Mandibular Advancement Devices - is your mouth supposed to be closed ?

[Sleepster]

I got a SomnoGuard AP MAD and 2 days ago went to get it adjusted for me to my ENT. Yesterday I tried it for the first time and I couldnt fall asleep with it because I had a feeling that my mouth was full of saliva which I couldnt swallow, which was uncomfortable. 

Sounds like it wasn't adjusted properly.

But I just started sleeping through the full night with the CPAP 2 weeks ago roughly, so its not easy to stop now since its already making a difference.

If the CPAP machine is working for you then I would stick with that and forget about the mandibular device. A huge part of overcoming obstructive sleep apnea is adaptation. If you try switching back and forth you can't adapt.

MAD's are less effective than CPAP therapy (statistically speaking) and are really only for people who can't or won't tolerate CPAP therapy.

The other advantage to CPAP therapy is that you can use your computer to look at the data it generates and use it to determine if your CPAP therapy is effective, and to make adjustments to the CPAP machine to improve the effectiveness of your therapy.

Do you really do that much traveling that taking your CPAP machine with you is a burden? It doesn't count towards your carry-on luggage limit.

[ardenum]

I did recommend narval to you but you have to know, I use a mad together with a machine and a full face mask. On it's own it was not able to resolve my obstructive apneas. It did help me reducing them by about 20% (when used together with cpap)

[vrapche031]

I do a fair amount of weekend trips and I dont want to carry it everywhere with me.especially because sleeping with it without my cpap pillow is absolutely crappy. 

And I can get this for free, so no point in not giving it a go and getting that as well if it helps. I will definitely stick with CPAP though, no intention to stop

[delta]

I have never seen a mandibular advancement device satisfactorily resolve obstructive sleep apnea, and know them to be expensive torture devices designed to extract the maximum amount of cash from your bank account while delivering suffering, pain and poor sleep.

Sleeprider, you got my word out of my mouth. These devices depend greatly on the anatomy and on the manufacturer skill ( I mean the technician that gets yur dental mould and builds your device exactly upon your teeth). And they are pretty expensive, even the no-name ones (on amazon from $20).

I tried some self moulding ones (thermoplastic) and they did not worked at all - they slide and went away during the night, unless I wear a chin strap -this was a solution, as I have OOSA; I think it`s because of the mandible going back too much (and progressively as I realised). And of course, the fat collar...

I consulted a colleague orthodontist (I myself am a phisician) and the consclusion was that even a $250 customized MAD has similar issues, even the silicone material is the same or similar.

Plus: the cause of the mandible getting back and obstruating the airways is the bad occlusion and the bad positioning of the lower teeth, so the logical way, to do the right thing first is to correct their position wearing a brace for a year and a half - "This is the way"

You cannot expect to corect the recess of mandible using a device that by leaning on your lower teeth protrude them even more forward (that`s what a MAD do, it pushes your mandible forward by pushing your lower incissives, and thus rising your occlusion point, the point where your front teeth meet). A phisiological mould would grip the molars instead of pushing the incissives, but thermoplastic is not hard enough to hold the molars, polyurethane, polycarbpnate or other plastics should be used, and the orthesis should "snap" in place on your molars. And could be even more painfull, depending on how strong your parodontal ligaments are (If you have parodonthosys, you`ll lose them).

I consulted a BMF surgeon (they are dentists and surgeons at the same time) if he could adjust my mandible surgically. Yes, an expensive, and a very as in VERY difficult opperation with a lenghty recovery, that I could not have anyway because it`s something wrong with my TMA, the mandible developed an assimetry, consequence of the bad teeth occlusion untreated during childhood with a brace. Sometimes it hurts in the morning and sometimes there is a position that has to be overcome in order to be able to close my mouth. So it`s definitely something wrong with my ATM, but no one of my colleagues, the orthodentist nor the surgeon, did comment on that. I`m an internist, and I care about thinghs that are not internal, I can`t see why they just ignored the fact the ATM is malfunctioning as it had nothing to do with the bad occlusion or the mandible malpositioning.

I myself, as well as many of my patients, are often confronted with such lack of dilligence from doctors. Or at least that it seems - when we don`t know, we usually assume.
Maybe they simply don`t know what can be done, its quite frustrating anyway.

So, the CPAP (with positive expiration presure) is my chosen solution, with all goods and bads. And it kind`a worked the last 2 years - i have 2-3 AHI, but sometimes it feels like I have a debt of sleep. And still sleep the first minute on my pillow. But I can write this now, at 2.13 in the morning, that`s something.

[Sleeprider]

I am flattered that a professional would concur with my uncompromising dismissive statement on the effectiveness of a mandibular advancement dental appliance, and thankful you are not someone making your living by selling them. Clearly we see eye to eye on the need for physicians to LISTEN to their patients. Patinet feedback is meaningful, even if we may disagree; it comes from their experience with their own health. Too many doctors take offense if their expectations that a recommendation they made is not effective or unable to be followed.

My doctor is also an internist, and an open-mined man with in interest in what I have to say. He treats me as an equal and uses my input to design his therapy recommendations. I am invariably open to his recommendations, which come from his experience, education, concern for my well-being and willingness to accept my input. I hope I am able to reflect the same qualities on this forum, and it sounds to me that you do the same in your practice. Give me a shot at your Oscar charts on your own therapy thread, and maybe we can get you to an even better place. Thanks again for the compliment.

[theunk]

Congratulations on exploring ways to improve your health through better sleep - that what it is all about right? I am not a papered respiratory person but I am an expert on my personal experiences from some 30 years of wrestling with this beast. In this game, you and you alone are the best expert regarding your personal requirements. 

I have hauled a cpap around the globe since 1994ish and you are right, they are a pain, from educating airport security to explain trace amounts of OTC cold medication residue on the unit. But what is available today is much better and compact than what I started out with. Still a pain for sure.
Since 2013 I have used Oral Appliance Therapy (OA) via the Somnodent appliance, the Panthera D-SAD, several Cheapies- MYOSA, SnoreRX and one other one I do not remember. I looked at the Somnoguard AP and SPX devices before commenting. The AP2 , being a "boil and bite” looks much like the SnoreRx in construction and fitting at around 10 times the cost!. I personally could not use these because of my overbite.
My Somnodent and Panthera are made from a custom mould that factors in your specific bite. Each cost around CAD$1800.00 and are moulded just like a full denture plate. They do not move around very much and seem to resist allowing the mouth to open. The Somnodent is calibrated by adjusting 2 little screejacks on each side- 5 turns=1mm. The D-SAD has arms on each side in .5 mm increments. 
My experience for 7 years of nightly use.
In January 2015, I had a  Level 1 Polysomnography. Over 7.5 hrs I recorded:
6 hypopnea, 
Apnea index 0/hr,
Apnea-hypopnea index: 0.77/hr.
AHI inN REM: 0.8/hr
AHI in REM: 0.8/hr
I also had pulmonary function and arterial blood gas tests done shortly after. All good, all documented.

There you have evidence that this therapy can be effective subject to the technology used and the patients acceptance of the therapy. Just like CPAP, not all technologies work for all patients. We all need options and proper support from others to explore those options!

1. Saliva. Put a hard lozenge in your mouth at anytime and the saliva flows until it is gone. Who hasn’t sought temporary relief for a dry mouth this way? Tuck a lozenge between your check and upper gum and lie down for a few hours. For me, that lozenge will be stuck where I put it. No excess saliva at all. Your mouth is built for food and water intake, and slicking back your hair on a bad day ?. Your mouth responds to anything foreign by starting the pre-digestive process. Normally you would chew and mix in whatever amounts of saliva required to get the material to a state that you can move it along to the gut. This big block of plastic isn’t responding, so until your mouth gets accustom to this foreigner, you will have to contend with the saliva. Because this "lozenge" is not securely held in place, you mouth is trying to get rid of it. 

2. Mouth position. By opening up your airway, you changing the airway. If you cannot keep your mouth closed, the force of the CPAP will follow the path of least resistance. I gave up on pillows 20 years ago for different reasons, but think they would create the very problems you report. I have only used OA with full face masks. Initially in 2015 with the Resmed Quatro Pro. At that time I did not notice any advantage to combing CPAP with OA. To help the OP out, I fired up my old REMStar Auto M and combined my Panthera D-SAD with a Resmed Airfit 30 mask. This was the sweetest first night with a mask I have ever experienced, BUT…. For both, more likely all, of us changes to our sleep bring consequences. 
When I switched from CPAP to 100% OA, I had to learn how to sleep all over again. Body and head position, lack of CPAP noise and I had to strengthen my diaphragm. To do this test I have had re-learn to mange all of this again. I have noticed the odd instance where air makes its way into my mouth, but not enough volume or frequency to be a concern.  

To help bring you all up to speed on Oral Appliance Therapy
This therapy has been available in various forms since at least Y2K. The American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) published a Clinical Practice Guideline for the Treatment Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. https://jcsm.aasm.org/doi/10.5664/jcsm.4858

The website for the Academy of Sleep Medicine has published additional studies subsequent to this publication. 

Of great interest are the 6 recommended guidelines. My first physician, a Diplomat, American Board of Sleep Medicine and a number of other letters, had me in his office annually and scheduled Level 1 polysomnography testing 4 times over about 25 years. The two dentists who got me into OA, have never fulfilled the requirements of this guideline. Fortunately, I have a good understanding of my condition and my first OA experiences were with appliances that fabricated in accordance with Guideline 2. Had I gone with a boil and bite or other OTC solution, I would have been disappointed.

Unlike some of the advice offered, this this collection of sleep specialists advocate exploring alternatives rather than doing nothing. 

While CPAP remains the gold standard, many find the therapy intolerable. If you are like me with a significant overbite or "short-jaw", the mask keeps the jaw retracted reducing the space needed for the tongue, potentially restricting the airway, requiring more pressure, more leaks and noise and frustration. Properly constructed oral appliances are fitted independently to the upper and lower jaws. These two components can then be very finely tuned to give the user the best mix of efficacy and comfort. The Somnodent has unlimited adjustment, the Panthera is adjusted in 0.5mm increments. The key factor for us short-jaws is the device, without and adjustments, fits your normal bite, just as dentures would. If I recall, the finial adjustment is around 70% of the distance between the upper and lower incisors. The boil and bites start at 100% (incisors together) and are designed to advance the lower incisors ahead of the upper incisors. For me, a product like SnoreRX, and likely the Somnoguard referenced by the OP, do not facilitate a proper bite impression. Just to try this creates incredible discomfort.

The value of the information we get from forums like this, including mine, are worth the price we pay: $0.00.  I strongly encourage anyone who has confirmed OSA and difficulty with CPAP, or like the OP, want a really good travel solution to:
- review the guidelines in the link, 
- do some additional qualified research. This is a good user site but most advice comes from users who have no name or professional designation. The professional sites such as the AASM and AADSM sites have discussions papers that talk about OA therapy. Visit them, then
- make an informed decision.
Please, at all costs disregard Sleeprider's "uncompromising dismissive statement" as it is just an opinion based on??. Even delta's story is just another example of what we all know for sure about OSA therapy. We are all put together a little differently. Otherwise there would only need to be one CPAP and one mask assembly. The one thing we do have in common is we need to sleep and we need to work together to find the best therapy solution(s). 

Good dreams everyone.  

[theunk]

Sorry I made some typos before my wife proof read it.

[Sleeprider]

I guess we can agree that MADs may be better than no therapy at all, and I also thing we need options in addition to CPAP and bilevel, especially where severe flow limitation arises from maxillofacial artifacts that limit airflow in the nose and pharynx or that arise from a oral malformations that don't allow appropriate positioning of the tongue. There is a place for hothe professions of orthodontia, dentistry, oral surgeons, Otolaryngologists and other professions. I think sleep medicine is currently poorly served by the various flavors of sleep specialists that currently dominate the diagnosis and treatment of obstructive sleep apnea, and that the profession is completely overlooking the broader problem of inspiratory flow limitation. My prejudice regarding oral appliance is mainly based on the experience of seeing these inappropriately prescribed at very high cost, to individuals that failed to benefit from their use. The same can be said for many oral surgery options which tend to be favored by the surgeon that may not seek less invasive approaches before pursuing surgery. Again, lots of good and bad results have come across the forum, but my first knee-jerk reaction is to ensure less invasive approaches are exhausted first. As you know, the biggest problem with sleep medicine is that it has been fully hijacked by Medicare and the medical insurance industry to define what is insurable and therefore treatable. Doctors no longer diagnose to a health standard, but to an insurance qualification. So we have problems throughout the therapy spectrum.

Your experiences in oral appliances seems extensive, and beneficial, and deserve consideration in balance. On the other hand the AASM reference you cite seems less than enthusiastic about their efficacy and (Table 5) actually rates them low for effectiveness. I hope you will stick around and help us better understand the application and benefits of oral devices and orthodontia in resolving problems. Perhaps you will reconsider in time whether I should be ignored or not, however I made full disclosure of what my post was going to be in that circumstance.

[theunk]

Sleeprider,
I certainly did not mean to imply that I would ignore you or anyone. You obviously have much to offer this community. I could not understand why you would make such a statement in this specific thread. As the first response to the question/problem I felt you did not provide any advice to the OP related to his very specific issue. On my part, I did not do a good job of reading all of the thread carefully, especially the start date of the thread. And yes, like you, I intended to shake the tree.
The study referenced cites a lack of feedback and points out the fact that many prescribers are not fulfilling their obligation to the patient. This is no different from the CPAP world. If practitioners were following the same guidelines, you and the other great people who advise on this and other forums would not be providing this free service to support this industry. 
This then raises the question: How do organizations like the AASM get any data on any treatment therapies?
 
Full time OA is dangerous as well as beneficial. It can not be monitored other than by how you feel, nor is it automatic adjust like CPAP. Most OA users, me included adjust based on jaw comfort not sleep quality. My CPAP is 10 years old so I do not know how accurate it is. The previous auto setting was 10-17. Combined with the OA, 10 was too much, 8 was too much. I figured if this thing is Auto, then as long as I can fall asleep, I can set it to one off I want. I went to 4 and no issues yet. But I am feeling better, actually much better.  
Perhaps a new thread dedicated to alternate OSA therapies would be a good place to begin. 
We are good. I am upgrading to a AirSense 10 in the next week, and maybe the OA will go in the suitcase, for sometime when we can travel again and I will tap into your Oscar threads. 

[jadepearl]

Hi everyone here!  I have recently diagnosed with OSA with a AHI reading of 21.57/hr and REM AHI 26.67/hr with a mere sleep period time of 371.0.  I am completely shock with the result and has no clue how this condition was developed.  It started with my implant tooth keep loosening and my dentist suspected i have Sleep Bruxism and i have TMJ condition (without pain, just the clicking sound on my right jaw) however the sleep test result came back my Sleep Bruxism is Negative.  My ENT doctor has exanimated my anatomy structure via a CT scan and endoscopy shows a very narrow airway behind the tongue base.  Surgery is not an option for me now and I am still not prepare to put myself on CPAP, i have no idea why, just not prepare, it could be the price, it is very expensive and the average mask price here is exorbitant mark up in Singapore where i live.  Hence, i decided on MAD.  I have a short jaw too.   It does need some adjustment initially but i am able to sleep well.  With this positive feel and not using the sleep test to show how optimal is the result.  I do feel MAD did achieved my expectation.  Having say that, I am not certain what MAD will have a long term effect on my anatomy or will i experience pain in the future.  My MAD is from OrthoApnea Classic.  I have yet to discover it's side effect likewise for CPAP treatment.  

In summary, I would think I will have to work with whatever I am comfortable with.  The funny part is after i am on MAD, my ENT doctor or his nurses are no longer as enthusiastic toward me as before.

This site is awesome.  I just started to read up recently.  My ENT doctor did not really explained to me about my Sleep result.  I ended up received a few sheets of papers with his chop on the result that i am Moderate Obstructive Sleep Apnea.

Thanks everyone here for the information and encouragement!  It really helps to reduce my anxiety on what to expect.