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Oral Appliance - Teeth Shifting, Pain, Wisdom Teeth, Space Between Teeth
I've been using an oral appliance and have been happy with it for the most part. The first few weeks were tough (uncomfortable teeth sensitivity), but it got better. I feel like my teeth have shifted a bit. Especially the ones in the back. I'm using the Somnodent. I had some pain in the region at border of my molars and hidden wisdom teeth (still got em) on upper right side last night and decided not to use the appliance last night. The pain went away. What have you guys seen? How much can I really expect from my dentist to sort all this out? I had them thin out the front part of the appliance touching my front bottom and top teeth. I feel like the fit will never be ideal...not saying isn't worth it, just curious about people's experiences.
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Replies to This Discussion
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Permalink Reply by Rock Conner RRT on
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I agree that zero tolerance for AHI is over-reaching.
dr. martin bassiur said:All my patients are referred for follow-up sleep studies with mandibular advancement appliances and I request a copy of the study and report be sent to me. If the appliance can reduce a patient to AHI <5 and also establish Oxygen saturation >94 would that not be a successful criteria when the patient was orignally mild-moderate AHI and having an Oxygen saturation <89?? Appliance therapy may help a severe apneic patient and bring them to a level of mild -moderate apnea, if they are not compliant with CPAP, is that not still helpful? Patients can also use nasal pillow therapy with oral appliance therapy as an adjunct to the nasal therapy. Is the criteria for cure a zero AHI? If that be the case do you believe all patients who have AHI 1-5 should be put on CPAP?
Rock Hinkle said:
applianceI have seen the results Dr. Mack. They are not good. I have very little evidence that an oral device by itself will produce the needed effect. I have seen some very good results in studies using both a PAP and an oral device. However I did not do any of the studies on these pts prior to them using both devices. I have never had a dentist refer a pt for a sleep study. Everytime someone tells me that they have an oral device I look for the dentist name. Have yet to find one in any chart.
Mack D Jones, MD, SAAN said:I am not convinced that oral appliances do what they claim to do. I haven't seen any PSG results after the appliances are in use. Unless the AHI is reduced to zero by the appliance, in my opinion, it is not successful. I seriously doubt that any of them completely eliminate all obstructive apneas.
Loving your oral appliance and getting fabulous results doesn't mean that your AHI has been reduced to zero. I wouldn't be satisfied with any oral appliance unless a sleep study proves that it is actually eliminating all apneas.
Show me the proof that they are actually doing what they are supposed to do and I'll support them.
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Permalink Reply by Sleeping Ugly on
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There are studies that show the effects of dental devices on AHIs, daytime sleepiness, etc. I'm reading some of them now. Last night I read a study in which AHI, Snoring, side effects, sleepiness, and quality of life were examined after progressive MA titration using sequential PSGs. Interestingly, 75% of the subjects were referred because they had moderate-severe OSA and had abandoned CPAP due to inability to tolerate it, despite "attentive management and correction of side effects" (Gindre et al., 2008).
There is another study that I tried to read by Marie Marklund (2006), "Predictors of long-term orthodontic side effects from mandibular advancement devices in patients with snoring and obstructive sleep apnea". I didn't understand much of it, as I needed internet access to look up the meaning of words such as "overjet", "occlusions", etc. and I didn't have it.
There are other studies that use PSG to determine the effects of dental devices on relevant constructs.
I can appreciate Dr. Mack's point about variability in AHI from night to night, and that an AHI of X on a given night, doesn't mean it's X every single night. I also read something (can't remember where) to suggest that the cutoff of 5 as a "normal" AHI was chosen fairly arbitrarily. That said, there must be norms available indicating what AHI "normals" have, and some of these studies must have measured them at more than one point in time (I say "must be" because what excuse could there be for not having this data, as it would be fairly easy data for researchers to collect?!). IF, hypothetically, it were determined that normals' AHIs range from 2-5 or 4-7, or whatever, then while it doesn't sound appealing to have that many events a night, that is NORMAL and we don't treat normalcy. It would be like saying, "Let's run an iron panel (or magnesium, or Vitamin B12, or whatever)...OK, labs are back and they are all within the reference range. Start supplementation tomorrow." Of course if research were to show that normals have ZERO events on a nightly basis, then the cutoff should be changed, and therapeutic guidelines should follow. Just as now we recognize that the reference ranges for TSH were probably too high for many years, and now we treat people sooner than we did in the past.
By the way, everything I've read suggests that compliance with oral devices is much higher than with CPAP, and clearly CPAP's efficacy is zero if it's sitting in the closet collecting dust.
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I am a board certified dentist in dental sleep medicine. Your concerns/coimplaints are common and not without answers. Treatment of life-threatening problems such as sleep apnea should be placed in the hands of a competent and experienced doctor; most general dentists do not have much or any real training or experience. You will get help if you contact the American Academy of Dental Sleep Medicine (see: www.AADSM.com) and find a dentist with credentials...that is a good start. Additionally, 89% of people who use oral device will have some bite changes...it is totally unavoidable but it happens over months or years not over night and it is not a problem in most instances. It sounds like you need some time and adjustments. If you are clenching your teeth at night becuase of restless legs (untreated) or if you still have apnea you will need to adjust your SomnoMed more and until the apnea is fixed, you will probably still have some tooth grinding problems. "Back" teeth discomfort might be becuase the internal ball clasps in the SomnoMed might be a bit too tight...easy adjustment. Also, make certain that you are using your blue bite tabs in the morning to loosen up your jaws; chewing gum on the way to the shower is helpful too but don't obsess over it and make yourself miserable. Sometimes, a muscle relaxant to help with sleep while accomodating is helpful too...I took some clonazepam for a couple of weeks and it helped me a lot...oh yes, I have apnea too but I am "hybridized" i.e. I use BOTH an oral device and CPAP...works great...took some time but the best of both worlds-low CPAP pressure and moderate jaw advancement...this is how it should be approached more often, in my view.
Dan Tache
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Permalink Reply by Banyon on
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Tache, IMO, your post is the best one in this thread so far. You are open about bite changes and discomfort. You also emphasize the importance of treating sleep apnea as the life-threatening problem it is. Reading between the lines, I can imagine you wince at a dentist fitting an appliance and saying "problem solved, 100% of the cases, 100% compliance". It is not that simple.
Your approach with your own case of using a dental appliance to achieve lower CPAP pressure is an excellent one. This approach needs to be used much more.
As a patient yourself, you understand how difficult obstructive sleep apnea can be to treat and you understand what we suffer through.
I generally caution against using the "pam" drugs, but your approach to using them for a couple of weeks during a beginning phase is reasonable.
Thank you.
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Permalink Reply by RockRpsgt on
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My personal studies have shown great outcomes with this approach.
Dan Tache said:I am a board certified dentist in dental sleep medicine. Your concerns/coimplaints are common and not without answers. Treatment of life-threatening problems such as sleep apnea should be placed in the hands of a competent and experienced doctor; most general dentists do not have much or any real training or experience. You will get help if you contact the American Academy of Dental Sleep Medicine (see: www.AADSM.com) and find a dentist with credentials...that is a good start. Additionally, 89% of people who use oral device will have some bite changes...it is totally unavoidable but it happens over months or years not over night and it is not a problem in most instances. It sounds like you need some time and adjustments. If you are clenching your teeth at night becuase of restless legs (untreated) or if you still have apnea you will need to adjust your SomnoMed more and until the apnea is fixed, you will probably still have some tooth grinding problems. "Back" teeth discomfort might be becuase the internal ball clasps in the SomnoMed might be a bit too tight...easy adjustment. Also, make certain that you are using your blue bite tabs in the morning to loosen up your jaws; chewing gum on the way to the shower is helpful too but don't obsess over it and make yourself miserable. Sometimes, a muscle relaxant to help with sleep while accomodating is helpful too...I took some clonazepam for a couple of weeks and it helped me a lot...oh yes, I have apnea too but I am "hybridized" i.e. I use BOTH an oral device and CPAP...works great...took some time but the best of both worlds-low CPAP pressure and moderate jaw advancement...this is how it should be approached more often, in my view.
Dan Tache
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Permalink Reply by Dave on
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It's been a number of weeks and just wanted to update you guys on what happened. So my teeth definitely shifted a bit, however, it doesn't materially affect my bite. Because of the change in spacing in my teeth, more food was getting stuck in places that I was not used to. We surmise that I accidentally cut my gum as I overcompensated with my flossing technique to remove unwanted food stuck between my newly shifted teeth.....like flossing a new mouth. It seems to have healed well and I feel good again. In addition, it seems that my teeth have gotten used to the new device and actually some of the gap that had been created with my previous appliance has started to disappear!
So to be clear to newbies and to voice my opinion clearly, these are minor inconveniences that may or may not happen to you. My view of the benefits of the oral appliance has not been diminished in anyway. I just think we need to be honest as most of us are about the potential setbacks and discomfort you sometimes feel on your way to better health! This way people are more prepared for them, not stressed out unnecessarily, and don't give up!
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Thank you. Apnea is sometimes very difficult to manage with oral appliances alone; it takes time or as we both agree, the two worlds must come together; one complements the other. I agree with you and the "pam" drugs as well. I just personally found it so helpful for the first few weeks; to awaken realizing I had once again 'tricked' myself into wearing the CPAP (again) all nightand after enough nights, I really became desensitized. Hey, I will also say this, when we see a new patient who is CPAP-intolerant, we do take a hard look at the whys of why a patient might not be tolerant and I'll lay down a truism: too many people are CPAP-intolerant becuase they cannot breathe through their noses. We send a lot of people out for "nose jobs" and they are (often) forever grateful and some even find a way to begin to tolerate this wonderful therapy, FINALLY. If not, I feel good about going to an oral appliance.
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Dan Tache said:... I'll lay down a truism: too many people are CPAP-intolerant becuase they cannot breathe through their noses. We send a lot of people out for "nose jobs" and they are (often) forever grateful and some even find a way to begin to tolerate this wonderful therapy, FINALLY. ....
That is another good point. I toughed it out for two years and then finally had the full nose job. It did not help lower my pressure but it helped in other excellent ways - asleep and awake. I highly recommend it if you have enlarged turbinates or a deviated septum.
With a name like Tache, I guess a trache was tempting. :):)
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great to hear for me to...I have both enlarged turbinates and a deviated septum - having surgery mid-may....
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Permalink Reply by terri on
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Ok, so it's been a month and I am very pleased with my oral appliance. It was custom fitted and readjusted after 2 weeks. my husband says I don't snore and "seem to be sleeping sounder" :) No drooling, no teeth pain, no trouble getting used to wearing it. I have definately been dreaming more. I consider this a BIG step in the right direction for me considering I have tried to use a CPAP with very limited success. To be continued............
terri said:I went to a Sleep Dentist and my SomnoMed is supposed to be ready on April 14th. We will see.
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