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.

Incomplete Resolution of Sleep Apnea Can Be Corrected With Tongue Tapper

I recently had a request from a Dentist about how the Tongue Tapper works. It is something that I add to an oral appliance on occasion when incomplete resolution of sleep apnea is a problem.

Don: Dr.S, In one of the recent AADSM forum discussions you mentioned a tongue tapper to help with tongue reflexes. Can you share how you do that with a MAD? Thank.

Dr Shapira Response:I use a 1 mm ortho spring wire from either the lower or upper appliance with a small composite or acrylic button that very lightly touches the posterior lateral surface of the tongue. If the tongue drops back and touches it elicits a protrusive reflex of the tongue.

Light touch not brute force similar to how tonsils cause tongue thrusts.

THERE ARE MANY ORAL AND PHARYNGEAL REFLEXES THAT CAN EFFECT BREATHING IN SLEEP. THE TONGUE TAPPER TAKES ADVANTAGE OF ONE OF THESE REFLEXES TO CREATE TONGUE PROTRUSION. ONE OF THE REASONS I LIKE THE TAP 1 APPLIANCE IS THAT IT ELIMINATES OR DECREASES RETRUSIVE TONGUE REFLEXES.

tHE MOSES APPLIANCE IS DESIGNED TO PREVENT RETRUSIVE REFLEXES AS WELL.

The Inventor of CPAP, Colin Sullivan is speaking on the emerging role of Dental Sleep Medicine in treating Sleep Apnea

I have just received the following post that Colin Sullivan the inventor of CPAP is speaking in Germany at the Dental Sleep Meeting on the Role of Dental Sleep Medicine.

I have heard an unconfirmed rumor that Colin Sullivan the inventor of CPAP actually wears an oral appliance. I have e-mailed him for confirmation but he has not yet replied.

""Dear All,
Next weekend there will be the 10th symposium on dental sleep medicine of our German Academy of Dental Sleep Medicine DGZS in Bremen, Northern Germany.
You find the program here www.dgzs.de/tagungen.

This year I have invited Prof. Colin Sullivan , the CPAP inventor, for the key note lecture to speak to our DGZS dental sleep professionals.

He gave a great lecture at the Asian Sleep conference last year in Osaka and talked about the emerging role of dental sleep medicine.

I have recommended to the AADSM board to invite Prof. Sullivan for the key note lecture in Minneapolis 2011 J

Best regards

Susanne Schwarting""

SUAD not Working: what about combination therapy?

Comment: Steve Would like information about OPAP treatment for sleep apnea.

Comment Christy
Hello,
Steven my name is Christy I work with Dr. Ira Shapira in the Chicago-land area. He is the founder of the ihatecpap web site. The site is dedicated for alternative treatment to the machines. We have sleep apnea trained dentist all around the country. Where exactly do you live what the closest larger city. Please forward me this info and I will try to locate someone in your area to help you.
Keep Smiling
Christy

Steve:
I live closest to Philadelphia. I have a custom made oral appliance (Suade device/?spelling). While I have noted some improvement, I still have sleep apnea. I suspect I could tolerate and would benefit from CPAP if the machine were attached to an oral appliance with appropriate connections. I was unable to tolerate conventional CPAP with face mask.
I have not been able to find any local practitioners who offer that particular option (oral appliance with connector to allow connection to CPAP unit), but rather only offer oral appliances.
Thanks for your help. It is really, really appreciated.

Dr Shapira

I frequently see out of town patients in my Gurnee office but I am sending you contact info for George a regional sales manager for TAP who has the best appliance interface but would require a new appliance. I am copying this e-mail to George.

The OPAP is not my favorite appliance. There is considerable danger of inflating stomache which is problematic

CPAP Pro also makes an appliance that attatches to an appliance but does not advance the mandible.

It is possible to add an extension to the maxillary portion of the SUAD and connect a nasal mask with Velcro to the appliance extension. It is also possible to connect to CPAP Pro

Without access to you sleep study I do not know details but some patients can use a positioner to stay off their back in conjunction with an appliance if there is a positional component to the sleep apnea.

Another option is to revamp SUAD and reshape to remove retrusive reflex contacts to tongue and/or add protrusive tongue reflex aaptations.

Occasionally adding an anterior vertical stop to a SUAD can improve success as can additional anterior moverment. I usually do not use a SUAD as an initial appliance but titrate with TAP ! and then make SUAD to the titrated treatment position.

The TAP 1 appliance is still the the most effective appliance due to ability to advance mandible beyond maximum protrusion and ease of titration during sleep study. The TAP 3 fits the new interface that Keith Thornton designed. They also can make a custom fit nasal mask connected to TAP 3

There are always custom appliances that can improve efficacy but are not FDA approved.

The full Breath appliance invented by Bryan Keropian also works via a different method of maintaining airway by rstraining the tongue.

I hope this is helpful.

Dr Ira L Shapira

"Oral appliance therapy for obstructive sleep apnea is an effective treatment and ideal for use in military recruits" ACCORDING TO NEW STUDY

A study reported in the January, 2010 Sleep and Breathing discusses effectiveness of oral appliances in treating sleep apnea. The study also showed that periodic leg movements occured in a small subset of patients during oral appliance titration. This problem has been shown previously to occur with CPAP as well. This can be a cause of continued tiredness after treatment with CPAP or an Oral Appliance and is another reason to always have a sleep study to evaluate CPAP OR ORAL APPLIANCE THERAPY SUCCESS.

Frequently low (normal) ferritin levels can cause periodic leg movements and this should be evaluated prior to drug therapy for restless leggs.

I have also had patients see relief of leg movements by taking calcium/magnesium supplements.


(PubMed abstract)
Sleep Breath. 2010 Jan 23. [Epub ahead of print]
Oral appliance titration in patients with obstructive sleep apnea induces the appearance of periodic limb movements.
Guerrero ML, Kim D, Rupp TL, Balkin TJ.

Department of Behavioral Biology, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA, Melanie.guerrero@us.army.mil.
STUDY OBJECTIVES: Oral appliance (OA) therapy is considered a first line choice of therapy for some patients with mild or moderate obstructive sleep apnea (OSA) and an alternative form of treatment in those intolerant of continuous positive airway pressure (CPAP) use. According to several studies, periodic limb movements (PLM) appear during effective treatment of OSA with CPAP, but a similar phenomenon has not been described with the use of oral appliance. Herein, we describe the incidence of PLM in patients with OSA who underwent oral appliance therapy titration. DESIGN: This is a prospective, observational study set in a six-bed sleep center in an academic, military referral hospital. PATIENTS AND METHODS: Patients with OSA (n = 21; 15 men and six women; mean age, 43 years; and age range, 25 to 53 years) treated with OA during a 1-year period were enrolled. Patients were categorized according to the severity of sleep apnea and incidence of PLM on diagnostic polysomnography. Effective treatment of OSA and appearance or disappearance of PLM with arousal on subsequent oral appliance titration polysomnography were recorded and compared. RESULTS: Twenty-one patients were enrolled. During baseline polysomnography, three of 21 (14%) patients had five or more PLM with arousal per hour while 11 of 21 (52%) patients had PLM with arousal during the oral appliance titration trial. CONCLUSION: Oral appliance therapy for obstructive sleep apnea is an effective treatment and ideal for use in military recruits. The appearance of periodic limb movements with arousal during oral appliance use should be considered as a cause of persistent daytime sleepiness despite effective treatment of obstructive sleep apnea in this subset of patients.

Bite Change with TAP 3 Oral Appliance Cures Sleep Apnea But Changes Your Bite. What comes next?

JIM:
I have a TAP3 appliance for OSA and I found that using it every night for 2 years changed my bite to where I could not get it back into alignment even using the little blue tabs every day. I am back on CPAP, but if you have any suggestions, I would love to hear them.

Dr Shapira Response: Bite changes often happen after long term year especially if patients do not do 2 minutes of exercise daily. I have a few thousand patients with oral appliances and rarely do they quit because of bite changes. Not wearing the appliance will often let bite settle back to its original position or possibly settle back incompletely.

I explain to my patients up-front about the changes because I hate surprises. The reasons that your bite changes is that it was pathological to begin with. The reason you had sleep apnea was due to a jaw relation that predisposed you to the problem. When you wore the appliance at night you corrected the 24/7 pathology eight hours a day. Your bite change is actually healing of the underlying pathology of your jaw position. Your apnea actually becomes less severe even when you are not wearing your CPAP. Therefore when they titrate you on CPAP it may be wrong in a few months. As your jaw returns to old position the apnea will worsen again. An advantage to a bite change is lower CPAP pressure initially.

Patients sometimes switch between oral appliances and CPAP to prevent bite changes (very effective) but in general dentists seem more upset by the bite changes than patients.

I have had many patients who report relief of neck pain, headaches, back pain, sinus pain and other problems and that pushing the bite back causes recurrence of symptom so they chose to ignore the exercises and let the bite changes happen.

When we treat patients with TMJ disorders or headaches we have them wear an appliance 24/7 and want the bite change an then if tx is successful make the new jaw position permanent with crowns, ortho or occlusal adjustment.

You did not say wether you are now wearing your CPAP all night - every night. Dying in your sleep or having a stroke is a big deal, a bite change is manageable.

The key to preventing bite changes is to do the exercises regularly from the beginning and continue. If bite changes begin discuss it with your dentist promptly.

Why Don't Sleep Doctors, Sleep Centers, Sleep Techs and DME's tell patients that CPAP fails most patients?

A Recent John Hopkins University study published in August 2009 in PloS Medicine has indicated that snoring with severe obstructive sleep apnea doubles the chance of premature deaths in men aged 40 to 70 years. PloS Medicine is a peer-reviewed open-access journal published by the Public Library of Science.

This is not new information but just another study showing the severe risks associated with untreated sleep apnea. Other facts are that patients with untreated sleep apnea have a six fold increase in motor vehicle accidents and they are more likely to die in their sleep that while exercising.

I see so many patients who are not being treated for sleep apnea because they hate CPAP or could not deal with problems associated with CPAP use. The Sleep Centers, Doctors , Sleep Techs and DME companies that fail to refer patients for alternative therapies must bear the brunt of responsibility. 60 % of patients abandon CPAP use but there is no concerted effort to refer them for oral appliances.

The real question is why aren't more patients referred for appliance therapy.

I think ignorance is the primary cause, many sleep professionals are unaware of the high success rates of oral appliances, and some just do not know much at all. There is a subgroup that has vested interests in CPAP prescriptions. The sleep centers are often own DME companies, Sometimes the doctor's wife or children own the DME company. I do not find this to be a problem as long as patients who do not tolerate CPAP are then referred for oral appliances or surgical intervention.

I have patients tell me that they are made to feel like it is their failure when they can't tolerate CPAP. They are not told the the majority of patients are CPAP intolerant and/or fail CPAP. CPAP is a excellent treatment for a significant number of patients with very high eficacy, unfortunately more patients fail with CPAP then succeed.

It is the makers or CPAP, Distributors and DME companies and all sleep professionals to honestly explain to patients that the majority of patients never learn to tolerate CPAP and to help them find alternative treatments.

Insurance companies are probably most at fault because they share a common interest with patients. Finding alternative treatments for patients who fail CPAP will save insurance companies enormous amounts of future medical expenses. Insurance companies are aware that oral appliances are more expensive than CPAP in the short run but pale compared to costs for treating heart attacks or strokes. Insurance companies should review their files and identify patients prescribed CPAP who do not order additional supplies. In all likely-hood these patients are not using CPAP and therefore are at a greatly increased risk not just of cardiovascular events but also faced increased risks related to diabetes, motor vehicle accidents, and other serious medical problems.

DEFENDING THE CHARGE: I HATE CPAP! ACCUSED OF MISLEADING PATIENTS

The following response was sent to me on the I HATE CPAP site and because it was from a Registered POLYSOMNOGRAPHIC TECHNOLOGIST I felt it should be posted and responded to. I would appreciate your feedback as well.

Madeleine H RPSGT

comments : How do you address criticisms that your website and information misleads patients with moderate to severe apnea? It is well documented that oral appliances are not effective for most patients with sleep apnea. It seems you efforts would serve patients better if you helped them adjust to CPAP versus feeding anxieties around the gold standard treatment for sleep apnea.

Dear Madeleine,

I take very seriously criticisms that I mislead patients because it is not true. All of the information that is found on the I HATE CPAP site is backed by scientific evidence. The American Academy of Sleep Medicine now considers oral appliances to be FIRST LINE TREATMENT for mild to MODERATE sleep apnea along with CPAP. Further, the AASM considers oral appliances as an alternative to CPAP for patients with severe apnea who do not tolerate CPAP. It is documented that oral appliances do work for severe sleep apnea but they may not be as effective as CPAP especially in the morbidly obese., That is why it is essential that all patients receiving an oral appliance have a follow-up sleep study to insure efficacy. I have had patients with severe apnea (indexes over 100 AHI with de-sats into 50-60's) with complete response to oral appliances. I also have patients that use combinations of CPAP and appliances to lower CPAP pressure from 24 cm or more of pressure (which can damage lung alveoli) to 6-8 cm pressure by combination treatment.

I believe it is cavalier attitudes that patients need to be taught to adjust to their CPAP are more dangerous. While it is true that CPAP is considered the Gold Standard it is only because compliance is not factored into success. Published studies show that the majority of patients abandon CPAP use and even patients who use CPAP average only 4-5 hours of nightly use not the 7 1/2 hours recommended. Strokes are most common in the early morning hours with Sleep Apnea, most patients have already quit using their machines by then. There is a subgroup of patients who love their CPAP from first use and are very successful with CPAP use. That group only makes up 25% of the total population. I do not want patients who are successful and happy with CPAP to abandon it, I am more concerned with the 75% of patients who are untreated or under-treated.

I have seen thousands of patients in the last 28 years of treating sleep apnea who were only offered CPAP so chose no treatment. These untreated patients are left to suffer severe medical consequences because they are not offered alternatives they can accept.

You should seriously consider that a full night of oral appliance use is probably far superior to CPAP that is not used or only used for a couple of hours. I do not feed anxieties of patients but I do recognize them. This website took its name from what patients who came to my office told me, "I HATE CPAP!"

I do not Hate CPAP, but I offer a comfortable alternative for patients who do hate it. My goal is for every patient to know all of the options available to treat their sleep apnea including changes in health habits, cpap, oral appliances, surgery position etc.

As you are probably aware the NHLBI considers sleep apnea to be a TMJ disorder. Please read their report "CARDIOVASCULAR AND SLEEP-RELATED
CONSEQUENCES OF TEMPOROMANDIBULAR
DISORDERS" http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

If you talk to anyone who knows CPR you will be aware that the first step is to check airway and if the patient isn't breathing the airway is opened with a jaw thrust.

Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO

I am posting you question and my response on the I HATE CPAP blog. I will not post your full name or e-mail unless you give me permission.

Madelaine H RPGST Response: Please note that "success" in most apnea studies is defined as 50% or greater reduction in AHI. This is not the clinical definition of "success", though, even as defined by the AASM and Stanford University's suggested protocols.

While oral appliances may be helpful for some patients, I hope your organization is responsible enough to inform patients when they could benefit from cpap or bipap treatment.

Thank you for your prompt response.

I define success as an AHI under 5 and ideally "0" and no snoring. For the majority of my patients we achieve that success though we sometimes have to cheat and combine positional therapy with oral appliance therapy.

The most difficult patient for oral appliances are the morbidly obese, Cheyne Stoke Breathing and Central apnea, and patients who have had severe pharyngeal scarring after UP3 surgery.

It is important to note that to get these high success rate we usually work with sleep techs who have been taught how to titrate an appliance. Rem supine sleep with high AHI on patients who must sleep on their back can be a difficult situation. I have many patients who we try to place on CPAP who again fail. In those patients oral appliances are used to make their disease less severe. Some treatment is better than no treatment. Many appliance patients that are "merely partially improved" polysomnographically have total relief of EDS and cognitive consequences during the day.

I also hope that all those involved with patient care recognize that less than 50% of CPAP patients continue use and are responsible enough to refer those who do not use CPAP for oral appliance therapy. CPAP success is defined as 4 hour use 4 nights a week in most studies and as you say this is not clinical success. 7- 7 1/2 hours nightly is needed for full benefit.

Dr Shapira

WHILE IT IS TRUE IT IS NOT ALWAYS POSSIBLE TO ACHIEVE 100% SUCCESS IN ALL PATIENTS THE MAJORITY OF PATIENTS WITH MILD TO MODERATE APNE ASHOW EXCELLENT RESULTS WITH ORAL APPLIANCE TREATMENT. PATIENTS OFFERED A CHOICE BETWEEN ORAL APPLIANCES CHOSE AN APPLIANCE 90-95% OF THE TIME. IN SOME CASESIT IS NECESSARY TO USE CPAP OR COMBINATION THERAPY SUCH AS TAP-PAP TO ACHIEVE COMPLETE CONTROL OF SLEEP APNEA.

APPLIANCE DESIGN IS ALSO VERY IMPORTANT AS WELL AS HAVING A DOCTOR WHO CAN "TROUBLESHOOT" A PATIENT WHO HAS LESS THAN COMPLETE CONTROL OF SLEEP APNEA. IT IS VITAL TO HAVE A FOLLOW-UP SLEEP STUDY TO INSURE THAT THE MEDICAL PROBLEM IS RESOLVED. SOME PATIENTS ARE RESISTANT TO DOING A FOLLOW-UP STUDY IF THEIR SNORING IS RESOLVED AND THEIR DAYTIME SYMPTOMS RELIEVED. POLYSOMNOGRAPHY AND APPLIANCE TITRATION COMBINED WILL LEAD TO SUPERIOR RESULTS. MADELAINE IS CORRECT THAT SOME DOCTORS AND PATIENTS DO NOT TAKE THE RESPONSIBLE ROUTE OF DOING FOLLOW-UP POLYSOMNOGRAPHY WHEN TREATING SLEEP APNEA.

Tom Farrell has left a new comment on your post "DEFENDING THE CHARGE: I HATE CPAP! ACCUSED OF MIS...":

Agree with the use of oral appliances as a potential treatment for SDB. Especially think the concept of combination treatment- cpap and an oral appliance- needs further study. Great idea.

As far as I know, most sleep labs- and most of the physicians who medically direct them- are strictly cpap-oriented. But I agree that all methods of relieving SDB should be evaluated when looking at treatment options.
Second: most people may not know this, but all registered sleep techs and any and all techs working in a hospital and/or accredited sleep facility are CPR credentialed, and in some cases ACLS certified.
My best to you,

Tom Farrell, BS, RPsgT, RPFT, CRT

Oral Appliances for Severe sleep Apnea

I have severe sleep apnea 56 per minute is your process appropriate?

The answer is yes, Oral Appliances are appropriate for treating severe apnea when patients do not tolerate CPAP. I have treated many patients with severe apnea successfully. The AASM and the AADSM consider oral appliances as a first line treatment for mild to moderate sleep apnea and an alternative treatment for severe sleep apnea. The TAP appliance is the most effective appliance , in my opinion, for severe sleep apnea.

It is vital to have a follow-up study to insure efficacy.

Allergic reaction to somnodent by somnomed cofirmed by clifford test.

Thank you for your assistance regarding my negative reaction to the SomoDent MAS Acrylic. I followed your advise and had a Clifford Test. Unfortunately, the results indicated the Somnodent is not suitable for me. This makes me very unhappy because I am very satified with the results of the device assisting me in terms of sleep. With the device I am able to sleep well throughout the night. Unfortunately, I get small blisters mostly in my upper lip and inside my cheek area which disappear after a couple of hours but what is worse is that my gum area around my upper teeth becomes inflamed and has increased over time ( I keep the oral device in water during the day to reduce reaction but this has not atopped the reaction). I consulted with Dr. Stuart and the device was sent to the lab to change the metal wiring although I suspected I was also reacting to the acrylic material as well – I am still awating for them to return the device back to me. Since then, I have received the results of the Cliffor test which indicated I am not well suited for this device due to contraindicating reactions which were seen in my blood test. I am wondering if SomnoDent makes similar devices with different materials. I paid close to $3,000.00 out of my own packet and I cannot afford to spend as much again. Please advice. Thank you very much.

The appliance comes with a soft liner and with hard acrlic and stainless clasps and screws, They do make a version with a titanium screw. If this is not acceptable I would check with somnomed to see if they could make the appliance out of a material you are not sensitive to. There are other options available otherwise that you can discuss with Dr -------

Dr Ira Shapira