Problems with TAP 3, What to do?

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

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

Dr Shapira Response
Phil,

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

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

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

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

Dr Shapira

What is the best oral appliance for treating sleep apnea?

Any appliance that eliminates sleep apnea is a "best" choice.

The TAP appliances are the most effective for severe sleep apnea. I discuss which appliance is most appropriate for each patient based on their sleep study results, overall health, dental health and many other factors.

This is why I always set up each patient for a one hour consultation to explore multiple alternatives and to help my patients make informed choices on which treatment is most effective for treating each individuals sleep disorder.

I believe each patient deserves to understand how sleep apnea occurs and all treatment alternatives not just be "sold" an Appliance.

It is also important to insure successful treatment by doing follow-up sleep studies with appliances in place to insure efficacy.

I always give a full year of necessary follow-up visits when I make a patient an appliance. Appliances are not 100% successful but with proper follow-up they are 90-95% successful and vastly prefered to CPAP. Most patients have minimal problems with appliances but a small percentage may need several problem solving appointments.

Chosing the proper appliance for each patient eliminates the majority of problems.

BITE CHANGES AND TOOTH MOVEMENT FROM SOMNOMED APPLIANCE

PATIENT;
I have been using somnomed dental appliance for several years. I love it, but it has moved my lower teeth forward and to the left so that I can't close my teeth together -- the top teeth go behind the bottom ones. Do you have suggestion for an appliane that might keep this from happening or maybe allow my teeth to go back to normal positioning? Thanks so much.

Dr Shapira Response
I have written a lot about tooth movement and bite changes with appliance use. It is important to do the exercises daily to prevent this type of problem. I frequently find that patients have stopped doing their exercises because their chronic headaches or neck pain went away as the bite changes.

I strongly advise that patients seek treatment from dentists trained in treating TMJ disorders. The American Academy of Sleep Medicine also Rx that Dental Sleep Medicine and Oral Appliances for Sleep Apnea be provided by dentists with extensive training in treating TMJ disorders. The AADSM does a very poor job of stessing this to new mwmbers, I stress it to doctors who take my Sleep Apnea treatment course. Personally, I Rx seeing a dentist specifically trained in Neuromuscular Dentitry. See my sister site www.ihateheadaches.org

I have seen many patients in whom we uoptimizee the bite changes by combining Neuromuscular treatment utilizing a daytime diagnostic orthotic with the sleep appliance. The NHLBI (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf) considers sleep apnea to be a TMJ disorder and we combine treatment. Reconstruction via crown and bridge or orthodontics lead to a long term stable position. This frequently also corrects forward head position, chronic headaches, migraines and/or neck pain.

Oral appliances can have problems but they are minimal to the problems from untreated sleep apnea. An interesting fact is that CPAP also can move teeth but the movement is different than that caused by dental appliances.

Oral Appliances and Sleep Study results. What are my options

QUESTION: I have a dental appliance that works great. I sleep soundly, my mental alertness has increased since changing from the CPAP. The problem is I had a sleep study and it did not go well. There were a lot of noises that woke me up. The leads kept pulling my body hair so I never really could relax enough to sleep well. Is the sleep study the end all be all for determining the effectiveness of a dental appliance? I can't go back to using a CPAP. Do I have any recourse for insisting on using the dental appliance?

ANSWER: There are actually several questions. First, like many patients you feel great with the appliance and symptoms have been resolved. When you said the sleep study did not go well you discussed problems with the study not your results. Did they still show you have sleep apnea and if so how severe?

Important considerations are the apnea hypopnea index and oxygen nadir. Think of the sleep test as a opportunity to continue to improve the effectiveness of your oral appliance. It sounds like it was not an ideal situation , sometimes sleep medication can help for study night. The only way to know treatment is successful is a sleep study but it is posible to do home studies. I prefer to use a lab study because your appliance can be titrated uring the night for improved quality of treatment but this means your expert in Dental Sleep Medicine has taught the lab how to titrate appliances.

Some sleep labs are very negative about oral appliances and only offer CPAP. This is an example of poor medical treatment. Stuies have shown that the majority of patients reject CPAP. Oral appliances are a safe and effective treatment and it is medically-legally incumbent that all options are offered. For severe apnea oral appliances are an alternative when CPAP is not tolerated or refused by the patient. MANY PATIENTS CAN CONBINED POSITIONAL TREATMENT WITH ORAL APPLIANCE THERAPY AND VASTLY IMPROVE RESULTS. Frequently an oral appliance can be combined with nasal surgery to reduce turbinates or correct deviated septums improving results. I suggest that patients avoid labs and physicians that are completely negative about oral appliances. These labs often have financial intreasts in CPAP treatment. I would also suggest patients avoid dentists who are not careful in doing follow-up sleep studies with physicians your health is always the primary concern. The I HATE CPAP site is sometimes seen as being negative about CPAP but that is certainly not the case. CPAP is excellent treatment and highly effective, when used. The I HATE CPAP site is interested in insuring that patients who do not tolerate CPAP find effective alternatives.

I would suggest you continue to work to improve the results you obtained with your appliance. You are definitively better with some treatment than no treatment but your health is at stake.