In my last post, I described 5 reasons why I like oral appliances to treat obstructive sleep apnea. This is a continuation of my love/hate, pro/con blog posts about various sleep apnea tests and treatment options.
Here are my 5 reasons why I don’t like oral appliances:
1. It’s challenging to find a qualified dentist for every patient. For most people who live in metropolitan areas, there are lots of options. If you live in rural areas or if you have insurance that’s not common accepted (like medicaid plans) it’s much more challenging.
2. It can change your bite. This is an expected, and common side effect. If you work with a good dentist, this can be minimized or reversed. Some people don’t care, since they’re sleeping so much better.
3. It’s much more expensive than CPAP. If you don’t have insurance, it can cost a few thousand dollars, whereas CPAP is well below $1000.
4. It can be lost or damaged. Because it’s so small, it’s easier to lose. I’ve also had a handful of patients that told me that their dog chewed up their devices.
5. Although these devices will pull the tongue forward, it also takes up space within the mouth, leaving less room for the tongue.
For the most part, I find that mandibular advancement devices are helpful and in general, better liked by patients. This is in line with published studies.
In my next post, I’ll describe the 5 things you need to know before you see a dentist, to maximize the chances that an oral appliance will work for you.
When given a choice for treating obstructive sleep apnea, many people hate the idea of using a mask attached to a hose every night. Fortunately, there are a number of good alternatives.
Mandibular advancement devices (also called oral appliances) for obstructive sleep apnea come in various models, but they all have one thing in common: The lower jaw is pushed forward against the upper jaw, moving your tongue forward, opening up your airway. Different models have different bells and whistles, and all have their pros and cons. This is why it’s important for a dentist to be experienced with a number for different models, since everyone has different needs.
Continuing on my love/hate themes for various treatment options for obstructive sleep apnea, in this post I’m going to describe 7 reasons why I think dental appliances are a great alternative to CPAP for obstructive sleep apnea.
1. No headgear or straps around your face. Most oral appliances fit completely inside the mouth.
2. It’s silent. Because it’s not a pump, it’s completely silent.
3. It’s small and convenient. It’s also easy to take with you on trips, compared to CPAP machines.
4. Compared to even a few years ago, more dentists are available to make these devices, and are usually covered through most major insurances.
5. Recent studies have shown that oral appliances are equivalent to CPAP for people with mild to moderate obstructive sleep apnea. The American Academy of Sleep Medicine has stated that oral appliances can be considered a first line treatment option in addition to CPAP.
6. An oral appliance can be made as a holder for CPAP using a nasal pillow-type mask. This way, there are no straps or headgear for CPAP. The appliance can be set at a neutral position just to hold the CPAP in place, or it can used as an advancement device in addition to allowing for nasal pillows.
7. It can be used effectively for snoring, even if you don’t have obstructive sleep apnea.
Oral appliances are very helpful for many patients in my practice. However, these devices do have some drawbacks. For my next post, I will give 5 reasons why I don’t like oral appliances.
If you are successful at using an oral appliance to treat your sleep apnea, how did it compare to using CPAP? How were the different options explained to you by your sleep physician? What was your experience like getting the device made by your dentist? Please describe your experiences below.
In-between nasal surgery cases today in the operating room, my resident asked me why the standard over-the-counter isotonic nasal saline preparation said .65% saline, rather than .9% saline.
The normal salt concentration in our bodies is 0.9%, which can also be mimicked by adding 9 grams of salt into 1 liter of water. This is called isotonic saline.
Nasal saline rinses are a helpful way of helping you to clear out your nose and open up your sinuses. There are a number of different concentrations, formulations, and ways of getting saline into your nose. Most physicians recommend isotonic saline, which is the same salt concentration as what’s in your body. There are certain reasons for use more or less concentrated versions.
Hypertonic saline is saltier than your body’s salt concentration, so irrigating your nose will cause water to leave your nasal membranes into the saline to equalize the salt concentrations. It’s like what happens when you add salt to a cucumber. Water leaves the cucumber and it shrivels up, like what happens to your nasal membranes. Swimming in ocean water also does the same thing. This process is called osmosis. Using hypotonic (less saltier) saline will cause water to enter your nasal membranes, causing more swelling and congestion.
In theory, you should use isotonic saline to flush out nasal mucous and cause some mild shrinkage of your nasal membranes. This is why nasal saline irrigation can make you feel and breathe much better. Then why do many products say that .65% is “isotonic”?
After doing some research, it turns out that one of the common brand names (Ayr®) is isotonic at .9%, but only .65% is salt. The rest is made up of a buffering agent (sodium hydroxide) to make it less irritating, with two other preservatives. The first one is EDTA, which acts to bind to heavy metals, and also has antibacterial and anti fungal properties. It’s also used in a number of other applications, as a food stabilizer to cosmetics and even for lead poisoning. The other one is benzalkonium chloride, which is used in many eye drops and nasal sprays as a preservative. It also has antimicrobial properties.
Neilmed®, on the other hand, comes in dry packets which you use to make your own isotonic saline. It contains only sodium chloride and sodium bicarbonate.
If you also look at the list of ingredients for Ayr gel, it contains a lot more ingredients that you may normally see in hand lotions:
- methyl gluceth-10
- propylene glycol
- aloe barbadensis leaf juice (aloe vera gel)
- PEG/PPG-18/18 dimethicone
- sodium chloride
- xanthan gum
- glyceryl polymethacrylate
- sodium hydroxide
- poloxamer 184
- diazolidinyl urea
- glycine soja (soybean) oil
- geranium maculatum oil
- tocopheryl acetate
- blue 1.
This may explain why I personally can’t tolerate any kind of nasal saline, since it burns too much, even with added buffering agents. However, most people do well with nasal saline irrigation.
There’s also some concern about long-term use of nasal saline, but for short bursts or intermittent use, it should be safe.
The least expensive way is to make your own saline. Mix 2 cups of distilled water or boiled tap water that’s been cooled to lukewarm temperature with one teaspoon of sea salt or Kosher salt and one teaspoon of baking soda. Don’t use regular table salt, as it may contain iodine. You can recycle one of the over-the-counter bottles or containers, or even use a very large medical syringe or even a turkey basting syringe. Baby suction bulbs can also work. You can store homemade saline at room temperature for 3 days.
The bottom line is that not all saline is the same. If you walk down the aisle in the pharmacy, you’ll see many more options. Take a look at all the ingredients. Not only are the ingredients different, the way you get the salt water into your nose is also different. This ranges from squeeze bottles, to Neti-pots, and syringes, and even aerosol cans. There are even pressurized irrigation systems.
What you’re experience with nasal saline washes? Are you sensitive to various added ingredients? If you make your own, what helpful tips can you offer? Please enter your experiences and suggestions in the text box below.
Robert was clearly anxious about spending a night in a sleep lab, since he never liked sleeping in hotel rooms. He always followed a specific bedtime routine, and was concerned that he would not be able to sleep at all in the sleep lab. Due to the very high likelihood of having obstructive sleep apnea, and with a history of leg movements, I recommended an in-lab study.
An in-lab comprehensive sleep study is considered the “gold standard” for sleep apnea testing. A number of different wires are attached to your body to measure the following: brain waves, nose and mouth channels for airflow, chin and leg movements, oxygen levels, snoring microphone, and chest and stomach belts to detect movement.
Because it’s so comprehensive, it can also be somewhat intrusive. Being hooked up from head to toe (actually ankle) can prevent you from getting a good night’s sleep. Here are 7 reasons why an in-lab study is not the most ideal way of measuring your sleep quality:
1. It’s not your normal sleep environment.
It’s bad enough traveling and having to sleep in a hotel room with an unfamiliar bed and surroundings. How about adding wires to your scalp, eyes, chin, chest finger and legs? Many of you have asked me, “How can you expect me to sleep in a strange room with all those wires and with someone watching me?
The good news is that despite people’s fears, the vast majority of people are able to sleep long enough to be able to calculate a sleep apnea score, or the apnea-hypopnea index (AHI).
2. Not your normal sleep times.
No matter how well you try go to bed at a set time, it’s almost impossible to time it just right, especially if you’re in a new environment. Many patients have told me that they were expected to go to sleep much later or much earlier than their normal sleep times. This is like trying to sleep in a different time zone. Make sure you call ahead to see approximately when you’ll be able to go to sleep.
3. All wired up and tethered.
Having all those wires on your entire body can definitely make it uncomfortable for you to sleep. It can also tether you to some degree, preventing you from rolling side to side.
4. Not your normal sleep position.
Having wires attached to your body will also prevent you from sleeping in your normal sleep position. Many labs will tell you to sleep on your back. For some of you, this can be a form of torture, since you won’t be able to sleep at all on your back.
5. Not your usual pillow.
Most likely, you’ll forget to bring your favorite pillow. Many people are very particular about their pillows. It’s also important to realize that a pillow can significantly affect your head position and your airway size.
6. Stuffy nose from nasal cannula.
In-lab and home sleep studies all use a plastic nasal channel with two prongs that fit inside your nostrils. This measures nasal airflow. But in some cases, having something in your nose can create more vacuum forces that causes your nostrils to cave in more, which can keep waking you up. One exception to this situation is the Itamar WatchPAT unit, which doesn’t use a nasal cannula.
7. Overkill for most routine OSA.
For most run-of-the-mill cases of obstructive sleep apnea, a home study should be more than adequate. There are very specific situations where an in-lab study may be needed, such as in patients with neuralgic conditions, heart failure, or patients with special needs. However, for the vast majority of patients with sleep apnea, in-lab studies can be overkill.
Despite all these limitations, it’s the best that we currently have. Home testing is getting better, and there may come a time when most routine testing for sleep apnea can be handled through home testing, with the medically complicated patients reserved for in-lab studies. With better technology and perhaps with advances in smartphone features, screening for sleep apnea will definitely undergo rapid changes in the near future.
In case you’re wondering, Robert was found not to have any significant sleep apnea, but did have lots of leg movements (called periodic limb movements). Upon further questioning, he reported that he had to shake his legs and walk around just before bedtime, which was consistent with Restless Leg Syndrome (Willis-Ekbom disease). He also had low iron levels. After being given iron supplements for 3 months, his sleep quality improved.
In my next post, I will reveal the 7 Reasons Why I Don’t Like Home Sleep Studies.
If you agree of disagree with any of my 7 points, I’d like to know. Please enter your comments below.
This year, health coach and founder of Healify Your Life, Lianne Soller, has invited me to participate in the Sweet Sleep Summit. I’m incredibly excited because along with that invitation, I was offered the chance to extend to you the opportunity to watch.
If you’re looking for proven solutions for deep sleep to feel restored, awakened and refreshed every day… this is your chance!
Every day for twelve days, you’ll get exclusive access to an all expert panel as we open your mind to the possibility of a better night’s sleep and…
- Learn from scientific experts exactly WHY you are not getting enough sleep…
- Discover what happens to your body and brain when you don’t sleep properly, and the IMPORTANT benefits of a good night’s sleep…
- Learn simple strategies to help you BEAT STRESS so that you can sleep better than a baby…
- Explore natural remedies and techniques to improve your sleep and increase your energy IMMEDIATELY.
Are you going to miss this completely FREE Event?
Reserve your “seat” here.
Don’t pass this opportunity up to get insider access to some of the brightest minds in sleep and stress management today.
Thanks for all your feedback and suggestions in helping me choose the new design for my book, Sleep Interrupted: A physician reveals the #1 reason why so many of us are sick and tired. It’s just been updated on Amazon for the softcover and Kindle versions.
I’m working furiously on my forthcoming book, The Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need and the Life You Want. I plan on publishing it by the fall of 2015.
Thanks for all your encouragement and support.
Barbara was angry. She was happy to hear that she didn’t have to spend a night in a sleep lab, sleeping in a strange bed with someone watching you all night. After watching the instructional video the night she was planning to do her study at home, she attached the finger probe, chest belt and the nasal probe as directed. As she started to fall asleep, she felt that her nose was stuffy and had trouble getting to sleep. Even when she was able to fall asleep, she kept waking up. To make matters worse, the device kept beeping and telling her to check her leads. The next day, she mailed it back to the company. One week later, her sleep doctor called to tell her that there wasn’t enough data for analysis and that she would have to do the test over again.
Granted, this is an extreme example, but I do see this happening more often than it should. Fortunately, technology has improved over the years, and many of these problems have improved as well. Some companies will have you do two or three nights in a row. Other companies have computer algorithms that can tell if you enough data for a useful study.
Most home sleep studies will measure the following 3 types of information: nasal airflow, finger oxygen level, chest/abdomen movement. Other units will also have sensors that can tell your sleep position and snoring levels.
In contrast, in-lab studies also include brain wave signals (which determine sleep stages), chin muscles activity, leg muscle activity, and oral airflow thermometer. Comprehensive testing can be done at home, but not very practical, since leads tend to fall off when you move around during sleep.
Here are 7 reasons why I prefer not to use home sleep studies and the reasons why:
1. Home studies can’t tell sleep stages. You need to see specific brain wave patterns (using scalp EEG, or electroencephalogram leads) to determine sleep stages (awake, light sleep, deep sleep, and REM sleep). Oftentimes, you’ll see that apneas happen much more often during REM sleep, especially on your back.
2. Home studies don’t measure limb movements. It’s important to see how often your legs move, as this can be a sign of periodic limb movement disorder (PLMD).
3. Home studies can’t tell arousals. Since you don’t normally see brain activity, you won’t be able to see how often you wake from deep to light sleep or wake up completely.
4. More technical problems. Since there’s no technician to come in to troubleshoot, simple mechanical problems are less likely to be solved immediately.
5. Not as good with mild disease. It’s been shown that home sleep studies will underestimate sleep apnea severity by about 10 to 20%, especially if you have mild obstructive sleep apnea. One particular reason is that an in-lab study is scored manually, with periods of wakefulness being ignored when calculating total sleep time. So if you remove the time that you’re awake from your total sleep time, the total avery number of obstructive events per hour will be higher.
6. Too many false alarms. To prevent errors when recording, these units will have built-in algorithms to sound an alarm if it detects that something is wrong. Somethings, it will keep beeping too much, leading to a bad night’s sleep.
7. Can cause more obstructions and arousals. This is a problem with both in-lab and home studies. The probe that’s placed in your nose to measure airflow is like an oxygen cannula that you use to deliver oxygen in hospitals. If you have flimsy nostrils, breathing in through your nose may cause your nostrils to cave in more, causing more nasal congestion, leading to more fragmented sleep. Having a stuffy nose due to having a cold or an allergy attack is why your sleep quality goes downhill temporarily.
There are a number of different companies that make home sleep study units, but one in particular (Itamar) is very different. It uses one finger probe that measures oxygen levels and subtle blood vessel sympathetic tone changes, which has been found to correlate very well with apneas and hypopneas. It can even report sleep stages. All the different devices have additional variations, and their pros and cons, with sleep physicians having personal preferences. Although I prefer in-lab testing, I’m OK with home testing. Some insurances require home testing.
Despite all these problems, home sleep studies can be very helpful in making a sleep apnea diagnosis, especially for patients with a relatively high chance of having obstructive sleep apnea. This technology is rapidly advancing and is likely to get better and better. There are now smart phone apps being developed using sophisticated algorhithms that may be able to calculate the number of times you stop breathing. In the Apple Watch rumor mills, it’s been even speculated that the watch can not only measure heart rate, it has technology built in to potentially measure oxygen levels.
Barbara eventually was able to undergo another home test, but this time, with lots of guidance from the home testing company, she was able to do the test properly, and was found to have moderate sleep apnea. She started using an APAP machine the following week, and is now sleeping much better every night.
If you’ve undergone a home sleep test, what are some problems that you experienced? Did it give you useful results? Was it convenient, or more of a pain? Please enter your comments below.
I can’t tell you how many times patients complain to me about their in-lab sleep study experiences. The vast majority of feedback is about how terrible the night was. Once in a blue moon, I’ll have someone tell me it was the best night of sleep in years. More often than not, it’s usually because there are no children or pets around to keep waking them throughout the night.
I’ve gotten literally hundreds of different complaints, but here are the 7 top complaints that I get:
1. I didn’t sleep at all. Can they even tell whether or not I have sleep apnea? Patients state that they only slept for one or two hours. Granted, it’s less than ideal. It’s been stated that you need a minimum of 4 hours to solid data to be able to have quality data for analysis. However, If you only slept for one hour, but you stopped breathing 30 times that hour, then you have obstructive sleep apnea with an apnea-hypopnea index (AHI) of 30, regardless of how little you slept. In most cases, enough sleep time is seen, despite very fragmented sleep. Light sleep (Stage N1) can be perceived as being awake, when technically, you’re sleeping.
2. It was too cold. Different labs have different heating or cooling systems. There are standard temperature settings that all accredited labs must adhere to. However, everyone has different preferences, and the technicians should be able to accommodate requests for more blankets or to change the room temperature.
3. It was too noisy to sleep. You may think that bedrooms in sleep labs are soundproof, but they are not. Many labs are in office buildings or stand-alone facilities, so they are just as susceptible noises coming from surrounding areas. You may want to go by the site to see if there’s any construction activity next door.
4. The technician kept coming in to reattach my leads. Having so many leads attached to your body, it’s inevitable that one or more leads may fall off, especially if you toss and turn a lot. Rather than waste the entire night’s study due to a missing critical lead, it’s better for the tech to come back into the room to reattach the wire to your body. This is one of the disadvantages of a home study. If one important lead falls off, the entire night’s study can be useless.
5. The bed was too uncomfortable. Everyone has different bed preferences. Most modern sleep labs use high quality beds that are used by high-end hotels. However, some labs still use cots, like what they used to use in the early days 40 to 50 years ago. One way of avoiding this problem is to ask what type of mattress they use.
6. They had me go to sleep too early/woke me up too early. If your normal sleep time is 12 midnight, then making you go to bed at 9 PM is not a good idea. Waking you up too early can cut off critical times in REM sleep, when you’re dreaming, and most likely to have an apnea. In theory, labs should be able to accommodate for your normal bed times and routines. Ask about these issues before your appointment.
7. No body called me to schedule the sleep study/it’s been two weeks and nobody called me the the results. Different labs have different levels of service, from making the appointment to the aftercare events, including forwarding the test results to your physician in a prompt manner. In some cases, pre-authorization is needed, which may delay things even further. Don’t be afraid to call the sleep lab or your referring physician. Referrals can fall through the cracks occasionally, even with the best sleep labs.
Like with other service-oriented facilities, quality will vary. Do your due diligence by asking others that have gone the sleep lab you’re considering. Online review sites can be helpful, but take everything you read on the internet with a grain of salt. Past experiences from friends or family are probably the most helpful.
What other positive or negative experiences have you had while undergoing an in-lab sleep study? What’s your one piece of advice to a friend or family member that’s about to undergo a sleep study?
One of my main goals this year has been to publish my second book, The Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need and the Life You Want. I’ve been working on it furiously for the past year, squeezing in time here and there.
I know I told you that my book will be published by the Spring of 2105. As you can see, we’re in the middle of spring, and I’m only up to the second draft. However, the one thing that I’ve seen over and over again in my life is that when major events or projects get delayed, it happens for a good reason (in retrospect). As I repeatedly go through the manuscript, I’m constantly revising and fine-tuning my message so that I can serve you better as a trusted adviser.
With that in mind, I have set a new publishing date: Fall of 2015. With your continued support and positive feedback, I’m confident that I can get this important book to you by this fall. You have been my most important teachers, more so than any textbook or medical journal.
In the meantime, please comment on my blogs, listen to my podcasts and let me know what resonates with you. The more encouragement I get from you, the more likely I’ll have a quality book that will be able help you get the sleep you need and the life you want.
Thanks for all your support. I won’t let you down.
In this episode, My special guest is Dr. Mark Cruz, who is a dentist in private practice in Dana Point, CA, close to Laguna Beach. He has spent over 10 years educating dentists and doing research at UCLA and is now on the data safety monitoring board of the NIH’s institute for craniofacial research, the dental arm of the NIH. He has collaborated with many sleep luminaries including Dr. Christian Guilleminault, and Dr. David Gozal.
In this interview, we’ll discuss
What’s the role of the dentist and dentistry as a profession in airway related health?
Is the airway wellness concept new for dentistry?
Who are the key team members that are needed for airway health?
How can someone find an airway focused dentist or orthodontist in his or her community?
and so much more.
Dr. Mark Cruz, DDS
Dental Airway Mini-Residency
If you enjoyed this podcast, please go to doctorstevenpark.com/itunes to subscribe, rate this podcast, and leave comments on iTunes. Through your comments and ratings, you can help more people find these podcasts.
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