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.

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]

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.

THE BEST SLEEP APNEA TREATMENT: CPAP vs ORAL APPLIANCES. A QUESTION OF COMPLIANCE AND EFFECTIVENESS.

This is a reprint from a recent press release. The time where CPAP is considered the only treatment is already behind the curve. Current realities show that compliance issues favor oral appliances over CPAP for 60% of patients who abandon CPAP use. What is the best treatment for sleep apnea? Is CPAP the best treatment for sleep apnea or are oral appliances the best treatment for sleep apnea. Compliance is the real issue for what is the best treatment.

THE BEST SLEEP APNEA TREATMENT: CPAP vs ORAL APPLIANCES. A QUESTION OF COMPLIANCE AND EFFECTIVENESS. Young thinner healthier patients are often better served with oral appliances due to comfort.

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 Morbidly Obese patients CPAP is Best

FOR IMMEDIATE RELEASE
(Free-Press-Release.com) August 13, 2010 -- 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 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

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.

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 elminates apnea based on a sleep study it is equivlant to CPAP. The issue of compliance almost always favors oral appliances but objective monitor for appliance use are not yet available.

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.

Information on oral appliances is available at http://www.ihatecpap.com

Dr Shapira is a Diplomate of the American Board of Dental Sleep Medicine and offers Oral Appliances to Chicago area patients at his offices in Gurnee, Skokie and Schaumburg. Call today 1-8-NO-PAP-MASK

More information can be found online at http://HTTP://WWW.IHATECPAP.COM