Using an Oral Appliance with CPAP Really Helped - Details

Background:

• • 42-year old male, 5’8”, 190 pounds, mouth breather, standard sleeping position – on back almost exclusively, years and years of loud snoring from an early age.
  • Diagnosed with Severe Sleep Apnea at age 40, AHI: 80, using CPAP, titration at 14, Full Face Mask.
  • I’m an infrequent member of this forum. I just use it when I need to research the particular issue I’m dealing with at the time (such as which mask, how to deal with leaks, rainout, changing settings, etc.).

Problems:

• • CPAP worked, but due to various reasons, could not be used all night. Averaged 1-3 hours per night. In short, CPAP therapy not effective overall.
  • Main issue with CPAP was leaks, wetness, waking up.
  • Tried everything. Changed sleeping position to side as much as possible. Tried 4-5 masks over last 2 years – could not find one that eliminated leaks. I have a file at the sleep center larger than most encyclopedias. Tried BiPAP, APAP, all CPAP settings.
  • Last sleep study could not be finished because technician could not get CPAP machine to correct pressure to eliminate AHI without having too much leakage.

Solution:

• • Desperate, so tried Oral Appliance from an Orthodontist specialized in sleep therapy solutions.
  • An oral appliance is like a mouth guard that attaches to your teeth and pushes your lower jaw forward to open up the air passages and give the tongue more room to stay in the mouth area and not “fall back” to an apnea position. Obviously this is my layman description.
  • Oral appliance reduced AHI from 80 to 6! This was without using any CPAP at all. Ecstatic with results.
  • Re-titrated CPAP machine to pressure of 7. Down from 14 to 7. Mask stays on all night, rare leaks, much more effective.
  • May not need to use CPAP at all, though there may be differing opinions on that.
  • For now, I use the Oral Appliance every night with CPAP at 7.
  • Feel much, much better, more refreshed, more energy, better concentration, no clouded thinking. I even deal with our kids stress much better!

Conclusions:

• • I’m speculating, but maybe my apnea was not like mainstream apnea. This case study might be an anomaly. I have a narrow face and perhaps that structure was causing most of my apnea issues. Would explain snoring at an early age. With the oral appliance, it is almost impossible to snore.
  • If you try an oral appliance, set expectations that you’ll need it with CPAP and to make CPAP more effective. I researched this and a lot of the results seemed to be a lower pressure of only 2-3 points though, but they vary. Mine dropped from 14 to 7 (I was OK at 6 too in my tests). I have no problem continuing to use CPAP with this device if it continues to make me feel this way.
  • Get the right oral appliance. My first one (the best one) did not work. The second one (still good but not the best) was much, much more effective.
  • Oral appliances are expensive and not covered by insurance (at least by mine). Out of pocket cost for appliance - $1000. All the ortho visits were covered, just not the device.
  • The oral appliance has to be custom fitted. You can’t just “try” one to see if it works without taking impressions at the office, shelling out the $1000 and trying it out. Rolling the dice a bit. However, the ortho worked with me here and I got the second device 100% for free since he recommended the first device initially.
  • Expect the oral appliance process to take a few months. From start to finish for me was about 4 month. Tried two devices, then had to adjust final device to correct setting, which you have to gradually adjust. Have to be careful here.
  • My oral appliance design was a little particular (I think). The upper part was connected to the lower part, as opposed to two separate pieces. I also needed to apply rubber bands to connect the front of each half together. The device with the rubber bands keeps my mouth from opening wide – which I believe is a key part of the solution. It is also designed to still have an opening in the front so that I continue to breathe through my mouth, though it is a much smaller opening than my big wide open mouth at night. These were the key parts of the solution – keep the mouth much more shut and have the lower jaw forward. I will try to attach pictures.
  • Question – do you even need CPAP if your AHI is only 6? Also, isn’t there some subjectivity to the “scoring” of the sleep study? Are sleep centers trying to score the data such that the AHI setting is > 5 so that they can conclude you have at least mild apnea (to continue their insurance billing)? Should I have my real ENT score the raw data to get a second opinion? NOTE – these are not my conclusions at all – just throwing it out there to be complete with the case study information. I am using the Oral Appliance to make my CPAP therapy more effective.

A very interesting post.
I'm using APAP with great success and hence haven't considered anything else. I'm a front sleeper and don't have any problems with mouth leaks.
My sister tried APAP, but had a lot of issues with various masks and is now using an Oral Appliance with apparent success. She regularly monitors her SPo2.
My younger brother also has mild sleep apnea but hasn't started any treatments yet.
I'd be very interested to see a photo of your oral appliance.
Do you monitor your SPo2?

greg-g wrote:A very interesting post.
I'd be very interested to see a photo of your oral appliance.
Do you monitor your SPo2?

Thanks - I thought this detailed information would be very helpful.

Here's three pictures of the device I used.

Link to Album: https://picasaweb.google.com/mike.snodg ... _ad4oeMWg#

I don't monitor oxygen desaturation, but the sleep report said "oxygen desaturations associated with events had a nadir of 88%" which I think is fine.

Hope this helps!

I have a narrow face as well and after using my CPAP for the first few days, you have me thinking.

This is the link to my dental appliance called Silent Nite http://www.ihatecpap.com/oral_appliance.html
Have been using it for about a year or more. Now, I can't sleep without it. It took me about a year (no kidding) to become one with it.
A little less than a year before the night drooling final stopped. Mouth was not used to something that foreign in it all night. Took a long time to get used to. I'm glad to read it's working for you. Remember Mike, the cpap and dental appliance work together as a team to combat against sleep apnea.

Starlette

Thanks for the info - looks like my dental appliance was like the Herbst Telescopic Appliance. I just looked at my official polysomnogram report again. My AHI with just the oral appliance was actually 1/hr, but the overall Resperiatory Disturbance Index (RDI) was 6/hr. Shows how effective this device was for me.

This is an old post...but is that pic of your oral appliance an Oral Systemic Balance (OSB) Appliance?

saltyk9 wrote:This is an old post...but is that pic of your oral appliance an Oral Systemic Balance (OSB) Appliance?

Sorry - have no idea at all! I can have you contact the dentist though if you are interested. Just send a direct message and I can supply you with his contact info.

Hi Mike, just reviving your old thread so I can ask more about experiences people have had combining CPAP with oral appliances.

My situation is that I have long duration apneas (>60 sec), even at high pressures (18 cm) (viewtopic.php?f=1&t=68516). Sometimes the CPAP will work well, and I'll have a nice hour or two of proper sleep, but I'm equally likely to run into a train of obstructive apneas that the machine is just unable to "bust" through. This is even under perfect "no leak" conditions (difficult to achieve at these pressures, but I've done it!).

An ENT doctor examined me and told me that my obstruction arises from a combination of a large tongue and a receding jaw -- once I fall asleep, my tongue base smushes up into my throat and becomes difficult to dislodge.
He suggested that an oral appliance could make CPAP a lot more effective for me. A displacement of just a few millimeters would open up my airway and allow the pressure to do the rest of the work.

I'm quite excited about this prospect of effective treatment, but have so many questions --

(1) Would it be worth trying out mass-market appliances (i.e. puresleep.com) first, as a proof of concept? or is custom-fit really necessary for it to work at all?

(2) Is it practical to use a full face mask together with an oral appliance? Do they all fit together? Are there any parts that "jut out" and create leaks?

(3) Has anyone tried this crazy looking contraption, the TAP-PAP (http://www.austinapnea.com/combination_ ... tment.html)? It looks designed for this very purpose, but I haven't heard reports from any actual users.

(4) Can one still breathe through the mouth with the appliance in place? I have a severely deviated septum which makes breathing through my nose difficult.

(5) Does the oral appliance reduce other side effects of CPAP therapy, like "chipmunk cheeks?" I have been getting used to sleeping with inflated cheeks; there's no way I can get my tongue to seal my mouth off once I fall asleep. If the appliance holds my tongue in place, will the inflation disappear?

(6) Any particular recommendations for devices? I've heard good things about the TAP series, but any basis on which to pick one?

(7) Does insurance cover any of this?

Thanks much! I'm intrigued by these "hybrid" approaches and figure the forums are an excellent place to find people pushed by necessity to find new and interesting treatment solutions ..

Sorry for the delay! Great questions. Here's my thoughts:

(1) Would it be worth trying out mass-market appliances (i.e. puresleep.com) first, as a proof of concept? or is custom-fit really necessary for it to work at all?

I tried one of these (forget the name). Was completely useless for me, however. Might have been because of my particular needs, but the generic device did not move my lower jaw forward or keep my mouth from completely opening wide. For me, I needed a custom fit, including rubber bands that kept the top part of the device close to the bottom part.

(2) Is it practical to use a full face mask together with an oral appliance? Do they all fit together? Are there any parts that "jut out" and create leaks?

Practical? That's what I do every night. Oral appliance is what enables my CPAP to work at a MUCH lower pressure (I'm at 6 now - almost not even necessary). The oral device pushes the skin around my mouth out a little, the full face mask still fits fine. No leaks with both together.

(3) Has anyone tried this crazy looking contraption, the TAP-PAP (http://www.austinapnea.com/combination_ ... tment.html)? It looks designed for this very purpose, but I haven't heard reports from any actual users.

Have never seen that device or heard of anyone using it. Would not work for me, since I still have my mouth partially open at night.

(4) Can one still breathe through the mouth with the appliance in place? I have a severely deviated septum which makes breathing through my nose difficult.

Yep - I still breath though my mouth with the oral appliance in place. They can adjust the opening that is left when the top and bottom pieces are in place and attached with little rubber bands. I can't breath through my nose either.

(5) Does the oral appliance reduce other side effects of CPAP therapy, like "chipmunk cheeks?" I have been getting used to sleeping with inflated cheeks; there's no way I can get my tongue to seal my mouth off once I fall asleep. If the appliance holds my tongue in place, will the inflation disappear?

When you reduce your pressure from 18 to 6 or so, you will have no chipmunk cheeks. And less gas too! Tongue not in play here, just much less air to puff out the cheeks.

(6) Any particular recommendations for devices? I've heard good things about the TAP series, but any basis on which to pick one?

Likely various by doctor. At first, the ortho recommended SomnoMed, but it didn't work for me. I need a setup where the top part actually physically connects to the bottom part. Here's my dentist's link: http://aakatzdds.com/ You can literally call him and mention my name if needed. They're great - honestly.

(7) Does insurance cover any of this?

My insurance covered all the office visits and part of the device. But, out of pocket costs for the custom oral appliance was $1000. I ended up getting a backup device too (the first one had a little repair issue, but I didn't want to be without one) and the backup was only $500.

Hope all this helps!! Let me know if you need anything else.
-Mike

Hi Mike, thanks for the reply! These are all exactly the answers I wanted to hear. Being able to go down to 6 cm would be a dream -- I barely feel anything below 12 cm anymore. And the way my ENT doctor explained, my particular anatomy makes me an excellent candidate for the dental appliance (or maximilliar advancement surgery -- but of course I'd rather get a dental device vs sawing my jaw apart). So I am already optimistic that there will be an improvement.

I'm receiving the puresleep device in the mail tomorrow, and I will check out how it works tomorrow in combination with my bilevel machine. I think regardless of whether it works or not, I'll do as you did and make an appointment to get a dental appliance done.

I'll update the board about the results. Thanks again Mike, much appreciated.

I'm curious... Does anyone know if one can use a MAD with a nasal mask or does it just promote mouth leaks?

Very good post and info, OP.

I initially tried the ZQuiet appliance, which kinda worked but I kept spitting it out during the night.

Always wondered if appliance + cpap would work.

Hi everyone. I went ahead and did a little experiment, using an over-the-counter PureSleep "boil-and-bite" dental device. This device has been the subject of some controversy on the board before (viewtopic.php?f=1&t=28887), so I thought I would add one data point to the discussion.

For me, 16 cm is a minimum therapeutic pressure. Here are the apnea events present when I use a sub-therapeutic pressure of 8 cm (recorded with an Resmed S9 VPAP):



Here is last night, where I used 8 cm pressure + the PureSleep device:



Results: When I woke up, my jaw was sore, and I needed to rub my jaw muscles before my bite would return to normal, suggesting that it had held my jaw in an extended position for some duration.
The device does seem to create a period of 30 min to 1 hr within each sleep cycle where obstructive events do not occur. After that time though, the events occur as usual.
The device also appears to diminish the overall severity of the obstructive episodes.

Discussion: The PureSleep device is limited by its ability to stay positioned in my mouth while I sleep. It is held in place by friction, quite snugly on the lower jaw, and loosely on the upper jaw.
The problem is that during deeper sleep stages and REM cycles (I assume), my jaw relaxes, which likely leads to the device becoming dislodged, at which point it ceases to be effective.

Conclusion: Dental devices can eliminate obstructive apneas (at least for me), but measures need to be taken to ensure the device remains securely in place during sleeping.
This seems to be a problem common to over-the-counter devices, which is why custom-fitted devices are recommended (from what I have read).

p.s. I have an appointment to get an oral appliance made tomorrow morning. Once I get it, I'll post further results on the board.