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

[BC3B]

I'll save you the DIATRIBE BELOW if ya want and here's the point...  I am starting to wonder if most diagnosed Sleep Apnea cases are just lower jaw growth forward, and would a basic athletic mouth guard be a good test for oral appliance use as sleep apnea treatment..???

(EXPANDED - LOL)
I have been wondering for many years if I would be fine with simple oral appliance (I think they call em).  But I have not wanted to spend the money to find out...  Here is my logic and thoughts any feedback appreciated.

I pretty much put on my CPAP whenever I am in the bed.  Its a habit I created when I fist got my machine the logic was to get used to it.  But now, I can't be in bed without it on its just a habit formed.  I spend a lot of time there on the computer when trying to do work at home with kids in a small house its one of the only safe places for quiet.  But the point is that I have spent A LOT OF TIME awake with CPAP on which gives me interesting perspective.  I was kind shocked to find out how many just used em for sleep!!  LOL.

So I have spent some time with the CPAP on and awake to consciously think and consider the operation and application.  Have ya ever been laying there on yer back and paid attention to lower jaw position.  I am not kidding either, but all you have to do is relax a bit, concentrate on yer bite, and notice that if you slide yer jaw back just a hair - YOU THROAT WILL COMPLETELY CLOSE AND OBSTRUCT, and EVEN with the CPAP ON!.  It also amazes me that it you put your front teeth together and hold them there, there does not seem to be any hint of obstruction possible.  the proof seems to be that if you lay there and hold your front teeth edge to edge (like you were biting a nail), it just does not seem possible for the airway to close...

I have always heard that as we age everything "grows forward".  This obviously includes the lower jaw.  That being a part of the body that moves it stands to reason it will sustain a great amount of stimulation thus encouraging growth.  Not to mention the TMJ Joints getting looser, expanding, growing, inflaming, etc..

Also, If I make a bite and test how far my lower teeth move both behind and in front of my upper front teeth, I also notice that I can pretty much get more space moving the lower jaw forward and do a pretty good Gomer Pyle imitation.  I recall when I was young I could NEVER get my lower jaw that much forward...

The problem appears to lie in the fact that we simply can't fall asleep without attempting to hold a proper occlusion (hold the jaw with lower teeth behind uppers).  So its just not possible to rest the top front teeth on the lower front teeth and fall asleep.  I would imagine I would break all my teeth out grinding or whatever if I could even manage to do it.

So is our normal bite and the interlocking tooth pattern our natural way to keep airway open and flowing in our sleep?, and when the lower jaw grows bigger it simply forces the throat back and closed when we make that bite?

It also seems to be an issue when we are horizontal and not standing, in that if I lay there and attempt to make a good bite, my jaw will get inflamed in the TM Joints.  But if I am standing, I have no issues making a proper bite..

It makes me wonder how many "apneas" (and I think I read they have over 150 classifications for SA) are just jaw growth issues.?  Yes it makes sense that heath insurance is not going to pay to have a maxilfacial doc take a couple of teeth out of the lower jaw, wire it up to heal, and get braces to re-align everything either.  Which makes me wonder why they don't just cover oral appliances?!?!??  Or would that be an admission of a REAL medical issue related to natural jaw growth?  I would digress to insurance issues here.

So I am just really wondering on this one now and I am thinking I am going to get the football type mouth guard and give it a try.  I am thinking the one to test with will be one that just applies to the upper teeth and has a flat smooth bottom side.  At first I was thinking that this wont help because it does not have the design mechanism to hold the lower jaw out and forward like the medical ones are made to do, and because it would be flat underneath.  But on second thought, I am wondering if perhaps just having that smooth solid surface there on top of the lower teeth would simply ALLOW for the lower teeth and jaw to come forward where it needs to be.??

The caveats to oral devices which I can see to this would be that...:
1) There is going to be a risk of TMJ injury with any unnatural positioning of the jaw especially with consideration of potential grinding and stressing at night. (which is probably a reason Insurance carriers dont cover them and these never took off).  YOU DON'T WANT THAT INJURY.
2) An unspoken would be the toxicity or "Xeno-estrogens" from the plasticizers in the device.  Which is why I would most likely have to pay for a high grade one if the football mouthpiece does work.  And still...
3) Also, the not letting the jaw ATTEMPT to make a proper bit all night (even if underbite is present) would undoubtedly make for a "daily transition" back to a normal bite every waking day.  Could this caused some daily accidental "Mis-bites" when eating thus chipping some teeth?  
4)  Perhaps, I wonder if using an oral device with a flat bottom that lets the lower jaw move freely would even allow for and promote this natural forward growth progression of the lower jaw.??

From a positive standpoint.  If using an appliance with a smooth flat bottom side to rest on the lower teeth, it may very well minimize the risk for TMJ injury since it wont "lock things" in place so much. 

Call me silly, but IMHE, a CPAP doc is the FIRST to discount an oral device and the impression I get is that it minimizes their social/professional value in some way that they don't like as the issue then generalizes stigmatically as "not so big a deal if a simple mouthpiece can fix it"...  I have found some docs to be really passionate about the science.  And others unfortunately QUACKERISTS that have no business practicing medicine at all...

I scored a 46 I think on my Sleep test which is significant.  I literally cant live without my CPAP and this bothers me greatly cause if the power goes out or my machine fails I KNOW IT.  And any real CPAP user KNOWS what I am talking about..  That's not to discount anyone, but i know they will prescribe them for "nasal snoar type apneas" too, which in my mind stand a better chance of just opening the mouth in their sleep (could be wrong/no discount or offense intended).  But I am here to tell ya that when yer throat closes in yer sleep and that 100% positive air path lockdown occcurs - IT SUCKS...

So I am just thinking aloud mostly.  I would appreciate any feedback from those using oral devices or have tried them.  As well as thoughts from CPAPer's on whether you think your issues are related to bite occlusion and lower jaw progression forward with age?

I will let you know if I do attempt this...

[PaulaO2]

Oral devices work for some people. The problem with them is there is no way to truly check if they are working other than using a recording oximeter and go by how you feel. It is like dosing your insulin based on how you feel vs knowing the caloric content of what you eat and your blood glucose. Sure, it may work, but is it?

The apnea events that happen with the use of a CPAP are minimal and, if below 5, are similar to what a non-sleep apnea person would experience. This is why an auto PAP is so important. If your pressure need as you sleep is, say, 9, then the APAP runs that. It detects you are having or did have an apnea event so it increases the pressure in an effort to either stop the one that is happening or to prevent the next one. When it detects that the situation has run its course, it begins to decrease the pressure. This process works amazingly well as long as the pressure settings (min and max) are appropriate for that person.

Using the insulin analogy, it is like the insulin pump. It provides the insulin needed at the point it is needed. The blood glucose will fluctuate. Higher until the pump reacts. Another example is blood pressure medication. It does not keep your blood pressure at exactly 75/120. It reacts inside your body, regulating silently. Stress will cause it to rise (rolling onto your back will cause apnea events to increase) and relaxation will cause it to decrease.

I did not read all of your "diatribe". That said, I recommend this: Stop overthinking it. If you have an xPAP, use it. Gather the data. Notice your trends. But ultimately the decision is yours. Live well rested or die slowly as you leap from one concept to another, one non-xPAP treatment to another.

[willo]

I'm curious though: couldn't you wear your oral appliance, then sleep with the CPAP machine at the same time and see if you have fewer events?

I've never seen one of these oral appliances, so forgive me if that's a dumb question!

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

Respectfully,
--willo

[Marillion]

I have tried a number of oral appliances and all it did for me was painfully alter my bite. I still snored and did not get any more restful sleep. Never again.

Oral appliances may help some, but from what I have read they are of limited benefit (mainly to those with very minor sleep apnea) and have a whole raft of potential issues that they can bring up. Personally, based on my own experiences and from all that I have read, I'm sticking with the gold standard of sleep apnea treatment and my advice to you is that you should as well.

[mesenteria]

I'm curious though: couldn't you wear your oral appliance, then sleep with the CPAP machine at the same time and see if you have fewer events?

I've never seen one of these oral appliances, so forgive me if that's a dumb question!

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

Respectfully,
--willo

In a word, yes....but..  Okay, okay, two words.


As has been pointed out, the problem with these devices is that they have high 'face validity', meaning they have strong intuitive force working for them.  What they don't have is a way to measure, or to record and to evaluate, exactly what their efficacy is...what they actually accomplish.  What you propose could work, though, because our machines do give a measure of sorts.

The problem is that our PAP devices do not make for an ultra-low variance correction.  We get nightly data, and we also wear our mouth-pieces nightly.  But each night has relatively high variance in events and benefit as our machines set the records.  Also, we are different each night, as much as we might not think so.  Too much caffeine one day, too much alcohol the next, GERD acts up on us on Day 5, and so on.  

So, what will any night tell us?  If our records say we have an AHI on Day 2 of only 0.7, and 1.8 on Day 7, was it the mouth-piece that made the difference on Day 2?  Or was it the GERD?  I mean that there are too many confounds for us to make strong conclusions and inferences about the efficacy of either the PAP device or our mouth-piece.

You would need many nights where you wore the mouth-piece for several days, and then not use it for several days, and see if there is a strong associated reduction in measured 'snoring', or other common events detected in our AHI.

[ardenum]

I'm curious though: couldn't you wear your oral appliance, then sleep with the CPAP machine at the same time and see if you have fewer events?

You're saying that like its some unicorn. I do that since I started my cpap. Thats 3 years, cpap blows my airwaves open, the oral piece keeps my jaw and toungue away from the back. Two things work differently and together.

[Sleepster]

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.

[BC3B]

You guys are motivating me to start pulling my data.  @Willo - you mentioned "poor compliance".  I have heard this from folks not using their CPAPs and I simply can't fathom.  I personally would consider them "over-prescribed" and did not need one in the first place.  For me, when my apnea first set in, I simply could not breath anymore.  It was an insane 3 days of falling asleep and stopping breathing, then waking, and repeat.  Tireder and tireder I became and soon could not hold my airway open at all and swear I almost died.  I don't even know how I made it through the next ten days till I had a box.  I would have a conniption if I did not have my machine...  That's a nightmare I don't want to relive ever.

I would wager I don't have ANY events when wearing my cpap so it will be interesting to see if I loose that bet.  Even scoring 46 events per hour in my initial diagnosis, a setting of just 8-10 does the trick and I recall well what it was like to suffocate all night.  Its like on ON or OFF scenario for me...  As soon as I doze off if I am not wearing it them BAM...  Its rough...

I will say that could be all wrong here though Cause I recall I was snoaring like a sawmill toward the end of my time before I was diagnosed.  What's the best free software for the ResMed 10 series..? 

Further on the oral appliance, what I am hypothesizing is as follows.  My premise just thinking....
1)  Its not that our lower mandible needs help to be moved forward,
2)  BUT - we must STOP moving it back...!

RE-PHRASED - 
It IS really a question of the pressure from the top teeth PUSHING and forcing the lower jaw back, and NOT so much a "lazy collapse" of the lower jaw and associated.  Which is what the normal occlusion causes once the lower jaw grows forward with age.

I've seen those oral appliances and I cant tell you that if you are a grinder you would not want to have your lower mandible extended out as it would mean sure TM Joint damage pretty soon.  I am starting to wonder more and more about the simple flat bottom athletic mouth guard as it would most likely accomplish keeping you from completing a full bite in sleep and thus that rearward pressure on the lower jaw may never occur...  For me, its that last 2-3 centimeters to full bite where the back of the front top teeth really start to snug up against the lower front teeth and then force the lower jaw back...  I'm sure we're all different...

[jaswilliams]

The best software to look at your data is SleepyHead there is a download link in my signature you need to ensure there is an SD card in your machine when you sleep with it otherwise data is missing. If there was not a SD card supplied get the cheapest one you can from wallmart or similar any size from 2Gb to 32Gb will do the job.

[Dawnstar]

I had a custom oral appliance made for this purpose, by an endodontist (dentist who specialises in making oral appliances). I really wanted it to work after my first attempt with CPAP, and I almost convinced myself that it did, but it didn’t. And it was pretty painful. My dentist adjusted it after my first attempt failed, it was so much more painful (and clear it would start to misalign my teeth), that I bailed.

If your baseline AHI is relatively low, then it might work. On the other hand, CPAP, APAP, or BiPAP will work, if you stick with it.