I NEED HELP WITH MY CPAP MASK!

TOM:

I NEED HELP WITH MY CPAP MASK. I HAVE TRIED SEVERAL BUT HAVE CONTINUOUS PROBLEMS WITH LEAKS AND DRY EYES. THE NASAL PILLOWS WERE AN IMPROVEMENT OVER THE NASAL MASK FOR A WHILE BUT THE QUIT WORKING. I AM NOW USING A FULL FACE MASK WHICK IS OK ON SOME NIGHTS BUT I FEEL WORSE THAN I DID BEFORE CPAP. MY DOCTOR TOLD ME I AM NOT A CANDIDATE FOR AN ORAL APPLIANCE BECAUSE MY APNEA IS SEVERE. I QUIT BREATHING 50 TIMES AN HOUR. I USUALLY MANAGE TO GET AN HOUR OF TWO OF SLEEP BEFORE I GIVE UP ON IT. HELP!

DR SHAPIRA RESPONSE: Tom, I understand your frustration and I commend you on your efforts to comply with treatment. 60% of patients give up on CPAP and that is very dangerous. I suggest that you get a copy of your sleep study and contact a dentist who is experienced in treating sleep apnea. Oral appliances are a comfortable alternative to CPAP and are a first line choice for treatment of mild to moderate sleep apnea according to the American Academy of Sleep Medicine. They are an acceptable alternative to CPAP for severe sleep apnea when patients do not tolerate or want CPAP treatment.

I advise you to continue to use your CPAP with your appliance until after a sleep study show the it is effective. Recent studies have shown that properly titrated appliances are as effective as CPAP and can be used for severe apnea in many patients. It is vital that a titration sleep study be done to find the ideal position to maintain an open airway.

An appliance that is not properly adjusted is a "POP" or piece of plastic not an effective treatment unless your problem is a congenital lack of plastic.

I frequently see patients who say they tried an appliance and it didn't work. This is usually because the dentist did not choose the right appliance or properly adjust it for effective treatment. Their is both art and science to the field of Dental Sleep Medicine. Many doctors take a single course from a manufacturer of appliances and only have one tool in their belt. When I teach my courses I purposely limit class size to six dentists and their teams to insure that each dentist has a comprehensive understanding of sleep medicine and the role of the dentist. It is also important to understand the basic principles and how different anatomy may demand different types of appliances. I do have my favorits based of effectiveness.

I am frequently asked by dentists what is the best oral appliance. The answer is that it depends on many factors and different appliance are best for different patients.

Surgery is also an option for treating sleep apnea but is no longer considered a first line treatment because of high morbidity and poor results. I stronly suggest you avoid soft palate surgery ie UP3, LAUP, Somnoplasty, Pillars. Tongue reduction is a more useful surgery but can be brutal. If contemplating base of tongue surgery somnoplasty is a good choice but several procedures will probably be necessary. Nasal surgery can be helpful but is rarely a cure. It can make both oral appliance therapy and CPAP more effective and comfortable and can improve your quality of life if you live with chronic impaired breathing 24/7.

Bimaxillary advancement or madibular advancement or chin advancement can be very effective but a trial with an oral appliance is recommended prior to surgery to determine the amount of advancement that is necessary. You do not want to go thru traumatic surgery and still need CPAP afterwards.

If you are in the midwest, Illinois or Wisconsin feel free to see me in Chicago, Gurnee, Skokie, Vernon Hills or Schaumburg.
Good Luck Tom

Somnomed Appliance Caused Patient To Develop "TMJ"

JEFF: I have an oral device (sonomed) for sleep apnea. It gave me TMJ. I haven't been able to tolerate cpap.


Dr Shapira: YOU STATE THAT YOU HAVE A SOMNOMED TO TREAT SLEEP APNEA BECAUSE YOU CANNOT TOLERATE CPAP.
It is excellent that you have chosen to treat the sleep apnea which can cause heart attacks, strokes, memory loss and excessive daytime sleepiness.

YOU THEN STATE THAT YOU DEVELOPED TMJ BUT GAVE NO SPECIFICS AS TO SYMPTOMS. TMJ STANDS FOR TEMPOROMANDIBULAR JOINT, NOT A DISEASE. It is important to understand the SPECIFIC problems so they can be addressed. Patients wearing oral appliances for sleep apnea may experience bite changes or tooth movement but damage should not occur to the joints. It is essential to work with a dentist who has training in treating sleep apnea and TMJ disorders.

ACCORDING TO THE NHLBI SLEEP APNEA IS A TMJ DISORDER. SEE http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf You have actually developed a new symptom from the same disorder but because you didn't specify symptoms I can not specify what to do next.

The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances should be well trained in treating TMJ disorders.

IF YOU CAN GIVE ME SPECIFIC INFORMATION I MAY BE OF MORE HELP. Please review www.ihateheadaches.org to learn about Neuromuscular Treatment of TMJ Disorders, headaches and migraines.

The following is the result of a web form submission from:
comments: I have an oral device (sonomed) for sleep apnea. It gave me TMJ
I haven't been able to tolerate cpap

THIS IS A RECENT NEW POST; I also got tmj from sonomed sleep appliance / it was pulling my jaw forward too much. It clicks when i chew and my ear feels like watery.

DR SHAPIRA RESPONSE: THESE PROBLEMS ARE USUALLLY EASY TO PREVENT OR CORRECT BUT YOU MUST BE PROCACTIVE FROM THE START OF APPLIANCE USE

Problems with TAP 3, What to do?

I am frequently asked questions like the one that follows. There are often many answers to problems. This question is not from one of my patients. I always suggest you discuss all problems with your sleep physician and your dentist.

Question from Phil:
I had been diagnosed with moderate/severe sleep apnea approximately 10 years ago and tried using CPAP as a treatment option. After trying it for a while, I found it to be detrimental to my sleep and noisy both for myself and my wife. Therefore, I first threw the mask off during the night and finally quit alltogether. Since then, I have had multiple back surgeries and a knee replacement which necessitate my taking Advil before sleep in order to eleviate discomfort. I can sleep well most of the time. However, my regular physician recommended that for all of the right reasons, that I have another sleep study done which again confirmed my sleep apnea condition.
As the CPAP and I did not get along the first time, I now chose the 2nd option of an oral device, TAP 3, applied by a certified dentist after fighting with Blue Cross for 11 months before they gave in and agreed to pay. However, the necessary adjustments to allow the desired airflow ha ve proven to hurt my jaw and the long-term side effects can be undesirable as confirmed by my wife as a former dental assistant. What are the thoughts of other users of such a device on the long-term side effects vs. using a CPAP machine which, I understand, have become easier to use since I last tried one?

Dr Shapira Response
Phil,

If you are having jaw pain with the TAP 3 it can be altered occlusally for comfort.(possible posterior stops) More frequently it means you were adjusted forward too fast. You may be able to back it up and bring it forward more slowly. There are long term bite changes and/or tooth movement that are controllable with morning exercises and or retainers.. Studies show no long term joint problems. Approximate 1/2 of patients find changes favorable. Almost all problems are manageable.

It is essential that the apnea be treated. A stroke or heart attack is a lot more serious than a change in bite. Sometimes you can alternate between cpap and applainces. Even though the new CPAP machines and Masks are more comfortable 60% of patients still abandon CPAP treatment.

The Tap 3 can be turned into a TAP-PAP giving you more comfort, lower cpap pressure and less jaw advancement. It can retain your mask with no straps

Most of my patients stay oral appliance therapy long term, though some do alternate with CPAP.

Dr Shapira

PATIENTS WITH UNTREATED SLEEP APNEA EXHIBIT "cortical excitability in patients with obstructive sleep apnea syndrome (OSAS) during wakefulness

A recent study in Sleep Med on altered Cortica Excitability in sleep apnea concluded that " This TMS-based study suggests that untreated severe OSAS patients have imbalanced cortical excitabilities that enhanced inhibition or decreased brain excitability when awake during the day."

This may be a cause of chronic headaches or migraines or other biochemical imbalances leading to stress disorders ofr depression.

I have included a few relevant pubmed articles below.

Sleep apne is the result of a TMJ disorder (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf)

Neuromuscular Dentistry can help reduce incresed corticl activity, Treatment of sleep apnea can do the same.

Patients with sleep apnea have a smaller airway 24/7 that collapses at night. Correction of apnea and daytime jaw position may be ideal for all patients with chronic pain and sleep apnea.



Sleep Med. 2010 Oct;11(9):857-61.

Altered cortical excitability in patients with untreated obstructive sleep apnea syndrome.
Joo EY, Kim HJ, Lim YH, Koo DL, Hong SB.

Sleep Center, Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Comment in:

Sleep Med. 2010 Oct;11(9):820-1.

Abstract
OBJECTIVE: To investigate cortical excitability in patients with obstructive sleep apnea syndrome (OSAS) during wakefulness.

METHODS: The authors recruited 45 untreated severe OSAS (all males, mean age 47.2 years, mean apnea-hypopnea index=44.6h(-1)) patients and 44 age-matched healthy male volunteers (mean apnea-hypopnea index=3.4h(-1)). The TMS parameters measured were resting motor threshold (RMT), motor evoked potential (MEP) amplitude, cortical silent period (CSP), and short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF). These parameters were measured in the morning (9-10 am) more than 2h after arising and the parameters of patients and controls were compared. The Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS) were also measured before the TMS study.

RESULTS: OSAS patients had a significantly higher RMT and a longer CSP duration (t-test, p<0.001) compared to healthy volunteers. No significant difference was observed between MEP amplitudes at any stimulus intensity or between the SICI (2, 3, 5ms) and ICF (10, 15, 20ms) values of OSAS patients and healthy volunteers (p>0.05).

CONCLUSIONS: This TMS-based study suggests that untreated severe OSAS patients have imbalanced cortical excitabilities that enhanced inhibition or decreased brain excitability when awake during the day.

PMID: 20817550 [PubMed - in process]

Handb Clin Neurol. 2010;97:73-83.

Biological science of headache channels.
Pietrobon D.

Abstract
Several episodic neurological diseases, including familial hemiplegic migraine (FHM) and different types of epilepsy, are caused by mutations in ion channels, and hence classified as channelopathies. The classification of FHM as a channelopathy has introduced a new perspective in headache research and has strengthened the idea of migraine as a disorder of neural excitability. Here we review recent studies of the functional consequences of mutations in the CACNA1A and SCNA1A genes (encoding the pore-forming subunit of Ca(V)2.1 and Na(V)1.1 channels) and the ATPA1A2 gene (encoding the alpha(2) subunit of the Na(+)/K(+) pump), responsible for FHM1, FHM3, and FHM2, respectively. These studies show that: (1) FHM1 mutations produce gain-of-function of the Ca(V)2.1 channel and, as a consequence, increased glutamate release at cortical synapses and facilitation of induction and propagation of cortical spreading depression (CSD); (2) FHM2 mutations produce loss-of-function of the alpha(2) Na(+)/K(+)-ATPase; and (3) the FHM3 mutation accelerates recovery from fast inactivation of Na(V)1.5 channels. These findings are consistent with the hypothesis that FHM mutations share the ability to render the brain more susceptible to CSD, by causing excessive synaptic glutamate release (FHM1) or decreased removal of K(+) and glutamate from the synaptic cleft (FHM2) or excessive extracellular K(+) (FHM3).

PMID: 20816411 [PubMed - in pr

Handb Clin Neurol. 2010;97:47-71.

Pharmacology.
Bolay H, Durham P.

Department of Neurology, Gazi Hospital and Neuropsychiatry Centre, Gazi University, Besevler, Ankara, Turkey.

Abstract
Headache treatment has been based primarily on experiences with non-specific drugs such as analgesics, non-steroidal anti-inflammatory drugs, or drugs that were originally developed to treat other diseases, such as beta-blockers and anticonvulsant medications. A better understanding of the basic pathophysiological mechanisms of migraine and other types of headache has led to the development over the past two decades of more target-specific drugs. Since activation of the trigeminovascular system and neurogenic inflammation are thought to play important roles in migraine pathophysiology, experimental studies modeling those events successfully predicted targets for selective development of pharmacological agents to treat migraine. Basically, there are two fundamental strategies for the treatment of migraine, abortive or preventive, based to a large degree on the frequency of attacks. The triptans, which exhibit potency towards selective serotonin (5-hydroxytryptamine, 5-HT) receptors expressed on trigeminal nerves, remain the most effective drugs for the abortive treatment of migraine. However, numerous preventive medications are currently available that modulate the excitability of the nervous system, particularly the cerebral cortex. In this chapter, the pharmacology of commercially available medications as well as drugs in development that prevent or abort headache attacks will be discussed.

PMID: 20816410 [PubMed - in process]

Cephalalgia. 2010 Sep;30(9):1101-9. Epub 2010 Mar 19.

Cortical hyperexcitability and mechanism of medication-overuse headache.
Supornsilpchai W, le Grand SM, Srikiatkhachorn A.

Department of Physiology, Faculty of Medicine, Chulalongkorn University, Patumwan, Bangkok, Thailand.

Abstract
The present study was conducted to determine the effect of acute (1 h) and chronic (daily dose for 30 days) paracetamol administration on the development of cortical spreading depression (CSD), CSD-evoked cortical hyperaemia and CSD-induced Fos expression in cerebral cortex and trigeminal nucleus caudalis (TNC). Paracetamol (200 mg/kg body weight, intraperitonealy) was administered to Wistar rats. CSD was elicited by topical application of solid KCl. Electrocorticogram and cortical blood flow were recorded. Results revealed that acute paracetamol administration substantially decreased the number of Fos-immunoreactive cells in the parietal cortex and TNC without causing change in CSD frequency. On the other hand, chronic paracetamol administration led to an increase in CSD frequency as well as CSD-evoked Fos expression in parietal cortex and TNC, indicating an increase in cortical excitability and facilitation of trigeminal nociception. Alteration of cortical excitability which leads to an increased susceptibility of CSD development can be a possible mechanism underlying medication-overuse headache.

PMID: 20713560 [PubMed - in process]

WHAT IS THE BEST ORAL APPLIANCE:MAD VS TRD

I AM FREQUENTLY ASKED WHAT IS THE BEST ORAL APPLIANCE. THIS IS A RECENT ARTICLE PUBLISHED IN THE JOURNAL SLEEP.

IT COMPARES TONGUE STABILIZATION WITH MANDIBULAR ADVANCEMENT APPLIANCES.

MANDIBULAR ADVANCEMENT APPPLIANCES HAVE BETTER COMPLIANCE, IE PATIENTS USED THEM MORE. I THINK THAT PATIENTS NEED TO SEE SLEEP APNEA DENTISTS WITH EXPERIENCE WITH MANY TYPES OF APPLIANCE AND WHO UNDERSTAND TMJ DISORDERS AND NEUROMUSCULAR DENTISTRY.

THERE IS NO BEST ORAL APPLIANCE BUT THERE MAY BE A BEST APPLIANCE FOR A SPECIFIC PATIENT AND SPECIFIC SYMPTOMS AN ANATOMY.

Sleep. 2009 May 1;32(5):648-53.
Comparison of mandibular advancement splint and tongue stabilizing device in obstructive sleep apnea: a randomized controlled trial.

Deane SA, Cistulli PA, Ng AT, Zeng B, Petocz P, Darendeliler MA.
Department of Orthodontics, Faculty of Dentistry, University of Sydney, Sydney Dental Hospital, Sydney, Australia.
Erratum in:
Sleep. 2009 Aug 1;32(8):table of contents.

Abstract

STUDY OBJECTIVES: To compare the efficacy of a mandibular advancement splint (MAS) and a novel tongue stabilizing device (TSD) in the treatment of obstructive sleep apnea (OSA).
DESIGN: A randomized crossover design was used.
PATIENTS: Twenty-seven patients (20 male, 7 female), recruited from a tertiary hospital sleep clinic.
MEASUREMENTS AND RESULTS: The apnea-hypopnea index (AHI) was reduced with MAS (11.68 +/- 8.94, P = 0.000) and TSD (13.15 +/- 10.77, P = 0.002) compared with baseline (26.96 +/- 17.17). The arousal index decreased for MAS (21.09 +/- 9.27, P = 0.004) and TSD (21.9 +/- 10.56, P = 0.001) compared with baseline (33.23 +/- 16.41). Sixty-eight percent of patients achieved a complete or partial response with MAS, compared with 45% with TSD. The Epworth Sleepiness Scale (ESS) score was decreased with MAS (P = < 0.001) and TSD (P = 0.002). Subjective improvements in snoring and quality of sleep were reported, with a better response for MAS than TSD. Compliance was poorer for TSD, and the side effect profiles of the 2 modalities were different. All patients were satisfied with MAS compared to TSD, and 91% of patients preferred the MAS.
CONCLUSION: Objective testing showed the MAS and TSD had similar efficacy in terms of AHI reduction. Patients reported improvements with both devices; however, better compliance and a clear preference for MAS was apparent when both devices were offered. Longer term studies are needed to clarify the role of TSD

CPAP Failure is Common. 60% of Patients Abandon CPAP and Users Average Only 4-5 Hours A Night

The following blog entry is reprint of a JANUARY 2010 press release. I am frequently asked what is the best sleep apnea treatment or what is the best CPAP machine. The best treatment for sleep apnea is not a simple question as it will vary between patients. One thin we no for certain, the best treatment is a treatment that is used. CPAP machines sitting in your closet do not constitute the best treatment. The press release below discusses the fact that the majority of patients do not use their CPAP. CPAP is not the best treatment for those patient. Dr Ira L SHAPIRA (PRESS RELEASE FOLLOWS BELOW)

CPAP is still considered the Gold Standard of treatment even though the majority of patients discontinue use. CPAP failure occurs do to lack of patient compliance not because CPAP is not effective. CPAP is very effective when used all night.

CPAP failures are common and everyone is left frustrated. Patients feel like failures because they are frequently unaware of the fact that up to 60% of patients fail CPAP. Spouses are upset and worried, their loved ones are not only disturbing their sleep with loud snoring but they are also worried about heart attacks and stokes. Patients with untreated sleep apnea have a 36% decrease in 8 year survival compared to treated patients.

Patients with untreated apnea are more likely to die in their sleep than while exercising . They have slower reaction times than someone who is legally drunk and have a sis-fold increase in motor vehicle accidents. The number one reason for CPAP failures is that patients "Hate CPAP!"

Dr Ira Shapira is a pioneer in the field of Dental Sleep Medicine who did research as a visiting assistant professor at Rush Medical School in Chicago in the 1980's. After treating patients with oral appliances for over 25 years he was very excited when the American Academy of Sleep Medicine changed their parameters of care and determined that oral appliances along with CPAP were a first line standard of care for snoring and mild to moderate apnea treatment. The AASM also said that oral appliances were an alternative to CPAP for severe apnea when patients do not tolerate CPAP.

The National Sleep Foundation the declared that "oral Appliances are a Therapy Whose Time has Come!" in SleepMatters their regular magazine.

Dr Shapira who is a Diplomate of The American Board of Dental Sleep Medicine and a member of the AASM, DOSA and the ADSM realized that even though the appliances were extremely effective many patients were still unaware of oral appliances. While more knowledgable sleep physicians were referring patients for oral appliances most patients were unaware of this option. Studies have shown that patients prefer comfortable oral appliances to CPAP when offered a choice. Dr Shapira created the website http://www.ihatecpap.com because "i HATE CPAP!" was the number one statement he heard from patients over the years when he asked why they wanted an oral appliance.

The website is extremely popular with over 10,000 individual visits a month. Thousands of patients have found out about oral appliances at the area of the site (http://www.ihatecpap.com/oral_appliance.html) on oral appliances which has photos of many appliances.

The I HATE CPAP! website has been so successful that Dr Shapira has now created a new site http://www.ihateheadaches.org that helps patients with migraines, chronic daily headaches, sinus headaches and tension headaches find help thru Neuromuscular Dentistry.

The NHLBI considers Sleep Apnea to be a TMJ disorder and published a report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" In their report they state " About 60-90% of cases appear to experience satisfactory resolution of symptoms with a range of interventions" This is actually better results than almost any drug regiment for treating migraines or chronic daily headaches.

Dr Barry Cooper published a paper in Cranio that describes "overwhelming relief" of TMJ symptoms and headaches after treatment with a neuromuscular dental orthotic. The I HATE Headaches! website offers help to patients tired of living in pain. TMJ disorders are often called "The Great Imposter" because there are so many symptoms such as headaches and migraines that patients do not associate with bite problems or their jaws.

An excellent resource for patients with TMJ disorders or headaches is a story in Sleep and Health Journal "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR" which can be found at http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor.
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Dr Ira L Shapira is an author and section editor of Sleep and Health Journal, President of I HATE CPAP LLC, President Dato-TECH. He was a founding and certified member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine, A founding member of DOSA, the Dental Organization for Sleep Apnea. He is a Diplomate of the American Board of Dental Sleep Medicine, A Diplomat of the American Academy of Pain Management. He is a former assistant professor at Rush Medical School's Sleep Service where he did research. Dr Shapira is a consultant to sleep centers and teaches courses in Dental Sleep Medicine in his office to doctors from around the U.S. He is the Founder of I HATE CPAP LLC and http://www.ihatecpap.com Dr Shapira also holds several patents on methods and devices for the prophylactic minimally invasive early removal of wisdom teeth and collection of bone marrow and stem cells. Dr Shapira is a licensed general dentist in Illinois and Wisconsin.