Are Sleep Apnea oral appliances & sleep apnea mouth pieces underrated?

[Marillion]

Thanks for the perspective willo. Alternatives are always interesting to read about and we do need to keep an open mind about them. Particularly for those that need something to treat their Apnea but cannot use a machine, for whatever reason.

But my personal experience with oral devices has not been positive (to say the least) and in my own research, I have encountered many negative consequences about their use. This is why I have spoken out so strongly about them in this thread. Not meaning to say people shouldn't try them if they want to. I just wanted to warn about their dangers.

[BC3B]

What I don't understand is that if someone is already using a CPAP or such machine to treat their sleep apnea...why on earth would you also use an oral device??  It seems completely unnecessary to me and you are introducing an element of risk that is simply not needed to treat your apnea. 

Cpap and a mouthpiece work differently. Pressure from the cpap isnt enough to move the jaw forward and open the airway, thats pretty easy to understand. Also It's not enough when your tongue collapses. Both are complimentary to each other. In my case my throat muscles relax, my tongue and jaw collapse to the back, just the pressure puts me into 20's AHI, with the mouthpiece below 5, Best results I get under 1 with a tongue retaining/jaw forward device combo.

Where the risk?

Let me explain a different way...  If your CPAP is adjusted properly, you do NOT need to move your jaw forward or put pressure on your teeth.  Like I said earlier, the mouthpiece is redundant and unnecessary IF and only if the settings on your CPAP or APAP are set up properly and you have the correct type of machine.  If your CPAP is not set up properly or you have the wrong type of machine for your needs, you will get AHI numbers in the 20 range.  

If you want us to look at your CPAP results and make suggestions please download Sleepyhead and post your data in a new thread.  My original sleep test resulted in an AHI of around 45.  I average .2 to .4 now and just the other night for the first time I received a 0, using the same machine you are.  It took a few changes to the settings over a period of time with some time spent acclimatizing to each setting to achieve this.

As to where the risk is using mouthpiece devices...  Please re-read my last post.  Changing your jaw alignment and bite lines are rarely without consequences.  You may or may not be affected in the long term.  I choose not to take that risk and I think I have said all that I wish to on the matter.

And I agree, a cpap will hold the airway open in these circumstances...

Which AGAIN is one of the POINTS which I am trying to make....  Do we really need to "PULL" the lower jaw forward??

OR is it more of a matter of CHANGING THE CONDITIONS in which we are forcing it back...?

Now far be it from me to think that the medical/pharma Industry may try to PROFIT from a simply fix.  But if I were to realize that a simply method of preventing FULL OCCLUSION of the teeth (complete bite) during sleep would prevent the rearward forcing of the lower jaw, that might be just a bit simple to mimic...  So I would in that case be forced to COMPLICATE the method unnecessarily and to justify my pending profiteering event...

Still have not tried it yet.  But ya have to wonder would a simple mouth guard stop the issue?

I will go ahead and change the example experiment a little.  So not instead of laying there in bed relaxed and consciously moving the lower jaw back to create the "Obstructive conditions".  TRY OPENING THE LOWER JAW JUST 1/2 INCH FIRST AND THEN PULL IT BACK AND WHAT DO YOU HAVE?  Nothing.  No obstruction...  Then close jaw a bit and BAM / back to obstructive conditions...

I suspect I am on to something.  Which is an open airway and no UNUSUAL/Unnatural POSITIONING of lower jaw... I am really thinking that many obstructive apnea cases are just a matter of that ever forward growing lower jaw being forced backwards by the upper teeth excessively when completing full bite.

The only question in my mind at this time is will the unlimited space for the lower jaw to move forward in sleep be conducive to and allow for even faster growth and forward progression of the lower mandible?  Or will the opposite happen and since there is no stress applied on the joint all night would this decrease the stress and stimulation to grow..?  I'm kinda thinking the former unfortunately, as the jaw will be stressed all day and then have more freedom to grow while at rest in the night as per these conditions...

[BC3B]

Given how poor CPAP compliance is, though, for the patients who need them, I do think we need more and better options for treatment...

We do have more, but we don't have better.

Research has been done to show the effectiveness of an oral appliance. Yes, you can wear one during a sleep study, or you could even wear one while using a CPAP machine. You could set the pressure at 4 cm (the lowest possible setting) and see how many apneas you experience.

Likewise, research has been done to show the effectiveness of CPAP therapy.

The results show CPAP to be more effective.

I think some researchers have concluded that, given how many people are failed by CPAP therapy (can’t tolerate it), the real world effectiveness may be inverted, in spite of using CPAP being more effective than using oral devices (or throat exercises, etc.) I saw a scholarly paper proposing this theory recently, but don’t have the link at hand.

I want to be clear: I’m a new CPAP user. I am working hard to be compliant. A few weeks in, I am in compliance with almost 100% nightly usage and >4 hours per night on all but one night of use. 

I’m delighted that there are people who are fully treated using CPAP. I just don’t think CPAP as it is today is sufficient to treat the full body of patients who require it at this time.

As an engineer, IMHO, any system that results in a high percentage of users failing to get what they want/need is a system that wants improvement! (46-83% failure to adhere, according to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645251/)

For myself, the lifestyle impacts are huge, and the results of my treatment are subtle thus far. I’m in compliance, and I plan to remain so, but I’m finding it harder, not easier, to keep using the machine as I go along because it is making my life subjectively worse in spite of making my “breathing during sleep” objectively better. 

(My personal list: I can’t hear my asthmatic child breathe at night over my CPAP; I’ve lost intimacy with my partner; my partner is bothered by the white noise that I need to cover the sound of the CPAP which bothers me; my skin is irritated and causing me pain; caring for the machine parts is onerous; travel, my favorite hobby, will be negatively impacted by lugging the machine...)

I’m not knocking CPAP. I think anyone prescribed it should give it their best efforts. I want desperately to live a healthy life and stick around for my kids and family. HOWEVER, I’m eagerly following every alternative treatment available and being suggested for the future in research. That’s what interested me in this thread.

My treatment experience will be uniquely mine, as is true for every patient. Those who aren’t currently having their apnea resolved by CPAP need and deserve better options for them.

Respectfully,
—willo

I saw where you were talking about 'Lost intimacy'.  LOL.  I recall my wife getting P*ssed when I would put it on and her proclaiming finally one night - that she did not like it when I put it on "BECAUSE SHE KNEW THAT WAS IT FOR THE NIGHT".  It was not like she wanted sex or anything.  Just that HER CHANCE FOR ATTENTION WAS OVER...  Took me a while to realize her petty childishness.  YOUR CASE IS DIFFERENT I AM SURE..

MOREOVER, I saw where you were talking about "white noise" and I IMMEDIATELY THOUGHT "he must have a Phillips.  ..  And yes THEY ARE GARBAGE.  Thank God my DME changed to ResMed.  This AirSense 10 or whatever its called is absolutely quite.   There is NO SOUND i kid you not.  And I came from 4 years of SYSTEM TORTURE...  Trash it....  Not kidding.  Just go rent a ResMed and see...  IT is what it is...  Case closed...

As far as how it feels on your face and the science behind sleeping with an apparatus... If you are having trouble getting used to it then do what I did and get in bed early and wear it while you are awake each night for a few hours. And the SLOW RAMP features are COMPLETELY BACKWARDZ BS. As they should be giving higher air pressure while awake and not lower. So dont use that.

Finally.  If you are uncomfortable sleeping with the device then I first suggest you make sure you have one of the most efficient pillows out there.  I personally would think that the DreamWeaver is too advanced for a new used and that you should start with a SWift FX.  Having to worry about mask contact and leakage is too much for new at this.  Just my advice on that one..

[mesenteria]

I am firmly in the boat where a holistic approach is likely to yield superior results.  Yes, a single technique or tool may suffice, and even be tolerable, but often a two-pronged or multiple technique will offer considerable, and gratifying, improvements.

My other hobby is model trains.  The various fora erupt almost monthly into 'this is the way we've always done it' challenges to people who offer a novel approach to one of the hobby's hundreds of challenges.  If things go well, we eventually agree, the few willing to tolerate exchanges until the end of the fourth or fifth page of discussion, that there are many ways to skin the cat.  If they don't go well, the thread gets locked, and the seething continues below the surface like a forest fire not quite quenched.

I have to tape, as some of you will recall.  My tongue will only stay up at the very back until I get into a deeper sleep, and because it isn't especially wide, I get leakage around its sides quickly.  I can't sleep when that happens, and the dry mouth if plainly awful.  So, tape I must...and do.  There are caveats, but perhaps not the ones with which you might be familiar.  My father's RT cautioned that as I age, my skin will get fragile and thin, and removing tape is likely to result in torn skin.  As a person on blood thinners, this ain't what you would call grand.

In the end, it's what we can endure that comes closest to allowing us to have the best quality of life possible under our circumstances.  Some of us can, even must, use dental appliances to achieve our aims, and some will have to use them to augment our therapy under PAP of its various kinds.

Just like in the model trains hobby, we each have a duty to our own path of learning and experience.  When we understand, as Herbert Hoover said, that the stove is hot, we'll know not to put our hands there.  Or, continue to do both dental appliances and PAP.

[Marillion]

I have to tape, as some of you will recall.  My tongue will only stay up at the very back until I get into a deeper sleep, and because it isn't especially wide, I get leakage around its sides quickly.  I can't sleep when that happens, and the dry mouth if plainly awful.  So, tape I must...and do.  There are caveats, but perhaps not the ones with which you might be familiar.  My father's RT cautioned that as I age, my skin will get fragile and thin, and removing tape is likely to result in torn skin.  As a person on blood thinners, this ain't what you would call grand.

I also tape.  For the same reasons you give above.  To give you a suggestion to prevent damage to the top of your lips (the most sensitive part) based on my own experience.  I use a small dab of Vitamin E oil (purchasable at the pharmacy) or chapstick or something similar there in a very, very small spot where I can occasionally get irritation.  The trick is to not use too much or you won't get any adhesion at all above your lip and you will get air leakage. I find Vitamin E oil provides protection but still allows the tape to slightly adhere right above the lip. Chapstick can prevent the tape from sticking completely with resultant leaks.  Another thing that helps is rolling the tape along to remove it instead of ripping it straight off...ripping it off straight up does the most damage.

[mesenteria]

Than-you for the nifty tip, Marillion.  So far so good for me, 'though I'm only 66.  I suspect that when I get closer to the mid-80's it might get dicey, but not now.  I won't forget your advice, though, nor your kindness.

[rebtennis]

Ok. Let me start that I am brand new to this board and less than a week into APAP therapy. 

I have read many posts on this board today (last few days) and have been experimenting and tell my story below (with oral appliance, APAP and future experimenting).

I  agree with willow on the statement, "My treatment experience will be uniquely mine, as is true for every patient." and with BC3B, "In the end, it's what we can endure that comes closest to allowing us to have the best quality of life possible under our circumstances."

Background:

Over the last 2 years or so, I continued to be very sleepy during the day and taking naps and being crabby and not having great cognitive function. So off to an ENT I went. I was fortunate to have a great doctor who spent a lot of time with me. I did not mind paying for the catscan, the scope of my nasal passages, the home based sleep study (2 nights), etc. The results came back as 20 AHI and that my SPO2 was low at times (percent time below 90% SpO2 1.3% and Min SpO2 85.1%) which he marked as very important. I have the report, but not attached. So of course, he recommend APAP therapy (all this was in early November 2018).

Another note, I have had a turbinectomy and a septoplasty and have no tonsils (surgeries many, many years ago).

So going back further (about 8 years ago) my wife was tired of my snoring and I had an oral appliance made by my dentist who is certified in making these devices (and uses one himself). This certainly helped tremendously with my snoring and just had to have it adjusted properly for jaw ache the next morning.

This is important, since I was not keen on having to wear a mask with a hose since I flop quite a bit during the night and was not sure I would be able to stay compliant. So I did some research that a dental appliance can help with sleep apnea and SPo2, so on Nov 30, 2018, purchased a pulse oximeter device with a watch that can record overnight (Comtec CMS50). I wanted to experiment with this for oxygen levels and with the dental appliance (which we refer to as the snoring appliance)


I started using it overnight by itself, then with my snoring appliance and the stats were better with the snoring appliance. I even tried with and without a Breathe right strip. (no APAP therapy, had not gone in for fitting or purchased anything). I did this testing in Dec 2018 - for SPO2 only with Contec Pulse oximeter device.

After not feeling remakedably better the next day after using the snoring appliance (did feel slightly better though), I made the decision to go with APAP therapy and purchased a slightly used Dreamstation on Jan 8, 2019 (with warranty until 10/2020) , with full mask and with humidifier (but not using humidifier yet, more experimenting to come). Note that I downloaded and used Sleepyhead 2 days ago and was pleasantly surprised that the Sleepyhead software supports the CMS50 and can integrate that data.

Data below from testing with CMS50F and last column is with APAP and CMS50F at the same time (all data from Contec software that comes with the device) and for those of you that actually read this post, the PR - Pulse rate was lower with the snoring appliance and even lower than with APAP.

SpO2 Data - partial data: (without snoring appliance)       (with snoring appliance)   (with CPAP on Jan 10 and wearing Contec Pulse Oximeter device)
Time (min) <88%           5.6                                            0.8                                                               0.1
Events <88%                  19                                               9                                                                1
Avg Low SpO2 (%)          89.6                                          90.7                                                              92.2

Any feedback on these is most welcome!

So even before reading these posts on this board today, I went and purchased the nasal (pillows) mask yesterday (Dreamwear) and did self pay. My thoughts are that since I am a heavy mouth breather, my experiment is to use this new mask (for nose only) and wear my snoring appliance at the same time. I hope to have this completed by next weekend, since I fly out for work on Sunday and just staying with my full mask while traveling - will update when I finish this experiment - and I will also wear the pulse oximeter device to see the results from that software.

and yes, this data in the table above is from a one time use (test) and not many nights of use (tests) since we all know some nights are better than others.

For the 4 nights thus far with APAP therapy (and struggled a couple of nights, waking up that I was suffocating), my overall AHI is 5.48, 6.60, 6.99 and 4.50. (with low from about 2 to high of 18 one night). My beginning pressure is always 5.5 and maximum has been about 10 or 11. I certainly push the ramp button after I wake up so restart at 5.5 so I can go back to sleep.

I can clearly state that APAP therapy is definitely helping, in that I have more energy, better cognitive thinking and less crabby. But I still don't feel 100% and by 4 or 5pm in the afternoon, I feel tired and still take a short nap (mostly out of habit and I can). I am on thyroid medicine also, so have ruled that out some time ago for extreme tiredness.

But, can I tolerate the sleeping in a separate bed, waking up in a panic 2 nights out of 4, waking up to adjust the mask, dry mouth and sometimes dry eyes and the maintenance/cleaning, etc. Back to the very first statements by others, we have to weigh the benefits and the inconveniences (what can we tolerate) for our own situation and lifestyle.

Sleep well and please ask any questions since I have rambled and may have missed some points.

rebtennis

[SleepFoo]

"less than a week into APAP therapy"

Well, you'll get the discomfort; dry eye, dry mouth, waking stuff figured out with continued usage as you get used to the machine and keep doing more research on how to deal with those issues.

About my little experience with these tools so far:
I tried two appliances for the mouth. One was a mouth piece to hold my jaw in place. It began altering my bite. Stopped using it because my lower front teeth now dig in a little into my upper teeth. It was a heat moldable version, not from a specialist.
The second one I tried was an oral appliance that holds your tongue in place like a tongue depressor. It is a mouthpiece that also presses down on your tongue to hold it in place and prevent it from sliding backwards.
I stopped using that device because I noticed that it was hard to keep my mouth shut while using the nasal mask and headgear.
I noticed that this device while used with my BiPAP device dropped my AHI below 1. Pretty darn impressive numbers.
But I feel like the reason why the numbers got lower was because I was waking for some reason caused by the device. Like drool or repositioning the device because my mouth opened up slightly. Your teeth are what hold it in place and my teeth would separate slightly during the night.
So my guess is that because I was awake more often I was breathing normally and that is likely the real reason my numbers improved...?

I ordered a cervical collar to see if that will work better.

The one thing I did not try with the oral device is a full face mask. Now that I write this, it makes me realize I should try it that way too. If I do, I'll repost.

[OMyMyOHellYes]

"Are Sleep Apnea oral appliances & sleep apnea mouth pieces underrated?"

Not likely.

[SleepFoo]

"Are Sleep Apnea oral appliances & sleep apnea mouth pieces underrated?"

Not likely.

There. I said it.

OMyMyOHellYesUDid!