Still exhausted after 8mo of CPAP -- is oral appliance better? Skinny young male, fat tongue, narrow palette

Hi all,

I have an untreated AHI of 10.0, diagnosis of mild OSA, no major health issues (only thing is low ferratin levels which I am taking iron supplements for), and have been on CPAP for about 8 months now. I am a healthy young male in 20s at a healthy weight and physically active. I use the ClimateLine tubing with the airsense 11. I wear a P30i large pillow.

Despite my machine's reported AHI being around or under 1.0 most nights, I have generally been sleeping pretty poorly. In particular, I am conciously waking up 1-2x per night, and experiencing eye twitches, dry eye, brain fog, memory loss, speech issues, and fatigue throughout the day. I feel exhausted every morning and never wake feeling rested or restored.

I have tried many different settings on my CPAP with no clear improvements from any. When I increase pressure too much, I get minor issues with aerophagia. Below are links to various settings and results:

APAP, 7.6-10, EPR 3
https://sleephq.com/public/ca64e888-c62 ... 451b08d676
https://sleephq.com/public/e1036edf-d92 ... 5980c0651e

CPAP, 10, EPR 3
https://sleephq.com/public/5def8a63-2cb ... a0c38a1faa
https://sleephq.com/public/588015d1-e15 ... b031c32180

CPAP, 11, EPR 3
https://sleephq.com/public/9667828e-83f ... a4b6bf9ae6
https://sleephq.com/public/d55fb2a1-049 ... ba73c42b8f

APAP, 6-10, EPR off
https://sleephq.com/public/19801ed3-0b3 ... 43f0d85fd7
https://sleephq.com/public/3ac99e98-bbd ... d209d49c36

APAP, 8-12, EPR 2
https://sleephq.com/public/59e58b27-e61 ... 0b26942520

My graphs don't seem to look that bad but I am concerned about the symptoms. I have tried mouth taping but it does not seem to help, even though from my data, it seems like this event sequence happens a fair amount:
1) flow limitation causing decrease in tidal volume
2) leak occurs, maybe(?) from my mouth opening to take in air since my volume has decreased
3) apnea event and arousal

If it's relevant, I sometimes wake up with nasal congestion, dryness, and inflammation (my nose looks swollen and larger in the morning). My humidity is as high as possible without causing rainout. I had a functional septorhinoplasty in January 2023 to resolve a deviated septum and enlarged turbinates, so my nose breathing is very good generally, though often dry. Sometimes my mouth is dry when I wake up too.

I have seen two dentists who suggest I have a narrow palette and large tongue which cause my disordered sleep breathing. My Mallampati score is Class IV (or even worse). They of course want me to buy their oral appliances (a MAD plus a retainer I'd wear for 10mins the morning after to hopefully prevent shifting of my teeth). Their rationale: though my sleep apnea is being treated well by CPAP (as evidenced by the AHI reduction), CPAP is just not working for me and my body, as evidenced by my symptoms. They think that CPAP should not have been prescribed to me because mine is mild and I am a skinny guy, and they think the oral appliance will similarly treat the apnea but in a less intrusive way that my body will tolerate much better.

I understand there are concerns/risks with MAD and messing up my jaw alignment. I have a very slight overbite so I actually wouldn't mind a slight shift of the lower jaw forward over time. I also think this downside could be worth proper sleep breathing, but I am open to people's thoughts here.

My question to the board given all this context: would an oral appliance really be the next best step to try? Am I being duped? What other treatment options do I have?
Note that I have tried sleep drugs (trazodone, gabapentin, lunesta) and wakefulness drugs (modafanil) without success.

My sleep doctor has no idea what to do with me because they see good looking data from the CPAP and assume I should be feeling great.

Any help would mean the world.

Misc: I follow healthy bedtime habits, eat healthy, don't drink/smoke, am in therapy, hydrate well, take magnesium and vitamins, etc etc.

Also, here are much more details from my sleep study... note that most of the night was on my back as instructed, though I still had (fewer) events on my side. At home I always sleep on my side.

https://imgur.com/a/UD0jeV3

I am a newbie with no knowledge of how to interpret charts, but I will share with you my experience with oral appliances.

My family also has narrow palates and at least one of us, my younger sister, was told she has a fat tongue. She has been successfully using CPAP and is very happy with the results. She says she has her life back.

My older sister and I tried the dental appliance. I gave up because of jaw pain. It turns out my jaw is very flexible, which the dentist thought was great because I could advance my jaw very far forward. It wasn't great. It was a sign of weak connective tissue. The dentist knew nothing about this. He adjusted and adjusted but I always had pain. He told me not to give up. I gave up. After that I learned about my connective tissue problem and discovered I had permanently damaged my jaw by moving it forward unnaturally, making it very hard to find a CPAP mask I can use.

My older sister, who tried CPAP first, is about to give up on her mandibular device and go back to CPAP, which she quit because it gave her dry eyes (which is a problem for her even without CPAP). She's not happy with the dental device and doesn't feel much better using it. She doesn't know why. The device gives no objective feedback.

I am still in the adjusting to CPAP phase and getting help from this forum. Because the machine gives feedback, it is possible to get help with problems.

Sleep doctors, a a rule, do not seem to know much about how to interpret data correctly. I don't really think it's their thing.

Hope that is helpful.

Snake oil.
Avoid.
Edit: after several tries, the forum FINALLY let me post.
Ready to give up!

For experimenting you really should own a recording O2 monitor... I use the O2Ring. Not cheap, worth every penny. It tells the tale of how your therapy is going.

I've experimented with MAD... it did lower my APAP pressures about 2cm and did let me go supine at normal pressures. Now that I'm on Herculean bi-level pressures it doesn't do much and I've discontinued it. I used the SnoreMD, available from Walmart for 40$, one of the many boil-n-bite ratcheting jaw advancers. I used it upside-down due to my overbite... basically advance my jaw to near even, then take it out for bedtime, and avoid clenching until morning... I found my jaw still somewhat advanced on waking. Now I can advance my jaw somewhat at will, I end up advancing it through the night and find it somewhat advanced in the morning. It does mess with the bite somewhat, but at 40$ it's just as good as the 2500$ your dentist wants you to spend.

So for 180$ O2Ring and 40$ SnoreMD you can do your own experiments! Let us know how it goes... if I were a pilot or truck driver with mild OSA I'd certainly try this route before being sleep-studied.

Looks like you had a pretty good workup, what where the results of the Actigraphy and MSLT your sleep study references?
Have you had any further testing to look for other issues that could explain your brain fatigue?

How does your mask fit? Sometimes a poor fitting mask can cause dry eyes. Do you have allergies? Also some do better and some do worse with high humidity, might want to experiment with that.