Friday, January 28, 2011

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

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

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


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

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

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

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

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

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




Which oral appliance works best for treating sleep apnea?.

I usually know what type of oral appliance, CPAP, BiPAP or surgery will best suit my patient with obstructive sleep apnea after a short interview and exam. Success is not only efficacy of the appliance but also compliance which is a complex issue poorly addressed by randomized trials. The way the patient responds to the exam, impressions and bite often give the final clues to which treatment will be most beneficial. (many types of appliances are shown on the I HATE CPAP! site)

I present below a recent study on which appliances are the most effective. I review the information but I would like to make some personal comments about evidence based medicine and how it ignores the clinical knowledge and experience of trained physicians and dentists. Having done thousands of appliances I believe I am very adept at determining which patients will do best with various appliances. Unfortunately, clinical experience is not easy to integrate into randomized controlled studies. In fact, clinical experience and "gut feelings" about patients are ruled out of these studies. Randomized controlled studies work best with a limited number of variables. A problem many patients who try oral appliances have is that there dentist was trained by a manufacturers course and the doctor only has a single tool in his belt or only one appliance he understands and is comfortable using.

I teach a dental sleep medicine course that extensively covers the entire field of dental sleep medicine. I do give dentists who take my course a handful of appliances that are extremely effective for different patient groups. I also know that experience is vital to treating patients and therefore offer unlimited phone follow-up for 6 months with doctors that I train. I review sleep studies and frequently help them thru the diagnostic regimen to pick an appropriate appliance.

My article review follows and I include the PUB MED abstract with additional comments.

A brand new article looked at the effectiveness of various oral appliances. They found 1475 articles comparing efficacy of various appliances. The study showed that 116 of these studies compared an oral appliance to a control. They gave weight to only 14 of these studies that were randomized controlled trials (RCTs). All of the studies concerned MAD or mandibular advancement devices. The study concludes that "The evidence shows that there is no one MAD design that most effectively improves polysomnographic indices, but that efficacy depends on a number of factors including severity of OSA, materials and method of fabrication, type of MAD (monobloc/twin block), and the degree of protrusion (sagittal and vertical). These findings highlight the absence of a universal definition of treatment success. Future trials of MAD designs need to be assessed according to agreed success criteria in order to guide clinical practice as to which design of OAs may be the most effective in the treatment of OSA."

Eur J Orthod. 2011 Jan 13. [Epub ahead of print]
A systematic review of the efficacy of oral appliance design in the management of obstructive sleep apnoea.
Ahrens A, McGrath C, Hägg U.

Discipline of Dental Public Health.
Oral appliances (OAs) are increasingly advocated as a treatment option for obstructive sleep apnoea (OSA). However, it is unclear how their different design features influence treatment efficacy. The aim of this research was to systematically review the evidence on the efficacy of different OAs on polysomnographic indices of OSA. A MeSH and text word search were developed for Medline, Embase, Cinahl, and the Cochrane library. The initial search identified 1475 references, of which 116 related to studies comparing OAs with control appliances. Among those, 14 were randomized controlled trials (RCTs), which formed the basis of this review. The type of OA investigated in these trials was mandibular advancement devices (MADs), which were compared with either inactive appliances (six studies) or other types of MADs with different design features. Compared with inactive appliances, all MADs improved polysomnographic indices, suggesting that mandibular advancement is a crucial design feature of OA therapy for OSA. The evidence shows that there is no one MAD design that most effectively improves polysomnographic indices, but that efficacy depends on a number of factors including severity of OSA, materials and method of fabrication, type of MAD (monobloc/twin block), and the degree of protrusion (sagittal and vertical). These findings highlight the absence of a universal definition of treatment success. Future trials of MAD designs need to be assessed according to agreed success criteria in order to guide clinical practice as to which design of OAs may be the most effective in the treatment of OSA.

PMID: 21239397 [PubMed - as supplied by publisher]

The article states " These findings highlight the absence of a universal definition of treatment success." The definition of success should be the elimination of all obstructive apneas, hypopneas and RERA's or respiratory related arousals and/or UARS upper airway resistance syndrome. Ideally snoring should also be resolved. Success should also consider central apneas that are not treated by appliances. If there are substantial episodes of central apnea other alternatives may need to be considered.

Positional treatment and oral appliance therapy are frequently used together if incomplete results are obtained with just an oral appliance. It is important to remember that even patial therapy with an oral appliance is far superior to no therapy in patients who reject CPAP. The physician/dentist should try to eliminate all sleep disordered breating.

Allergies and nasal congestion can be addresses with nasal breathing strips, medication, correction of deviated septums or reduction of turbinates.

Irrigation with a Netti Pot utilizing saline or black tea and saline can reduce mucous congestion. I have seen several patients who clain great relief from NAET, I do not understand or endorse this therapy but I have seen many patients who claim significant relief.

The bottom line, it is essential to control all apneic episodes. Untreated sleep apnea is dangerous and can be fatal. Heart disease, hear attacks, strokes, hypertension, short term memory loss, increased risk of motor vehicl accidents, earlier and more severe onset of dementia and/or Alzheimers are just the tip of the iceberg for possible negative consequences related to sleep apnea.

My advice: See a sleeep apnea dentist with experience and/or a mentor who is trained in multiple oral appliances. I am a Diplomate of the American Academy of Dental Sleep Medicine. There are many dentists who are well trained but have not received Diplomate status. Choosing a Diplomate in dental sleep medicine does insure a wide range of experience but is only one of many considerations.

Researchers Recommend Sleep Study for Children Undergoing Surgery

We have already discussed that sleep apnea can significantly increase a person's risk for anesthesia complications. One of the tools recently implemented for identifying adults with sleep apnea risk is the STOP-BANG questionnaire. Now researchers have noted that children with sleep apnea are also at a greater risk for anesthesia-related complications and therefore should be screened before surgery, especially tonsils and adenoid surgery.

The children who were most likely to experience post-surgical complications had several factors in common, including:

  • Higher apnea-hypopnea index
  • Higher hypopnea index
  • Higher body mass index (BMI)
  • Lower oxygen saturation at lowest point

There are currently no standards of care that indicate whether children should be screened for obstructive sleep apnea before undergoing surgery. This study suggests that perhaps there should be. The article recommends that using a sleep study to identify at-risk patients before surgery so that surgeons can plan optimal postoperative procedures to avert or identify complications.

We often think of obstructive sleep apnea as an adult condition, but a large number of children also suffer from this potentially deadly condition, which may manifest itself during the day in symptoms like ADHD, mood disorders, behavioral problems, lethargy, and other generic symptoms. If you would like to learn more about childhood sleep apnea, how to identify it, and how to treat it, please contact a local sleep dentist today.


Dawn: My 5yo daughter had T&A sx at 22mos which seemed to help her osa up until about 8months ago. She is now going to start using a cpap for severe osa. I now know she will need orthodontic and/or maxillofacial close monitoring. I am wondering if any of thes oral applianced are used with children this young also, and if there is anyone in the northern ******** area who is best trained for this.

Dr Shapira: Dear Dawn,

There is an excellent Sleep Apnea Dentist in your area Dr *********** I just talked to him and he would be happy to work with you and your daughter. If there are any questions during treatment we can discuss it as treatment pprogresses.

There would actully be two appliances involved a nightime appliance and a daytime appliance. This will allow the widening of the maxilla while using an appliance to prevent apnea...Dr ******* has a great deal of experience in treating sleep apnea.

This will not only treat the sleep apnea but begin treating the underlying orthopedic problem. You child will still need orthodontics (probably) in the future but the early orthopedic therapy will make future orthodontics easier.


There is a question whether tonsilectomy and adenoidectomy should occur before of after widening of the maxilla. Widening the maxilla will improve the airway and possibly lower post-op complications. If T&A is done prior to widening studies have shown that it does not correct the development orthopedic problems. All patients should be reevaluated for sleep apnea and for maxillary expansion.

Wednesday, January 26, 2011

Sleep Apnea May Consume Energy

According to research reported in the Journal of Physiology, missing a night's sleep may cause a person to consume about 161 extra calories, even if the person is lying in bed all night. Sleep apnea may cause a person to consume even more energy.

The information comes from a new, highly sophisticated study of sleep and energy consumption by doctors at the University of Colorado. The researchers put subjects in sealed rooms for three consecutive days during which the subjects were kept in bed both when awake and asleep. Subjects were fed the same amount of calories at the same time every day and their oxygen consumption and carbon dioxide exhalations were measured. This allowed researchers to precisely plot the amount of energy used when awake or asleep.

Researchers discovered that waking was a highly energetic process. Even if a person awoke for just a few seconds, energy consumption shot up precipitously. This may partly contribute to sleep apnea sufferer's reports of fatigue and daytime sleepiness.

Though sleep apnea sufferers consume more energy, they are unlikely to lose weight. Other research has shown that sleep apnea can impact a number of hormones involved in the consumption and storage of energy, making it very hard for sufferers to lose weight.

If you suffer from sleep apnea, it is important that you get treatment as soon as possible to avoid the condition's potentially deadly consequences. To learn more about sleep apnea and its treatment, please call or email a local sleep dentist today.

Thursday, January 20, 2011

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:

"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"

Wednesday, January 19, 2011

What do patients feel about wearing an oral appliance vs CPAP?

I just received a e-mail from a patient who recently switched to a comfortable oral appliance from CPAP. I think he clearly stated the answer to how comfortable an oral appliance is so I copy and pasted his answer below.


Why do patients abandon CPAP? They appreciate the benefits but dislike the mask, hose and entire CPAP set-up. Give most patients an appliance and they blown away by how small and non intrusive appliances are. This is especially true for patients who feel claustrophobic when using CPAP. Some patient may feel a little claustophobic with an appliance initially but it is rare. Patients who switch from CPAP to appliance therapy tend to agree with Gene, ie Niiiiiiiiiicccceee!

BiPAP, ramping, APAP, humidification, heated CPAP hoses all increase the comfort of the patient using CPAP but none of these statistically increase compliance.

The best method of increasing compliance in non-compliant CPAP users is to offer a more comfortable treatment alternative. Oral Appliances are not perfect but the have a 90+% compliance. This is especially impressive because there is an adverse selection of patients, ie, those who have already failed another treatment.

Studies have shown the huge ajority of patients offered a choice between CPAP and Oral Appliances chose the appliance.

Friday, January 14, 2011

Sleep Apnea a Good Reason to Keep New Year's Resolution

This year, did you resolve to get in shape and lose weight? Are you having trouble sticking to it? Do you need an extra motivation? If so, then consider your risk of obstructive sleep apnea. Your risk of obstructive sleep apnea increases as your BMI increases. If you have a BMI of 30 or greater (are medically obese), you are more likely to suffer sleep apnea and are more likely to have a severe form of the disease.

Sleep apnea sufferers are at a greater risk for:

  • Heart attack
  • Stroke
  • Mental health problems
  • Cognitive decline
  • Car and work accidents
  • Many other conditions

Learn all about the dangers of obstructive sleep apnea. If you have a more severe form of the condition, you can generally only get treatment with continuous positive airway pressure (CPAP), a treatment option with a low compliance rate because many consider it uncomfortable and inconvenient. CPAP with poor compliance is approximately the same as getting no treatment at all. Sometimes, losing weight can reduce the severity of your sleep apnea to the point that you may become a good candidate for oral appliance therapy or other treatment options.

Whether you are overweight or not, if you have some of the symptoms of sleep apnea, you need to undergo a sleep study to determine whether you are suffering from this potentially deadly condition.

To learn more about sleep apnea and its treatment options, contact a local sleep dentist.

Wednesday, January 12, 2011

Sleep Apnea May Lead to Car Accidents, Still Not Good DUI Defense

In San Diego, the lawyer of a man being tried for "gross vehicular manslaughter while intoxicated," claimed that the fatal accident was caused not by alcohol, but by obstructive sleep apnea.

The driver had been diagnosed with sleep apnea the year before. It is unclear whether he was undergoing treatment at the time. However, the driver also admitted to a treating doctor that he had had at least five drinks before getting in his car to drive home. His blood alcohol content was more than double the legal limit when tested 2 1/2 hours after the accident, and was probably much higher at the time of the accident.

Sleep apnea can increase your risk of car accidents. It can, as the lawyer claimed, cause episodes of "micro-sleep" when you may black out for a few seconds at a time and never know that you fell asleep. When driving, these episodes of micro-sleep can lead to deadly accidents. However, it is unlikely that micro-sleep will work as an effective defense for a drunk driver in a fatal accident whose blood alcohol content was more than twice the legal limit.

To avoid an increased risk of car accidents and other dangers of sleep apnea, please call or email a local sleep dentist today to learn more about sleep apnea and its treatment options.

Friday, January 7, 2011

Shocking Treatment for Sleep Apnea: Hypoglossal Nerve Stimulation

People in the market for CPAP alternatives may soon have another option. If surgery is not recommended and if they are not a candidate for oral appliance therapy, they may be interested in an experimental treatment that is being developed by not one, but three medical technology companies: hypoglossal nerve stimulation.

In hypoglossal nerve stimulation, a pacemaker-like device is implanted under the skin with two leads that terminate near the lungs and another that connects to the hypoglossal nerve, which controls the genioglossus muscle, which is partly responsible for keeping the airway open. When the systems sense an effort to breathe, they stimulate the hypoglossal nerve, essentially mimicking the role the brain would play in reopening the airway, but without the brain's involvement so a patient keeps sleeping and does not experience the period of wakefulness that can be so disruptive in obstructive sleep apnea patients.

One of the companies--Inspire Medical Systems, a spin-off of Medtronic--has received FDA approval to test the technology. Inspire Medical Systems has already implanted one patient with the device, and is enrolling 100 more potential subjects to begin testing by the end of January.

It is unknown whether this device will prove successful in treating obstructive sleep apnea, but we hope so. The more options, the better the likelihood that the 12 million sufferers of this deadly condition will be able to find a cure that fits them. To learn more about all available treatment options, talk to a local sleep dentist today.