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.

Social Support May Help Sleep Apnea Sufferers Stick to Treatment

Although the use of a continuous positive airway pressure (CPAP) device can be effective in treating obstructive sleep apnea (OSA), many people who try CPAP do not continue its use long-term.

Ongoing research being conducted at the Penn State College of Medicine, however, indicates that OSA sufferers are more likely to adhere to sleep apnea treatment if a partner or parent is actively involved. Researchers reviewed 80 studies regarding sleep apnea treatment to determine key factors that triggered patients to seek sleep apnea diagnosis and treatment, as well as circumstances that affected patients’ likelihood to stick to treatment.

“Collectively, these studies suggest that patients who experience difficulties and proactively seek solutions to resolve problems are more likely to be adherent than those who use passive coping styles,” states the report published in the December issue of Sleep Medicine Reviews. Researchers also noted that patients who have access to social support, such as a partner or parent, are more likely to adhere to treatment long-term.

While the research focuses primarily on CPAP use, their findings may be of use to those who seek other forms of sleep apnea treatment. Numerous studies on people with various forms of addiction or other physical health problems have found that individuals who have access to social support—including regular phone calls, group meetings, routine conversations with family or spouses, or scheduled appointments with doctors and other healthcare providers—have an increased likelihood of following through on their treatment.

If you believe you or a loved one suffers from sleep apnea symptoms, please contact a dentist near you who specializes in diagnosing and treating sleep disorders. Left untreated, obstructive sleep apnea can lead to life-threatening health problems.

Sleep Apnea Discrimination Case Cleared to Proceed in Massachusetts

The Massachusetts Commission Against Discrimination (MCAD) has found probable cause to proceed with an investigation into possible discrimination and retaliation by the Holliston School District against a school psychologist. The school psychologist claimed that his sleep apnea treatment was insufficient to his symptoms and asked for accommodations for his intermittent fatigue. When the school district refused, he asked MCAD to intervene, at which point he says he received disciplinary actions that were retaliatory in nature.

According to the district, the type of accommodation sought by the psychologist was unreasonable. The psychologist had asked for permission to complete paperwork at home on days when he was fatigued, contingent on his immediate supervisor's consent. However, the district did not think this was reasonable because the school psychologist has to be available for crises and should not be gone for "an indeterminate amount of time each day," in the words of the superintendant.

In response, the psychologist took his request to MCAD, which made the preliminary findings that the case justified investigation. At which point, according to the psychologist, some accommodations were granted, but, he says, he also received unjustified disciplinary action based on conflicting reports about a meeting with a student and his grandmother.

Although it is unclear how this case will be resolved, it is clear that sleep apnea can significantly impair your ability to work if you do not receive adequate treatment. If you have been prescribed a treatment that you cannot tolerate or use successfully, you need to seek another treatment before your profession and livelihood suffer.

To learn more about CPAP treatment alternatives, please contact a local sleep dentist today.

I NEED HELP WITH MY CPAP MASK!

TOM:

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

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

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

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

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

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

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

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

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

Does CPAP cure Sleep Apnea? Do Oral Appliances Cure Sleep Apnea? Can surgery cure sleep apnea?

CPAP and Oral Appliances are not cures for sleep apnea but rather effective treatment for sleep apnea patients. They are only effective when they are used on a regular basis , all night - every night.

CPAP compliance is an enormous problem even though CPAP treatment is extremely effective. Recent studies have shown 60% of patients abandon CPAP use. CPAP that is not used is not only not a cure but is a total treatment failure.

Oral appliances while usually extremely effective for mild to moderate sleep apnea and often effective for even sever sleep apnea are much better tolerated by patients. The majority of patients chose an oral appliance over CPAP when offered a choice. Compliance with oral appliances is very high and patients who "Hate CPAP!" often love their oral appliances.

Oral appliances are also not a cure for sleep apnea just a very effective treatment. When compliance is considered along with efficacy oral appliances are probably more effective overall than CPAP. If an oral appliance is not used it does not work. Compliance is a much smaller problem with oral appliances but they are not a panacea.

Is surgery a permanent cure to sleep apnea? Surgery for sleep apnea can be curative but most surgeries fall far short of curing sleep apnea.

Soft palate surgery has a long history. Uvulopalatopharyngealplasty or UP3 surgery is extremely painful and rarely cures sleep apnea. There is a high morbidity rate with this painful surgery and most patients still require use of either CPAP or an oral appliance. Some patients have severe scarring that can drastically worsen the condition. Variations of the UP3 procedure are LAUP or Laser Assisted Uvuloplast, Somnoplasty, pillars and snoreplasty. All of these surgeries rarely if ever cure the patient but carry the severe risk of creating a "silent apneic" where snoring is eliminate but apnea is still present. MOST PATIENTS SHOULD AVOID THESE SURGICAL PROCEDURES, IF YOU DECIDE TO PROCEED WITH THESE SURGERIES I STRONGLY SUGGEST A SECOND OPINION FROM A NON-SURGEON SLEEP SPECIALIST.

Nasal surgery, correction of deviated septums and/or turbinate reductions are also not considered cures for sleep apnea but do increase nasal breathing and are helpful . I FREQUENTLY REFER PATIENTS FOR THESE PROCEDURE THAT OFTEN OFFER EXCELLENT RESULTS, BUT RARELY CURE APNEA. They almost always result in an improvement is quality of life and rarely have any long-term morbidity.

Bimaxillary advancement, usually best done by oral surgeons or plastic surgeons are frequently an effective long-term cure of sleep apnea. Orthognathic surgery is major surgery and should be carefully considered before doing surgery. The surgery consists of cutting the upper jaw away from the skull often splitting the maxilla in half as well, The lower jaw or mandible is sectioned into three sections and frequently the hyoid bone is split into three pieces. The patient is then wired shut for six weeks. The surgery is drastic and can make significant changes in patients appearances but is also extremely effective. In many patients there can be profoundly positive cosmetic results. I STRONGLY SUGGEST THAT PATIENTS CONSIDERING THIS SURGERY FIRST USE AN ORAL APPLIANCE TO ELIMINAT THEIR SLEEP APNEA. THIS WILL SERVE AS A GUIDE FOR HOW FAR THE SURGERY NEEDS TO ADVANCE THE MANDIBLE. IT IS THE BEST WAY TO INSURE THAT REPEAT SURGERY OR INCOMPLETE CORRECTION OF APNEA DOESN'T LEAVE A PATIENT WHO STILL NEEDS CPAP OR AN ORAL APPLIANCE AFTER SURGERY.

Transcend: Radical CPAP improvement over industry standards?

Transcend is a new "wearable CPAP" that promises to increase comfort and convenience for CPAP users. Dr Shapira the founder of I HATE CPAP applauds the company for this advancement.

Dr Shapira and the I HATE CPAP dentists do not "HATE CPAP" but rather offer comfortable alternatives to CPAP. Oral appliances are a convenient alternative to CPAP for traveling but some patients are best served by CPAP. This product should be a godsend to patients who must carry CPAP when they travel.

The 60% of patients who do not tolerate CPAP will continue to find comfortable oral appliances to be the most effective alternative to CPAP. The following information is from their site: http://somnetics.com/pages/Home1/

"Sleep anywhere. Literally.
You can with Transcend.
Never before has sleep apnea therapy been this easy. Transcend gives you freedom you’ve only dreamed of—freedom from stress, freedom of unlimited mobility, and freedom to sleep anywhere you choose.

Unlike any conventional CPAP, Transcend is incredibly hassle-free and goes where you go: driving over the road, flying off to your next business meeting, or taking that well-deserved vacation.

Transcend is the first practical, wearable sleep apnea therapy system on the market. It is small, lightweight, quiet, and vibration-free.

It’s unique, patent-pending heat moisture exchange humidification technology is clinically proven in hospitals to give you the warm, moist air you want for comfort—without the mess of a water-filled humidifier.

Plus, Transcend works with your existing mask seal* and compliance reporting is as simple as plugging into your computer and sending an email directly to your care provider.

Once you experience Transcend, you’ll see why it surpasses any CPAP you’ve ever tried. In the evolution of sleep apnea therapy, it offers an innovative replacement to old-fashioned, cumbersome CPAPs of the past.

Transcend truly fits your lifestyle, whatever it might be. So curl up in your hotel room, nestle into your sleeping bag, or stretch out in your truck cab with confidence. Transcend gives you peace of mind whether you’re traveling or at home and just want to know you can still get a full, restful night’s sleep should the power go out.

Transcend—advancing sleep apnea therapy to the highest level of comfort and mobility"

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.

Oral APPLIANCES AND NASAL CPAP ARE EQUAL IN EFFECTIVENESS ACCORDING TO NEW ARTICLE IN RESPIRATION.

A recent article " Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial" in Respiration compared oral appliance therapy and nasal CPAP therapy in treating mild to moderate sleep apnea. The article looked at carefully controlled studies in which both the CPAP and the oral appliances were carefully titrated. The article concluded that "There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively."

It is important to note that the article clearly states that treatment is equal when there is objective titration of the oral appliances. I have strongly been recommending titration on all oral appliance therapy for over ten years. This is trtuly a landmark study because while CPAP has always been considered "the gold standard for treatment of sleep apnea" that statement is no longer true for mild to moderate sleep apnea.

This study did not cover severe sleep apnea therefore CPAP is still considered the gold standard of treatment for severe sleep apnea and oral appliances are an alternative for patients who do not tolerate CPAP.

The major problem with CPAP has always been low compliance. A recent study showed 60% of patients do not tolerate CPAP treatment. If compliance is factored in then it is clear that oral appliances are now the "Gold Standard" of treatment for mild to moderate sleep apnea.



PubMed abstract:
Respiration. 2010 Oct 20. [Epub ahead of print]ral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial.
Aarab G, Lobbezoo F, Hamburger HL, Naeije M.

Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, Research Institute MOVE, University of Amsterdam and VU University Amsterdam, The Netherlands.
Abstract
Background: Previous randomized controlled trials have addressed the efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA). Their common control condition, nasal continuous positive airway pressure (nCPAP), was frequently found to be superior to MAD therapy. However, in most of these studies, only nCPAP was titrated objectively but not MAD. To enable an unbiased comparison between both treatment modalities, the MAD should be titrated objectively as well. Objective: The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device. Methods: Sixty-four mild/moderate patients with obstructive sleep apnea (OSA; 52.0 ± 9.6 years) were randomly assigned to three parallel groups: MAD, nCPAP and placebo device. From all patients, two polysomnographic recordings were obtained at the hospital: one before treatment and one after approximately 6 months of treatment. Results: The change in the apnea-hypopnea index (ΔAHI) between baseline and therapy evaluation differed significantly between the three therapy groups (ANCOVA; p = 0.000). No differences in the ΔAHI were found between the MAD and nCPAP therapy (p = 0.092), whereas the changes in AHI in these groups were significantly larger than those in the placebo group (p = 0.000 and 0.002, respectively). Conclusion: There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.

Copyright © 2010 S. Karger AG, Basel.
PMID: 20962502 [PubMed - as supplied by publisher]

Inland Empire Sleep Solutions offers alternatives to CPAP for Patients in Washington State and Idaho. Live a Better Life Through Sleep!

Reprinted information from 24/7 Press Release
Inland Empire Sleep Solutions: The Best Sleep Apnea Treatment: CPAP vs. Oral Appliances. A Question of Compliance and Effectiveness. Oral Appliances Win the Compliance Award. Snoring Can Be Cured!

CPAP is considered the gold standard for sleep apnea treatment but poor compliance issues with CPAP often make oral appliances the best sleep apnea treatment. For the morbidly obese patient, CPAP is the best first line treatment.

What is the best sleep apnea treatment? It is not CPAP, according to a recent study that showed 60% of patients abandon CPAP use. At least it is not the best treatment for the 60% of patients who abandoned it. This does not mean CPAP is not the most effective treatment, what it means is no matter how effective a treatment may be, it is a poor treatment if it is not used. Oral appliances are an extremely effective treatment for mild to moderate sleep apnea but less effective for morbidly obese patients and those with severe sleep apnea.

Oral appliances are the "Best Sleep Apnea Treatment" because patients actually use them. Compliance issues have always been the biggest problem with CPAP. Studies have shown most patients quit CPAP completely but even patients who use CPAP average only 4-5 hours/ night 4-5 nights a week. That is not the best treatment but it is better than no treatment. The best site for information on oral appliance therapy and dental sleep medicine is http://www.ihatecpap.com.

Dr Ira L Shapira is a Diplomate of the American Board of Dental Sleep Medicine. He is the president of I HATE CPAP LLC. He is proud to announce a new resource for Washington State and Idaho to help patients with sleep apnea and snoring find solutions. Inland Empire Sleep Solutions http://www.inlandempiresleepsolutions.com/ is bringing the best information on Sleep Apnea Treatment to the Inland Empire region.

Medicare recognized how poor CPAP compliance was and now has minimum usage schedules for CPAP that will save Medicare millions of dollars because such a small percentage of patients actually utilize their machines on a regular basis. Inland Sleep Solutions will feature dental offices where there has been training in Dental Sleep Medicine.

CPAP is the "best treatment" for the 25% of patients who love their CPAP, and use it all night, every night.

Oral appliances may be less effective across a range of all patients at eliminating sleep apnea but they are much more effective at achieving patient compliance. A treatment that is used will always be superior to a treatment that is not used.

Oral appliance success can be greatly improved by titration of appliances in the sleep lab. When an appliance eliminates sleep apnea based on a sleep study it is effectively equivalent to CPAP. The issue of compliance almost always favors oral appliances but objective monitors for oral appliance use are not yet available. They probably will be available in the very near future making oral appliances a leading choice of sleep medicine physicians who care about patients desires.

The best treatment is one that works and is used. For most patients with mild to moderate sleep apnea the best treatment is an oral appliance due to much higher compliance. If compliance is equal and CPAP or appliances are equally effective than both would qualify as the best treatment. The patient can chose their desired treatment. Studies have shown the majority of patients offered a choice prefer a comfortable oral appliance over CPAP.

Some severe sleep apnea patients refuse CPAP, for those patients an oral appliance is superior to "no treatment".

CPAP is almost always the best treatment for the morbidly obese patients but an oral appliance is still better than no treatment if CPAP is refused.

There are patients who are severe and/or morbidly obese and the "best treatment" is actually combination treatment of an oral appliance and CPAP combined. A mask retained by the teeth instead of straps may be considerably more comfortable for many patients and lower pressure from combined use makes CPAP easier to tolerate.

The best treatment may be CPAP but with a custom made nasal mask that is made from an impression of the patients face similar to how dentures are made. Custom masks combined with oral appliances are a new entry in the field coming from airway management.

Cleanliness is of major importance with both CPAP and oral appliance treatments. Dirty masks and hoses can lead to sinus infections, bronchitis and pneumonia while poor oral hygiene with an oral appliance can lead to periodontal disease. Dr Shapira advise all patients to keep their masks and hoses scrupulously clean. It is vital to be just as thorough in cleaning oral appliances and in maintaining oral hygiene care when wearing an oral appliance. They are not well suited for patients who do not regularly brush their teeth.

What is the best CPAP mask for patients who utilize CPAP? Studies have shown that different masks and machines usually do not increase patient compliance but they do increase comfort for patients who actually use CPAP. Other studies have shown that patients' usage of CPAP initially predicts long term compliance with CPAP. Patients who reject CPAP initially rarely embrace CPAP use in the long term. What is the best CPAP mask? A mask the patient actually uses. This will be very patient specific.

What is the best type of CPAP machine? There is standard CPAP machines that come in many styles and shapes. The industry has done a good job of making CPAP machines quieter and smaller. BiPAP machines have lower pressure during expiration that reduces claustrophobic feelings in some patients and often eliminates the sensation of drowning on air. Ramping is a gradual increase in pressure allowing patients to fall asleep prior to pressure increasing. Humidification and heated hoses are also increasing patient comfort. Unfortunately all of these advances have not been shown to increase overall patient compliance.

Servo-ventilation machines are more efficient and effective in treating central sleep apnea, which is a neurological condition where the brain "forgets" to breathe.

The best sleep apnea treatment is always patient specific. The 60% of patients who do not tolerate CPAP will likely find comfortable oral appliances are the best treatment.

A small minority of patients do not tolerate CPAP or oral appliances. The best treatment for these patients may be surgery.

What is the best sleep apnea surgery? The morbidly obese and extremely severe sleep apneics may find that a tracheotomy is the best treatment. Patients breathe through their throat bypassing the pharyngeal blockages. Most patients do not want a trach.

Soft palate surgery is almost never the best sleep apnea treatment. UP3 or Uvulopalatopharyngealplasty is painful and has very high morbidity but more importantly rarely eliminates sleep apnea and patients still require CPAP or oral appliance therapy. Pillars, somnoplasty, LAUP or laser-assisted uvuloplasty are less painful but still ineffective in treating most apnea patients completely.

Maxilo mandibular advancement is extremely effective but is major surgery where the upper jaw (maxilla) is cut loose from the skull and often split in pieces, the lower jaw (mandible) is sectioned into 3 pieces and the hyoid bone is sectioned in pieces and then the patient is wired shut for six weeks. This surgery is often very successful. A geniohyoid surgery is less invasive only splitting the lower jaw in pieces and advancing the chin and tongue. While it is effective in patients with severely recessed lower jaws (weak chin) in most patients it is the "Jay Leno" surgery creating his unique profile.

For severely obese patients with severe sleep apnea bariatric surgery may be the best sleep apnea treatment.

It is also possible to do several tongue reduction surgeries that vary in effectiveness. Dr Shapira suggests that patients attempt CPAP and/or Oral Appliances before considering surgery. Patients with blocked nasal airways frequently improve with partial turbinectomies and correction of deviated septums but while helpful this will usually not eliminate sleep apnea.

Dr Shapira reminds patients of the famous quote: "There is no disease or disorder known to man that can't be made worse by sticking a knife in it." This does not mean to avoid surgery cautions Dr Shapira but rather to approach any surgery with caution and consider the possible problems associated with surgery.

Information on the dangers of sleep apnea, sleep apnea treatment and comfortable oral appliances is available at http://www.ihatecpap.com.

We are currently looking for Dentists with training in Dental sleep Medicine in the following communities. Dentist wishing to become part of the program can contact Meg at meg@hamiltonsaunderson.com

Washington State
Clarkston
Colfax
Ellensburg
Ephrata
Kennewick
Moses Lake
Pasco
Pullman
Richland
Ritzville
Spokane
Spokane Valley
Walla Walla
Washougal
Wenatchee
Yakima
Idaho
Coeur d'Alene
Lewiston
Moscow
Priest Lake

DEPRESSION AND SLEEP APNEA: RESEARCH SHOWS SLEEP APNEA TREATMENT MAY RESOLVE RESIDUAL DEPRESSIVE SYMPTOMS. CPAP and Oral Appliances are indicated

A new study "Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms." (see abstract below) suggests that treatment of sleep apnea will aid in resolution of symptoms. While this study used CPAP, Oral Appliances should have identical results.

The study concludes that "The results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.

Another study "Obstructive sleep apnea and depression." (see abstract below) reports 21-41% depression in sleep pne patients. It sites a previous study that lists sleep apnea as a risk factor for depression. It is not surprising that " Patients who have depression as well as OSA appear worse off than those with OSA only" ties together symptoms and treatments of sleep apnea, headaches and depression.

An opinion statement in Curr Treat Options Neurol. 2010 Jan;12(1):1-15 on on "SLEEP AND HEADACHES" ties together headaches, psychiatric problems and sleep apnea but stops short of what the NHLBI report that focuses on masticatory/trigeminal orgin of these problems.

The NHLBI published a report on the "CARDIOVASCULAR AND SLEEP RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" THAT LOOKS AT MASTICATORY SYSTEM AS A COMMON CAUSE OF SLEEP APNEA, HEADACHES AND MANY OTHER PROBLEMS. Shimshak et al published two articles in Cranio that showed a 200-300% increase in medical costs in every field of medicine in patients diagnosed with TMJ disorders. This would include headache, migraine, depression and other diverse conditions.

The National Heart Lung and Blood Institue report states:
"The term TMD refers to a collection of medical and dental conditions affecting the temporomandibular joint (TMJ) and/or muscles of mastication, as well as contiguous tissue components. Symptoms range from occasional discomfort to debilitating pain and severely compromised jaw function. The masticatory apparatus is not only involved in chewing and swallowing but also in other critical tasks, including breathing and talking. Specific etiologies such as trauma and degenerative arthritides underlie some forms of TMD but there is no common etiology or biological explanation. TMD is hence comprised of a heterogeneous group of health problems whose signs and symptoms are overlapping but not identical.
Although broad longitudinal and cross-sectional epidemiological studies have not been carried out, TMD is estimated to affect about 12% of the general population, representing more than 34 million Americans. The majority of those seeking treatment are women in their reproductive years. As for many other pain conditions, the clinical scenario of TMD also tends to be more severe in women than men. TM disorders are considered a serious health problem because many individuals lose their ability to hold regular jobs and to function productively even within the context of a household environment.

The report talks about symptoms including "TMD has been used to characterize a wide range of conditions diversely presented as pain in the face or jaw joint area, masticatory muscle pain, headaches, earaches, dizziness, limited mouth opening due to soft or hard tissue obstruction, TMJ clicking or popping sounds, excessive tooth wear and other complaints."

The report also discusses effects on swallowing and breating ease: "There appears to an associated increase in coughing in subjects with sleep apnea. Occlusion of the pharynx can force residual secretions into the glottis and trigger coughing reflexes, swallowing reflexes, and other reflexes that could contribute to the disorganization of breathing during sleep. In addition to the muscles of mastication, the tongue plays an important role in the coordinated events of swallowing and breathing. The integration of breathing and swallowing is tightly linked, and these events in turn are in some manner linked to blood pressure regulation. Each of these pathways has been studied by scientists in individual disciplines, but there is a need for interdisciplinary studies to determine the interactions of the peripheral and central neural pathways controlling breathing, chewing, swallowing, and cardiovascular events. The presence of pain in patients with TMD would be expected to seriously impact upon these reflex and motor pathways. Little is known about the role of tongue position and how this may be altered in subjects with altered jaw location and structure. Sleep state has been shown to alter the central modulation of the coordination of breathing, airway dynamics, swallowing, and associated cardiovascular events. Differences in central modulation of these events in subjects with sleep apnea and TMD need to be evaluated using sleep as a dynamic change in the state of the individual. Cardiovascular, neuroendocrine, respiratory and swallowing alterations in awake and sleeping subjects need to be studied in a systematic manner in both in animal models and human subjects."

There are common developmental aspects that have been well documented between sleep apnea and TMJ disorders. There is an enormous cross over of signs and symptoms as well. While all sleep apnea may not be entirely related to masticatory structures there is unquestionably a large amount of crossover. There is a solid base of evidence based studies showing how airway issues change growth and development. There is also solid evidence based studies on treatment of sleep apnea with appliances that anteriorly position the mandible. there are numerous clinical reports and studies showing treatment of headaches and TMJ disorders with anterior positiong.

Is it time to look at a large proportion of sleep apnea as being related to jaw development. This would make it a treatment that could be treated and corrected by early interventions such as tonsilectomy and maxillary expansion. Maxillary expansion allows the mandible to automatically anteriorly position and frequently grow a healthier airway. A recent study showed that most pediatric patients having tonsils removed should also have expansion. Expansion according to many experts should precede tonsilectomy to reduce post operative risks.

The early correction of airway and jaw disorders could possibly save massive dollars in lifetime medical expenses if we extrapolate from the work of Shimshak. Shimshak did not show a correlation not cause and effect of TMJ disorders to increased medical expenses.

My opinion is that there is a definite cause and effect of TMJ disorders to massive increases in medical expenses. I believe that for the majority of patients sleep apnea are due to masticatory conditions that should be defined as a TMJ disorder. If we define sleep apnea as a TMJ disorder that other problems like ADD and ADHD are secondary TMJ disorders. This would also apply to morning headaches, cardiovascular, neurological, and psychiatric disorders


Sleep Med. 2010 Jun;11(6):552-7. Epub 2010 May 21.
Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms.
Habukawa M, Uchimura N, Kakuma T, Yamamoto K, Ogi K, Hiejima H, Tomimatsu K, Matsuyama S.

Department of Neuropsychiatry, Kurume University School of Medicine, Kurume, Fukuoka, Japan. hmitsu@med.kurume-u.ac.jp
Abstract
BACKGROUND: Although extensive studies have indicated a relationship between obstructive sleep apnea (OSA) and depressive symptoms, the effect of continuous positive airway pressure (CPAP) treatment on residual depressive symptoms in patients with both major depressive disorder (MDD) and coexisting OSA has not been examined.

METHODS: Seventeen patients with continued MDD despite pharmacotherapy such as antidepressants and/or benzodiazepines, who also had comorbid OSA, were required to complete the Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), and Epworth sleepiness scale (ESS) at the commencement of the study and then again after 2 months of CPAP treatment.

RESULTS: BDI and HRSD scores decreased from 19.7 to 10.8 and 16.7 to 8.0 after 2 months of CPAP treatment (both p<0.01). We also found significant correlations among the improvement rates in BDI, HRSD and ESS scores (R=0.86 and 0.75, both p<0.01). The mixed effect model demonstrated a significant ESS effect on BDI and HRSD.

CONCLUSIONS: The results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.

PMID: 20488748 [PubMed - indexed for MEDLINE]

Sleep Med Rev. 2009 Dec;13(6):437-44. Epub 2009 Jul 10.
Obstructive sleep apnea and depression.
Harris M, Glozier N, Ratnavadivel R, Grunstein RR.

Australasian Sleep Trials Network, Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia. melanie.harris@flinders.edu.au
Abstract
There are high rates of depression in people with obstructive sleep apnea (OSA) in both community and clinical populations. A large community study reported a rate of 17% and reports for sleep clinic samples range between 21% and 41%. A large cohort study found OSA to be a risk factor for depression, but we are unaware of any longitudinal study of the reverse association. However correlations have not generally been found in smaller studies. Well-designed longitudinal studies are needed to examine temporal relationships between the two conditions and further research is needed to establish the role of confounders, and effect modifiers such as gender, in any apparent relationship. Symptoms common to OSA and depression, such as sleepiness and fatigue, are obstacles to determining the presence and severity of one condition in the presence of the other, in research and clinically. Sleep clinicians are advised to consider depression as a likely cause of sleepiness and fatigue. Several possible causal mechanisms linking OSA and depression have been proposed but not established. Patients who have depression as well as OSA appear worse off than those with OSA only, and depressive symptoms persist in at least some patients in short term studies of treatment for OSA. Direct treatment of depression in OSA might improve acceptance of therapy, reduce sleepiness and fatigue and improve quality of life, but intervention trials are required to answer this question.

PMID: 19596599 [PubMed - indexed for MEDLINE]

Curr Treat Options Neurol. 2010 Jan;12(1):1-15.
Sleep and headache.
Rains JC, Poceta JS.

Center for Sleep Evaluation, Elliot Hospital, One Elliot Way, Manchester, NH, 03103, USA, jrains@elliot-hs.org.
Abstract
OPINION STATEMENT: Headache has been linked to a wide range of sleep disorders that may impact headache management. There are no evidence-based guidelines, but the authors believe that literature supports the following clinical recommendations: 1. Diagnose headache according to standardized criteria. Specific diagnoses are associated with increased risk for specific sleep and psychiatric disorders. 2. Collect sleep history in relation to headache patterns. Screening questionnaires and prediction equations are cost-effective. 3. Rule out sleep apnea headache in patients with awakening headache or higher-risk headache diagnoses (cluster, hypnic, chronic migraine, and chronic tension-type headache); patients with signs and symptoms of obstructive sleep apnea warrant polysomnography and treatment according to sleep medicine practice guidelines. There is no evidence for suspending conventional headache treatment in suspected or confirmed cases of sleep apnea. Treatment of sleep apnea with CPAP may improve or resolve headache in a subset of patients. The impact on sleep apnea headache of other treatments for sleep apnea (eg, oral appliances, surgery, weight loss) is largely untested. At a minimum, sedative-hypnotic drugs should be avoided in suspected apneics until the sleep apnea is treated. 4. Among patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients. Patients who suffer from chronic migraine or tension-type headache may benefit from behavioral sleep modification. Pharmacologic treatment may be considered on a case-by-case basis, with hypnotics, anxiolytics, or sedating antidepressants used to manage insomnia, tailoring treatment to the symptom pattern. 5. Individuals with chronic headache are at increased risk for psychiatric disorders. Assessment for depression and anxiety may be warranted when either insomnia or hypersomnia is present. Psychiatric symptoms affect the choice of sedating versus alerting versus neutral pharmacologic agents for headache. 6. All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management.

ORAL APPLIANCES ARE A CONSERVATIVE METHOD OF TREATMENT ACCORDING TO THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE.

THE FOLLOWING PAGE FROM THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE OF THE NIH IS REPRINTED FROM http://www.ninds.nih.gov/disorders/sleep_apnea/sleep_apnea.htm

IN ADDITION TO THE WELL KNOWN SYMPTOM OF EXCESSIVE DAYTIME SLEEPINESS IT ALSO RECOGNIZES "morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression AS ASSOCIATED DISORDER.

WHILE MANY IN THE MEDICAL SLEEP COMMUNITY ALWAYS LOOK AT CPAP AS THE FIRST LINE TREATMENT THE NINDS RECOGNIZES ORAL APPLIANCES AS A CONSERVATIVE TREATMENT OF SLEEP APNEA. THE FIRST LINE THERAPY FOR SLEEP APNEA ARE CONSERVATIVE METHODS "Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep." AND CPAP IS COSIDERED A LESS CONSERVATIVE APPROACH ALONG WITH SURGERY. THE ARTICLE STATES "If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway.

THE SLEEP COMMUNTIY OFTEN MAKES CPAP THE FIRST AND SOMETIMES ONLY TREATMENT OF CHOICE. THE MORE RATIONAL APPROACH OF THE THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE OF THE NIH IS A FRESH APPROACH.

WHY CONSIDR CPAP A FIRST LINE TREATMENT WHEN MOST PATIENTS DO NOT TOLERATE CPAP.

CONSIDERING SLEEP POSITION, WEIGHT LOSS AND ORAL APPLIANCES AS CONSEVATIVE APPROACHES RECOGNIZE NOT JUST THE EFFECTIVENESS OF THESE TREATMENTS BUT ALSO THE CONSERVATIVE NATURE OF THESE TREATMENTS.

THE FOLLOWING IS INFORMATION FROM THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SITE.

What is Sleep Apnea?
Sleep apnea is a common sleep disorder characterized by brief interruptions of breathing during sleep. These episodes usually last 10 seconds or more and occur repeatedly throughout the night. People with sleep apnea will partially awaken as they struggle to breathe, but in the morning they will not be aware of the disturbances in their sleep. The most common type of sleep apnea is obstructive sleep apnea (OSA), caused by relaxation of soft tissue in the back of the throat that blocks the passage of air. Central sleep apnea (CSA) is caused by irregularities in the brain’s normal signals to breathe. Most people with sleep apnea will have a combination of both types. The hallmark symptom of the disorder is excessive daytime sleepiness. Additional symptoms of sleep apnea include restless sleep, loud snoring (with periods of silence followed by gasps), falling asleep during the day, morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression. Not everyone who has these symptoms will have sleep apnea, but it is recommended that people who are experiencing even a few of these symptoms visit their doctor for evaluation. Sleep apnea is more likely to occur in men than women, and in people who are overweight or obese.

Is there any treatment?

There are a variety of treatments for sleep apnea, depending on an individual’s medical history and the severity of the disorder. Most treatment regimens begin with lifestyle changes, such as avoiding alcohol and medications that relax the central nervous system (for example, sedatives and muscle relaxants), losing weight, and quitting smoking. Some people are helped by special pillows or devices that keep them from sleeping on their backs, or oral appliances to keep the airway open during sleep. If these conservative methods are inadequate, doctors often recommend continuous positive airway pressure (CPAP), in which a face mask is attached to a tube and a machine that blows pressurized air into the mask and through the airway to keep it open. There are also surgical procedures that can be used to remove tissue and widen the airway. Some individuals may need a combination of therapies to successfully treat their sleep apnea.
What is the prognosis?

Untreated, sleep apnea can be life threatening. Excessive daytime sleepiness can cause people to fall asleep at inappropriate times, such as while driving. Sleep apnea also appears to put individuals at risk for stroke and transient ischemic attacks (TIAs, also known as “mini-strokes”), and is associated with coronary heart disease, heart failure, irregular heartbeat, heart attack, and high blood pressure. Although there is no cure for sleep apnea, recent studies show that successful treatment can reduce the risk of heart and blood pressure problems.
What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research related to sleep apnea in laboratories at the NIH, and also support additional research through grants to major medical institutions across the country. Much of this research focuses on finding better ways to prevent, treat, and ultimately cure sleep disorders, such as sleep apnea.

HYPERTENSION, SLEEP APNEA AND CPAP COMPLIANCE. ORAL APPLIANCES ARE A CPAP ALTERNATIVE.

AN ARTICLE IN CHEST JOURNAL LOOKS AT SLEEP AND HYPERTENSION. According to the August 2010 article in Chest "even small increases in BP, particularly nighttime BP levels, are associated with significant increases in cardiovascular morbidity and mortality.". This increase in in Blood pressure "sleep deprivation and insomnia have been linked to increases in incidence and prevalence of hypertension.is related to many types of sleep disorders including restless legs "sleep disruption attributable to restless legs syndrome increases the likelihood of having hypertension".

Patients with sleep apneathe article states "observational studies demonstrate a strong correlation between the severity of obstructive sleep apnea (OSA) and the risk and severity of hypertension, whereas prospective studies of patients with OSA demonstrate a positive relationship between OSA and risk of incident hypertension. Intervention trials with continuous positive airway pressure (CPAP) indicate a modest, but inconsistent effect on BP in patients with severe OSA and a greater likelihood of benefit in patients with most CPAP adherence."

The problem is that CPAP compliance is poor or non-existent for the majority of patients. Due to the severe problems that can result from untreated sleep apnea more and more concerned and compassionate cardiologists and internists are turning to Oral Appliances and Dental Sleep Medicine as the Best Sleep Apnea Treatment for their patients that do not tolerate CPAP.

There is no question that CPAP therapy is very effective when it is used. There is also no longer a belief that most patients will tolerate CPAP. Because non adherence and non-compliance is the rule not the exception in sleep apnea treatment the question about "What is the Best Sleep Apnea Treatment?" is still open.

Chest. 2010 Aug;138(2):434-43.
Sleep and hypertension.
Calhoun DA, Harding SM.

Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-1150, USA. dcalhoun@uab.edu
Abstract
Ambulatory BP studies indicate that even small increases in BP, particularly nighttime BP levels, are associated with significant increases in cardiovascular morbidity and mortality. Accordingly, sleep-related diseases that induce increases in BP would be anticipated to substantially affect cardiovascular risk. Both sleep deprivation and insomnia have been linked to increases in incidence and prevalence of hypertension. Likewise, sleep disruption attributable to restless legs syndrome increases the likelihood of having hypertension. Observational studies demonstrate a strong correlation between the severity of obstructive sleep apnea (OSA) and the risk and severity of hypertension, whereas prospective studies of patients with OSA demonstrate a positive relationship between OSA and risk of incident hypertension. Intervention trials with continuous positive airway pressure (CPAP) indicate a modest, but inconsistent effect on BP in patients with severe OSA and a greater likelihood of benefit in patients with most CPAP adherence. Additional prospective studies are needed to reconcile observational studies suggesting that OSA is a strong risk factor for hypertension with the modest antihypertensive effects of CPAP observed in intervention studies.

PMID: 20682533 [PubMed - indexed for MEDLINE]PMCID: PMC2913764 [Available on 2011/8/1

Respiratory Care Article Details Problems with CPAP Adherence.

The Respiratory Journal looks at problems related to CPAP adherence. The September 2010 article states "Adverse effects such as nasal congestion, dry mouth, or skin irritation occur in approximately 50% of CPAP users" These side effects are only a few of the problems patients experience that lead to CPAP non-compliance. There are many advances in CPAP treatment that have little effect for most patients on CPAP success. The article states "The use of sophisticated therapy modalities such as auto-titration or bi-level PAP units has been shown to improve adherence in certain subsets of OSA patients" but other research shows little change in CPAP compliance rates. The problems associated with CPAP are the reasons so mmany patients exclaim "I HATE CPAP!".

What kind of patient does not do well with CPAP? The article further states " though a search for consistent predictive factors related to CPAP adherence has proven elusive. Other influences, such as sex, age, socioeconomic status, and personality traits are less robust predictors." In essence all types of patients in every category do not tolerate or adhere to CPAP treatment.

Cpap is a very effective treatment but it is not the best sleep apnea treatment for those patients who do not use it. A recent study showed 60% of patients abandon CPAP. In other words when compliance is factored in the majority of patients are not helped by CPAP'

Dental Sleep Medicine and Oral Appliances may be the best sleep apnea treatment for the majority of patients. Even though they may not be as effective as CPAP they are far more effective than no treatment.

Cardiologists recognize that "the undertreated OSA patient at risk of development or worsening of comorbid medical conditions, including hypertension and cardiovascular disease.". They are also aware of the poor compliance that plagues CPAP.

The concerned and informed cardiologists are now recognizing that CPAP is a dismal failure for the majority of sleep apnea patients and are starting to refer more patients for oral appliance therapy. When patients lives are at stake there must be alternatives to CPAP offered to the patients who do not tolerate CPAP. Regardless of the effectiveness of CPAP it is a worthless treatment if it is not used.

Dental Sleep Medicine offers life-changing alternatives to CPAP to cardiac patients who do not tolerate CPAP.

Respir Care. 2010 Sep;55(9):1230-9.
Encouraging CPAP Adherence: It Is Everyone's Job.
Bollig SM.

Hays Medical Center-Sleep and Neurodiagnostic Institute, 2500 Canterbury Drive, Suite 108, Hays KS 67601. suzanne.bollig@haysmed.com.
Abstract
Obstructive sleep apnea (OSA) is a chronic disease treated effectively with the use of continuous positive airway pressure (CPAP) therapy. Patient adherence to prescribed CPAP is variable, however, leaving . The severity of disease and the presence of daytime sleepiness appear to have some predictive quality for subsequent adherence, though a search for consistent predictive factors related to CPAP adherence has proven elusive. Other influences, such as sex, age, socioeconomic status, and personality traits are less robust predictors. The use of sophisticated therapy modalities such as auto-titration or bi-level PAP units has been shown to improve adherence in certain subsets of OSA patients. Adverse effects such as nasal congestion, dry mouth, or skin irritation occur in approximately 50% of CPAP users, and addressing these adverse effects may improve adherence in some patients. More encouraging, studies on the use of intensive patient education and behavioral interventions have shown more positive effects on adherence, leading to the conclusion that improvement in patient adherence to CPAP therapy requires a multi-layered approach, using combined technological, behavioral, and adverse-effect interventions.

PMID: 20800003 [PubMed - in process]

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

WELL IT IS WELL ESTABLISHED THAT ORAL APPLIANCES ARE EFFECTIVE IN TREATING SLEEP APNEA AND SNORING THIS ARTICLE SHOWS IT ALSO REDUCES BLOOD PRESSURE SIMILAR TO CPAP TREATMENT.

HEAVY SNORING HAS BEEN SHOWN TO INCREASE CAROTID ATHEROSCLEROSIS DUE TO VIBRATIONS. THIS IS ALSO WELL TREATED BY ORAL APPLIANCE THERAPY.

IF SLEEP APNEA IS ELIMINATED THAN THE DISORDERS RELATED TO THE DISORDER WILL ALSO BE ELIMINATED. I EXPECT THAT RESEARCH WILL CONTINUE TO SHOW THAT ORAL APPLIANCES ARE EQUAL TO CPAP WHEN SLEEP APNEA IS SUCCESSFULLY TREATED.

BECAUSE 60% OF PATIENTS ABANDON CPAP IT IS INEFFECTIVE FOR THOSE PATIENTS. SIMPLY STATED CPAP DOES NOT SUCCESSFULLY TREAT ANY DISORDERS IN THE 60% OF PATIENT WHO DO NOT USE IT.

WHAT IS THE BEST SLEEP APNEA TREATMENT? THE BEST SLEEP APNEA TREATMENT IS BOTH EFFECTIVE AND IS USED BY PATIENTS.

THE BEST TREATMENT WILL ALWAYS BE A TREATMENT THAT IS USED BY THE PATIENT. COMFORTABLE ORAL APPLIANCES ARE PREFERRED OVER CPAP BY MOST PATIENTS OFFERED A CHOICE.

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.

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

WHAT IS THE BEST ORAL APPLIANCE:MAD VS TRD

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

IT COMPARES TONGUE STABILIZATION WITH MANDIBULAR ADVANCEMENT APPLIANCES.

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

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

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

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

Abstract

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

SLEEP APNEA AND RISK OF STROKE: CPAP THAT IS NOT USED INCREASES RISKS OF STROKES. ORAL APPLIANCES ARE AN EXCELLENT ALTERNATIVE TO CPAP.

Several articles detailing increased risk of stroke in patients with sleep apnea and worse medical outcomes have recently been published (see PubMed abstracts below).

One article "Worse Outcome after Stroke in Patients with Obstructive Sleep Apnea: An Observational Cohort Study." suggests that patients who have had strokes should be screened for apnea and patients with sleep apnea are at an increased risk of death. "Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke."

A second article "Is obstructive sleep apnea an independent risk factor for stroke? A critically appraised topic" concluded that "OSA independently contributes to stroke risk."

These articles show both the danger of sleep apnea and emphasize the fact that treatment is very important. It is also known that the majority of patients abandon CPAP. The best treatment for sleep apnea in patients at risk for strokes or with a history of strokes is one that is used nightly. Recent studies have shown the majority of CPAP users abandon CPAP use. I make the case that the best treatment for sleep apnea is one that is used, hopefully all night every night.

Medicare has recognized the fact that the majority of patients do not continue to use CPAP. They have set standards for minimal usage for medicare reimbursement.

If the majority of patients abandon CPAP, what is the best treatment for obstructive sleep apnea.

My opinion, is that oral appliances are the best treatment because a vast majority of patients prefer them to CPAP. Oral appliances are not perfect and do have problems and drawbacks. There is no question that if an oral appliance successfully treats sleep apnea it is a better treatment than a CPAP machine sitting in the closet.

Morbidly obese patients are the patients who will usually find cpap the most effective treatment. Younger thinner healthier patients who do not use CPAP swhould consider oral appliances the best alternative treatment to CPAP.


Expert Rev Neurother. 2010 Aug;10(8):1267-71.
Risk of stroke from sleep apnea in men and women.
Djonlagic I, Malhotra A.

Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
Comment on:

Am J Respir Crit Care Med. 2010 Jul 15;182(2):269-77.
Abstract
Obstructive sleep apnea (OSA) is a common sleep disorder, and research on the effects of sleep apnea is important to gain insight into how sleep affects health. Untreated OSA has been associated with important health consequences, such as an increased risk for hypertension, cardiovascular disease and diabetes. Previous studies have shown that OSA also represents a risk factor for stroke. The relationship between OSA and stroke is particularly relevant, as stroke is the second leading cause of death globally. The reviewed article presents new data from the Sleep Heart Health Study, a longitudinal cohort study, which shows an association between incident stroke and untreated OSA of varying severity for men and possibly more severe OSA for women. The study is discussed in the context of the current state of knowledge about OSA, in particular its health consequences, and the general limitations in conducting research with OSA patients.

PMID: 20662752 [PubMed - in process]

J Stroke Cerebrovasc Dis. 2010 Jul 24. [Epub ahead of print]
Worse Outcome after Stroke in Patients with Obstructive Sleep Apnea: An Observational Cohort Study.
Mansukhani MP, Bellolio MF, Kolla BP, Enduri S, Somers VK, Stead LG.

Department of Family Medicine, Mayo Clinic, Rochester, Minnesota.
Abstract
To evaluate the risk and presence of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke, and examine the correlation of OSA with age, sex, ischemic stroke subtype, disability, and death, a prospective cohort study was conducted in all consecutive patients presenting with acute ischemic stroke between June 2007 and March 2008. Exclusion criteria were age <18 years, refusal of consent for the study, and incomplete questionnaire. The Berlin Sleep Questionnaire was used to identify patients at high risk for OSA. A total of 174 patients with acute ischemic stroke were included; 130 (74.7%) had a modified Rankin Scale (mRS) score >/=3 at dismissal, and 11 patients (6.3%) died within 1 month. The Berlin Sleep Questionnaire identified 105 patients (60.4%) at high risk for OSA, along with 7 patients (4%) with a previous diagnosis of OSA. Those with a previous diagnosis of OSA were more likely to die within the first month after stroke (relative risk, 5.3; 95% confidence interval, 1.4-20.1) compared with those without OSA. Patients at high risk for OSA did not demonstrate increased mortality at 30 days (P = 1.0). In multivariate analysis, after adjusting for age and National Institutes of Health Stroke Scale score, previous diagnosis of OSA was an independent predictor of worse functional outcome, that is, worse mRS score at hospital discharge (P = .004). The mRS score was 1.2 points higher (adjusted R(2), 40%) in those with OSA. Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke.

PMID: 20656506 [PubMed - as supplied by publisher]

Neurologist. 2010 Jul;16(4):269-73.
Is obstructive sleep apnea an independent risk factor for stroke? A critically appraised topic.
Capampangan DJ, Wellik KE, Parish JM, Aguilar MI, Snyder CR, Wingerchuk D, Demaerschalk BM.

Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA.
Abstract
BACKGROUND: Obstructive sleep apnea (OSA) is associated with hypertension, atrial fibrillation, coronary artery disease, congestive heart failure, and diabetes. These disorders are also risk factors for stroke.

OBJECTIVE: To determine whether OSA increases the risk of stroke independently of other cerebrovascular risk factors.

METHODS: The objective was addressed through the development of a structured critically appraised topic. This evidence-based methodology included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of sleep medicine and vascular neurology.

RESULTS: A large observational cohort study was selected and appraised to address this prognostic question. The unadjusted analysis revealed that OSA (apnea-hypopnea index >5) was associated with stroke or death from any cause (hazard ratio, 2.24; 95% confidence interval [CI], 1.30-3.86; P = 0.004). The adjusted OSA analysis retained a statistically significant association with stroke or death (hazard ratio, 1.97; 95% CI, 1.12-3.48; P = 0.01). In separate unadjusted analyses, OSA was associated with death and stroke with relative risks of 1.68 (95% CI, 1.10-2.25) and 5.16 (95% CI, 3.72-6.60), respectively.

CONCLUSIONS: OSA independently contributes to stroke risk.

PMID: 20592572 [PubMed - in process]

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

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

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

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

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

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

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

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

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

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

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

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

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