Medicare and Tricare coverage for oral appliances

Medicare, Tricare and other government insurances should cover oral appliances but that does not mean it will be easy. Medicare requires dentists form a DME, then pays poorly, See question from Eduardo received 8/31/12

Question from Eduardo: Why has my dentist taken so long to see if I can get an oral appliance for sleep apnea and snoring. Also I need to know if most of your Dentist take medicare and Tricare for life, I need to get something going.The doctor I have is taking too long I aplied back in May 2012 and still nothing

Dr Shapira response: Unfortunately while covered by medicare most docs won't take it. Medicare requires that an the dentist has a DME and choice of appliances is very limited. I do not accept medicare and have opted out and medicare patients pay my fee. My office is near great lake navak base but tricare has never paid for an appliance.

The good news is that CPAP is very successful if you can tolerate it. If not you must be proactive with Tricare and/or medicare that they find you a provider.

My suggestion is just to pay out of pocket if you can afford it otherwise get on CPAP while waiting for approval.

The good news about untreated sleep apnea is that it can kill you......the bad news is that it can cause a stroke!

IRA L SHAPIRA DDS, D,ABDSM, D,AAPM, FICCMO

There are several questions when it comes to Medicare coverage. First is whether medicare can afford to take on the cost of oral appliances considering the majority of seniors have some sleep disordered breathing. The requirement that dentists form DME's for each office is ridiculous, expensive and cumbersome. The proper approach is for Medicare to contract with Medicare approved labs that make appliances for sleep apnea and to pay the lab cost directly to the manufacturer. The dentist professional fee should be governed by standard Medicare B pay codes and fees. The alternative is that dentists opt out and patients make private arrangements for professional services.

Medicare should cover appliance manufacturers for the appliance based on specific appliances. My personal feelings is that there should be a minimal qualification of the dentist to have medicare cover the lab costs. A good idea might be to use diplomate status in the AADSM. Dentists who do not meet requirements would just do private contracts for the full amount. The dentist would not need to participate in Medicare but could if they desired.

Labs would have to meet Medicare standards for coverage, a difficult to define and ever changing target. Because labs serve thousands of dentists it would be financially effective.

It should be clearly understood that medicare would limit the number of appliance types.

In Illinois, Southern Wisconsin I personally treat patients with medicare after an opt out is signed. Patients who opt out of medicare can use the appliance of their choosing but must pay for it themselves.

Survey on Sleep Apnea for patients and physicians

Sarika Mahajan Sharma posted on I HATE CPAP's Wall "Hi everyone, We are MBA students at the University of Dallas in Irving, TX. We are currently conducting a study onObstructive Sleep Apnea (OSA), and the various treatment options available for it. Kindly take one of the surveys below if you are suffering from OSA, or if you are a physician that treats OSA patients. It will only take about 3 minutes of your time and will be an extremely valuable contribution to our study. We would appreciate it greatly if you can also forward this survey to anybody you know that has or treats OSA. If you are an Obstructive Sleep Apnea Patient, please take this survey -https://www.surveymonkey.com/s/sleepapfb If you are a physician treating OSA patients, please take this survey -https://www.surveymonkey.com/s/sleepdocs

Overweight and are unwilling or unable to use CPAP: Learn about new study

The majority of patients are unable to use CPAP and oral appliances are usually the single best treatment. Katy McNulty has informed me of a free study for overweight patients unable or unwilling to utilize CPAP. The study is done in Atlanta but you do not need to live in Atlanta. Morbid obesity is a contraindication to a comfortable oral appliance but merely being overweight is common and oral appliances are usually a comfortable and effective alternative to CPAP.

Please mention I HATE CPAP if you contact Katy and send me your feedback.

STUDY INFORMATION FOLLOWS:

We are conducting a clinical trial in Atlanta that your audience might find interesting. It's for people who are overweight and are unwilling or unable to use CPAP. I pasted the link to the study information below.

http://www.atlantasleep.com/osaovw

	Katy	McNulty
Contact Email:		kmcnulty@neurotrials.com
Contact Phone:		404-851-9934

DO I HAVE TO WEAR A CPAP ( BiPAP) MACHINE FOR THE REST OF MY LIFE?

This is a frequent question asked by patients with sleep apnea that is treated with CPAP> There are many answers to that question. Obviously the best alternative to CPAP is an oral appliance for most patients but there are also many other alternatives.

While the majority of patients complain about CPAP and 60% discontinue using it completely it is important to remember that one i four patients using CPAP love their CPAP machines, masks and hoses. They give them back their lives and these patients have no desire to be free from CPAP.

Their are alternatives to CPAP and Oral Appliances. Weight loss is very effective for some patients who see their obstructive sleep totally resolve with weight loss.

WEIGHT LOSS ALONE IS NOT EFFECTIVE FOR ELIMINATING OBSTRUCTIVE SLEEP APNEA FOR MOST PATIENTS. IT WILL ALMOST ALWAYS REDUCE THE SEVERITY OF SLEEP APNEA BUT THE TRUTH IS THAT MANY PATIENTS ORIGINALLY GAINED THE WEIGHT DUE TO SLEEP APNEA. METBOLIC SYNDROME IS WEIGHT GAIN DUE TO APNEA AND RELATED HORMONAL DISRUPTIONS.

MANY THIN AND/OR ATHLETIC PATIENTS HAVE SLEEP APNEA DUE TO THEIR ABNOMAL (pathologic) ORAL PHARYNGEAL ANATOMY.

PATIENTS WITH POSITIONAL SLEEP APNEA USUALLY RESPOND WELL TO WEIGHT LOSS THERAPY.

Positional therapy is excellent for patients who only have apnea episodes on their back (supine). A danger in this treatment is patients who no longer have apneas or hypopneas may now have UARS or RERAs.

Bimaxillary advancement surgery is the most effective long term surgical solution. i strongly suggest that prior to surgery an oral appliance trial be done. It will predict success but also increase success rates because the amount of advancement necessary can be determined prior to surgery.

Morbidly obese patients are not good canidates for oral appliances or jaw advancement surgeries. Bariatric surgery to first lose weight it probably a more reasonable first step. Any surgery is more dangerous in the morbidly obese and in patients with sleep apnea.

OBSTRUCTIVE SLEEP APNEA, WOMEN SNORE AND HAVE SLEEP APNEA OFTEN IN CONJUNCTION WITH TMJ DISORDERS

Jacque: I am a 51 year old woman and have snored most of my life. Sleep study said Chronic Obstructive blahblah and the doc told me I had the WORST sleep patterns he had ever seen. Tried CPAP...NO WAY...couldn't stand it. Had shots in the back of my throat...didn't work. Tried a mouth appliance about 5 years ago and it flared up my TMJ terrrrrribly. So I was just wondering what my options are or if you mouth devices don't flare up the jaw?

DR SHAPIRA RESPONSE: Sleep Apnea and TMJ disorders have the same underlying causes, functions and problems. Usually we treat patients with TMJ disorders with an appliance that is worn 24 hours/day 7 days a week. This is done to stabilize the jaw joints (Temporomandibular Joints, TMJ), relax the muscles and control facial pain, TM Joint pain, headasches, migraines, sinus pain, ear pain, stuffiness in the ears, tinnitus, and other numerous symptoms.

For sleep apnea patients we usually use an appliance that is only worn at night and give the patient exercises that return the jaw to its original pathologic position. The original position is pathologic because it does no perform the single most important function of maintaining a patent airway. This works well for the majority of patients without problems. Patients with TMJ disorders may need their appliances adjusted with design changes or alterations based on symptoms.

Long Term research has shown bite changes but not negative changes to the TM Joints. Most symptoms of TMD from oral appliances to treat sleep apnea will be only during initial treatment. Long term problems are rare.

The best treatment would be combining TMJD and Sleep Apnea treatment.

This is accomplished with a small comfortable diagnostic neuromuscular orthotic during the day and a MAD sleep apnea appliance at night. Most TMJ problems are caused by the jaw healing at night but the muscles resist going back to your original pathologic position in the morning. This combination treatment allows the jaw joints and muscles to heal at night and supports this healthier position during the day. It no longer requires the patient to return to their original pathologic position.

An interesting fact is the changes in bite seen with oral appliances is actually healing.

Dr Shapira Response:

"Life is not about waiting for the storms to pass - it is learning to dance in the rain!"

SEVERE SLEEP APNEA? BEST TREATMENT MAY BE AN ORAL APPLIANCE.

Donna:

I have severe sleep apnea I was tested and my breathing is interrupted or slowed 71 times during the sleep study. Will any of these alternatives work for me and do you take health insurance? Dr Shapira response: Donna, I have good news you are probably an excellent candidate for an oral appliance for treating sleep apnea. A total of 71 awakenings from sleep apnea over the course of a full night sleep would put you in the mild to moderate range of apnea where oral appliances and CPAP are considered a first line treatments of sleep apnea. Medical insurance will usually cover treatment with an orl appliance subject to deductibles and co-insurance. Most insurance companies understand that untreated sleep apnea is dangerous and treating the effects of untreated sleep apnea is more expensive than treating the sleep apnea.

Sleep Apnea Diagnosis Can Make Health And Life Insurance Extremely Expensive. Insurance Agents Have Experienced Problems Insuring Clients

Sleep Apnea Diagnosis Can Make Health And Life Insurance Extremely Expensive. Insurance Agents Have Experienced Problems Insuring Clients Diagnosed With Sleep Apnea.

Adverse Insurance Ratings can be avoided by doing off the grid sleep studies.

Sleep Apnea is a dangerous problem that can lead to heart attacks, strokes, excessive daytime sleepiness, short-term memory loss and increases in motor vehicle accidents. It is essential to diagnose and treat sleep apnea. One study showed a 36% decrease in 8 year survival comparing treated and untreated sleep apnea. Learn more about the dangers of sleep apnea @ http://www.ihatecpap.com/sleep_apnea_dangers.html

A problem frequently experienced is that the cost of health, life and disability insurance policies can increase exponentially following diagnosis of sleep apnea. This is problematic for owners of small businesses and wealthy individuals who utilize life insurance to protect their estates.

Financially savvy patients are turning to off the record sleep studies. Patients pay for their sleep studies and treatment in cash to avoid any footprints of the diagnosis. Patient’s records may be identified only by numerical accounts or convenient name misspellings or addition of new names can protect patient’s identities. (Example Barack Obama could become Eric B Obama).

Cash payment secures patient privacy. HIPPA regulations theoretically protect our personal medical information. When obtaining new insurance you forfeit these HIPPA rights in order to qualify for coverage. Insurance benefits can be denied in the future if there is a record of undisclosed illness.

There are two primary treatments for sleep apnea, CPAP and Oral Appliances. Severe Sleep Apnea especially in morbidly obese patients is usually CPAP initially and an Oral Appliance for patients who don’t tolerate CPAP. Studies have shown that the majority of patients reject CPAP and prefer comfortable oral appliances when offered a choice of treatments. Learn more about Oral Appliance therapy for Sleep Apnea at http://www.ihatecpap.com.

Patients who are interested in off the grid sleep studies can contact Dr Ira L Shapira, a Gurnee, Il dentist who has been treating Sleep Apnea with oral appliances since the early 1980’s. As a Visiting Assistant Professor at Rush Medical Schools Sleep Center he did research on jaw position and Sleep Apnea.

Dr Shapira is a Diplomate of the American Board of Dental Sleep Medicine and practices Dental Sleep Medicine at Delany Dental Care in Gurnee and at Chicagoland Dental Sleep Medicine Associates in Skokie, Schaumburg and Vernon Hills. In Skokie his practice is located in American Sleep Medicine and in Vernon Hills he utilizes the office of Sleep and Behavioral Medicine.

http://www.delanydentalcare.com/sleep_apnea.html

http://www.chicagoland.ihatecpap.com/

Dr Shapira realizes the importance of accurate diagnosis and treatment of sleep apnea but also understands the financial impact a diagnosis of sleep apnea can create. Working to create both value and privacy for his patients he arranges for off the grid sleep studies. Baseline studies are essential for diagnosis and titration sleep studies insure treatment efficacy. Post-treatment studies are essential for Oral Appliance Therapy and for CPAP therapy.

Special off the grid pricing has been arranged for Dr Shapira’s sleep patients desiring privacy. Contact Dr Shapira at 1-8-NO-PAP-MASK or at 847-623-5530 for more information on insuring your medical privacy.

Dr Shapira stresses that avoiding sleep studies can have serious medical consequences. Diagnosis and Treatment are the most important medical considerations.

Grinding (Bruxism )appliances and Sleep Apnea: Can a grinding appliance make Sleep Apnea Worse? The answer is a definite maybe.

A recent article inthe Journal of Oral Rehabilitation examined the question as to whether a grinding appliance could make sleep apnea aworse. ( of 18 patients showed increases in AHI when their bites were opened without mandibular advancement but only 2 were significantly changed. The article considers whether the vertical opening is responsible for increasing AHI but it is also possible that grinding and/or clenching habits may be protective of the airway and the utilization of these appliances may reduce that activity that is protective against sleep apnea.

It has been previously reported that bruxism appliances can increase sleep apnea in some patients.


J Oral Rehabil. 2011 Apr 5. doi: 10.1111/j.1365-2842.2011.02221.x. [Epub ahead of print]
The effect of raising the bite without mandibular protrusion on obstructive sleep apnoea.
Nikolopoulou M, Naeije M, Aarab G, Hamburger HL, Visscher CM, Lobbezoo F.
Source

Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE, University of Amsterdam and VU University Amsterdam, Amsterdam Department of Clinical Neurophysiology and Center for Sleep-Wake Disorders, Slotervaart Medical Center, Amsterdam, The Netherlands.
Abstract

Summary  It has recently been suggested that wearing a maxillary occlusal splint (i.e. a hard acrylic resin dental appliance that covers the occlusal surfaces of the maxillary dentition and that is being indicated for the treatment of, e.g. temporomandibular pain) may be associated with a risk of aggravating obstructive sleep apnoea (OSA). The present study tested the hypothesis that raising the bite without mandibular protrusion in OSA patients is associated with an increase in the apnoea-hypopnoea index (AHI). Eighteen OSA patients (13 men; 49·5 ± 8·1 years old) received a mandibular advancement device in 0% protrusion of the mandible (0%MAD). The MAD caused a bite rise of 6 mm as measured interincisally. Polysomnographic recordings were obtained at baseline and with the 0%MAD in situ. No statistically significant difference in AHI was noted between the baseline night and the 0%MAD night. However, nine patients had an aggravation in AHI during the night they used the 0%MAD. Taking into account the previously established smallest detectable difference of 12·8 in AHI, the AHI increased in only two of the patients. The outcomes of this study suggest that an increased jaw gape without mandibular protrusion might be associated with a risk of aggravation of OSA for some, but not for all OSA patients. Dental practitioners should be aware of this possible association when treating patients with oral devices that raise the bite.

© 2011 Blackwell Publishing Ltd.

PMID:
21463349
[PubMed - as supplied by publisher]

GOOD NEWS - BAD NEWS ABOUT SLEEP APNEA

The good news about sleep apnea is that it easily diagnosed and treated.

The bad news is that sleep apnea can cause Hypertension and an estimated 50-70% of people with sleep apnea have hypertension, or high blood pressure. This increases the risk for heart attack, stroke, and other health problems.

The Good news is that sleep apnea is easily and effectively treated with CPAP.

The bad news about sleep apnea is that 60% of patients diagnosed with sleep apnea cannot tolerate CPAP. When sleep apnea is not treated it can lead to Coronary Heart Disease. Sleep apnea can lead to activation of the sympathetic nervous system which is responsible for the “fight-or-flight” response. Sleep apnea also is responsible for problems with the lining of blood vessels, inflammation, and problems with metabolic regulation.

The good news is that oral appliances are a comfortable alternative to CPAP.

The bad news is that your doctor probably never told you that oral appliances are considered a first line treatment for mild to moderate sleep apnea. Because patients are unaware of this effective and comfortable alternative to CPAP they are at increased risk for Stroke, Chronic Heart Failure and Sudden Death.

The association between stroke and sleep apnea according to considerable research is as convincing as the association between smoking and stroke. During apneic episodes the blood vessels of the brain dilate when the oxygen levels fall. Patients with sleep apnea are more susceptible to clots that may lead to stroke. Research has shown that the number of strokes in patients with untreated sleep apnea are staggering and that 40-60% of people experiencing strokes have been found to have obstructive sleep apnea. In addition to stoke sleep apnea leads to chronic heart failure and numerous serious cosequences from this condition as well as a staggering risk of dying in their sleep. Half of patients with sleep apnea die between midnight and 6 AM compared to only 21% of patients without sleep apnea.

The good news is that weight loss can improve sleep apnea.

The bad news is that it is almost impossible for patients with untreated sleep apnea to lose weight because of metabolic changes associated with their sleep apnea.

The good news is that oral appliances are effective for treating sleep apnea and that the vast majority of patients prefer them to CPAP. Patients who treat their sleep apnea with oral appliances usually have more energy and find it easier to exercise and to lose weight.

The bad news is that patients who treat their sleep apnea with oral appliances need to save more for retirement.

The good new is the reason they need to save more is because they live longer.

The bad news about sleep apnea is that patients with untreated sleep apnea have a six-fold increase in motor vehicle accidents and slower reaction times than drivers who are legally drunk.

The good news is effective treatment with CPAP or a comfortable oral appliance reduces that risk to to normal. Also good news is that recent studies have shown that when properly titrated oral appliances can be as effective as CPAP for a majority of patients with severe sleep apnea.

The bad news is that snoring and associated sleep apnea can lead to marital difficulties, separate bedrooms, reduced sex drive and even impotence. According to a study at Mayo Clinic spouse of snorers lose up to 15% of their sleep. According to anecdotal evidence I have seen this pisses them off.

The good news is that there are oral appliances with volume controls for the spouse to turn off the snoring and eliminate sleep apnea. The bad news is your spouse will live longer, no thats the good news.

Saving Marriages: Elimination of Snoring and Sleep Apnea Can Improve Marriages Inside and Outside the Bedroom

Snoring is often considered funny ,but it can seriously disrupt otherwise good marriages. The spouses of snorers lose up to 15% of their sleep according to Mayo Clinic. This can lead to shortened tempers, weight gain, daytime sleepiness and buried anger and hostility for your spouse. Frequently, it leads to one of the partners leaving the marriage bed on search of quiet.

Sleep Apnea, is usually characterized by snoring and excessive daytime sleepiness but other symptoms can be devastating to marriage tranquility. Communication breakdown is frequent due to short term memory loss associated with untreated sleep apnea. Motor vehicle accidents, personality changes and trouble at work are also frequently seen in patients with sleep apnea.

Of course there are many medical problems associated with sleep apnea and snoring but often the damage to interpersonal relationships can be the most damaging. There is frequently hostility directed toward the patient who refuses treatment.

The primary reason patients refuse treatment is the the "HATE CPAP!". Studies have shown that 60 % of patients abandon CPAP. Not wanting to wear CPAP is also a major reason that patients avoid being evaluated for sleep apnea. This avoidance can lead to heart attacks, strokes and other serious medical consequences.

It is vital that sleep apnea be treated effectively but it does not matter if the effective treatment is CPAP, BiPAP, and Oral appliance or surgery.

Childhood Sleep Disorderes, ADD, ADHD and other "Mental Disorders"

I was directed here from a childhood sleep forum after investigating the connection between sleep and ADHD and other mental illnesses from the book It's Not Mental and the blog on sleep being a causative factor.

I didn't know alternative devices to CPAP even existed, and have a family member who absolutely hates the CPAP and the parents will be very happy with the information you have provided.

Thank you!

Dr Shapira Response: Research is finding that sleep is involved in almost every physiologic and disease process to some extent. I believe that early intervention with young children willl make incredible changes in developing children. Research has shown that the speed of brain development is strongly affected by the quality of sleep (especially in the case of sleep apnea). Patients with undiagnosed and untreated sleep apnea have permanent changes in brain development.

Treatment of pediatric sleep apnea is often limited to removal of tonsils and adenoids and this can be a grave mistake. The developmental changes in the oral, nasal and pharyngeal tissues do not normalize after T&A surgery.

Orthopedic widening of the maxilla (and maybe mandible) is incredibly safe and effective in children should always be considered as part of the total treatment. It has also been suggested that Rapid Maxiallry Expmansion or RME be considered prior to removal of tonsils oradenois to reduce surgical risk and morbidity. I frequently build expansion into appliances that treat sleep apnea. The same bite changes that are considered problematic in some adults are actually beneficial to children wearing oral appliances.

Parents in the Midwest have access to Dr Alexander Golbin (http://chicagosbmi.com/about-us) who is a leading expert on children and sleep disorders. He wrote the book on Children's Sleep and was head of Child Psychiatry at cook County Hospital for 25 years. He is an excellent resource for parents of children with Autism, ADD, ADHD, and bedwetting and other developmental challenges.

I have an adult practice with the exception of children with sleep disordeers, TMJ disorders, TMD or chronic headaches. Chronic headaches in children and adolescents are almost always related to the stomtognathic sytem including teeth, jaws, jaw joints, jaw muscles, sinus regions and the all important Trigeminal Nerve.

I have thousands of visitors sent to my site from other health blogs and I thank you for listing my site on those blogs. We can improve the health and quality of life for patients

Cardiologists embrace oral appliances as an alternative treatment to CPAP for sleep apnea

Cardiologists have long recognized that sleep apnea is a leading cause of hypertension (high blood pressure), heart attacks and strokes. Cardiologists have referred patients for sleep studies and CPAP therapy for years. Cardiologists have become disillusioned by the poor compliance with CPAP that has been documented in patients with sleep apnea. The majority of patients with mild apnea as well as moderate and severe sleep apnea reject CPAP in large numbers. A recent study showed 60% of patients abandon CPAP therapy.

Cardiologists who are proponents of sleep apnea treatment are referring more and more patients for oral appliance therapy as an alternative to CPAP. They recognize that CPAP therapy is worthless if it is not used. Oral appliances are considered a first line treatment for mild to moderate sleep apnea. Oral appliance therapy is also an alternative to CPAP for severe sleep apnea when patients do not toleratte CPAP.

THE MAJORITY OF PATIENTS DO NOT TOLERATE CPAP!!! MEDICARE IS NO LONGER COVERING CPAP THERAPY FOR PATIENTS WHO DO NOT USE CPAP ON A REGULAR BASIS. MOST PATIENTS DO NOT USE CPAP ON A REGULAR BASIS.

Cardiologists are more comfortable referring patients for CPAP but have come to realize that patients are much more compliant with oral applainces than CPAP.

This means that patients use their oral appliances to treat their sleep apnea. Cardiologists know this is vital to their patients health. While CPAP may be more effective for some patients it is a total treatment failure for those patients who do not use their CPAP.

In addition to heart attacks and stroke untreated sleep apnea can also cause short term memory loss, lead to drammatic increases n motor vehicle accidents because patients with untreated sleep apnea have slower reaction times than patients who are legally intoxicated. Untreated sleep apnea can increase severity and speed of onset of Alzheimer's and Dementia, is implicated in up to 80% of ADD and ADHD in children, can increase the severity of metabolic problems from diabetes to obesity.

The National Sleep Foundation has declared that oral appliances are a therapy whose time has come!

The American Academy of Sleep Medicine considers oral appliances to be a first line treatment for mild to moderate sleep apnea.

The American Academy of Dental Sleep Medicine has published reports on the success of treating severe sleep apnea with comfortable oral appliances.

MORBIDLY OBESE PATIENTS SHOULD STILL CONSIDER CPAP AS THE TREATMENT OF CHOICE. A RECENT STUDY SHOWED THAT PROPERLY TITRATED ORAL APPLIANCES ARE EQUALLY EFFECTIVE TO CPAP FOR SLEEP APNEA PATIENTS.

THE UNITED STATES GOVERNMENT HAS ENDORSED ORAL APPLIANCES FOR TREATING SLEEP APNEA BY ACCEPTING DENTAL SLEEP MEDICINE FOR COVERAGE UNDER MEDICARE.

THE NEW MEDICARE POLICY ALSO RECOGNIZES THE DISMAL COMPLIANCE RATES OF CPAP WITH NEW MINIMAL USAGE REQUIREMENT FOR CPAP COVERAGE. THIS NEW POLICY WILL BENEFIT EVERYONE AS MANUFACTURERS AND DME'S WORK TO INCREASE COMPLIANCE WITH CPAP.

Chronic Cough? Sleep apnea evaluation is probably indicated according to new article in Journal Cough.

A new article in the Journal Cough suggests that patients with chronic cough should be evaluated for obstructive sleep apnea (OSA). The article "Chronic cough and obstructive sleep apnea in a community-based pulmonary practice." details evaluation of 75 chronic cough patients. 38 of these patients were evaluated for OSA and 33 were positve for OSA. That translates into 44% of all patients had OSA. That also translates into over 86% of patients with a chronic cough were positive for sleep apnea. The authors also reported "93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough" which is an incredible relief. This is especially true since CPAP causes cough in some patients. The patients who did not get relief from CPAP should be evaluated on an oral appliance. Oral Appliances are better tolerated than CPAP by the majority of patients with obstructive sleep apnea.

The article Quantifying chronic cough: objective versus subjective measurements." from Respirology. 2010 Nov 5 discusses counting coughs and this approach could be used in patients to see if there is a circadian pattern to the coughs in apnea vs non-apnea patients. The authors stated "Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity" .

A major fault of the authors, Sundar KM, Daly SE, Pearce MJ, Alward WT was that they did not go back and evaluate the other 37 patients for sleep apnea. I assume that the other patients were not "typical" sleep apnea patients but many patients with sleep apnea do not fit the typical pattern of obese, thick neck and older male patient. If the 86% OSA figure was consistent throughout the Chronic cough population than perhaps chronic cough would be an absolute indication for sleep apnea testing.

Another interesting correlation would be to GERD (gastroesophageal reflux) and OSA which is a known risk factor for GERD. GERD accounted for 37% of cough population as a single etiology but GERD was also involved in multiple etiologies cough in 31 of the 75 patients. Multiple etiologies for the chronic cough included: GERD-upper airway cough syndrome (UACS), 31%, GERD-cough variant asthma (CVA), 5%, and GERD-UACS-CVA 3%

There is a commonality between cough, breathing, TMJ disorders and oral and pharyngeal reflexes. These reflexes that control breathing and pharyngeal structures are well described by A J Miller in "ORAL AND PHARYNGEAL REFLEXES IN THE MAMMALIAN NERVOUS SYSTEM: THEIR DIVERSE RANGE IN COMPLEXITY AND THE PIVOTAL ROLE OF THE TONGUE"

I have frequent references to his work in the www.ihateheadaches.org site and the www.ihatecpap.com site. These reflexes have direct effects on swallowing and breathing two essential functions of the jaws, tongue and oral cavity. Chronic misuse of these structures leads to repetitive strain injuries to the muscles and joints. These are frequently lumped into a junk diagnosis of TMJ, TMD, MPD, myofascial pain, Myofacial pain and are associated with sleep disorders, chronic pain, fibromyalgia and other central sensitization disorders involving the trigeminal nerve.

Cough. 2010 Apr 15;6(1):2.
Chronic cough and obstructive sleep apnea in a community-based pulmonary practice.
Sundar KM, Daly SE, Pearce MJ, Alward WT.

Intermountain Utah Valley Pulmonary Clinic, 1055N, 300W, Provo, UT 84604, USA. krishna.sundar@imail.org
Abstract
BACKGROUND: Recent reports suggest an association between unexplained chronic cough and obstructive sleep apnea (OSA). Current guidelines provide an empiric integrative approach to the management of chronic cough, particularly for etiologies of gastroesophageal reflux (GERD), upper airway cough syndrome (UACS) and cough variant asthma (CVA) but do not provide any recommendations regarding testing for OSA. This study was done to evaluate the prevalence of OSA in patients referred for chronic cough and examine the impact of treating OSA in resolution of chronic cough.

METHODS: A retrospective review of chronic cough patients seen over a four-year period in a community-based pulmonary practice was done. Patients with abnormal chest radiographs, abnormal pulmonary function tests, history of known parenchymal lung disease, and inadequate followup were excluded. Clinical data, treatments provided and degree of resolution of cough was evaluated based on chart review. Specifically, diagnostic testing for OSA and impact of management of OSA on chronic cough was assessed.

RESULTS: 75 patients with isolated chronic cough were identified. 44/75 had single etiologies for cough (GERD 37%, UACS 12%, CVA 8%). 31/75 had multiple etiologies for their chronic cough (GERD-UACS 31%, GERD-CVA 5%, UACS-CVA 3%, GERD-UACS-CVA 3%). 31% patients underwent further diagnostic testing to evaluate for UACS, GERD and CVA. Specific testing for OSA was carried out in 38/75 (51%) patients and 33/75 (44%) were found to have obstructive sleep apnea. 93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough.

CONCLUSIONS: OSA is a common finding in patients with chronic cough, even when another cause of cough has been identified. CPAP therapy in combination with other specific therapy for cough leads to a reduction in cough severity. Sleep apnea evaluation and therapy needs to considered early during the management of chronic cough and as a part of the diagnostic workup for chronic cough.

PMID: 20398333 [PubMed]PMCID: PMC2861010Free PMC Article

Respirology. 2010 Nov 5. doi: 10.1111/j.1440-1843.2010.01893.x. [Epub ahead of print]
Quantifying chronic cough: objective versus subjective measurements.
Faruqi S, Thompson R, Wright C, Sheedy W, Morice AH.

Division of Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, United Kingdom. HU16 5JQ.
Abstract
Background and objective: The assessment of chronic cough has been improved by the development of objective ambulatory cough monitoring systems and subjective quality of life questionnaires. Experimental induction of cough is a useful tool in the assessment of the cough reflex. We wanted to assess the reproducibility of and association between these measurements. Methods: This was a prospective observational study in patients with chronic cough of greater than six months duration. All patients had an initial 24 hour cough recording. They also completed a Leicester Cough Questionnaire, a Symptom Assessment Score, a Visual Analogue Score for cough and had a capsaicin cough challenge performed. They were reviewed at 8 weeks when all assessments were repeated. Results: The study included 25 patients (15 females) with a mean age of 54 years. The median cough count at the second visit (302) was significantly lower compared to the first visit (381, p<0.01). However the cough counts at both the visits correlated well (r=0.9. p<0.01).All the other forms of assessment were found to be highly reproducible at 8 weeks (r= 0.6-0.9, p<0.01). Cough counts correlated well with the other forms of assessment (r= 0.4-0.6, p<0.01). There was good correlation between each of the subjective forms of assessment (r= 0.6, p<0.01). Conclusions: The various forms of assessment of cough are reproducible. Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity. It appears to lie between these latter two assessments of cough and may represent the best global objective synthesis of cough.

© 2010 The Authors. Respirology © 2010 Asian Pacific Society of Respirology.
PMID: 21054670 [PubMed - as supplied by publisher]

WHAT IS THE GOLD STANDARD OF TREATMENT FOR SLEEP APNEA?

THE QUESTION OF WHAT IS THE BEST SLEEP APNEA TREATMENT IS ACTUALLY A VERY POOR QUESTION. THE CORRECT QUESTION IS WHAT IS THE BEST SLEEP APNEA TREATMENT FOR A SPECIFIC PATIENT. Most patients prefer oral appliances to CPAP.

CPAP or Continuous Positive Air Pressure has long been considered the "Gold Standard" for treating sleep apnea. It is extremely effective when patients use it but patient compliance has always been a major problem It is interesting that the NHLBI lists oral appliances before CPAP. (See website info below) but also says that oral appliances are for mild apnea and snoring while it has now been shown that when properly titrated Oral Appliances are equally effective to CPAP for treating mild to moderate sleep apnea. Oral Appliances are also considered to be an alternative to CPAP when it is not tolerated.

The NHLBI website states
"The goals of treating sleep apnea are to:
Restore regular breathing during sleep
Relieve symptoms such as loud snoring and daytime sleepiness
Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes."

Approximately one in four CPAP users actually meet those goals. Those patients generally adapt easily to CPAP and rarely go without using it. 60% of patients abandon CPAP entirely and 15% struggle with it and use it in less that effective manner. It is the 75% that are not adequately treated with CPAP that usually utilize oral appliances or surgery. Oral Appliances are also not tolerated by everyone and patients need significant numbers of teeth or implants to use many types of appliances. While most patients prefer oral appliances to CPAP there are some patients who do not tolerate appliances and must seek alternative treatments.

This Goal statement is a very interesting statement. Is use of CPAP a restoration of "Normal Breathing" or "Regular Breathing" ? I would propose that an effectively titrated oral appliance actually restores both regular and normal breathing. CPAP breathing is not "normal" trhough it may be regular. BiPAP breathing is probably closer to "normal" breathing.

Secondly treatment should relieve snoring and daytime sleepiness. Daytime sleepiness is an interesting aspect as it can be measured subjectively (patient opinion) or objectively by MSLT (multiple sleep latency test) or MWT (Maintenance of Wakefulness Test)

Patients utilizing oral appliances frequently report being more rested with an oral appliance than when treated with CPAP even when the CPAP machine gave more complete resolution of AHI. This may be a difference between regular and normal breathing.

The statement "Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes" is extremely important. Treatment of sleep apnea has numerous health benefits. These benefits are achieved with CPAP, Surgery and Oral Appliances.

The NHLBI site also discusses that some patients may benefit from surgery. It is important to note that the surgery must meet the goals stated. Soft palate surgery does not restore regular breathing and should be cosidered adjunctive surgery not curative surgery.


THE FOLLOWING INFORMATION IS TAKEN FROM THE NATIONAL HEART LUNG AND BLOOD INSTITUTE WEBSITE http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html

How Is Sleep Apnea Treated?

Lifestyle changes, mouthpieces, breathing devices, and surgery are used to treat sleep apnea. Medicines typically aren't used to treat the condition.

The goals of treating sleep apnea are to:

Restore regular breathing during sleep
Relieve symptoms such as loud snoring and daytime sleepiness
Treatment may improve other medical problems linked to sleep apnea, such as high blood pressure. Treatment also can reduce your risk of heart disease, stroke, and diabetes.

If you have sleep apnea, talk with your doctor or sleep specialist about the treatment options that will work best for you.

Lifestyle changes and/or mouthpieces may be enough to relieve mild sleep apnea. People who have moderate or severe sleep apnea may need breathing devices or surgery.

If you continue to have daytime sleepiness despite treatment, your doctor may ask whether you're getting enough sleep. (Adults should get at least 7 to 8 hours of sleep; children and adolescents need more.)

If treatment and enough sleep don't relieve your daytime sleepiness, your doctor will consider other treatment options.

Lifestyle Changes

If you have mild sleep apnea, some changes in daily activities or habits may be all the treatment you need.

Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep.
Lose weight if you're overweight or obese. Even a little weight loss can improve your symptoms.
Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
Keep your nasal passages open at night with nasal sprays or allergy medicines, if needed. Talk with your doctor about whether these treatments might help you.
If you smoke, quit. Talk with your doctor about programs and products that can help you quit smoking.
Mouthpieces

A mouthpiece, sometimes called an oral appliance, may help some people who have mild sleep apnea. Your doctor also may recommend a mouthpiece if you snore loudly but don't have sleep apnea.

A dentist or orthodontist can make a custom-fit plastic mouthpiece for treating sleep apnea. (An orthodontist specializes in correcting teeth or jaw problems.) The mouthpiece will adjust your lower jaw and your tongue to help keep your airways open while you sleep.

If you use a mouthpiece, tell your doctor if you have discomfort or pain while using the device. You may need periodic office visits so your doctor can adjust your mouthpiece to fit better.

Breathing Devices

CPAP (continuous positive airway pressure) is the most common treatment for moderate to severe sleep apnea in adults. A CPAP machine uses a mask that fits over your mouth and nose, or just over your nose. The machine gently blows air into your throat.

The air presses on the wall of your airway. The air pressure is adjusted so that it's just enough to stop the airways from becoming narrowed or blocked during sleep.

Treating sleep apnea may help you stop snoring. But not snoring doesn't mean that you no longer have sleep apnea or can stop using CPAP. Sleep apnea will return if CPAP is stopped or not used correctly.

Usually, a technician will come to your home to bring the CPAP equipment. The technician will set up the CPAP machine and adjust it based on your doctor's prescription. After the initial setup, you may need to have the CPAP adjusted on occasion for the best results.

CPAP treatment may cause side effects in some people. These side effects include a dry or stuffy nose, irritated skin on your face, dry mouth, and headaches. If your CPAP isn't adjusted properly, you may get stomach bloating and discomfort while wearing the mask.

If you're having trouble with CPAP side effects, work with your sleep specialist, his or her nursing staff, and the CPAP technician. Together, you can take steps to reduce these side effects. These steps include adjusting the CPAP settings or the size/fit of the mask, or adding moisture to the air as it flows through the mask. A nasal spray may relieve a dry, stuffy, or runny nose.

There are many types of CPAP machines and masks. Tell your doctor if you're not happy with the type you're using. He or she may suggest switching to a different type that may work better for you.

People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP.

Surgery

Some people who have sleep apnea may benefit from surgery. The type of surgery and how well it works depend on the cause of the sleep apnea.

Surgery is done to widen breathing passages. It usually involves shrinking, stiffening, or removing excess tissue in the mouth and throat or resetting the lower jaw.

Surgery to shrink or stiffen excess tissue in the mouth or throat is done in a doctor's office or a hospital. Shrinking tissue may involve small shots or other treatments to the tissue. A series of such treatments may be needed to shrink the excess tissue. To stiffen excess tissue, the doctor makes a small cut in the tissue and inserts a small piece of stiff plastic.

Surgery to remove excess tissue is done in a hospital. You're given medicine that makes you sleep during the surgery. After surgery, you may have throat pain that lasts for 1 to 2 weeks.

Surgery to remove the tonsils, if they're blocking the airway, may be very helpful for some children. Your child's doctor may suggest waiting some time to see whether these tissues shrink on their own. This is common as small children grow.

Sleep Apenea Surgery: Soft Palate Surgery is rarely, if ever a first line treatment for sleep apnea.

There are only two first line treatments for Sleep Apnea, CPAP and Oral Appliances. CPAP is extremely effective but the majority of patients abandon CPAP use due to comfort issues. Oral Appliances are a first line treatment for mild to moderate sleep apnea and an alternative to CPAP for the 60% of patients who abandon CPAP and those who use CPAP but just want to experience a more comfortable alternative to CPAP.

Note: For the morbidly obese CPAP is still the best treatment, for younger thinner and healthier patients oral appliances are effective and easy to fit into busy lifestyles.

Surgery, especiall soft palate surgery used to be considered a first line of treatment for sleep apnea but dismal results and high morbidity have relegated soft palate surery to a secondary proceedure, at best.

There were several types of soft palate surgery but the grandfather of all was the UP3, UPPP surgery or Uvulopalatopharyngoplasty. This surgery was excruciatingly painful, had a high morbidity and was usually unsuccessful in treating sleep apnea. According to Wikipedia the risks of UP3 surgery include:

"One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP experienced a worsening of their breathing following UPPP.
Others have spoken of severe acid reflux.
After surgery, complications may include these:
Sleepiness and sleep apnea related to post-surgery medication
Swelling, infection and bleeding
A sore throat and/or difficulty swallowing
Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery.
Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
Patients who have had the uvula removed will become unable to correctly speak French or any other language that has a uvular 'r' phoneme."

All surgeries to the soft palate carry risk and are painful. The LAUP procedure or Laser Assisted Uvuloplasty was less painful than up3 but still very painful. There was less chance of scarrig that dangerously narrowed the airway as seen with UP3.

Somnoplasty of the soft palate was less painful but equally ineffective in treating sleep apnea. Somnoplasty is a procedure to consider in patients with soft palate snoring and no sleep apnea. Other surgical alternatives are snoreplasty and pillars which again are useful for snoring but minimally helpful for treating sleep apnea.

Tracheotomy is the grandfather of surgeries and allows patients to breathe thru their throats. It is very successful but most patients do not want a long term tracheotomy.

The majority of sleep apnea is caused by the base of the tongue obstructing the airway or pressing on the epiglottis that blocks the airway.

There are several procedures that can be done to either advance the tongue or make it smaller. Somnoplasty on the base of the tongue is probably the preferred surgery for most patients contemplating reducing tongue size.

MaxilloMandibular Advancement is probably the most successful sleep apnea surgery but is extensive surgery carring definite risks. I strongly recommentd that patients undergoing this rocedure avoid ENT's and Plastic Surgeons and utilize Oral Surgeons with extensive experience in this type of surgery. The dental background of Oral surgeons make themthe first choice. They frequently do these surgeries for orthodontic purposes and understand stomatognathic function.

PATIENTS CONTEMPLATING MAXILLOMANDIBULAR ADVANCEMENT SHOULD ALMOST ALWAYS GO THRU A TRIAL OF AN ORAL APPLIANCE TO DETERMINE THE BEST POSITION FOR THE JAWS AFTER THIS RADICAL SURGERY. THIS WILL PREVENT NEEDLESS SECONDARY SURGERIES.

Nasal surgery is frequently helpful but rarely is a cure for apnea when done alone. Correction of deviated septums and turbinate reduction offer greater comfort for most patients with obstructed breathing due to anatomical or allergic problems.

Nasal surgery is usually and ENT procedure but is frequently one by oral surgeons as well.

Pediatric patients with sleep apnea are usually candidates for removal of tonsils and adenoids. While effective at opening the pharyngeal airway newer research suggests that orthodontic widening of the hard palate should be done either before or after T&A procedures. Widening prior to surgery may reduce post-operative complications.

Sleep apnea is probably responsible for at least 80% of the cases ADD and ADHD in children. The earlier the airway obstructions are addressed the healthier it is for future development.

ORAL APPLIANCES TREATING SLEEP APNEA REDUCE BLOOD PRESSURE SIMILAR TO CPAP.

A FREQUENT QUESTION IS WHETHER SLEEP APNEA IS BEST TREATED WITH CPAP OR ORAL APPLIANCES. ARE THE MEDICAL RESULTS AS EFFECTIVE WITH ORAL APPLIANCES? THE RESEARCH SAYS ORAL APPLIANCES ARE AS EFFECTIVE AS CPAP IN REDUCING SYMPTOMS WHEN IT IS USED EFFECTIVELY.

THE BEST SLEEP APNEA TREATMENT IS ONE THAT IS USED ON A REGULAR BASIS. IT IS WELL ESTABLISHED THAT CPAP FAILS THE MAJORITY OF PATIENTS DUE TO COMPLIANCE ISSUES. WHEN COMPLIACE IS FACTORED INTO TREATMENT EFFECTIVENESS ORAL APPLIANCES ARE THE MOST EFFECTIVE AND BEST TREATMENT OF MILD TO MODERATE SLEEP APNEA. ORAL APPLIANCE EFFICACY MUST BE CONFIRMED BY OVERNIGHT POLYSOMNOGRAPHY.

CARDIOLOGISTS ARE RECOGNIZING THAT CPAP TYHERAPY IS INEFFECTIVE IN MOST PATIENTS DUE TO POOR COMPLIANCE.

Sleep. 2004 Aug 1;27(5):934-41.
Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial.

Gotsopoulos H, Kelly JJ, Cistulli PA.
Department of Respiratory & Sleep Medicine, St George Hospital, The University of New South Wales, Sydney Australia.
Comment in:
Sleep. 2004 Aug 1;27(5):842-3.

Abstract

STUDY OBJECTIVE: To investigate the short-term effect (4 weeks) of oral appliance therapy for obstructive sleep apnea on blood pressure.
DESIGN: Randomized, controlled, crossover trial.
SETTING: Multidisciplinary sleep disorders clinic in a university teaching hospital.
PATIENTS: Sixty-one patients diagnosed with obstructive sleep apnea on polysomnography (apnea hypopnea index > or = 10 per hour and at least 2 of the following symptoms--daytime sleepiness, snoring, witnessed apneas, fragmented sleep; age > 20 years; and minimum mandibular protrusion of 3 mm).
INTERVENTION: A mandibular advancement splint (MAS) and control oral appliance for 4 weeks each.
MEASUREMENTS AND RESULTS: Polysomnography and 24-hour ambulatory blood pressure monitoring were carried out at baseline and following each 4-week intervention period. Patients showed a 50% reduction in mean apnea hypopnea index with MAS compared with the control and a significant improvement in both minimum oxygen saturation and arousal index. There was a significant reduction with the MAS in mean (+/- SEM) 24-hour diastolic blood pressure (1.8 +/- 0.5 mmHg) compared with the control (P = .001) but not in 24-hour systolic blood pressure. Awake blood-pressure variables were reduced with the MAS by an estimated mean (+/- SEM) of 3.3 +/- 1.1 mmHg for systolic blood pressure (P = .003) and 3.4 +/- 0.9 mmHg for diastolic blood pressure (P < .0001). There was no significant difference in blood pressure measured asleep.
CONCLUSION: Oral appliance therapy for obstructive sleep apnea over 4 weeks results in a reduction in blood pressure, similar to that reported with continuous positive airway pressure therapy

Dangerous Consequences of Pediatric Sleep Apnea: Diagnosing and treating sleep apnea is vital to lifetime quality of life.

Question from Sylvia: What are the most common symptoms in children with sleep apnea? Does it affect their brain if left untreated

Dr Shapira Response: Dear Sylvia,
Great Question! There are many short term and long term problems related to sleep apnea. 80% of all ADD and ADHD are related to apnea. There are studies that show both delayed development and permanent changes in brain devlopment.

There are also hormonal (endocrine) changes that affect growth and development.

It is vitally important to children of all ages to iagnose and treat sleep apnea ASAP. Children may never recover from damages that occur in their first few years of life. I have publishe just a few studies below. Recent studies have shown tonsilectomy and adenoid removal may be insufficient treatment and that palatal widening is usually indicated in these patients. Pediatric may be better treated by doing rapid maxillary expansion prior to T&A surgery to create a better post-op healing situation.

It is never to soon to treat sleep apnea. snoring and even minimal apnea AHI of 1 or more should never be ignored but rather taken as an ominus sign of future developmental problems that can be prevented.

I would like to offer my highest recommendation to Dr Alexander Golbin at Sleep and Behavioral Medicine for Chicago area patients. Dr Ira L Shapira

See Pub Med abstracts below:

Pediatr Pulmonol. 2009 May;44(5):417-22.
Neurocognitive and behavioral impact of sleep disordered breathing in children.
Owens JA.

Department of Ambulatory Pediatrics, Rhode Island Hospital, Providence, Rhode Island 02903, USA. owensleep@gmail.com
Abstract
The consequences of poor quality and/or inadequate sleep in children and adolescents have become a major public health concern, and one in which pediatric health care professionals have become increasingly involved. In particular, insufficient and/or fragmented sleep resulting from primary sleep disorders such as obstructive sleep apnea (OSA), often compounded by the presence of comorbid sleep disorders as well as by voluntary sleep curtailment related to lifestyle and environmental factors, has been implicated in a host of negative consequences. These range from metabolic dysfunction and increased cardiovascular morbidity to impairments in mood and academic performance. The following review will focus on what is currently known about the effects of sleep disordered breathing (SDB) specifically on neurobehavioral and neurocognitive function in children. Because of the scarcity of literature on the cognitive and behavioral impact of sleep disorders in infants and very young children, this review will target largely the preschool/school-aged child and adolescent populations. In addition, the focus will be on a review of the most recent literature, as a supplement to several excellent previous reviews on the topic.

Sleep Med. 2010 Aug;11(7):714-20.
Autonomic alterations and endothelial dysfunction in pediatric obstructive sleep apnea.
Kheirandish-Gozal L, Bhattacharjee R, Gozal D.

Department of Pediatrics and Comer Children's Hospital, Pritzker School of Medicine, The University of Chicago, IL 60637, USA. lgozal@peds.bsd.uchicago.edu
Abstract
The cardiovascular consequences of obstructive sleep apnea syndrome (OSAS) in children have started to emerge over the last decade. It is clear that the respiratory and sleep alterations that characterize this relatively prevalent condition induce substantial alterations in autonomic nervous system control, ultimately generating high sympathetic outflow and reactivity that reflect an imbalance between sympatho-excitatory and vagal inhibitory inputs. In addition to these important consequences, the constitutive elements of OSAS also elicit a rather extensive activation of systemic inflammatory pathways that in turn pose substantial risk to the integrity and functional homeostasis of the endothelial network. The complex interactions between the multiple injury-associated pathways recruited by OSAS are further compounded by the potential release of angiogenic factors and by the mobilization and homing of progenitor cells that have the potential to repair and restore the OSAS-disrupted vascular function. Improved characterization of the mechanisms involved in every one of these processes and identification of the determinants of susceptibility in pediatric populations along with the interactions with obesity will clearly modify our approaches to OSAS in the future.

PMID: 20620107 [PubMed - in process]

Clin Chest Med. 2010 Jun;31(2):221-34.
Pediatric obstructive sleep apnea syndrome.
Katz ES, D'Ambrosio CM.

Division of Respiratory Diseases, Department of Medicine, Children's Hospital, Mailstop 208, 300 Longwood Avenue, Boston, MA 02115, USA. eliot.katz@childrens.harvard.edu
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common and serious cause of metabolic, cardiovascular, and neurocognitive morbidity in children. Children with OSAS have increased upper airway resistance during sleep due to a combination of soft tissue hypertrophy, craniofacial dysmorphology, neuromuscular weakness, or obesity. Consequently, children with OSAS encounter a combination of oxidative stress, inflammation, autonomic activation, and disruption of sleep homeostasis. The threshold amount of OSAS associated with adverse consequences varies widely among children, depending on genetic and environmental factors. The choice of therapy is predicated on the etiology, severity, and natural history of the increased upper airway resistance.

PMID: 20488283 [PubMed - in process]

Pediatr Ann. 2008 Jul;37(7):465-70.
The snoring child.
Perez IA, Ward SL.

Keck School of Medicine, University of Southern California, Division of Pediatric Pulmonology, Childrens Hospital Los Angeles, 90027-6062, USA.
Abstract
Snoring is a common manifestation of obstructive sleep apnea and represents one end of the spectrum of sleep-related breathing disorders. Children with primary snoring initially may develop OSAS later, so inquiring about symptoms of OSAS should be part of each visit. Obstructive sleep apnea can result in serious cardiovascular and metabolic consequences and neurocognitive deficits. Adenotonsillar hypertrophy remains the most common cause of OSA although the rising prevalence of obesity is of increasing importance. Polysomnography remains the gold standard in the diagnoses of OSAS and in assessing the risks associated with surgery. Most children with OSAS can be treated with adenotonsillectomy in the ambulatory surgery center. However, there are children at risk for severe OSAS and for postoperative complications, who will need PICU care. In addition to adenotonsillectomy, OSAS can be treated successfully in referral centers with other surgical approaches and by the use of positive airway pressure. Children with obesity-related OSAS often require CPAP or BPAP for control of OSAS.

PMID: 18710136 [PubMed - indexed for MEDLINE]

Nasal Symptoms from CPAP Decreased with Heated Humidification. Patients Prefer Oral Appliances.

This blog entry is a reprint of a recent press release:

Nasal CPAP frequently causes problematic nasal symptoms including congestion, dry nasal tissues, nasal itchin, and sinus pain. A recent study showed that heated humidification decreases nasal inflamation.

FOR IMMEDIATE RELEASE

PRLog (Press Release) – Jul 03, 2010 – A recent study "Nasal inflammation in sleep apnoea patients using CPAP and effect of heated humidification." (see PubMed abstract below) looked at nasal symptoms caused by nasal CPAP. CPAP is considred the gold stanard of treatment but is rejected by 60% of patients accoring to recent studies. Many patients abandon CPAP in favor of Comfortable Oral Appliances http://www.ihatecpap.com The current study concluded that heated humidification "nasal obstruction of OSA patients on CPAP treatment is inflammatory in origin, and the addition of heated humidification decreases nasal resistance and mucosal inflammation. "

The percentage of patients who tolerate CPAP is usually determined by the initial experience with CPAP. CPAP suppliers should consider starting CPAP on all patients with the use heated humidification to improve compliance.

Many studies have shown that oral appliances have much higher compliance and patient satisfaction ratings than CPAP. There is a growing sentiment that for mild to moderate sleep apnea and snoring Dental Sleep Medicine and Oral Appliances should precede CPAP trial.

Oral Appliance compliance and patient satisfaction far exceeds those ratings for CPAP. Examples of many oral appliances can be found at: http://www.ihatecpap.com/oral_appliance.html

Patients in Chicago, Northern Illinois an Southern Wisconsin should contact Dr Ira L Shapira at Chicagoland Dental Sleep Medicine Associates for information and treatment of sleep apnea and snoring with a comfortable appliance.

Dr Shapira can be reached at 1-8-NO-PAP-MASK or thru his websites:
http://www.chicagoland.ihatecpap.com/
http://www.delanydentalcare.com/sleep_apnea.html
http://www.ihateheadaches.org
http://www.ihatecpap.com

Eur Respir J. 2010 Jul 1. [Epub ahead of print]
Nasal inflammation in sleep apnoea patients using CPAP and effect of heated humidification.
Koutsourelakis I, Vagiakis E, Perraki E, Karatza M, Magkou C, Kopaka M, Roussos C, Zakynthinos S.

Medical School of Athens University, Dept of Critical Care and Pulmonary Services, Evangelismos Hospital.
Abstract
Nasal continuous positive airway pressure (CPAP) can cause undesirable nasal symptoms such as congestion to obstructive sleep apnoea (OSA) patients, which symptoms can be attenuated by the addition of heated humidification. However, neither the nature of nasal symptoms nor the effect of heated humidification on nasal pathophysiology and pathology are convincingly known. Twenty patients with OSA on nasal CPAP who exhibited symptomatic nasal obstruction were randomized to receive either 3 weeks of CPAP treatment with heated humidification or 3 weeks of CPAP treatment with sham-heated humidification, followed by 3 weeks of the opposite treatment, respectively. Nasal symptom score, nasal resistance, nasal lavage interleukin-6, interleukin-12 and tumour necrosis factor-a, and nasal mucosa histopathology were assessed at baseline and after each treatment arm. Heated humidification in comparison with sham-heated humidification was associated with decrease in nasal symptomatology, resistance and lavage cytokines, and attenuation of inflammatory cell infiltration and fibrosis of the nasal mucosa. In conclusion, "nasal obstruction of OSA patients on CPAP treatment is inflammatory in origin, and the addition of heated humidification decreases nasal resistance and mucosal inflammation. Trial Registration clinicaltrials.gov Identifier: NCT00850876.

PMID: 20595158 [PubMed - as supplied by publisher]

# # #

Dr Shapira is the founder of I HATE CPAP LLC that promotes awareness of the dagers of sleep apnea and promotes the field of Dental Sleep Medicine.

He is a Diplomate of the American Board of Dental Sleep Medicine and founder of Chicagoland Dental Sleep Medicine Associates. He is a former Assistant Professor at Rush Medical School's Sleep center and has been involved in research and treatment of sleep apnea with oral appliances since the early 1980's.

Dr Shapira also founded I HATE Headaches LLC and the website www.ihateheadaches.org. He has several device and/or method patents on collection of stem cells from the jaws and developing wisdom tooth buds.

Dr Shapira is the Dental Section Editor of Sleep and Health Journal and has chaptered a chapter in a bmedical textbook on Anti-Aging Medicine.

Delany Dental Care was founded in 1984 as a general dental practice with special emphasis on treating sleep apnea, snoring, headaches, migraines and Temporomandibular (TMJ) disorders

Restless Legs and Celiac Disease

Below is an interesting abstract that ties restless legs to low serum feritin and restless legs to Celiac disease.. Sometimes restless legs is tied to UARS or RERA's other times it is due to low feritin levels or other problems.



Sleep Med. 2009 Aug;10(7):763-5. Epub 2009 Jan 12.
Celiac disease as a possible cause for low serum ferritin in patients with restless legs syndrome.
Manchanda S, Davies CR, Picchietti D.

University of Illinois at Urbana-Champaign, College of Medicine, 506 S. Mathews Avenue, Suite 190, Urbana, IL 61801, USA. smanchan@illinois.edu
OBJECTIVE: To describe celiac disease (CD) as a possible cause for low serum ferritin in patients with restless legs syndrome (RLS). BACKGROUND: Low iron stores have been found to be a risk factor for RLS with serum ferritin levels less than 45-50 ng/mL associated with increased severity of RLS. It has become routine clinical practice to test serum ferritin in the initial assessment of RLS. CD is a common genetic disorder that can cause iron deficiency. METHODS: Consecutive case series of four patients with RLS and serum ferritin below 25 ng/mL, who had positive screening tests for celiac disease. RESULTS: We report four patients who had serum ferritin < 12 ng/mL and positive screening tests for CD. All had CD confirmed by duodenal biopsy and response to a gluten-free diet. RLS symptoms improved in all four, with two able to discontinue RLS medication and two responding without medication. CONCLUSIONS: In patients with RLS and low serum ferritin who do not have an obvious cause for iron deficiency, we suggest looking for CD by simple, inexpensive serologic testing. Diagnosis and treatment of CD is likely to improve the outcome for RLS, as well as identify individuals who are at risk for the significant long-term complications of CD.

PMID: 19138881 [PubMed - indexed for MEDLINE]

Secret Weight Loss Hormone Now Available for Free. Leptin Can Be Your Answer! Lose Weight /Cure Sleep Apnea

Sleep Apnea and weight(BMI)have long been linked. Leptin and ghrelin are two hormones that are intimately linked to sleep and weight loss or weight gain. Leptin is the hormone that helps suppress your appetite and increase your metabolism. Increases in Leptin will make it easier to lose wieght because the cravings and nervous eating are decreased by this powerful appetite suppressant. It is not available at pharmacies and not covered by insurance but you can start to receive free doses immediately.

People who sleep less hours produce less leptin and tend to have lower blood levels of leptin. Low levels of this important hormone that helps suppress your appetite and increase your metabolism causes weight gain. Poor sleep,as seen with untreated sleep apnea will aslo decrease leptin production. Sleep loss also tends to increase your level of the hormone ghrelin. Grehlin stimulates your appetite which makes trying to diet a difficult ordeal. As a result of these two hormones people who sleep less may crave more and eat more. They especially may crave and eat more foods that are unhealthy. Patients in studies with sleep restriction have been shown to crave sweets, starch and salty snacks as a result of that sleep restriction.

TO RECEIVE YOUR FREE LEPTIN: SEVEN AND ONE HALF HOURS OF GOOD SLEEP IS THE ANSWER. iF YOU HAVE SLEEP APNEA MAKE SURE IT IS TREATED ALL NIGHT/ EVERY NIGHT.

Dieters have stuggled for years with every conceivable type of diet to produce weight loss. Sleeping better may be the easy answer to solving your weight issues.

There are several cycles in sleep and control of thyroid hormone and insulin hormone as well as cortisol the stress hormone are also affected by poor sleep. Disrupted sleep seen with sleep apnea can exacerbate all of these issues. With better sleep we are more active during the day which also increases our metabolism. With sleep apnea our oxygen levels are lower and our physiology slows down. The first period of Delta Sleep is where our body produces the majority of Growth Hormone. If that is disrupted by sleep apnea we are more likely to build up fat in our bodies at the expense of lean muscles according to a Universit of Chicago study.

The "Sleep Diet" may be the answer you have been looking for and a part of solving our national health crisis. Obesity in the U.S. is rising at an alarming pace among all age groups and all races and both sexes. The majority of Americans are overweight or obese with estimates of 60-75% of the population falling in these categories. The weight alone increases risks of high blood pressure,cancer and cardiovacular diseases including atherosclerosis, heart attack and stroke.

Research has shown many intriguing links between sleep quality, sleep quantity and BMI. Sleeping fewer hours tends increse the BMI to higher levels than people who sleep longer. Numerous studies have linked sleep to some of the hormones that help control body weight and appetite. There is no question about the link of sleep to insulin resistance and sugar metabolism. Obstructive sleep apnea probably repesents the single biggest risk of obesity because apnea is resposible fer massive in several health risks. Even mild sleep apnea and/or snoring related arousals can disrupt sleep patterns sufficienty to destroy normal sleep patterns and hormonal controls.

While good sleep may not be a total answer for obesity there is no doubt that improving the quality and quantity of healthy sleep will make weight loss easier both emotionally and physically on patients.