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Dental Appliances
Looking at this post I don't see much information about dental appliances which if done by a qualified well trained dentist is a very effective solution for many people. Why?
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Replies to This Discussion
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Permalink Reply by Mike on
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Good question, Belinda. Oral appliances are an effective tool in the arsenal of Sleep Apnea treatment. They tend to get too short shrift in my opinion, and they are not as widely used as CPAP. I think the main reason is reimbursement: insurance companies won't pay for dental devices the way they do for CPAP. Once that changes -- and it's the dentists who should be the one to push for it to change -- then you'll see a lot more people using dental devices and talking about them on the forum.
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I agree jnk -- CPAP works. Period. That said, a good friend of mine has had much success with the dental appliance after having failed to use CPAP regularly. his experience has really opened my mind up to the possibilities of dental devices. I question to what extent the limited track record of dental appliances in comparison to CPAP has to do with the big money behind CPAP and the small money behind dental appliances. CPAP is reimbursed consistently by insurers, so it's a money maker that is prescribed often and for which big industry (Respironics and ResMed) is able to sponsor new scientific research about its efficacy. Dental devices are a pain in the neck for dentists to get reimbursed on, so it's given less often and has less money behind it to underwrite scientific studies supporting its efficacy. You're 100% dead on that there is to date no way to get nightly data off a dental device. I have heard, though, that is about to change . . .
j n k said:That is because PAP therapy consistently gets the majority of patients' apnea-hyppopnea index well below 5 as verified by a sleep test, and does so every night as verified by the nightly data from the machine itself when a full-data machine is used. Follow-up testing with dental appliances have shown that they do not consistently accomplish that for the majority of patients with moderate-to-severe OSA, as I understand it as a patient.
Many good dentists and surgeons (some associated with this board) have the consistent policy of making sure a moderate-to-severe OSA patient gives PAP therapy the FULL shot FIRST, because of its track record with efficacy, before they will even consider persuing surgery or a dental appliance for such a patient, since those approaches (with a few notable exceptions) do not yet have the sort of numbers that PAP therapy has had. Many good doctors feel that surgery and dental applicances are approaches best reserved for those patients who are for some reason unable, or unwilling, to make PAP therapy work for them.
-jeff
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Permalink Reply by sleepycarol on
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Don't forget those that have dentures, bridge work ect. How does that segment of the population fit into the dental side of therapy? Are there means to allow them to use a dental device?
Then, of course, you have the older population that need help with basic health needs and cpap is easier for caretakers to manage probably.
I think as time goes on that the advancement of dental appliances will move forward -- but not as rapidly as other methods since there is more expense involved, more follow-ups, lack of tracking, etc.
I know I have all my own teeth but wouldn't consider a dental device since I tend to have problems with my bite somewhat. Some of my teeth are more prone to ache due to "pressure points" than others. I think a dental device would only make the problem worse in my case.
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Permalink Reply by bkp on
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Actually there are appliances available for denture wearers and those with other removable dental devices as well as fixed devices. If you have ache due to "pressure points" it would seem to me that your occlusion is not correct and that is one factor evaluated when determining if a patient is a candidate for an appliance. We make adjustments in the appliance to accommodate this as well.
As far as the misconception of too expensive, our experience is that in the long run it is less costly than a CPAP and far easier to use. If you took our most expensive device along with our initial exam, testing, and X-rays and divided it by the number of years that the manufacturer states as average longevity it would cost $40 a month without any insurance payment. Keep in mind there is no water to deal with, no electricity to use, etc.
The appliance is very easy to use, we have patients in their 80's who have no difficulty with them.
In the beginning the followups are more frequent as we want to assure proper fit and comfort. However once the patient has titrated the appliance to a desired position and is ready to return to the sleep lab, those visits become yearly. That is primarily to assure the integrity of the appliance to achieve maximum longevity as well as to evaluate any side effects such as bite changes. Bite changes can be minimized with following recommended morning protocols.
Do not fool yourselves into thinking that your dental situation is left untouched by CPAP. Studies have shown that continued pressure from the CPAP mask on your maxilla causes deterioration over time. Which in turn leaves your teeth unstable.
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I still have not had any insurance carrier deny coverage for the appliance. The difficulty in this is that the office needs to file medically and not dentally. I'm not going lie it is difficult and time consuming in the beginning but we felt that it was best for our patients and are committed to helping them in every way possible.
Mike said:Good question, Belinda. Oral appliances are an effective tool in the arsenal of Sleep Apnea treatment. They tend to get too short shrift in my opinion, and they are not as widely used as CPAP. I think the main reason is reimbursement: insurance companies won't pay for dental devices the way they do for CPAP. Once that changes -- and it's the dentists who should be the one to push for it to change -- then you'll see a lot more people using dental devices and talking about them on the forum.
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At the AADSM meeting last month the study that was presented talked about the longevity of use of CPAP versus oral appliances. CPAP is effective but studies show that long term use declines with CPAP but not with OAs.
j n k said:More info, if anyone is interested . . .
Here is a review of studies on oral appliances as of 2006, which includes a success-rate chart showing different ways of defining success and what percentage of people responded and a chart showing side-effects and compliance rates:
http://216.21.56.228/Resources/PracticeParameters/Review_OralApplia...
Here are statements in that "evidence-based review of literature regarding use of oral appliances":
"Overall, those with mild to severe OSA have a 52% chance of being able to control their sleep apnea using an [oral] appliance. OAs [oral appliances] are on the whole less effective than CPAP. . . . In each of the crossover studies CPAP reduced the AHI to low levels in nearly all patients, whereas OA failed to do so in a third or more of patients. . . . An important limitation of OA therapy includes the lower levels of effectiveness in terms of reducing the AHI and improving oxygenation when compared to CPAP. Therefore, OAs are not indicated as first-line therapy for patients with severe OSA, severe daytime sleepiness or in patients who have very low oxygen saturation levels during sleep. They may be indicated in patients who have failed other treatments even if they have severe OSA although results are less predictable in this group."
They defined "success" as 10 AHI or below, by the way, not 5 AHI.
That being said, I agree 100% with Beinda and with Mike that oral devices don't get discussed enough on OSA boards, and they certainly DO have a place in treatment of some with sleep-disordered breathing problems that involve any obstruction. (That odd wording was my attempt to include UARS.) Some people just plain can't find a way to be compliant with PAP therapy no matter how hard they try. So as long as proponents don't argue equality with PAP therapy, I support wholeheartedly all attempts to make the benefits and possiblilities of oral applicances known, myself. As I say, I own one that I used for over a year and still occasionally use it.
-jeff
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Oral appliances are effective tools for treatment of mild-moderate apnea and in some cases are used with nasal cpap- insurance carriers will reimburse patients for the appliance- patients must be treated by in network providers. They may have treatment with out-of-network providers- in such cases payment is often times covered either in full or partially- always discuss your insurance concerns with your provider or carrier.
Mike said:Good question, Belinda. Oral appliances are an effective tool in the arsenal of Sleep Apnea treatment. They tend to get too short shrift in my opinion, and they are not as widely used as CPAP. I think the main reason is reimbursement: insurance companies won't pay for dental devices the way they do for CPAP. Once that changes -- and it's the dentists who should be the one to push for it to change -- then you'll see a lot more people using dental devices and talking about them on the forum.
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Permalink Reply by Tim on
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Belinda, What did you mean when you said "CPAP is effective but studies show that long term use declines with CPAP ..."?
Do you mean that there are studies that show that the efficacy of CPAP declines with long term use?
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Permalink Reply by TorontoCPAPguy on
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Have friends using the dental devices without any issues and they love them; having said that they each paid over $3,000CDN for the device with the express understanding that there was NO guarantee with it as to its effectiveness in the short nor the long term and that there were risks involved as well. That is the reason that I went with APAP and my incidence of OSA events is now ZERO. Period. The downside is that it is a pain in the ass having to rig up every night in order to get a decent night of sleep and depending on my 'mood' ... my mindset itself may prevent me from getting a good night of sleep with the contraption running and I am using what I believe to be the best and have spent months trying different masks. My bottom line is that I cannot afford to live without the APAP machine... and I am wondering if the the dental appliance would make a difference equally as effective. It sure would be easier to carry, but one stops and thinks about placing $3,000 on 'double zero' and spinning the wheel at the same time.
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I have a question...are we talking a dental device that is used to stop grinding my teeth at night? I hesitated to even get this device due to the fact that I am a CPAP user....I will be picking up my dental device on 7/6/2010 - can I used this and CPAP or is this device totally different than the one we are talking about. This device took about an hour for all the measuring/fitting/molds to be done - sorry, but I'm confused...
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I use a mandibular advancement device for UARS. I actually felt worse on CPAP. Upon awakening the first morning after using the MAD, I woke up and did not want to get out of bed, not because I felt unrested, but because I was so relaxed...my limbs felt both heavy and heavenly because I had not struggled all night to breathe. I had completely forgotten what that feels like...it has been years! I use my MAD every night and my sleep deprivation symptoms have gone away. It has been over a year now, and I would never choose to go to sleep without it.
Interestingly, my husband was diagnosed with UARS one year later. He has been using the CPAP religiously for a year now and feels no better. My dental device was approved through insurance without problem while 6 months later, my husband's prior authorization request to the same insurance company for the very same device and for the very same diagnosis was denied...after 4 appeal letters, it is being covered...he is anxiously awaiting the final fitting. So, the insurance piece, at least for UARS, clearly can be tricky.
Some sources have indicated that patients with UARS are less tolerant to CPAP use due to an increased sensitivity in the nervous system...I understand that UARS is placed on a continuum with OAS, and it is treated the same as OAS; however, there are some differences that I think need to be taken into consideration.
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Permalink Reply by Shelia Shafer on
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I have been fitted for my dental appliance which I understand moves the lower jaw forward to open up the airway. Should be here in a couple of weeks and I'll keep you updated.
I am on a bi-pap, except I don't use it because I feel like I'm tied down on a ventilator. My nose gets stopped up and I claw my face trying to get the mask off because I can't breathe. It may work fine with 100% compliance but I don't use it. Hopefully, once I get used to the dental appliance, I'll use it every time I sleep. I'm excited and cautiously optimistic. I'll keep y'all posted.
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