength to hold open the airway.

      1. KayMarie says:

        I did the whole sleep study thing for what ended up being upper airway resistance syndrome as well.

        Back in the day my BMI was 22 and they had a dickens of a time with some of the things to be belted around me as the straps they used for the children they usually see were way too big and had to be wrapped around twice. So obesity does seem to have a lot of association with Obstructive Sleep Apnea.

        Yep, diet and exercise are going to be important for some, but you can end up with problems when normal weight. I have heard some people do reduce their sleep apnea by losing weight.

        They ended up fixing the insides of my nose with surgery and that got me off the CPAP. I really don’t think any amount of weight loss even to anorexic worry levels would have helped the structural issues inside my nose. I really don’t think the first place I gain weight is inside my nose, but heck could be.

  2. Alia says:

    Just a short note – surgery to correct deviated septum can be very helpful, if it is the deviated septum that is causing problems. Not only with sleep apnea or snoring but also upper respiratory tract infections. It’s anecdata but my sister had such surgery and it really improved her quality of life. But of course, it’s only applicable when the main cause is deviated septum.

  3. MTDoc says:

    “In the past, tonsils and adenoids were usually removed only in cases of persistent infection”

    Had to chuckle when I read this line. When I was a kid, the indication for a T&A was the presence of tonsils. It was almost a rite of passage. About age six on the average, and sometimes all siblings at once. Then came the enlightenment and only severe and chronically infected tonsils were removed, and never for size alone. (Pediatricians and GPs had differing views on this subject, but the Peds prevailed).

    So,as so often happens, the past becomes the present, and then becomes the past again. The old time docs talked about obstruction, but by the 1960′s this was no longer considered as an appropriate surgical indication in a modern setting.

    Good article, and useful for MD’s as we have little exposure to our sister profession, dental medicine.

    1. n brownlee says:

      I, and my sisters, are the only people of our age I’ve ever known who kept their tonsils. My great-uncle, our doctor, insisted that it wasn’t necessary.

      1. MTDoc says:

        Sounds like we may be of somewhat the same vintage. To understand the rationale behind almost routine T&A’s, one has to go back to a time before penicillin, and a time when rheumatic heart disease was common. Tonsils, being lymphoid tissue, may protect the body from infection when they are healthy. However chronically infected (scarred & abscessed) tissue becomes a liability. If they are easy to remove surgically, they did not need to come out, and your uncle was absolutely correct!

        As for RF and RHD, with the resulting heart valve damage, I often wonder if we would have ever attempted to operate on the heart otherwise. Even the first mitral valve surgery, simple by today’s standards, was viewed as overly heroic, and criticized at the time. More involved procedures might never have gotten off the ground.

  4. Jay Walker says:

    I’ve been using a CPAP for about five years and it has made a huge difference in my life. When I started using it, I started dreaming again (or at least was able to remember my dreams), which was psychologically comforting. I was no longer drowsy during the day. Also, my blood pressure dropped and other things like aches and pains, and stress decreases.

    In addition to the CPAP, I’ve also lost a lot of weight (about 140, after a sleeve gastrectomy, which helped lower my AHI from 17 to 15.

    I want to thank you for writing such a well written article explaining the risks of sleep apnea and it’s treatments. I don’t think most people realize the serious adverse health risks that come with it and hopefully some people will be encouraged to have themselves tested.

  5. This is really cool stuff. And a lot of people with obstructive sleep apnea hate CPAP machines. They’re like a giant ball and chain to some. And if this treated snoring, I swear the divorce rate would drop.

    My question is that obviously dental insurance won’t pay for this unless you have some platinum level CEO plan.

    But if the evidence shows it works, then will Medicare, Medicaid or private insurers pay? Many health plans have dentists on the provider list, but it’s almost always for reconstructive purposes.

    Thus my questions are, is the dental community moving to get this procedure included in the standard of care for say heart patients. Or diabetics. And by doing so getting a system of referrals so that insurances covers it?

    And how much does it cost? Product plus fitting? Maybe it’s so cheap it doesn’t matter. I’m guess that’s not going to be true.

    1. Michael Busch says:

      Since I’ve recently been diagnosed with moderate obstructive sleep apnea, and had the impressions of my teeth for an oral appliance made last week:

      Total cost for the entire process (2 sleep studies + office visits / consults + appliance) would have been somewhere between $4000 and $5000 if I were paying out-of-pocket. Fortunately for me, my employer’s health insurance plan covers the sleep studies, office visits / consults, and most (although not all) of the cost of either an oral appliance or a CPAP machine.

      1. Calli Arcale says:

        I think in general you’ll be getting the oral appliance paid for by your regular medical insurance, not your dental insurance, so the fact that your dental insurance won’t cover it isn’t necessarily a deal-breaker. There is some overlap between what medical insurance and dental insurance will cover, because although dentists do most of the stuff inside the mouth, some of that stuff is absolutely important to whole-body health. In this case, you’re getting a dental appliance to treat what’s basically a respiratory problem.

  6. gary says:

    I have mild OSA and began to use a CPAP machine reluctantly in February. I can sleep with it, as long as the mask his a tight fit and the noise from leaking air isn’t too loud.

    I’ve also worn a “mouth guard” to prevent teeth-grinding at night. Is there a dental appliance that combines both functions that perhaps is covered by Medicare?

  7. Grant Ritchey says:

    Thank you everyone for your comments. This is most certainly an important topic. I’ll try to address some questions below to the best of my knowledge and ability.

    @Lulu: Oral appliances typically don’t cause any long term TMJ issues. Yes, your jaw position is changed, but only for a few hours per day. Initially, there may be some soreness in the jaw muscles, and you may even feel that your teeth don’t come together properly when you first remove the appliance in the morning. These changes are transient and are usually of no consequence. Of course, if someone does experience a bona fide TMJ problem, we manage that.

    @MTDoc: You’re right! I had mine amputated when I was five years old “Because they were there!”

    Regarding insurance reimbursement: Oral appliances will not be covered by dental insurance but are often covered by medical plans, just as if it was PAP therapy. I’m afraid I don’t know about Medicare, so I can’t help you there.

    Grant

    1. Michael Busch says:

      Thanks for writing this piece! It’s particularly timely for me, since I’m in the process of getting an oral appliance to manage moderate OSA.

    2. D Wetherington says:

      Grant, there are documented cases of permanent changes in occlusion. Resulting in heavy contact on the front teeth and less contact in the back teeth (a posterior open bite in dental speak). It is not common and from my understanding the complication is well tolerated by the patient. Risk increases with the amount of time the appliance is worn each day.

      1. Thanks David,

        Nice to hear from you. I agree that it can happen. I would assume that this is an orthopedic change, not dental since the appliance is rigid and prevents individual tooth movement, would you agree?

  8. Sawyer says:

    Welcome aboard Grant. Time to show those anti-dentite bastards some real science!

  9. oldebabe says:

    No one has addressed the apnea (?) that occurs during the day (for me it does, and I don’t know if or whether I have sleep apnea), and sometimes I just stop breathing, and when I feel it, have to gulp more air. Am I imagining this? Anecdote: my regular doc said “so, breathe” – accurate, but doesn’t stop the stopage from re-occuring. Perhaps this is a problem for all old people? Does anyone know?

  10. mho says:

    Thanks for the post–its great to have a dentist here. A few questions:
    Do the dental appliances create any additional problems from dry mouth?
    How common is it to feel “claustrophobic” when your teeth are held in place like that? How quickly can you extricate yourself from the appliance.
    Does insurance cover the dental appliances if you’ve had a CPAP in recent years?

  11. mho says:

    Is burning mouth syndrome or geographic tongue something dentists address, or is that the purview of ENTs? There was a ridiculous post on a cancer support board about treating burning mouth syndrome with acupuncture.

  12. @Sawyer Thank you! I am anti-anti-dentite!

    @oldebabe: Great question, and I’m afraid that’s out of my area of expertise. Anything south of the Adam’s Apple is off limits to me! But there are other disorders that behave like OSA. Central Apnea, for one, which can behave like you’re describing. I’d definitely check that out and wouldn’t accept your doc’s glib advice without proper follow up.

    @mho: Appliances cause far far fewer problems with dry mouth than a CPAP does. In fact, that’s one of the biggest complaints with PAP therapy. You can pop it out as easily as removing a football mouthguard or a retainer, so no big deal. It can be a mouthful and takes some getting used to, but a vast majority of patients adapt to it very well. Insurance companies are funny, and by funny I mean frustratingly awful. They should cover appliance therapy if you are determined to be “CPAP Intolerant.” But I often think that insurance eligibility determinations are made by drunk chimpanzees pulling levers and reading sheep entrails. A predetermination can usually be filed to determine eligibility and coverage, however.

    Burning mouth syndrome is quite an enigma for both physicians and dentists. Most of the time we have no idea what is causing it. Sometimes it can be linked to a vitamin deficiency (not as common these days), medication side effects, or conditions such as depression. Very tough and frustrating to diagnose and treat. And you’re right, any recommendation for acupuncture for ANYTHING is ridiculous.

    1. oldebabe says:

      Txs, Grant Richey. Much appreciated.

      I took your advice, and check with my regular dentist who recommended (after viewing what seemed to be a lump on my jaw by my ear), an ENT, who send me to an audio guy… as I was also starting to get `whirly’… I don’t know if anything will help the non-breathing, but at least I’m “following up”, as you suggested.

  13. MTDoc says:

    General comment, post martini. Just read the first paragraph above (don’t recall it when I opened the blog). I too wish to welcome you aboard. Being a bit compulsive, I always check the site on weekends, “just in case”, and once in a while I find an entry.
    As I said earlier, I could never understand how dentistry got separated from medicine in the practical world. As for me, I’m far too ADHD to be a dentist, but I sure do appreciate mine. Look forward to future contributions.

    1. Thanks MT.

      I think our separation was due to the fact that we wanted to be more in the barber guild than the blood-letting guild. Seemed like the right thing to do at the time.

      At my dental school (OU), we took all of our basic science courses the first two years alongside the OU medical students: anatomy, physiology, path, embryology, neuro, histology, etc. etc., so I felt we had a really thorough medical underpinning before we started sticking our fingers in people’s mouths.

      Thanks for the kind words! Keep in touch.

      Grant

    2. R. Miller says:

      This is not intended to be an exhaustive answer, but one contribution was probably simply how horrible dental hygiene was in 19th century. I don’t have any numbers on hand, but dental caries were one of the most common disease in the population. Basically, the extent of disease was so burdensome and there was such a high demand it entirely justified the construction of its own schools.

      You also have to recognize that at the time dental schools were being established medicine was highly fractured with such dubious practitioners as “the regulars”, the botanists, the homeopaths, the eclectics, the physios and other numerous groups. Thus, dentistry with a more narrow focus probably had little interest in aligning itself with what were more or less warring philosophies that were all misguided to some degree, as the scientific approach in medicine to separate the garbage ideas from the useful was only in its infancy.

  14. CS says:

    I am an NP working in a sleep medicine practice. Yes, Medicaid and Medicare will cover a dental appliance for OSA, although depending on your plan you may be limited to a particular brand or type of dental appliance. Also, they will cover CPAP but there is a chip inside the machine that sends them back information on usage, so if the patient is non-compliant they will take back the machine!

  15. Chebon Reese says:

    Perhaps it would be helpful to do research into the lives of those people who have overcome severe OSA and Sleep Hypopnea. Great scientific empirical falsification-based insight can be found in this data, the absence of which, casts doubt into the predictive-only information of the past.

    Sleep Apnea comes accompanied in most all sufferers by periods of Sleep Hypopnea, periods where the body stops breathing regardless of whether or not there is an obstruction or appliance. The sleep tech at my sleep lab indicated to me that nearly 90% of his moderate to severe patients had both apnea and hypopnea combined. So mouth appliances will not work for most moderate to severe OSA-H patients. The latest data shows that there is a very high coincidence with Food Sensitivity, Weight Gain, Hypothyroidism, and Autoimmune Disease which is extant before obstructive sleep apnea and hypopnea ever become a problem. Doctors and sufferers who have overcome the malady know this. Why do we not develop science around this, well perhaps because we think we have it all figured out.

    Science based – should not be synonymous with – “I know all the answers” If we know all the answers then we do not need science.

    To get off my CPAP machine I had to stop eating Wheat, Corn, Sodas, Dairy, Soy and Canola Oil. I lost 100 lbs, and my diabetes went into remission. I did not alter my caloric intake significantly – probably a net down of 200 calories per day, only replaced my food consumed. This is no BS. This is exactly what cleard up my OSA-H

    For me, I chose to address the root causes of my sleep hypopnea, – toxic food, autoimmune disorders, and the excess weight and atrophy which resulted from them. The hypopnea is gone, the apnea is gone, no machine and I sleep, feel and look so much better.

    Let’s turn the meaning of ‘science’ back in to ‘wanting to find out’ rather than ‘I have all the answers.’

    1. @Chibon Reese

      That would be an interesting study. I am not a research scientist; I am a practicing dentist, so I never claim to be on the front lines of primary research.

      I apologize if my post came across as “having all the answers.” I must work on my communication skills. My intent was to alert people to the fact that there are potential alternatives to PAP therapy and surgery. If you re-read my article, you will see that I do mention losing weight and other co-factors. And keep in mind that what works for you may or may not work for others. Everyone has to be evaluated for the particulars of their condition. If the take away from my article is that Oral Appliances are a panacea that work for all OSA patients, then I failed miserably and owe the readers of this great blog an apology.

      Last, your sleep technician was correct in saying that moderate to severe cases of OSA may not respond to appliance therapy alone. That is why I wrote “Oral appliances can be used in many cases of mild to moderate OSA, and in severe cases where the patient is intolerant to PAP therapy.” This is consistent with your statement and I don’t understand why you are taking issue with it.

      Thank you for your comments.

      1. brewandferment says:

        maybe it’s because this person has several dubious claims to trumpet: restrictive diets, “toxic food” and a claim that autoimmune diseases cause hypopnea — citation definitely needed for that one.

    2. Nick says:

      I’d like to add to Chebon’s comments, as my experience was similar. In addition, I would like to make a comment about dental appliances, as I did try one. I do appreciate that you took the time to blog about sleep apnea.

      You said to LuLu:

      “@Lulu: Oral appliances typically don’t cause any long term TMJ issues. Yes, your jaw position is changed, but only for a few hours per day. Initially, there may be some soreness in the jaw muscles, and you may even feel that your teeth don’t come together properly when you first remove the appliance in the morning. These changes are transient and are usually of no consequence. Of course, if someone does experience a bona fide TMJ problem, we manage that.”

      I wore a dental appliance and it permanently moved my mandible forward that created an ‘underbite’ so that my teeth no longer met properly. I could not chew food because my teeth could no longer grind food because they didn’t meet as before. When I stopped wearing the appliance, my jaw reverted back to its normal position in less than a week. I think this is something readers should be aware is a possibility. I was sleep tested with the dental appliance and it did not reduce my sleep disturbance events.

      Second, like Chebon, I removed foods from my diet and this had the effect of reducing what I had long thought, and been told, were environmental allergies. I was tested for being allergic to grass, dust mites, various weeds, etc. When I stopped eating wheat and other grains and vegetable oils my allergies went away. I think this reduced the inflammation in my throat, thus creating more room for air to pass during sleep. I stopped taking allergy meds. My BMI is 25, so I didn’t need to lose weight, nor did I before or after changing my diet. I returned to take my fourth polysomnogram and was told by the M.D. that I no longer needed to use CPAP. I still have a small number of events on my back, but no longer have any events on my side. My typical number of events was about 20 per hour, so this was a significant change for me.

      I’m glad you didn’t recommend radio frequency for sleep apnea. It also has a very poor record of helping sufferers of sleep apnea.

      Nick

  16. kaitch says:

    Great to have your expert input, Grant! I (as a med student) learned in little detail about dental management of OSA, but wasn’t sure if there was an evidence-based way of identifying the good candidates for dental management, given that it’s not possible to just trial a device that has to be custom-made at substantial expense, unlike CPAP. (I’m in Australia, so very different system).
    I recently met a retired dentist, now a patient, who, in spite of a significant cognitive impairment, was still able to relay the lack of evidence for long-term outcomes after dental implants. Will you be covering this topic?

  17. Stephen H says:

    I have severe complex sleep apnoea, that becomes more severe when CPAP is applied. For some reason, when a machine blows positive air pressure at me, my brain figures it doesn’t need to worry about breathing – which can be scary as you’re falling asleep. It didn’t just happen at the exact moment, though – and the CPAP machine recorded AHIs of around 60 while on plain CPAP.

    I tried a UPPP, the dental stuff etc, and ended up on VPAP. Unfortunately, the local sleep apnoea specialists just don’t know enough about VPAP and so I did a lot of the setup myself. It is still annoying, but I am sleeping a little better – although still averaging around 11 hours/night.

    The RLS doesn’t help.

  18. Joe R says:

    First, welcome aboard! I work for a dental health company and it will be refreshing to read columns on topics that might be directly relevant to my job!

    I have severe apnea. I had a sleep study done about 5 months ago and hit the threshold for number of events to indicate a strong possibility of the condition within the first 90 minutes. My pressure requirements were so high that the BiPAP was needed rather than the CPAP so I could comfortably(ish) exhale.

    I’ve had my BiPAP machine for almost 3 months now and I have to admit it’s been tempting to throw it out the window at times. I’ve finally found the sweet spot of mask placement, snugness, position, and mouth moisture. (Still VERY dry mouth, but found some helpful dry mouth gel that helps the worst areas)

    I’d heard commercials on the radio on my drive to work for almost a year about a dental appliance method of treating apnea. Without much information other than the practice was now authorized to take medical insurance, I didn’t want to check it out due to concerns it was just another sCAM kind of thing.

    It’s good to know it’s a real treatment with lots of potential. I might not be a good candidate for the appliance since my apnea is so severe, but I could always try a visit and see what they think. If not now, possibly when I’ve shaped up a bit and hopefully reduced the severity of my condition.

    Thank you for providing reliable information on this topic! It could be a game changer for me if it ends up being a possibility for me!

  19. mike says:

    I was diagnosed with sever sleep apnea after a sleep test showed my blood oxygen dropping below 80 at times. My insurance covered a bipap with a humidity chamber. I have not had any trouble with dry mouth. The only issue I have is air blowing past the gaskets on the mask which wakes me and my my wife up at times.

    I don’t like to take the biPAP on trips. How expensive are teh mouth guards? I would consider taking them on trips.

    1. John Miller says:

      I am a user of cpap and would suggest to all that have problems with mask leaks is to keep trying new masks. There a hundreds of styles and all have their tradeoffs but it is very possible to find a mask that does not leak and is quiet. Also a lot of time looser is better.

  20. nyudds says:

    Welcome, Grant! A very thoughtful and well-written presentation. I echo the thoughts of many, including MTDoc, and look forward to more scientific presentations of dental medicine in the future. I believe this will illuminate many practitioners @ SBM as to how dentistry has improved from painful drill, fill or extract to the modern treatments we all now know (but still do not necessarily love!)

  21. Kate says:

    I wear a sleep appliance similar to the one pictured because I had my TMJ disorder treated by moving my lower jaw forward (eliminating a small overbite) and having my teeth realigned with braces. It’s been about 5 years now since I started using it and you definitely get used to it over time. It does not cause me any extra issues with dry mouth.

  22. CandiO says:

    I have a dental appliance for my mild OSA, though I admit I have not learned to actually sleep with it in, yet (only had a for about 6 weeks). My insomnia problems preclude that happening easily, but it is a heck of a lot better than CPAP. I failed that completely after months of trials with every type of mask, nasal pillow etc that the company had. With regard to the TMJ issues, my dentist makes a morning guard to wear while getting ready in the morning (only need to wear it for about 30min). This is smaller, like a regular night gurad and is meant to realign the jaw and prevent the very jaw issues described above.

  23. Willibrord says:

    Thanks for this article, Grant!

    I’ve been using an oral appliance for mild to moderate OSA for several months now — no snoring (so a happy husband!), some TMJ pain but it’s manageable, high hopes for my second sleep test which I have yet to schedule.

    For the information of any Canadians here (or at least Ontarians), they are NOT covered by public insurance :-( , and spottily by private. Mine cost $2400 including all follow-up visits, etc.

  24. Frederick says:

    Really great post! I love when SBM take on new subject! I remember speaking about dental science with my Dentist, she’s great. the mouth and tooth are underrated toward the importance in the health of people. In canada we have universal health care, but dental heath is not include in it, only below 18 years old. I remember the president of the Quebec destist order speaking about that, and how it should be covered because it is a aspect of the health as important as any other. Also I remeber that on SGU they interviewed couple of dentist earlier this years. ( was a 2013 show I listen to so much of them lately lol), Steven Novella had given a speech at a “evidence based dentistry” conference. And I found that interview really interesting, So having a SB- Dentist here is going to be very interesting

    I have a friend with Sleep apnea, he use the machine, must be a pain to carry when you travel and all, But that mouth guard is good ( if it work for the person of course) in that case i guess, His wife got use to the machine, but it is still a little noisy and not really sexy. Maybe surgery will get better one day.
    Could they create some kind of implant that could support all that structure ?

    1. Thanks for your nice comments Frederick! Those dentists you heard on the SGU were my podcast co-host Jason Luchtefeld and myself! The two of us are very involved in Science Based Medicine, especially as it pertains to dentistry. We visited quite a bit with Steve (who gave an amazing keynote speech BTW) at the ADA conference and interviewed him on our podcast, which then led to us being on their show. If you search for The Prism Podcast on iTunes or your favorite podcatcher, you should be able to find his interview. Also, for those readers of SBM who would like to learn more about Evidence Based Dentistry, go to ebd (dot) ada (dot) org. Also, you would like our interviews with Dr. Julie Frantsve-Hawley (Episode 15 of The Prism) and Dr. Bob Weyant (Episode 12), who both give excellent overviews of the current state of EBD. They are both amazing “force multipliers” for the pro-science movement.

      Thanks!

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