FAQs for Sleep Apnea
- What is OAT, Oral Appliance Therapy?
- What Causes Snoring?
- Is it possible that I snore and don’t have apnea?
- Is it possible that I have apnea even though I don’t snore?
- My sleep physician and PCP never even mentioned Oral Appliance Therapy (OAT) as a treatment choice, why is that?
- I have asked my physician about oral appliances for sleep apnea, she has said that they have not been very effective for significant sleep apnea. What’s the general consensus?
- Are there patients for whom Oral Appliance Therapy does not work?
- Does Dr. Bobbitt have patients who have failed to be treated by OAT?
- Do I need to see my PCP first?
- How do I start the OAT process?
- Do I need to be a DENTAL patient of Dr. Bobbitt?
- Does my insurance cover OAT?
- Does Medicare cover OAT?
- How many appointments will it take to complete OAT?
- How will I know if my appliance is working?
- What are the side effects of OAT?
Sleep Apnea Answers
What is OAT, Oral Appliance Therapy?
OAT is a therapy that treats snoring and Obstructive Sleep Apnea using a dental appliance that opens the airway during sleep. This opening is accomplished by a variety of means in which the lower jaw is protruded in much that same way that jaw is manipulated into position in Rescue Breathing for CPR (Cardio-Pulmonary Resuscitation).
What Causes Snoring?
Snoring occurs when the soft tissue structures of the upper airway collapse onto themselves and vibrate against each other as we attempt to move air through them—much like the noise a straw makes when you try to draw the last drop of a thick milkshake through it. This produces the sound we know as snoring. Large tonsils, a long soft palate, a large tongue, the uvula, and excess fat deposits in the throat all contribute to airway narrowing and snoring. Usually, the more narrow the airway space, the louder or more habitual the snoring.
Is it possible that I snore and don’t have apnea?
Yes. Sleep disordered breathing is a full spectrum of breathing disorders. After normal breathing, there are two classes of “primary” snorers. The first, Non-Sleepy Snorers, snore but do not suffer any ill-effects health wise. The second group, Sleepy Snorers, suffer fatigue and/or excessive daytime sleepiness without the cardiovascular damage caused by apnea.
Is it possible that I have apnea even though I don’t snore?
Yes. That is the reason why a late night TV infomercial or dentist who merely dispenses a “snoring appliance” without follow-up and testing is doing a potentially dangerous and life-threatening disservice to the snoring patient. Recent studies have confirmed that up to 25% of patients that have successfully stopped snoring using an oral appliance still experience obstructive apnea events at dangerous levels. Follow-up testing and adjustments are mandatory in order to achieve long-term success and to decrease the health risks and excessive daytime sleepiness that accompany Obstructive Sleep Apnea.
My sleep physician and PCP never even mentioned Oral Appliance Therapy (OAT) as a treatment choice, why is that?
The average Medical School in the United States spends approximately 4 hours on average teaching their future graduates about sleep—the one part of the human existence that takes up (or should take up) a full third of our life. There isn’t enough time in a 4-year medical curriculum to cover everything in depth—that’s why residencies, specialty training and continuing education exist.
If you did broach the subject of an oral appliance with your physician, did he/she merely pass it off? Was there a consideration that surgical options are laden with risks (and only 40% effective) or that you’re not sleeping anyway because you can’t use the CPAP? The CPAP is, will be, and always has been the “gold standard” in sleep medicine because it works 100% of the time–but only in 25% or so of the population that needs it–so it is hardly “gold standard-worthy” in the eyes of many. If one can’t use a CPAP and surgical procedures don’t work–what other choice does one have?
I have asked my physician about oral appliances for sleep apnea, she has said that they have not been very effective for significant sleep apnea. What’s the general consensus?
It’s unusual in 2011–nine years after the American Academy of Sleep Medicine granted acceptance to oral appliance therapy for OSA treatment, especially in cases where the CPAP is not tolerated–for your doctor to report that oral appliances don’t work for significant apnea. It’s all I’ve ever used to treat my own moderate apnea and I can’t begin to tell you how many patients the dental community has helped over the past 25 years or so. In fact, I’ve never even tried a CPAP! The majority of my patients have confirmed what my studies revealed to me: that up to half of all apnea sufferers can’t tolerate a CPAP. To add to the dilemma, half of all those who can tolerate it, can’t where it all night!
The rest of my patients are post-surgical patients (only 40% or so of surgical procedures are effective) that still can’t breathe at night, or those can’t put up with the hassles, stigma (that was my concern), or claustrophobia that accompanies the wear of a CPAP in bed every night. For me, it was something about being 44 years old and being tied to the output end of a vacuum cleaner motor that didn’t sit well; in addition to being the son of an apnea sufferer who had a miserable experience with a UPPP surgery in 1985 (my father) that made me well aware of the hassles of treating apnea.
Are there patients for whom Oral Appliance Therapy does not work?
Oral appliance therapy (OAT) is not 100% effective–especially in those patients who have severe sleep apnea, but the results in my practice don’t support a total disregard of the therapeutic option. My most severe and successfully treated patient had an RDI (Respiratory Disturbance Index–a rough correlation of the number of times one stops breathing or breathing is interrupted each hour) of 60.
Does Dr. Bobbitt have patients who have failed to be treated by OAT?
Since 2006, I’ve had 3 (three) patients who were not substantially relieved of their apnea symptoms with an appliance. One had TMJ (jaw joint) problems that were severe before she started OAT and couldn’t handle the protrusion of the lower jaw. The second started with an RDI of 80–you read it right: she obstructs and stops breathing 80 (eight-zero!) times each hour–and can’t tolerate a CPAP because she lives in a part of NH where the power keeps going out at her house. No power, no CPAP, no oxygen, no sleep. Plus, she travels and has all the accompanying problems with the TSA at the airport. At home, she will occasionally use both an oral appliance and her CPAP–just in case the power goes out, because nothing works 100% for her.
I have had several patients who have been incompletely treated, who have resorted to combining or alternating treatment with a CPAP. The benefit of combination therapy is that the Oral Appliance creates enough of an airway that the CPAP setting can be substantially minimized. One patient dropped his CPAP setting from 14 to 3 by the addition of an Oral Appliance.
Do I need to see my PCP first?
The diagnosis of primary snoring or OSA (obstructive sleep apnea) is made by a Sleep Medicine Physician after reviewing an overnight diagnostic sleep study. Once a diagnosis is established, the patient will review the recommendations for treatment with their PCP in consultation with the Sleep Physician. If an Oral Appliance is deemed appropriate, the PCP can refer the patient to me for therapy.
How do I start the OAT process?
Once the diagnosis is confirmed, the patient can contact Dr. Bobbitt’s office to initiate therapy. Dr. Bobbitt’s office will send the patient an introductory package that will inform het patient about the office, about the process of OAT and provide a set of sleep related questionnaires to be completed. Your first appointment with Dr. Bobbitt will include a detailed consultation and oral evaluation to determine suitability for OAT.
Do I need to be a DENTAL patient of Dr. Bobbitt?
No. Not every general dentist treats patients with Obstructive Sleep Apnea. Dr. Bobbitt sees patients from many dental offices in New Hampshire and Massachusetts. He is happy to provide your dentist of record with copies of all correspondence sent to your PCP and may make recommendations for dental work that may be necessary to support an Oral Appliance.
Does my insurance cover OAT?
Yes, most of them anyway! I can’t speak for the particulars of any given plan as they are chosen by the one who purchased the plan (e.g. if you don’t buy comprehensive insurance on your car, you may be covered if in an accident, but won’t get coverage if a tree falls on your car.) My office has worked with dozens of different plans and found few, if any, that won’t pay a portion of therapy—especially in the event of a patient who has documented intolerance for the CPAP.
Does Medicare cover OAT?
Medicare has recently (2008) accepted OAT as an acceptable and reimbursable therapeutic option for patients who suffer from OSA. However, it is especially difficult because they act as a secondary to so many companies. In addition, Medicare deals primarily with physicians, not dentists. My office is a non-participating provider for Medicare, so co-pays apply, are generally paid by secondary/Gap insurance plans or by the patient as an out-of-pocket expense.
How many appointments will it take to complete OAT?
OAT is a course of therapy, not an appliance. There are multiple appointments necessary to assure fit and function of the appropriate appliance chosen for the patient’s specific needs, to titrate the appliance to the proper setting and to evaluate progress.
How will I know if my appliance is working?
The initial goals of OAT are a substantial (70%) reduction in snoring and comfort of the TMJs (“jaw joints”). Your bed partner will notice less noise and, hopefully, fewer gasping apneic events. You will begin to have more energy, to feel more rested in the morning and to have a clearer mind. The myriad of medical issues that are caused by sleep apnea will slowly start to improve. For example, mood my improve, depression may decrease, blood pressure will begin to fall and you will notice fewer headaches in the morning.
What are the side effects of OAT?
There are few permanent side effects, but several temporary ones. The most common long-term side effect is a change in the bite. Though minor, and often not a functional problem, it can be annoying. The most common complaint is that the teeth shift slightly and create a spot for food to impact or get stuck between.
Another common side effect is jaw discomfort in the morning. Similar to the stiffness one might experience in the knees/hips when trying to stand up after a long movie, the jaw is not permitted to return to its fully seated position in the socket. Some muscle stiffness is common in the morning. Most patients report that the symptoms dissipate within an hour or so. Because of my long history of TMJ (“Jaw joint”) problems, my jaw is unsettled and “stiff” until well after noon each day-sometimes even later. I decided that it was a small price to pay for being able to sleep soundly and silently all night long and to minimize the health risks of my apnea.
Other minor considerations include dryness of the lips and mouth, irritation of the cheeks/gums, and, though exceedingly rare, allergic reaction to the materials in the appliance.