My husband snores. Do you provide oral appliances?
Oral appliance therapy to treat snoring and obstructive sleep apnea should be provided by an experienced dentist. Dr. Williams is a member of the American Academy of Dental Sleep Medicine. However, prior to beginning treatment, an overnight sleep study (polysomnogram) should be performed by a certified sleep medical doctor to objectively identify the problem and its severity. Following this, we can work closely with the physician to treat the problem in the most effective way. We can arrange an overnight polysomnogram or it can be arranged through your family doctor.
When is an oral appliance indicated for sleep apnea patients?
There are many types of oral appliances, with some designed only to treat snoring and others for both snoring and sleep apnea therapy. The new practice parameters recommended by the American Academy of Sleep Medicine indicate that patients with mild to moderate OSA can use an oral appliance when they prefer it to CPAP, which is the most effective treatment for sleep apnea. An oral appliance should also be considered by patients who are unable to successfully use CPAP or who fail surgical intervention. Patients with severe cases of OSA may also benefit from an oral appliance when either CPAP or surgery is unsuccessful.
Are oral appliances effective? Where can I obtain studies demonstrating their effectiveness?
Oral appliances were first utilized in the 1930's to help people breathe properly during sleep. By the 1980's, physicians and dentists began to seriously study the effectiveness of oral appliances to treat snoring and obstructive sleep apnea and found them to be effective in many, but not all cases. Recent studies show oral appliances to be most effective in treating snoring and mild to moderate obstructive sleep apnea. However, some appliances have been shown to effectively treat severe apnea in some cases. While oral appliances are often effective, it is important to know that they are not adequate for everyone and to date, it is not possible to predict the successes from the failures prior to treatment.
I was diagnosed with sleep apnea. How do I know if I have mild, moderate or severe apnea?
The best way to diagnose sleep apnea is with an overnight sleep study. Depending on the physician's preference, this study can be performed in the hospital or at home. It will objectively measure many parameters throughout the night that will aid the physician in determining the severity of the problem. Some of the important measurements include: how often breathing is interrupted; the quality of sleep; the oxygen level in the blood; the heart rate; and excessive bodily movements. The severity of the sleep apnea is determined by the assessment of these parameters and should be thoroughly discussed with you by your physician. Properly trained dentists work closely with physicians and understand the details of the sleep study and they affect the therapy.
What does RDI stand for?
The term RDI stands for Respiratory Disturbance Index and is one very important measure of the severity of the sleep disorder. The RDI is a number that represents how many times per hour breathing stops or becomes very shallow. This index is important because it is often associated with disruption of sleep and dangerous drops in blood oxygen levels. Most physicians agree that an RDI below 10 is normal while an RDI over 40 may indicate severe disease.
What's the difference between snoring and obstructive sleep apnea?
The term Sleep Disordered Breathing describes a number of sleep breathing disorders that includes snoring, upper airway resistance syndrome and obstructive sleep apnea. Sleep Disordered Breathing is viewed as a continuum where simple snoring represents a mild disorder during which breathing during sleep is very loud due to the near collapse of the upper airway. When the snoring becomes worse due to further airway collapse (to the point where sleep is interrupted) the term upper airway resistance syndrome is used. Most serious is the complete collapse of the airway that is termed obstructive sleep apnea. During an apnea, breathing cannot occur and the sleeper is forced to awaken to resume normal breathing.
How does oral appliance therapy compare with CPAP. Are there studies that explain this?
When it became apparent that Oral Appliance Therapy was legitimate and desirable part of the treatment mix, questions naturally arose regarding its comparative effectiveness with positive airway pressure modalities. Recently, four studies have focused on Oral Appliance Therapy going head to head with nasal CPAP. Three of them used a cross-over design and the fourth a parallel group design. All of the investigations were randomized, controlled treatment trials. Each of the studies focused on effectiveness as a product of the treatment efficacy in combination with acceptance and adherence to treatment. Treatment efficacy was similar in all the trials and did not deviate significantly from past investigations. It was shown that Oral Appliance Therapy often, but not always decreased the apnea-hypopnea index whereas CPAP nearly always resolved sleep-disordered breathing entirely. Acceptance and adherence to treatment with CPAP were limited while that of Oral Appliance Therapy was less so resulting in the proportion of successfully treated patients being about the same in each study. In all three cross-over trials where patients were asked to choose a preferred treatment, the majority chose oral appliance therapy.
Bibliography: 1. Ferguson, KA,Ono T, Lowe AA, et al. A randomized cross-over study of an oral appliance vs nasal CPAP in the treatment of mild-moderate OSA Chest 1996; 190: 1269-1275 2. Ferguson KA, Ono T, Lowe AA, et al. A short-term controlled trial of an adjustable oral appliance for the treatment of mild-moderate OSA. Thorax 1997; 52:326-368 3. Clark GT, Blumenfeld I, Yoffe N, et al. A cross-over study comparing the efficacy of CPAP with anteriorly mandibular positioning devices on patients with OSA. Chest 1996; 109:1477-1483 4. Lowe AA, Sjoholm TT, Ryan CF, et al. Treatment, airway and compliance effects of a titratable oral appliance. Sleep (in press)
Will my appliance be covered by medical insurance? Will Medicare cover my appliance?
Oral appliances are sometimes covered by insurance. They are often not covered by commercial insurance carriers, HMO's and Medicare for a variety of reasons including lack of knowledge and understanding by insurance companies of the recent advances in oral appliance therapy in the treatment of sleep apnea; snoring (only) is not a recognized medical condition by the medical field; and lack of CPT or medical reimbursement code for oral appliance therapy.
What is the price range for oral appliances?
There are presently over 40 different oral appliances available. Fees are determined by the individual dentist and differ according to the cost of the appliance itself along with the time and skill necessary to achieve a long-term therapeutic end result. Patients are cautioned to understand that effective therapy rendered by a properly trained dentist using a durable, adjustable appliance will not fall into the inexpensive end of the fee scale.
Is there an insurance code for my appliance?
To date, there is no formal CPT or medical reimbursement code for oral appliances. However, some insurance companies have codes that may be utilized to attain benefits. These codes vary from company to company and require personal communications from the dentist to find these codes that may be of value.
Dr. Brad Williams is a member of the American Academy of Dental Sleep Medicine.