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.

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

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

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

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

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

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

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

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

Best regards

Susanne Schwarting""

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

Lexi has left a new comment on your post "New Medicare Guidelines for CPAP":

We are currently doing research on CPAP compliance and Medicare converage. However, I cannot find a Medicare definition of CPAP Compliance. Could you please tell me where you found this information where Medicare defined CPAP compliance as, "at least 4 hours a night and wear CPAP 70% of the time for a 30 consequtive day period"?

Thank you in advance,
Alexia Adams

Dear Lexi,
I cannnot reply directly as you did not leave an e-mail address

This is from ResMed "CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:
Continued coverage of a PAP device (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy,
documentation of clinical benefit is demonstrated by:
Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,
Objective evidence of adherence to use of the PAP device reviewed by the treating physician.
*************
********Adherence to therapy is defined as use of PAP > 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not medically necessary.
Beneficiaries who fail the initial 12 week trial are eligible to requalify for a PAP device but must have both:
Face-to-face clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to PAP therapy; and,
Repeat sleep test in a facility-based setting (Type 1 study)." It came from
http://www.resmed.com/us/dealers/reimbursement/cpap.html?nc=dealers
For more info use Google search "medicare cpap coverage minimal usage for coverage" it was hard to find, I know it from many different sources.

Medicare has issued these new rules because they are tired for paying for CPAP that is not used. Statistics show only 60% of patients use CPAP long term and the fact that 4 hours a night is not acceptable treatment but it is certainly better than no treatment. Sleep Apnea is a dangerous and serious condition and most heart attacks and strokes are in the early morning hours when patients have abandoed their CPAP.

Dr Shapira

Dr Shapira

SUAD not Working: what about combination therapy?

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

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

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

Dr Shapira

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

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

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

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

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

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

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

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

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

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

I hope this is helpful.

Dr Ira L Shapira

Nap 'boosts' brain learning power according to article on BBC news.

"Sleep not only rights the wrong of prolonged wakefulness, but, at a neurocognitive level, it moves you beyond where you were before you took a nap" according to Dr Matthew Walker,at UC Berkeley.

I found this post on BBC news " The latest study, from the University of California at Berkeley, suggests that the brain may need sleep to process short-term memories, creating "space" for new facts to be learned. " http://news.bbc.co.uk/2/hi/health/8524549.stm

The quality of sleep at night as well as during naps determine how successfully are brains function cognitively and in terms of short term memory.

According to the BBC news "Dr Matthew Walker, who led the study, reported at the AAAS conference in San Diego, said: "Sleep not only rights the wrong of prolonged wakefulness, but, at a neurocognitive level, it moves you beyond where you were before you took a nap.
"It's as though the e-mail inbox in your hippocampus is full, and, until you sleep and clear out all those fact e-mails, you're not going to receive any more mail.
"It's just going to bounce until you sleep and move it into another folder."
However, Professor Derk-Jan Dijk, the director of the Surrey Sleep Research Centre, said that there was no clear evidence that daytime napping offered a distinct advantage over sleeping just once over 24 hours.
"The sleep-wake cycle is not as rigid as we might think - we have the capability to sleep in different ways."
He said that while the brain effect reported in the study might be spotted in a laboratory setting, the picture became more clouded in the "real world".
"The size of these effects are much more difficult to assess - if I have to learn something, for example, it's easier to do this when I'm feeling awake and alert than when I'm sleepy.""

I will try to read original studies and post again.

Dr Shapira

New Medicare Guidelines for CPAP

The new medicare guidelines for CPAP coverage state that patients must have compliance of at least 4 hours a night and wear CPAP 70% of the time for a 30 consequtive day period.

These guidelines reflect how little CPAP is uded. Even with these looose standards medicare expects to save substantial dollars. $-5 hours is the average amount of time patients wear CPAP. 7-71/2 hours of nightly use is recommended. Ideally CPAP should be worn nightly.

If medicare required 90% usage or 6 hours of wear almost no one would qualify for coverage. I think the new standard for coverage is appropriate because it will save medicare the cost of buyiny CPAP machines that are not used (wasted taxpayer money)and patients who wear CPAP 4 hours nightly (average use for all patients) will have coverage. Medicare will cover CPAP based on low expectations of use that history and published studies have shown to be the case.

ARE YOU SICK AND TIRED OF BEING SICK AND TIRED?

PATIENTS WITH UNTREATED SLEEP APNEA ARE PRONE TO MANY NUMEROUS MEDICAL PROBLEMS FROM HEART ATTACKS,STROKES, SHORT TERM MEMORY LOSS, INCREASED MOTOR VEHICLE ACCIDENTS, WORSENING OF DIABETES, CORONARY ARTERY DISEASE, STRESS DISORDERS INCLUDING DEPRESSION AND MANY OTHER PSYCHIATRIC PROBLEMS.

THE MAJORITY OF PATIETS GIVEN CPAP ARE UNABLE TO TOLERATE IT OR ONLY WEAR IT FOR A FEW HOURS A DAY. CPAP IS THE GOLD STANDARD OF TREATMENT AND IS VERY EFFECTIVE WHEN USED ALL NIGHT/ EVERY NIGHT.

STROKES AND HEART ATTACKS USUALLY OCCUR IN THE EARLY MORNING HOURS 3-5 AM. PATIENTS WHO WEAR CPAP FOR ONLY A FEW HOURS HAVE USUALLY STOPPED USING THEIR CPAP BEFORE THEY REACH THIS HOUR WITH PEAK RISK FOR CARDIOVASCULAR EVENTS. IT IS CRITICAL FOR CPAP USERS TO WEAR THEIR CPAP FOR 7-7 1/2 HOURS A NIGHT.

PATIENTS WHO ARE INADEQUATELY TREATED OFTEN ARE TIRED AND MORE PRONE TO ILLNESS. IF YOU CANNOT TOLERATE CPAP TREATMENT OF YOUR SLEEP APNEA THAN AN ORAL APPLIANCE IS THE MOST SUCCESSFUL ALTERNATIVE TO CPAP. THERE ARE ALSO SURGICAL AND BEHAVIORAL METHODS OF TREATING OBSTRUCTIVE SLEEP APNEA INCLUDING POSITIONAL THERAPY AND WEIGHT LOSS.

IF YOU ARE SICK AND TIRED OF BEING SICK AND TIRED YOUR ANSWER IS TO TREAT YOUR SLEEP APNEA THOROUGHLY. IF YOU HATE CPAP COMFORTABLE ORAL APPLIANCES MAY BE A SOLUTION THAT WILL DRAMATICALLY IMPROVE YOUR QUALITY OF LIFE AS WELL AS PROTECT YOUR HEALTH.

ACNE from CPAP MASK

Question: I use the full face mask with cpap. It seems that where the mask contacts my face, acne breaks out. What causes this and what is best to treat the acne with?

Response: William, Acne from a CPAP mask is not uncommon. While most of my patients eventually switch to oral appliance I can offer a few suggestions.

1. Keep the mask and hoses scrupulously clean

2. A thin layer of Lanolin can be place on the ares where the mask contacts the face 1/2 hour before putting the mask on. The skin should be thoroughly washed and dried first.

Dr Shapira