Medicare and Tricare coverage for oral appliances

Medicare, Tricare and other government insurances should cover oral appliances but that does not mean it will be easy. Medicare requires dentists form a DME, then pays poorly, See question from Eduardo received 8/31/12

Question from Eduardo: Why has my dentist taken so long to see if I can get an oral appliance for sleep apnea and snoring. Also I need to know if most of your Dentist take medicare and Tricare for life, I need to get something going.The doctor I have is taking too long I aplied back in May 2012 and still nothing

Dr Shapira response: Unfortunately while covered by medicare most docs won't take it. Medicare requires that an the dentist has a DME and choice of appliances is very limited. I do not accept medicare and have opted out and medicare patients pay my fee. My office is near great lake navak base but tricare has never paid for an appliance.

The good news is that CPAP is very successful if you can tolerate it. If not you must be proactive with Tricare and/or medicare that they find you a provider.

My suggestion is just to pay out of pocket if you can afford it otherwise get on CPAP while waiting for approval.

The good news about untreated sleep apnea is that it can kill you......the bad news is that it can cause a stroke!

IRA L SHAPIRA DDS, D,ABDSM, D,AAPM, FICCMO

There are several questions when it comes to Medicare coverage. First is whether medicare can afford to take on the cost of oral appliances considering the majority of seniors have some sleep disordered breathing. The requirement that dentists form DME's for each office is ridiculous, expensive and cumbersome. The proper approach is for Medicare to contract with Medicare approved labs that make appliances for sleep apnea and to pay the lab cost directly to the manufacturer. The dentist professional fee should be governed by standard Medicare B pay codes and fees. The alternative is that dentists opt out and patients make private arrangements for professional services.

Medicare should cover appliance manufacturers for the appliance based on specific appliances. My personal feelings is that there should be a minimal qualification of the dentist to have medicare cover the lab costs. A good idea might be to use diplomate status in the AADSM. Dentists who do not meet requirements would just do private contracts for the full amount. The dentist would not need to participate in Medicare but could if they desired.

Labs would have to meet Medicare standards for coverage, a difficult to define and ever changing target. Because labs serve thousands of dentists it would be financially effective.

It should be clearly understood that medicare would limit the number of appliance types.

In Illinois, Southern Wisconsin I personally treat patients with medicare after an opt out is signed. Patients who opt out of medicare can use the appliance of their choosing but must pay for it themselves.

DO I HAVE TO WEAR A CPAP ( BiPAP) MACHINE FOR THE REST OF MY LIFE?

This is a frequent question asked by patients with sleep apnea that is treated with CPAP> There are many answers to that question. Obviously the best alternative to CPAP is an oral appliance for most patients but there are also many other alternatives.

While the majority of patients complain about CPAP and 60% discontinue using it completely it is important to remember that one i four patients using CPAP love their CPAP machines, masks and hoses. They give them back their lives and these patients have no desire to be free from CPAP.

Their are alternatives to CPAP and Oral Appliances. Weight loss is very effective for some patients who see their obstructive sleep totally resolve with weight loss.

WEIGHT LOSS ALONE IS NOT EFFECTIVE FOR ELIMINATING OBSTRUCTIVE SLEEP APNEA FOR MOST PATIENTS. IT WILL ALMOST ALWAYS REDUCE THE SEVERITY OF SLEEP APNEA BUT THE TRUTH IS THAT MANY PATIENTS ORIGINALLY GAINED THE WEIGHT DUE TO SLEEP APNEA. METBOLIC SYNDROME IS WEIGHT GAIN DUE TO APNEA AND RELATED HORMONAL DISRUPTIONS.

MANY THIN AND/OR ATHLETIC PATIENTS HAVE SLEEP APNEA DUE TO THEIR ABNOMAL (pathologic) ORAL PHARYNGEAL ANATOMY.

PATIENTS WITH POSITIONAL SLEEP APNEA USUALLY RESPOND WELL TO WEIGHT LOSS THERAPY.

Positional therapy is excellent for patients who only have apnea episodes on their back (supine). A danger in this treatment is patients who no longer have apneas or hypopneas may now have UARS or RERAs.

Bimaxillary advancement surgery is the most effective long term surgical solution. i strongly suggest that prior to surgery an oral appliance trial be done. It will predict success but also increase success rates because the amount of advancement necessary can be determined prior to surgery.

Morbidly obese patients are not good canidates for oral appliances or jaw advancement surgeries. Bariatric surgery to first lose weight it probably a more reasonable first step. Any surgery is more dangerous in the morbidly obese and in patients with sleep apnea.

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.

Sleep Apnea Diagnosis Can Make Health And Life Insurance Extremely Expensive. Insurance Agents Have Experienced Problems Insuring Clients

Sleep Apnea Diagnosis Can Make Health And Life Insurance Extremely Expensive. Insurance Agents Have Experienced Problems Insuring Clients Diagnosed With Sleep Apnea.

Adverse Insurance Ratings can be avoided by doing off the grid sleep studies.

Sleep Apnea is a dangerous problem that can lead to heart attacks, strokes, excessive daytime sleepiness, short-term memory loss and increases in motor vehicle accidents. It is essential to diagnose and treat sleep apnea. One study showed a 36% decrease in 8 year survival comparing treated and untreated sleep apnea. Learn more about the dangers of sleep apnea @ http://www.ihatecpap.com/sleep_apnea_dangers.html

A problem frequently experienced is that the cost of health, life and disability insurance policies can increase exponentially following diagnosis of sleep apnea. This is problematic for owners of small businesses and wealthy individuals who utilize life insurance to protect their estates.

Financially savvy patients are turning to off the record sleep studies. Patients pay for their sleep studies and treatment in cash to avoid any footprints of the diagnosis. Patient’s records may be identified only by numerical accounts or convenient name misspellings or addition of new names can protect patient’s identities. (Example Barack Obama could become Eric B Obama).

Cash payment secures patient privacy. HIPPA regulations theoretically protect our personal medical information. When obtaining new insurance you forfeit these HIPPA rights in order to qualify for coverage. Insurance benefits can be denied in the future if there is a record of undisclosed illness.

There are two primary treatments for sleep apnea, CPAP and Oral Appliances. Severe Sleep Apnea especially in morbidly obese patients is usually CPAP initially and an Oral Appliance for patients who don’t tolerate CPAP. Studies have shown that the majority of patients reject CPAP and prefer comfortable oral appliances when offered a choice of treatments. Learn more about Oral Appliance therapy for Sleep Apnea at http://www.ihatecpap.com.

Patients who are interested in off the grid sleep studies can contact Dr Ira L Shapira, a Gurnee, Il dentist who has been treating Sleep Apnea with oral appliances since the early 1980’s. As a Visiting Assistant Professor at Rush Medical Schools Sleep Center he did research on jaw position and Sleep Apnea.

Dr Shapira is a Diplomate of the American Board of Dental Sleep Medicine and practices Dental Sleep Medicine at Delany Dental Care in Gurnee and at Chicagoland Dental Sleep Medicine Associates in Skokie, Schaumburg and Vernon Hills. In Skokie his practice is located in American Sleep Medicine and in Vernon Hills he utilizes the office of Sleep and Behavioral Medicine.

http://www.delanydentalcare.com/sleep_apnea.html

http://www.chicagoland.ihatecpap.com/

Dr Shapira realizes the importance of accurate diagnosis and treatment of sleep apnea but also understands the financial impact a diagnosis of sleep apnea can create. Working to create both value and privacy for his patients he arranges for off the grid sleep studies. Baseline studies are essential for diagnosis and titration sleep studies insure treatment efficacy. Post-treatment studies are essential for Oral Appliance Therapy and for CPAP therapy.

Special off the grid pricing has been arranged for Dr Shapira’s sleep patients desiring privacy. Contact Dr Shapira at 1-8-NO-PAP-MASK or at 847-623-5530 for more information on insuring your medical privacy.

Dr Shapira stresses that avoiding sleep studies can have serious medical consequences. Diagnosis and Treatment are the most important medical considerations.

Incomplete Resolution of Sleep Apnea Can Be Corrected With Tongue Tapper

I recently had a request from a Dentist about how the Tongue Tapper works. It is something that I add to an oral appliance on occasion when incomplete resolution of sleep apnea is a problem.

Don: Dr.S, In one of the recent AADSM forum discussions you mentioned a tongue tapper to help with tongue reflexes. Can you share how you do that with a MAD? Thank.

Dr Shapira Response:I use a 1 mm ortho spring wire from either the lower or upper appliance with a small composite or acrylic button that very lightly touches the posterior lateral surface of the tongue. If the tongue drops back and touches it elicits a protrusive reflex of the tongue.

Light touch not brute force similar to how tonsils cause tongue thrusts.

THERE ARE MANY ORAL AND PHARYNGEAL REFLEXES THAT CAN EFFECT BREATHING IN SLEEP. THE TONGUE TAPPER TAKES ADVANTAGE OF ONE OF THESE REFLEXES TO CREATE TONGUE PROTRUSION. ONE OF THE REASONS I LIKE THE TAP 1 APPLIANCE IS THAT IT ELIMINATES OR DECREASES RETRUSIVE TONGUE REFLEXES.

tHE MOSES APPLIANCE IS DESIGNED TO PREVENT RETRUSIVE REFLEXES AS WELL.

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

GOOD NEWS - BAD NEWS ABOUT SLEEP APNEA

The good news about sleep apnea is that it easily diagnosed and treated.

The bad news is that sleep apnea can cause Hypertension and an estimated 50-70% of people with sleep apnea have hypertension, or high blood pressure. This increases the risk for heart attack, stroke, and other health problems.

The Good news is that sleep apnea is easily and effectively treated with CPAP.

The bad news about sleep apnea is that 60% of patients diagnosed with sleep apnea cannot tolerate CPAP. When sleep apnea is not treated it can lead to Coronary Heart Disease. Sleep apnea can lead to activation of the sympathetic nervous system which is responsible for the “fight-or-flight” response. Sleep apnea also is responsible for problems with the lining of blood vessels, inflammation, and problems with metabolic regulation.

The good news is that oral appliances are a comfortable alternative to CPAP.

The bad news is that your doctor probably never told you that oral appliances are considered a first line treatment for mild to moderate sleep apnea. Because patients are unaware of this effective and comfortable alternative to CPAP they are at increased risk for Stroke, Chronic Heart Failure and Sudden Death.

The association between stroke and sleep apnea according to considerable research is as convincing as the association between smoking and stroke. During apneic episodes the blood vessels of the brain dilate when the oxygen levels fall. Patients with sleep apnea are more susceptible to clots that may lead to stroke. Research has shown that the number of strokes in patients with untreated sleep apnea are staggering and that 40-60% of people experiencing strokes have been found to have obstructive sleep apnea. In addition to stoke sleep apnea leads to chronic heart failure and numerous serious cosequences from this condition as well as a staggering risk of dying in their sleep. Half of patients with sleep apnea die between midnight and 6 AM compared to only 21% of patients without sleep apnea.

The good news is that weight loss can improve sleep apnea.

The bad news is that it is almost impossible for patients with untreated sleep apnea to lose weight because of metabolic changes associated with their sleep apnea.

The good news is that oral appliances are effective for treating sleep apnea and that the vast majority of patients prefer them to CPAP. Patients who treat their sleep apnea with oral appliances usually have more energy and find it easier to exercise and to lose weight.

The bad news is that patients who treat their sleep apnea with oral appliances need to save more for retirement.

The good new is the reason they need to save more is because they live longer.

The bad news about sleep apnea is that patients with untreated sleep apnea have a six-fold increase in motor vehicle accidents and slower reaction times than drivers who are legally drunk.

The good news is effective treatment with CPAP or a comfortable oral appliance reduces that risk to to normal. Also good news is that recent studies have shown that when properly titrated oral appliances can be as effective as CPAP for a majority of patients with severe sleep apnea.

The bad news is that snoring and associated sleep apnea can lead to marital difficulties, separate bedrooms, reduced sex drive and even impotence. According to a study at Mayo Clinic spouse of snorers lose up to 15% of their sleep. According to anecdotal evidence I have seen this pisses them off.

The good news is that there are oral appliances with volume controls for the spouse to turn off the snoring and eliminate sleep apnea. The bad news is your spouse will live longer, no thats the good news.

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.

THE MAJORITY OF PATIENTS DO NOT TOLERATE CPAP!!! MEDICARE IS NO LONGER COVERING CPAP THERAPY FOR PATIENTS WHO DO NOT USE CPAP ON A REGULAR BASIS. MOST PATIENTS DO NOT USE CPAP ON A REGULAR BASIS.

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.

MORBIDLY OBESE PATIENTS SHOULD STILL CONSIDER CPAP AS THE TREATMENT OF CHOICE. A RECENT STUDY SHOWED THAT PROPERLY TITRATED ORAL APPLIANCES ARE EQUALLY EFFECTIVE TO CPAP FOR SLEEP APNEA PATIENTS.

THE UNITED STATES GOVERNMENT HAS ENDORSED ORAL APPLIANCES FOR TREATING SLEEP APNEA BY ACCEPTING DENTAL SLEEP MEDICINE FOR COVERAGE UNDER MEDICARE.

THE NEW MEDICARE POLICY ALSO RECOGNIZES THE DISMAL COMPLIANCE RATES OF CPAP WITH NEW MINIMAL USAGE REQUIREMENT FOR CPAP COVERAGE. THIS NEW POLICY WILL BENEFIT EVERYONE AS MANUFACTURERS AND DME'S WORK TO INCREASE COMPLIANCE WITH CPAP.

Chronic Cough? Sleep apnea evaluation is probably indicated according to new article in Journal Cough.

A new article in the Journal Cough suggests that patients with chronic cough should be evaluated for obstructive sleep apnea (OSA). The article "Chronic cough and obstructive sleep apnea in a community-based pulmonary practice." details evaluation of 75 chronic cough patients. 38 of these patients were evaluated for OSA and 33 were positve for OSA. That translates into 44% of all patients had OSA. That also translates into over 86% of patients with a chronic cough were positive for sleep apnea. The authors also reported "93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough" which is an incredible relief. This is especially true since CPAP causes cough in some patients. The patients who did not get relief from CPAP should be evaluated on an oral appliance. Oral Appliances are better tolerated than CPAP by the majority of patients with obstructive sleep apnea.

The article Quantifying chronic cough: objective versus subjective measurements." from Respirology. 2010 Nov 5 discusses counting coughs and this approach could be used in patients to see if there is a circadian pattern to the coughs in apnea vs non-apnea patients. The authors stated "Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity" .

A major fault of the authors, Sundar KM, Daly SE, Pearce MJ, Alward WT was that they did not go back and evaluate the other 37 patients for sleep apnea. I assume that the other patients were not "typical" sleep apnea patients but many patients with sleep apnea do not fit the typical pattern of obese, thick neck and older male patient. If the 86% OSA figure was consistent throughout the Chronic cough population than perhaps chronic cough would be an absolute indication for sleep apnea testing.

Another interesting correlation would be to GERD (gastroesophageal reflux) and OSA which is a known risk factor for GERD. GERD accounted for 37% of cough population as a single etiology but GERD was also involved in multiple etiologies cough in 31 of the 75 patients. Multiple etiologies for the chronic cough included: GERD-upper airway cough syndrome (UACS), 31%, GERD-cough variant asthma (CVA), 5%, and GERD-UACS-CVA 3%

There is a commonality between cough, breathing, TMJ disorders and oral and pharyngeal reflexes. These reflexes that control breathing and pharyngeal structures are well described by A J Miller in "ORAL AND PHARYNGEAL REFLEXES IN THE MAMMALIAN NERVOUS SYSTEM: THEIR DIVERSE RANGE IN COMPLEXITY AND THE PIVOTAL ROLE OF THE TONGUE"

I have frequent references to his work in the www.ihateheadaches.org site and the www.ihatecpap.com site. These reflexes have direct effects on swallowing and breathing two essential functions of the jaws, tongue and oral cavity. Chronic misuse of these structures leads to repetitive strain injuries to the muscles and joints. These are frequently lumped into a junk diagnosis of TMJ, TMD, MPD, myofascial pain, Myofacial pain and are associated with sleep disorders, chronic pain, fibromyalgia and other central sensitization disorders involving the trigeminal nerve.

Cough. 2010 Apr 15;6(1):2.
Chronic cough and obstructive sleep apnea in a community-based pulmonary practice.
Sundar KM, Daly SE, Pearce MJ, Alward WT.

Intermountain Utah Valley Pulmonary Clinic, 1055N, 300W, Provo, UT 84604, USA. krishna.sundar@imail.org
Abstract
BACKGROUND: Recent reports suggest an association between unexplained chronic cough and obstructive sleep apnea (OSA). Current guidelines provide an empiric integrative approach to the management of chronic cough, particularly for etiologies of gastroesophageal reflux (GERD), upper airway cough syndrome (UACS) and cough variant asthma (CVA) but do not provide any recommendations regarding testing for OSA. This study was done to evaluate the prevalence of OSA in patients referred for chronic cough and examine the impact of treating OSA in resolution of chronic cough.

METHODS: A retrospective review of chronic cough patients seen over a four-year period in a community-based pulmonary practice was done. Patients with abnormal chest radiographs, abnormal pulmonary function tests, history of known parenchymal lung disease, and inadequate followup were excluded. Clinical data, treatments provided and degree of resolution of cough was evaluated based on chart review. Specifically, diagnostic testing for OSA and impact of management of OSA on chronic cough was assessed.

RESULTS: 75 patients with isolated chronic cough were identified. 44/75 had single etiologies for cough (GERD 37%, UACS 12%, CVA 8%). 31/75 had multiple etiologies for their chronic cough (GERD-UACS 31%, GERD-CVA 5%, UACS-CVA 3%, GERD-UACS-CVA 3%). 31% patients underwent further diagnostic testing to evaluate for UACS, GERD and CVA. Specific testing for OSA was carried out in 38/75 (51%) patients and 33/75 (44%) were found to have obstructive sleep apnea. 93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough.

CONCLUSIONS: OSA is a common finding in patients with chronic cough, even when another cause of cough has been identified. CPAP therapy in combination with other specific therapy for cough leads to a reduction in cough severity. Sleep apnea evaluation and therapy needs to considered early during the management of chronic cough and as a part of the diagnostic workup for chronic cough.

PMID: 20398333 [PubMed]PMCID: PMC2861010Free PMC Article

Respirology. 2010 Nov 5. doi: 10.1111/j.1440-1843.2010.01893.x. [Epub ahead of print]
Quantifying chronic cough: objective versus subjective measurements.
Faruqi S, Thompson R, Wright C, Sheedy W, Morice AH.

Division of Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, United Kingdom. HU16 5JQ.
Abstract
Background and objective: The assessment of chronic cough has been improved by the development of objective ambulatory cough monitoring systems and subjective quality of life questionnaires. Experimental induction of cough is a useful tool in the assessment of the cough reflex. We wanted to assess the reproducibility of and association between these measurements. Methods: This was a prospective observational study in patients with chronic cough of greater than six months duration. All patients had an initial 24 hour cough recording. They also completed a Leicester Cough Questionnaire, a Symptom Assessment Score, a Visual Analogue Score for cough and had a capsaicin cough challenge performed. They were reviewed at 8 weeks when all assessments were repeated. Results: The study included 25 patients (15 females) with a mean age of 54 years. The median cough count at the second visit (302) was significantly lower compared to the first visit (381, p<0.01). However the cough counts at both the visits correlated well (r=0.9. p<0.01).All the other forms of assessment were found to be highly reproducible at 8 weeks (r= 0.6-0.9, p<0.01). Cough counts correlated well with the other forms of assessment (r= 0.4-0.6, p<0.01). There was good correlation between each of the subjective forms of assessment (r= 0.6, p<0.01). Conclusions: The various forms of assessment of cough are reproducible. Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity. It appears to lie between these latter two assessments of cough and may represent the best global objective synthesis of cough.

© 2010 The Authors. Respirology © 2010 Asian Pacific Society of Respirology.
PMID: 21054670 [PubMed - as supplied by publisher]

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.

Sleep Apenea Surgery: Soft Palate Surgery is rarely, if ever a first line treatment for sleep apnea.

There are only two first line treatments for Sleep Apnea, CPAP and Oral Appliances. CPAP is extremely effective but the majority of patients abandon CPAP use due to comfort issues. Oral Appliances are a first line treatment for mild to moderate sleep apnea and an alternative to CPAP for the 60% of patients who abandon CPAP and those who use CPAP but just want to experience a more comfortable alternative to CPAP.

Note: For the morbidly obese CPAP is still the best treatment, for younger thinner and healthier patients oral appliances are effective and easy to fit into busy lifestyles.

Surgery, especiall soft palate surgery used to be considered a first line of treatment for sleep apnea but dismal results and high morbidity have relegated soft palate surery to a secondary proceedure, at best.

There were several types of soft palate surgery but the grandfather of all was the UP3, UPPP surgery or Uvulopalatopharyngoplasty. This surgery was excruciatingly painful, had a high morbidity and was usually unsuccessful in treating sleep apnea. According to Wikipedia the risks of UP3 surgery include:

"One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP experienced a worsening of their breathing following UPPP.
Others have spoken of severe acid reflux.
After surgery, complications may include these:
Sleepiness and sleep apnea related to post-surgery medication
Swelling, infection and bleeding
A sore throat and/or difficulty swallowing
Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery.
Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
Patients who have had the uvula removed will become unable to correctly speak French or any other language that has a uvular 'r' phoneme."

All surgeries to the soft palate carry risk and are painful. The LAUP procedure or Laser Assisted Uvuloplasty was less painful than up3 but still very painful. There was less chance of scarrig that dangerously narrowed the airway as seen with UP3.

Somnoplasty of the soft palate was less painful but equally ineffective in treating sleep apnea. Somnoplasty is a procedure to consider in patients with soft palate snoring and no sleep apnea. Other surgical alternatives are snoreplasty and pillars which again are useful for snoring but minimally helpful for treating sleep apnea.

Tracheotomy is the grandfather of surgeries and allows patients to breathe thru their throats. It is very successful but most patients do not want a long term tracheotomy.

The majority of sleep apnea is caused by the base of the tongue obstructing the airway or pressing on the epiglottis that blocks the airway.

There are several procedures that can be done to either advance the tongue or make it smaller. Somnoplasty on the base of the tongue is probably the preferred surgery for most patients contemplating reducing tongue size.

MaxilloMandibular Advancement is probably the most successful sleep apnea surgery but is extensive surgery carring definite risks. I strongly recommentd that patients undergoing this rocedure avoid ENT's and Plastic Surgeons and utilize Oral Surgeons with extensive experience in this type of surgery. The dental background of Oral surgeons make themthe first choice. They frequently do these surgeries for orthodontic purposes and understand stomatognathic function.

PATIENTS CONTEMPLATING MAXILLOMANDIBULAR ADVANCEMENT SHOULD ALMOST ALWAYS GO THRU A TRIAL OF AN ORAL APPLIANCE TO DETERMINE THE BEST POSITION FOR THE JAWS AFTER THIS RADICAL SURGERY. THIS WILL PREVENT NEEDLESS SECONDARY SURGERIES.

Nasal surgery is frequently helpful but rarely is a cure for apnea when done alone. Correction of deviated septums and turbinate reduction offer greater comfort for most patients with obstructed breathing due to anatomical or allergic problems.

Nasal surgery is usually and ENT procedure but is frequently one by oral surgeons as well.

Pediatric patients with sleep apnea are usually candidates for removal of tonsils and adenoids. While effective at opening the pharyngeal airway newer research suggests that orthodontic widening of the hard palate should be done either before or after T&A procedures. Widening prior to surgery may reduce post-operative complications.

Sleep apnea is probably responsible for at least 80% of the cases ADD and ADHD in children. The earlier the airway obstructions are addressed the healthier it is for future development.

Why Don't Sleep Doctors, Sleep Centers, Sleep Techs and DME's tell patients that CPAP fails most patients?

A Recent John Hopkins University study published in August 2009 in PloS Medicine has indicated that snoring with severe obstructive sleep apnea doubles the chance of premature deaths in men aged 40 to 70 years. PloS Medicine is a peer-reviewed open-access journal published by the Public Library of Science.

This is not new information but just another study showing the severe risks associated with untreated sleep apnea. Other facts are that patients with untreated sleep apnea have a six fold increase in motor vehicle accidents and they are more likely to die in their sleep that while exercising.

I see so many patients who are not being treated for sleep apnea because they hate CPAP or could not deal with problems associated with CPAP use. The Sleep Centers, Doctors , Sleep Techs and DME companies that fail to refer patients for alternative therapies must bear the brunt of responsibility. 60 % of patients abandon CPAP use but there is no concerted effort to refer them for oral appliances.

The real question is why aren't more patients referred for appliance therapy.

I think ignorance is the primary cause, many sleep professionals are unaware of the high success rates of oral appliances, and some just do not know much at all. There is a subgroup that has vested interests in CPAP prescriptions. The sleep centers are often own DME companies, Sometimes the doctor's wife or children own the DME company. I do not find this to be a problem as long as patients who do not tolerate CPAP are then referred for oral appliances or surgical intervention.

I have patients tell me that they are made to feel like it is their failure when they can't tolerate CPAP. They are not told the the majority of patients are CPAP intolerant and/or fail CPAP. CPAP is a excellent treatment for a significant number of patients with very high eficacy, unfortunately more patients fail with CPAP then succeed.

It is the makers or CPAP, Distributors and DME companies and all sleep professionals to honestly explain to patients that the majority of patients never learn to tolerate CPAP and to help them find alternative treatments.

Insurance companies are probably most at fault because they share a common interest with patients. Finding alternative treatments for patients who fail CPAP will save insurance companies enormous amounts of future medical expenses. Insurance companies are aware that oral appliances are more expensive than CPAP in the short run but pale compared to costs for treating heart attacks or strokes. Insurance companies should review their files and identify patients prescribed CPAP who do not order additional supplies. In all likely-hood these patients are not using CPAP and therefore are at a greatly increased risk not just of cardiovascular events but also faced increased risks related to diabetes, motor vehicle accidents, and other serious medical problems.