I am considering an oral device but have an extream over bite.  Is this going to a problem?   The results or my sleep study have not been reviwed with by my doctor but I am positive I have apnea, I just don't know at what level yet.  As I've state in a previous post the machine is going to be a problem so I'm looking into the oral device.  Anyway any input would be appreciated.

An oral device is most effective if your sleep apnea is caused by an enlarged tongue base i.e. your tongue relaxes at night and cuts off your airway.  The oral appliance holds your lower jaw forward at night thereby keeping your tongue forward so it does not fall back.  An ENT can look at your oral cavity and tell you if this device will work for you before you shell out lots of money for it.  Check the archives of the dental appliance forum to see if an appliance will help you.  There is an ENT called "sypark" who posts on this forum - if you do a search you can see his posts.  You may try a boil and bite device before buying an appliance to see if this helps your apnea.   The overbite should not be a problem.  You probably have a receding jaw which is an indicator of sleep apnea caused by the tongue falling back.

New forum member "Lawler", is a sleep disorders accredited dentist who specializes in dential devices for OSA patients.  PM him also if he doesn't catch this post.

Vicki


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Being defeated is often a temporary condition. Giving up is what makes it permanent.
Marilyn Von Savant

That which does not kill you makes you stronger-Friedrich Nietzsche
Friedrich must of had apnea.

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You may try a boil and bite device before buying an appliance to see if this helps your apnea.   The overbite should not be a problem

My personal suggestion is to not mess around with a boil and bite appliance.  An oral appliance is going to help.  Period.  The issue is how much.  A boil and bite appliance cannot be adjusted gradually to the optimum position.  Our friend has, at least for now, ruled out CPAP.  So there is a lot riding on the effectiveness of an oral appliance.  Do it the right way and don't mess around.  

Your overbite will cause you no problem and will likely make you more suited to an excellent oral appliance result.


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David E. Lawler DDS, D,ABDSM

www.centerforsoundsleep.com

Better health through restful sleep

I first tried the boil and bite (puresleep) and it didn't work for me. It irritated my gums and did nothing for my snoring or my apnea.  I then found an ad in our major newspaper about a free consultation using an adjustable dental device.  Best decision I made was to check this out.  I was examined by a neuromuscular dentist that specialized in sleep dentistry.  I too was worried about wasting the money but I was offered a money back guarantee that if I was not satisfied I could get the cost of the appliance back.  I was offered two choices. I could have either the TAP3 or the Somnodent MAS.  I chose the Somnodent MAS as I found it much less restrictive to opening and closing my mouth.  It also had no adjustment screw in the area where my toungue would be during the night.  I am totally satisfied and the difference in the way I feel now is amazing.  I was adjusted out very slow and I have no problems returning my jaw in the morning using the bite tabs and a slight pressure pushing my jaw back.  I have also had three at home sleep studies with the Watch-PAT 100 device and will have another in March at one year mark of using the Somnodent MAS.  People on this forum say that a dental device won't help someone with severe apnea but it has helped me a great deal.  I fully expect my next sleep study to show I have an AHI less than 5.  Good luck to you.  I almost forgot I too have an overbite.

Your situation perfectly illustrates the problem that a boil and bite appliance presents.  Because it is a "one size fits all" device which is then modified by heating and moulding, it is not a custom fit.  So to derive any conclusions about whether a device like this can be worn during sleep as a "test" before jumping into a FDA approved mandibular repositioning device causes a decision to be made with faulty information.  I do not want to use words like never and always, but it is extremely rare that someone is not able to tolerate an oral appliance during sleep.  However, the appliance MUST be properly made and fitted.

Assuming that a boil and bite appliance can be tolerated, do not assume that the relief of symptoms with this device is representative of a properly fabricated and fitted mandibular repositioning device.  All FDA approved oral appliances can be very slowly adjusted to very gradually bring the lower jaw forward.  Picking the initial starting point is very important.  Picking this starting point is somewhere between art and science.  The experience of the clinician assessing this point is helpful in establishing a mandibular advancement that can be well tolerated to start with and, yet, be far enough forward to allow the adjustment mechanism of the appliance to advance to the "sweet spot".

We recently completed treatment on a patient whose dog ate an oral appliance that she had been wearing for some time and that had been fabricated by a dentist not formally trained in sleep medicine.  The appliance that had been eaten by the dog was a much nicer appliance than a boil and bite appliance.  However, in assessing her subjective symptoms between her old appliance and her new one, she stated that "there is no comparison" in how she is feeling now.  

Everything that you state in your post is an example of proper therapy.  Being adjusted out very slowly and proper follow-up is critical.  So, with this proper protocol, a significant number of severe sleep apnea patients can be properly managed.  As always, it is not possible to accurately predict who will and who will not have their sleep breathing normalized.  Being properly informed is vital to making good decisions about health care.


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David E. Lawler DDS, D,ABDSM

www.centerforsoundsleep.com

Better health through restful sleep

Dr. Lawler-
I hear so much about this "sweet spot".  Is this found by PSG testing or by relief of symptoms of OSA?  In your expert opinion at what point do you stop the adjustment phase?  Is it when you see no more improvement by PSG or is when pain developes?  The further you advance the greater the risk for TMJ/occlusion  complications.  Is the Watch-PAT 200 the latest from Itamar?  Looks much smaller and more comfortable than the Watch-PAT 100 that I used.  Hopefully they solved the problem with the positional/snore sensors falling off during the night.  I believe that this device is a great start for someone with limited funds or a fear of an overnite PSG at a clinic or hospital with all the wires and such.  Most people are very lucky to have access to some of the finest PSG facilities in the world.  But sadly a lot of OSA sufferers are basically on there own for diagnosis and treatment.  The negative light that is cast on dental devices is really unfortunate as I believe a lot of OSA sufferers that can't or refuse to tolerate CPAP could find beneficial relief using a dental device. Thank you on behalf of all those who come to this forum looking for information on dental devices.  I for one advocate treatment of OSA by what ever treatment effectively treats your sleep apnea.  I have not been paid or sponsored for this opinion about dental devices. I am just one of many successful dental device users that was unable to obtain prescription CPAP therapy. I only hope that dental device therapy is more widely recognized by the insurance and HMO medical establishment as a viable Sleep Apnea treatment.  All of my therapy costs were out of pocket.  Again I thank you and this forum for providing much needed information to those of us who fight the fight against this awful problem of Sleep Apnea and its complications.  Sorry for being so long winded.  dwsz06 - I hope you find the information you need and I apologize for hijacking your post. If you would like more information on my personal experiences with CPAP and dental devices please feel free to PM me.

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I hear so much about this "sweet spot".  Is this found by PSG testing or by relief of symptoms of OSA?

Your question is at the heart of our biggest challenge with oral appliance therapy.  We start with bed partner feedback, if one is available, coupled with symptomatic relief.  When it is apparent that good things are happening, we do a home study.  In our office it is done with a Watch PAT.  We have both the 100 and 200.  You are correct that the 200 is more comfortable since it is so small.  Having the sensors come off has not been a significant issue.  However, this is one of the downsides with home studies.  Since they are unattended, there is no one there to fix a sensor that has come loose.  On my desk today was a study where the pulse/oximeter had not been well secured resulting in quite a bit of excluded sleep data.

We refer back to the sleep lab when we believe that the results from the home study justify another PSG.  Often, we do multiple home studies until we are satisfied.  If we cannot get a patient completely normalized, we do our best to combine therapies.  Oral appliance therapy results, when not completely successful, can be greatly enhanced with palatal surgery.  Other options include CPAP/oral appliance hybridization or oral appliance therapy and weight loss.  We are now working with a personal trainer to help those who wish some weight loss but have not been able to do it on their own.  

I'm surprised to hear that your oral appliance was not accepted for reimbursement by your medical insurance company.  This is something that we have very little difficulty with.  Insurance typically will not pay the entire amount but, depending on the deductible, the amount is usually quite significant.


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David E. Lawler DDS, D,ABDSM

www.centerforsoundsleep.com

Better health through restful sleep

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I'm surprised to hear that your oral appliance was not accepted for reimbursement by your medical insurance company.  This is something that we have very little difficulty with.  Insurance typically will not pay the entire amount but, depending on the deductible, the amount is usually quite significant.

  
  
  
This is one the problems when you have an HMO like Kaiser Permenente of California.  My Metlife dental insurance won't cover it because its for a "medical condition".  Kaiser my medical provider won't cover it because its a "dental device not approved by them as a treatment for OSA"  They approve only the knife or CPAP.  I couldn't get CPAP because I couldn't complete a successful titration study.  They wouldn't allow me to use APAP to try and get use too the mask and the exhalation pressure.  Hence my journey to the dental device world for relief.  At least the ENT did not recommend surgery.  I just use the "Breath-rite strips to facilitate better airflow.
  
 I believe that my ongoing weight loss efforts is also contributing to my success. Along with giving up alcohol, caffeine and the increase in my energy levels giving me the ability to excercise.  What ever the reason I feel great and glad to be alive.

For Papahemi and others: oral appliances for sleep apnea are covered by MEDICAL insurance (which sleep dentists use).

I recently had my oral appliance made and covered by my medical insurance. I have a wonderful regular dentist who I used to work for that wanted to make my appliance for me, but couldn't because his office doesn't bill "medically." Therefore, I had to find a sleep dentist who bills medically. There are different codes for insurance, and if your dentist isn't a medical dentist then he/she only bills your dental insurance using dental codes -- not to your health insurance.

The oral appliance is billed to your health insurance as a prosthesis, when it is determined that the device is necessary to your health. Just as CPAPs are covered. Just to check, call a sleep dentist (or look on the TAP website) and get the diagnosis and procedure code for a device like the TAP. Then call your health insurance and ask what is covered. Remember, health - not dental insurance!

That being said, I know all insurances differ -- but find a dentist who bills medically to your health insurance, not dental insurance, and you may get at least a little something covered.

Hi,  I also have a large overbite and have been using the Tap 3 since mid-September.  After the first fitting, I used it for about a week and it did not work too well, my jaw hurt and I could not get my bite to return to normal until the end of the day and then it would start all over again.  I went back and they put some pieces on the back so that the jaw teeth would be supported at night.  I let my jaw get back to normal before I used it again. It worked good but I still couldn't get my bite to go back to normal.  They then made a bite guide for me to use in the morning.  It is kind of like a retainer and it is molded to your mouth when you are able to use your normal bite to mold it.    I am sorry this is not very descriptive, but I hope it helps.

I also found that the bite tabs that come with the appliance for use in the morning to get your bite back do not work for those of us with over bites.  The bite guide that was made for me helps much better.  I also chew a couple of pieces of gum for the up and down jaw movement.

I have used CPAP for 2 1/2 years and hated every minute of it.  This forum helped me find out that there was another alternative and I really wanted this to work.  I have had a little pain, and it has taken a little time, but I think I have made it to where it works for apnea without the jaw pain.  The bite goes back to normal a little quicker every day.

I hope this helps, I am very please with my results and the device itself is not uncomfortable to sleep with, the only problem is when you take it out in the morning and that is just something you have to work through.  I cannot tell you that it has cured my sleep apnea since I have not yet used the home test , but I know I am feeling much better and my spouse has told me that he has not noticed any sleep apnea symptoms.  My sleep study was 83
apneas per hour so I am classified as severe.  I have lost 20 pounds and had gotten my bipap air down to 4 with only 3-5 apneas per night just before I began the oral device.

Good luck with whichever method you choose. Just be sure to use one!!!  If you have any questions, please feel free to PM me and I will be glad to help.  I did all of the investigation into oral devices myself ( several hours worth) and decided to do it and even found a dentist that specializes in oral devices.  The sleep study doctors have never even mentioned this alternative.  I even mentioned that I was using it to my primary care doctor and he had never heard of it and asked me to have the dentist send him information so he could inform other patients of the alternative.  Again,   GOOD LUCK !!!

Hoot, I am extremely pleased for you that you have found some relief with oral appliance therapy.  You know better than most how frustrating it is to not be given all of your options.  You share your frustrations with this man <link to website removed>.  It is quite possible that you have your disorder well managed but without any follow-up you do not know!

As in the patient in the above link, you may respond extremely will due to your overbite, but I urge you to get another sleep study to find out.  

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Good luck with whichever method you choose. Just be sure to use one!!!

Sometimes it is extremely helpful to use MULTIPLE therapies to get the desired results.  If a subsequent sleep study show that you still have a significant problem, you might hate CPAP less if you joined it with your oral appliance that is helping you so much.  Or you might get a huge improvement if some palatal surgery was used.  The bottom line is that you are relying only on how you feel and this can be extremely misleading.

Having said all of this, your posting about your success is extremely helpful to those contemplating oral appliance therapy.

I'm so glad to have found this post!  I am a 31 y/o woman, 5'4" 120lbs, with mild sleep apnea (12 on the sleep apnea scale).  I've snored my entire life and finally had a sleep study because my husband was complaining about the snoring.  Before resorting to surgery -- dr said he could correct my very deviated septum, remove my tonsils and fix my soft palette and uvula all at once -- he's suggested I try an oral appliance.  Sent me to a DDS/MD who specializes in this stuff -- she gave me a TAP3.  I have an overjet, which is similar to an overbite -- my top jaw is out over my lower jaw by maybe 1/4" or so.  It means that the neutral position, the TAP3 is pulling my lower jaw more forward than someone without an overjet.  I also clench my teeth, which probably doesn't help.

Last night was my second night with the TAP3 in neutral and I'm in more pain today than I was yesterday.  My jaw is very sore, especially on one side right up by my ear.  I woke up at 6am because it was hurting so much so I took out the device and did my exercises for 45 mins or so to try to get my jaw back in the right position.  It's 12:30 now and it still feels a little off to me.  There is still pain in my jaw, although it's slowly subsiding.  It also hurts when I open my mouth widely.  Is it right to assume that this is just my muscles getting used to it?  If it's worse tomorrow, I'm definitely going to call my dr on Monday.  I'm curious to know about this retainer-like device I could use to reset my bite in the morning because I really don't want to make an permanent changes to my jaw.

I know it's early on in my treatment but any advice would be appreciated...

Hi.  I have a crossbite and some TMJ symptoms and tried an oral appliance.  It worked fine per my sleep study results but yes, it caused my TMJ pain to get worse after a few weeks of wearing it.  I even had to sign a waiver of non-liability before I received the appliance due to my pre-existing latent TMJ.  That should have rung a bell for me in my head.

Lawler:

If I might ask, what is the average cost of treatment using an oral device?  I understand that the appliance itself is costly, but you mentioned above that you need proper adjustments and possibly multiple home sleep studies (and possible an in-lab titration study).

I have been asked this question many times (as a sleep tech) and I am never sure what to say other than thousands of dollars...