Our Sleep Apnea Blog | I Hate CPAP

An article, Sleep and headache: a bidirectional relationship" in Expert Rev Neurother. 2010 Jan;10(1):105-17 discusses the connections between sleep and headache. The perception of both is similar and controllled by the Thalamus, Hypothalamus and Brainstem. The evidence, according to the article is "there is clinical evidence indicating that sleep disorders can precede the appearance of certain headaches and that head pain" this is well known among patients with slep apnea who frequently have morning headaches. A common cause of headache pain is TMJ disorders or non-physiologic neuromuscular function of the jaw, jaw joints (TMJ), jaw muscles and trigeminal nervous system. The study also stated that "that head pain, especially when frequent, can, in turn, affect sleep quality".

It turns out that the two primary causes of morning headaches are TMJ disorders and Sleep Apnea. The NHLBI actually considers sleep apnea to be a TMJ disorder. The report "Cardiovascular and Sleep Related Cosequences of Temporomandibular Disorders" explains the connections in detail at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf.

The authors hope to " In the present work the anatomy, physiology and pathology of sleep and head-pain perception will be reviewed with the aim of highlighting the points of contact and possible unifying treatment strategies." This is exactly what is done both by the NHLBI and on this website. Sleep and Headache are connected by the neuromuscular function of the masticatory system and the trigeminal nervous system.

Labels: headaches, morning headaches, related, sleep apnea Thalamus

comments : I am 25 years old and am suffering from headaches. I have had a headache every second of every day for the past 11 months. I saw a neurosurgeon who diagnosed me with a small Chiari Malformation that was constricting the flow of my spinal fluid. He performed a decompression surgery with the hope that my headaches would be relieved. It has been almost 8 months since the surgery, and I have found no relief. He prescribed me a couple of different narcotics, but I experienced no pain relief.He had me make an appointment with a headache specialist whom I will not be able to see for another month. I have, however, been seeing a Nurse Practitioner in the neurologist's office who has placed me on several tryptan medications (I have tried four so far). I was placed on Topamax, but it had no effect, and I developed kidney stones (a known side effect). She also had me take muscle relaxers for a month to see if they would have an effect on the pain, but they did not. I am curre
ntly on Keppra (500 mg a day). I have only been on it two weeks, and the severity of my headaches has increased. I have ocular symptoms as well, shadows and spots in my field of vision, which an opthamalogist believes are a result of the headache. Since I was 11 years old, I have had difficulties with my left temporomandibular joint. I have pain if I open my mouth to far, as well as the common popping and scraping soulnds. My jaw has become increasingly stiff over the past several months. The constant pain is wearing me down and making it difficult to concentrate in school as well as perform my job at a daycare due to my sensitivity to sound. I do not know if there is any type of advice or information you can offer me, but I would appreciate your consideration. HEATHER

Dear Heather
While they found the Chiari malformation because they investigated your headache symptoms that does not mean that it was the cause of your pain initially. It is relatively common to have an assymptomatic Chiari malformation. Because that did not help your headache pain it probably was not the cause of the pain but rather a accidental finding. The malformation was not new, only the severity of the pain was new.

The majority of headaches are related to problems or disturbances of the trigeminal nervous system. With your history of jaw problems and I would tell you to consider trying a DIAGNOSTIC Neuromuscular Orthotic. It is rare for patients not to have significant relief from an orthotic. That does not mean 100% relief. I tell my patients that we initially seek 50-80% relief and then seek 50-80% reduction in residual pain. I frequently get out of town patients who come to Chicago but I will be glad to work with your Neuromuscular Dentist to help you through this difficult time. Frequently trigger point injections and or SPG nerve blocks can be helpful in treating pain problems similar to yours.

I am leaving the country for the next couple of weeks but please feel free to contact me again.

Amiable brief and this mail helped me alot in my college assignement. Say thank you you on your information.

On a lighter note, we at IHateCPAP.com thought it'd be fun to lighten the mood a bit and share with our blog readers a different type of post today. We often provide very technical information about sleep apnea, its causes and its treatment, but today we're taking a break from the norm.

Some of you may find it reassuring to know that some of the most famous and gifted people in the world suffer (or suffered) with the same condition as you: sleep apnea.

For instance, Johannes Brahms, a great classical German composer of the nineteenth century suffered with obstructive sleep apnea most of his life, according to a study done a few years ago.

Jerry Garcia, an American musician best known for his work with the band The Grateful Dead, suffered with sleep apnea, which, it is alleged, contributed to his death of a heart attack in 1995, while he was in a drug rehab facility in California. Garcia had struggled for a long time with his weight, diabetes, and drug addiction, but it's a little known fact that he also had sleep apnea.

For you vampire lovers out there, author Anne Rice also suffered with sleep apnea. Rice gained a lot of weight after the death of her husband, and sleep apnea was a condition that accompanied her weight gain. She is best known for her work, Interview with the Vampire, later adapted for the big screen starring Tom Cruise and Brad Pitt.

Cool Hand Luke fans surely know George Kennedy, the actor who played Dragline; Kennedy won an Oscar for this role. Later in his career, Kennedy starred in the Airport series of plane disaster films and the in the Naked Gun series of movies as Captain Ed Hocken. Kennedy had sleep apnea much of his adult life.

NFL hall of famer, Reggie White, who held the record for quarterback sacks for a while died in 2004 of massive heart attack brought on by sleep apnea. He was only 43.

With so many treatments available now for sleep apnea, you need not suffer with this potentially life-threatening condition any longer. If you live in or around the Chicago, Gurnee, Illinois area, please contact sleep apnea specialist, Dr. Ira Shapira today to schedule a consultation.

A study from Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston showed that "Trigeminal nerve fibers in nasal and oral cavities are sensitive to various environmental hazardous stimuli, which trigger many neurotoxic problems such as chronic migraine headache and trigeminal irritated disorders" This study supports the use of Neuromuscular dentistry to decrease nociceptive input from the stomatognathic system into the trigeminal nerve. This should raise the threshold for environmental triggers to set of migraines.

The study by Wu J, Zhang X, Nauta HJ, Lin Q, Li J, Fang L appeared in Biochem Biophys Res Commun. 2008 Nov 28;376(4):781-6. The authors state that "the role of JNK kinase cascade and its epigenetic modulation of histone remodeling in trigeminal ganglion (TG) neurons activated by environmental neurotoxins remains unknown." While they do not understand all of the chemical pathways the fact that they exist and are stimulated in the sinus and innervated by the trigeminal nerve support neuromuscular dental treatment to prevent migraine.

Another study from the Department of Ophthalmology, University of Washington, Seattle, Washington, USA concluded that "Sympathetic nerves enter the orbit via the first and second divisions of the trigeminal nerve and a plexus of nerves surrounding the ophthalmic artery." This would support neuromuscular control thru the trigeminal nerve of opthalmic signs and symptoms being trigeminally innervated and therefore like to respond to removal of noxioux input from the masticatory system. There is now a rational for using neuromuscular dentistry to relieve and prevent opthalmic migranes.

The authors state " Sympathetics innervate ocular structures via the posterior ciliary nerves. Sympathetic axons travel anteriorly in the orbit via the nasociliary and lacrimal nerves to innervate the sympathetic eyelid muscles. Sympathetic nerves also travel with the frontal branch of the ophthalmic nerve to innervate the forehead skin. The ophthalmic artery and all of its branches contain a perivascular sympathetic nerve supply that may be involved in regulation of blood flow to ocular and orbital structures." This again supports migraine and opthalmic symptoms being mediated by the trigeminal nerve. Neuromuscular dentistry attempts to reduce the noxious input to prevent neural input from reaching a threshold that causes pain and other symptoms.

The above study, "Human orbital sympathetic nerve pathways" was published in Ophthal Plast Reconstr Surg. 2008 Sep-Oct;24(5):360-6 by Thakker MM, Huang J, Possin DE, Ahmadi AJ, Mudumbai R, Orcutt JC, Tarbet KJ, Sires BS

Labels: migraine trigger, opthalmic migraine, smells, Trigeminal nerver

Originally published in the British Medical Journal was an article that learning to play the Didgeridoo reduced both snoring and sleep apnea. It turns out that the circular breathing technique acts as a pharyngeal exercise. Circular breathing is difficult to learn. It allows a Didgeridoo player to play for long periods (20 minutes or more) without stopping to take a breath. The mouth and cheeks are used as a reservoir to blow out thr the mouth playing the Didgeridoo while breathing in thru the nose to fill the lungs

It is fun though while I could do the breathing I don't think I had enough musical ability to call the sounds I produce music. When played while it does have a rather cool sound

Dry mouth is a frequent complaint from patients with sleep apnea that is untreated, treated with oral appliances or CPAP. There is a prescription product called Gelclaire that is an oral sodium hyaluronate topical gel that is supplied in small packets that are meant to be diluted with water to form a rinse for treating oral mucositis or mouth sores associated with chemotherapy and/or readiation treatments. For dry mouth the oral form is excellent when used full strength to cover all intraoral surfaces of the mouth. I also have had CPAP patients report using it on nasal membranes as well. Used full strength each packet can be spread out over several nights to reduce costs.

This is an off label use of the product but has been fantastic for many patients suffering from dry mouth problems. The only complaints I have had is that it is relatively expensive but worth the cost. The second complaint is that it has a mild black licorice or anise flavor.

The following is a copy of a press release about the Pure Sleep Appliance. The appliance works in a similar manner to appliances discussed on this site. There are problems when the pure sleep appliance is used to treat sleep apnea. It may be as good or better than any other over the counter appliance or device for snoring. The pure sleep appliance is heavily advertised on Television for treating snoring. Beware it is a treatment for snoring not sleep apnea. Www.ihatecpap.com offers cpap alternatives for treating sleep apnea.

Snoring is often portrayed as a comic problem and is great material for the writers of sitcoms. It is also a warning sign of obstructive sleep apnea a life threatening disorder that increases the risks for heart attacks and strokes 600%. An eight year study showed a 36% decrease in eight year survival in patients with untreated sleep apnea. New studies have shown that heavy snoring alone drastically increases the risks for carotid atherosclerosis. The carotid proves blood to the brain and can lead to strokes. Sleep apnea is diagnosed with polysomnography and the gold standard of treatment is CPAP or continuous positive air pressure. CPAP is basically a small compressor that blows air thru a hose and a mask that presents airway collapse while the patient sleeps. The good news is that CPAP is extremely successful in treating sleep apnea and is considered the gold standard when treating sleep apnea. The bad news is that one half to two thirds of all patients prescribed CPAP do not actually use it on a regular basis. The American Academy of Sleep Medicine in 2006 declared that oral appliances were a first line of treatment for mild to moderate sleep apnea equal to CPAP and an alternative treatment for severe sleep apnea when patients do not tolerate CPAP. Studies have shown that most patients who are given a choice prefer oral appliances to CPAP. Patients wishing to learn more about dental sleep medicine and oral appliances should go to http://www.ihatecpap.com for information about the dangers of sleep apnea and treatment with oral appliances.

Pure Sleep is advertising on television commercials that it is FDA approved for treating simple snoring and that it works the same as oral sleep apnea treatment appliances. Research in dental sleep medicine has shown that oral appliances are very effective in treating snoring and sleep apnea. Pure sleep is not designed for treating sleep apnea but for simple snoring. A quick search on the internet will find stories of patients discontinuing use of CPAP in favor of the pure sleep appliance without medical consultation with their sleep physicians. This may effect both the patients health as well as public welfare. Some patients who quit snoring become silent apneics who are at greatly increased risk of heart attacks and stroke. These patients also have a 600% increase in motor vehicle accidents an have slower reaction times than people who are legally drunk and are definitely a dangerous when behind the wheel. Drowsy driving is considered to be a bigger problem than drunk driving. A study presented at the Thoracic Society meeting showed a 300% increase in motor vehicle accidents in patients with mild apnea and no symptoms of sleepiness.

Does the Pure Sleep appliance work? It probably will be very effective for many patients with simple snoring but should never be used to replace CPAP treatment without follow-up sleep tests. It will probably produce TMJ problems for many patients. The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances have special training in treating TMJ disorders. Patient with additional risk factors should absolutely have medical consultation prior to using a pure sleep appliance. A partial listing of medical conditions that my suggest sleep apnea include: Hypertension (high blood pressure), diabetes, fibromyalgia, gastric reflex, coronary artery disease, heart disease, lung disease, Memory problems, thyroid problems, daytime sleepiness, morning headache, and TMJ disorders including headache, earache, joint clicking or popping, eye pain, sinus pain and neck pain.

The public is already familiar with the warnings and caveats when prescription drugs are advertised in the media whether it is print, radio or television. Perhaps the FDA should require similar warnings to be placed in the marketing of the Pure Sleep Appliance. The FDA should examine whether strict disclaimers should be part of the advertising when the sleep physician is not involved in patient treatment.

The warning could state that snoring is often a sign of sleep apnea that is a severe life threatening disorder. Similar warnings to commonly associated disease and conditions could be listed as well as dangers of not being properly treated. Untreated sleep apnea is a greater to risk to public health and safety health than cigarette smoking. Unlike smoking the Pure Sleep Appliance is a positive development if used properly, the danger is if it used improperly in which case it is not only a danger to the user but also to the public. We have learned from our current economic crisis how lack of regulation can cause significant problems.

The real question is, if a patient with sleep apnea uses a pure sleep appliance that quiets the snoring but does not treat their sleep apnea and an innocent child is then killed in a motor vehicle accident who is responsible. The FDA for approving the appliance without insisting on appropriate warnings, the patient who used the appliance without realizing the risks or the company who supplies the appliance to the public. The paperwork explains to the patient that the appliance is for treating snoring and not for treating sleep apnea. How does the patient know if they have sleep apnea or just snoring. There are several pages of instructions that are designed to let the company claim that patients were informed that the appliance is only meant for simple snoring but research has shown that these type of warnings are rarely read or heeded by the public. Patients can assume if they are not having symptoms of tiredness that they do not have apnea. This is a dangerous assumption. A recent study presented to the American Thoracic Society showed a 300% increase in motor vehicle accidents involving serious physical injury in patients with mild sleep apnea and no symptoms of excessive daytime sleepiness.

Heavy snoring is also no longer considered just a cosmetic problem. A study in Sleep (Sept 2008) showed a large increase in carotid atherosclerosis in heavy snorers that could increase the risk of strokes up to ten fold. This snoring is a medical disorder that the FDA has decided can be treated by use of an over the counter appliance without follow-up. I wonder if the FDA considers this an acceptable increase in risk. Hopefully the Pure Sleep appliance helps patient with simple snoring but I am worried by how many lives could be lost when it is used inappropriately. For many years the FDA did not allow the sale of this type of device on the internet. Research must have convinced the FDA that this was an acceptable method of treatment.

I am not going to answer these questions, but they are questions that need to be addressed on a medical basis by the patient and their health care providers as well as by those who insure the safety of the roads. Oral appliances are definitely a comfortable alternative to CPAP in patients with mild to moderate apnea and an alternative for patients with severe apnea who do not tolerate CPAP. Learn more about dental sleep medicine at http://www.ihatecpap.com

To learn more about the dangers of Sleep Apnea and the treatment alternatives you can use the following resources:

http://www.sleepapnea.org/awake/index.html
http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2417141/k.27D9/Ho ... a_Poll.htm
http://www.sleepandhealth.com
http://www.ihatecpap.com/sleep_apnea_dangers.htm

Maxillomandibular surgery is an important option for some patients with severe sleep apnea who are also CPAP intolerant. Other surgeries used to treat slep apnea include UP3 or Uvulolopalatopharyngealplasty which has a very high morbidity rate and less that 50% of patients had a 50% reduction in apnea indexes and almost all patients still required either CPAP or oral appliances to treat residual apnea. Long term problems include multiple ear symptoms, swallowing problems, voice changes and velo-insufficiency with food and liquids entering nasal cavity. UP3 surgery has lost favor as a first line treatment. Alternatives to UP3 with lower morbidity were tried including LAUP or laser assisted uvuloplasty, often described as feeling like a blow torch was used in the throat and somnoplasty which is probably the most comfortable way to reduce the soft palate but requires several repeat surgeries and does not eliminate sleep apnea leaving patients still needing CPAP, Appliances or additional surgery. Pillar surgery involves placing stents in the soft palate and while it is relatively painless it is also useless for treating moderate to severe apnea but might be helpful for very mild apnea and/or simple snoring.

A newer soft palate surgical procedure involves using a sliding flap to advance the soft palate. The advantage to this surgery is that it is reversible. The biggest problem with soft palate surgeries is they increase the risk of velo-insufficiency following maxillary advancement. Because maxillary and mandibular advancement is the most effective surgical proceedure having a reversible soft palate surgery is vital. Tracheotomy is actually the single most effective surgery but is not accepted by most patients except in an emergency context. A tracheotomy lets the patient bypass the base of the tongue and breathe thru the throat. The base of the tongue and the epiglottis secondary to base of tongue pressure is the location of the majority of obstructive events. Surgery to reduce the tongue size or position include removing an anterior wedge from the tongue and letting the tongue posture forward, a median rhomboid glossectomy which removes a rhomboid shaped area from the center of the tongue. It is a challenging surgery and the physicians I have talked to have never done it more than once. I have never talked to who has had that proceedure. There are two prcoeedrures for reducing the Base of the tongue the radiofrequency or somnoplasty procedure has been shown to be as effective as the base of tongue surgery and is much easier on the patient. A paper comparing the procedures recommended that radiofrequency was preferred in spite of multiple procedures. Base of tongue reduction by either method may not cure apnea alone but will allow lower CPAP pressure and/or less advancement of the mandible for appliances therapy. It will have a positive effect relative to maxillomandibular surgery as well.

A less aggressive surgery than full maxillomandibular advancement is a genioglossus advancement. This involves cutting the chin loose from the lower jaw and bringing it forward and bolting it in place. I like to call this the "Jay Leno" surgery because everyone has the Jay Leno look after surgery. This is a good surgery for a patient with a weak or recessive chin but normal bite who would like to avoid more radical surgery. In these patients it can also be done in conjuction with maxillomandibular surgery.

Maxillomandibular advancement consists of cutting the upper jaw or maxilla loose from the skull and usually moving it downward and forward. In narrow maillas the surgeon may also cut the upper jaw into sections and then rearange the parts and either wire or bolt the bones together with titanium plates. The lower jaw is then cut into three pieces and the middle part is advanced and the parts are again either wired together or bolted with titanium screws and plates. The patient usually has the mouth wired shut for up to six weeks.

This is an extremely effective procedure and in some patients can be a cosmetic enhancement while in others it results in protrusive profile that is not acceptable. At this time I would say "let the buyer beware" This is a serious surgery and needs to be approached with caution and deliberation. I love the quote "THERE IS NO DISEASE OR DISORDER THAT CANNOT BE MADE WORSE BY STICKING A KNIFE IN IT." and I wish I knew who first said it. It does not mean you should not do surgery but rather take a cautious and informed approach to any surgery and ask about possible problems associated with the surgery.

In the case of Maxillomandibular surgery for treating sleep apnea I strongly recommend that maximum advancement with oral appliances be done before any surgery. The TAP 1 is probably the most effective appliance at achieving this position. Utilize a daytime appliance to eliminate pain or discomfort from trying to return to the original bite. If apnea is eliminated with the appliance the surgeon now has a surgical guide to determine where to reassemble the patient after cutting the jaws into multiple pieces to get the best results. This is major surgery an patients do not want to need to Need CPAP, Appliances or additional surgey to treat their apnea after going though this extensive surgery.

An article in the Journal of Otolaryngologic Head and Neck Surgery in November of 2009 reported on "Complications/adverse effects of maxillomandibular advancement for the treatment of OSA in regard to outcome" (abstract below) They reported adverse advents as well as cosmetic changes but state the patients considered these secondary to the surgical outcome. The most common side effect was mental nerve damage. This would feel like a numb (paraesthesia) lower lip to the patient similar to the feeling of having anasthetic for a filling on the lower jaw. It is also possible to have tongue paraesthesia.

The results were very good with the "mean apnea-hypopnea index decreased from 65.5 +/- 26.7 per hour to 14.4 +/- 14.5 per hour. In simple English this means that patients began with apnea-hypopnea indexes of as high as 92 to as low as 38 and after surgery the AHI was reduced to 28 to Zero. The patients with apnea indexes in the upper ranges would still need CPAP but some of the 50 patients had a complete cure. This is an excellent and effective surgical option that carries risks of adverse events and cosmetic changes. It is possible to effectiveness by oral appliance advancement as a trial to evaluate the best position to reassemble the patient.

PubMed abstract:
Otolaryngol Head Neck Surg. 2009 Nov;141(5):591-7.
Complications/adverse effects of maxillomandibular advancement for the treatment of OSA in regard to outcome.
Blumen MB, Buchet I, Meulien P, Hausser Hauw C, Neveu H, Chabolle F.

ENT Head and Neck Surgery, Foch Hospital, Suresnes, France. mbjblu@club-internet.fr
OBJECTIVE: To evaluate adverse effects/postoperative complications and surgical response rate of maxillomandibular advancement for the treatment of severe obstructive sleep apnea syndrome. STUDY DESIGN: Case series with chart review. SETTING: Otolaryngology Head and Neck Surgery Department in a teaching hospital. SUBJECTS AND METHODS: A total of 59 consecutive severe sleep apnea patients underwent maxillomandibular advancement. Systemic complications were evaluated from medical charts. Functional adverse effects and cosmetic consequences were evaluated by questionnaires. The treatment outcome was assessed by polysomnography. RESULTS: Fifty patients were evaluated. They had a mean age of 46.4 +/- 9.0 years. No serious postoperative complication was observed. The most frequent local complication was mental nerve sensory loss. Most patients reported cosmetic changes. The mean apnea-hypopnea index decreased from 65.5 +/- 26.7 per hour to 14.4 +/- 14.5 per hour (P < 0.0001). Light-sleep stages were also decreased (P < 0.0001), whereas deep-sleep stages were increased (P < 0.001). CONCLUSION: Maxillomandibular advancement can induce local adverse effects and cosmetic changes, but they seem to be considered as secondary to the patients according to the surgical outcome.

PMID: 19861196 [PubMed - indexed for MEDLINE]

Sleep apnea is a very serious, life-threatening condition in which one repeatedly stops breathing during sleep. The periods of not breathing can last several seconds, leaving you gasping for air, and sleep apneaics may have hundreds of these episodes during one night.

There are three types of sleep apnea: obstructive sleep apnea (OSA), central sleep apnea, and a combination of the two. OSA is caused by a blockage of your airway; excess tissue may be the cause of this blockage. The blockage could be in the nasal passages, or something related to the structure of the jaw and airway may also cause the sleep apnea.

Central sleep apnea is not as common as obstructive sleep apnea. In CSA, the brain does not send the appropriate signals to the breathing muscles to produce respiration.

The causes of sleep apnea are numerous and may include:

Structural problems in the airway that cause interrupted breathing during sleep
Throat muscles and tongue relax during sleep blocking the airway
Narrowing of the airway often occurs in obese individuals due to the excess tissue in the throat and neck areas

Some people are more prone to suffer from sleep apnea than others. A staggering 15 million people are estimated to suffer from this condition with more men than women having the condition. People who are overweight, have hypertension (high blood pressure) or snore loudly are at a greater risk of developing sleep apnea. Some studies indicate that the disorder may be hereditary.

There are a variety of treatments for sleep apnea, and treatment for sleep apneaics varies from case to case. In the past, CPAP (Continuous Positive Airway Pressure) has been used but because you must actually wear a mask while you sleep. The CPAP machine uses pressure to send air flowing through the nasal passages. Other treatments for sleep apnea include:

Oral appliances
Behavioral changes
Medication
Surgery

If you think you may suffer from sleep apnea, there is help out there for you. In Gurnee, Illinois, Dr. Ira Shapira has successfully treated thousands of sleep apneaics, and he can help you, too. Please contact sleep apnea specialist, Dr. Ira Shapira at his Gurnee, Illinois dental office today.

I am interested in alternatives to CPAP Machines. I am considering a sleep study only because my Pulmonologist thinks I should take one. I have no classic symptoms. Sometimes snore, am not tired upon awakening, no headaches, don't doze off during the day, even after meals, at movies, etc. So, I am not sure what to do regarding the study...thx, bob

I WOULD DEFINITELY TELL YOU TO HAVE THE SLEEP STUDY. MANY PATIENTS HAVE SEVERE PROBLEMS BUT ARE SYMPTOM FREE. TRUST YOUR PULMONOLOGIST ON THIS ONE.
DR SHAPIRA

I am an enormous fan of the talk about sleep website. Tracy who moderates it is fantastic. She has a company that makes the PAPillow that helps patients with sleep apnea find comfortable side positions to sleep. Patients looking to increase their CPAP comfort need to take a look at the PAP Pillow (http://www.PAPillow.com/) The PAPillwo also helps appliance patients and positional apnea patients increase side sleep, which is frequently where there is a decreased number of apnea episodes.
Dr Ira L Shapira

The folowing information is from Tracy's website:
Feel the PAPillow™ Difference!
The patented design of the PAPillow™ has solved CPAP compliance issues for thousands of CPAP users.

Helps prevent mask leaks and sore spots
Improves comfort and CPAP compliance
Helps you to achieve a good night's sleep
Designed by CPAP users, for CPAP users
All PAPillows Feature:
Sturdy construction, high quality interlock-knit
Proper support for neck and head
Accommodates both left or right side sleeping
Comfortable, hypoallergenic synthetic down fill
Quilted side panel prevents edge collapse
Machine washable, cool dryer safe
Fitted pillow case included
See how the PAPillow works
© 2000-2008 PAPillow.com. U.S. Patent No. 6,913,019. All Rights Reserved.

This site might be called I HATE CPAP! but we realize many patients like their CPAP or use it in conjunction with their oral appliances. I have recently received an e-mail from a company that promises to beat any other companies prices. I want to help all patients with sleep apnea find the most appropriate treatment. If you are a CPAP user and are concerned about the costof your equipment contact this company. Please let me know what you think of their prices and service. CPAP saves lives and and anything I can do to help CPAP users makes me happy

"comments : My name’s Nathan Frasher and I’m a marketer for BestCPAPprice.com We sell the same products that all the other CPAP websites sell except we have a Best Price Guarantee. If you find a competitor with a lower advertised price for a product that we stock, we will give you 110% of the difference! For example, if we advertise a product for $250, and a competitor has the same product advertised for $200, we will sell it to you for $195. There are also additional discounts that we can’t publish on the site due to trade guidelines. These discounts are available to customers who contact us If you would be willing to check out the site, http://www.bestcpapprice.com and possibly mention this deal to your readers, we would be very grateful."

For the best prices on CPAP contact BestCPAPprice.com If they dissapoint you I will make sure to pass on that information. If you are happy with their services I will pass that on as well.
Wishing you a happy holiday season.
Dr Ira L Shapira

Labels: BEST PRICE CPAP, BiPAP, BUYING CPAP, CPAP BiPAP, cpap supplies, cpap.com

Continuous Positive Airway Pressure (CPAP) has been the main treatment for people with sleep apnea. The CPAP machine works by using pressure to send air flowing through the nasal passages, keeping the throat from collapsing during sleep. CPAP, however, is uncomfortable, and many people do not use CPAP because its inconvenience and bulkiness.

If sleep apnea is left untreated, it can lead to many serious problems including:

Fatigue
Depression
High blood pressure
Diabetes
Sore throat
Dry mouth
Excessive daytime drowsiness
Poor concentration
Short-term memory problems
Anxiety
Mood swings
Impotence
Cognitive deterioration

Most of us are aware that a good night's sleep is essential. REM sSleep, the time during sleep when we dream, contributes to overall health and proper body function. But during a sleep apnea event, the individual leaves REM sleep many times throughout the night to restart his or her breathing. The result is a lack of deeply restful sleep that seriously affects the body's ability to function.

There are three different types of CPAP machines:

CPAP: delivers one continuous air pressure
APAP: adjusts to your need for oxygen by starting out at low pressure, senses raising the pressure during a sleep apnea event
BiPAP: uses a higher pressure when you inhale and lower pressure when you exhale

To learn more about snoring and sleep apnea, please contact sleep apnea specialist, Dr. Ira L. Shapira, in Gurnee, Illinois today to schedule your initial consultation.

Thank you for your assistance regarding my negative reaction to the SomoDent MAS Acrylic. I followed your advise and had a Clifford Test. Unfortunately, the results indicated the Somnodent is not suitable for me. This makes me very unhappy because I am very satified with the results of the device assisting me in terms of sleep. With the device I am able to sleep well throughout the night. Unfortunately, I get small blisters mostly in my upper lip and inside my cheek area which disappear after a couple of hours but what is worse is that my gum area around my upper teeth becomes inflamed and has increased over time ( I keep the oral device in water during the day to reduce reaction but this has not atopped the reaction). I consulted with Dr. Stuart and the device was sent to the lab to change the metal wiring although I suspected I was also reacting to the acrylic material as well – I am still awating for them to return the device back to me. Since then, I have received the results of the Cliffor test which indicated I am not well suited for this device due to contraindicating reactions which were seen in my blood test. I am wondering if SomnoDent makes similar devices with different materials. I paid close to $3,000.00 out of my own packet and I cannot afford to spend as much again. Please advice. Thank you very much.

The appliance comes with a soft liner and with hard acrlic and stainless clasps and screws, They do make a version with a titanium screw. If this is not acceptable I would check with somnomed to see if they could make the appliance out of a material you are not sensitive to. There are other options available otherwise that you can discuss with Dr -------

Dr Ira Shapira

Labels: allergy oral appliance, clifford test, somnodent, somnomed

I have been using dental implants for many years to replace missing teeth, secure dentures and to secure oral appliances for treating sleep apnea. This publication in Sleep and Breathing discusses the use of orthodontic implants to support oral appliances in patients who do not tolerate CPAP. This article goes a step further and is using elastic bands attatched to the implants to hold the jaw forward. It is an interesting concept of using the implants to connect directly to the bands because of insufficient support by teeth. It would also be possible to use combinations of a single arch appliance that would connect to implants on the opposing arch.

There are many methods to utilize dental implants to improves the lives of patients. In intolerant CPAP patients would be a life saving alternative. Should medical insurance companies be required to cover the costs of dental implants if they are needed to retain a sleep appliance?

It would be possible to create a simple appliance that utilizes two dental implants in the posterior mandible (back part of lower jaw, and use a tongue bumper held by the implants to prevent airway collapse during sleep. It could attatch to the implants and go behind the tongue to prevent collapse. This would create an appliance that works in a similar matter to TRD's or Full Breath appliance. It would have minimal effect on the teeth or jaw position.

As of now I think the best treatment is to use standard implants to hold fixed bridgework ot dentures and then standard appliances for most patients. It is always possible to do custom modifications of FDA approved appliances or one of a kind unique appliances to address unique problems.


PubMed absrtact
Sleep Breath. 2009 Sep 18. [Epub ahead of print]
Orthoimplants: an alternative treatment for SAHS?
de Carlos F, Cobo J, Fernandez Mondragon MP, Alvarez Suarez A, Calvo Blanco J.

Department of Surgery and Medical-Surgical Specialities, Area of Orthodontics, Faculty of Medicine, Universidad de Oviedo, Clinica Universitaria de Odontologia, C/Catedrático José Serrano, s/n 33006, Oviedo, Spain, fcarlos@uniovi.es.
Numerous sleep studies have been published recently regarding the use of intraoral devices (ODs) for the treatment of sleep apnea-hypopnea syndrome (SAHS). The effectiveness of these devices varies, however, according to the series studied (patient characteristics, parameters assessed, type of device, etc.). Two factors should always be assessed: the presence of an appropriate dental support and a possible temporomandibular joint pathology which can, on occasions, contraindicate the use of these devices. OBJECTIVES: To use orthoimplants as orthodontic anchorages for intermaxillary elastic bands which allow a mandibular advancement to be performed as an alternative treatment to ODs in SAHS patients without appropriate dental support. MATERIALS AND METHODS: Four orthoimplants were placed in an edentulous SAHS patient who did not tolerate continuous positive airway pressure (CPAP). The mandible is pushed forward using orthodontic elastic bands anchored to the orthoimplants. RESULTS AND CONCLUSIONS: Although more studies are still required, orthoimplants could be an alternative treatment for reducing snoring and the apnea-hypopnea index and increasing SaO2, which should be considered for patients who do not tolerate CPAP and lack appropriate dental support for attaching intraoral devices.

PMID: 19763651 [PubMed - as supplied by publisher]

A new study in Sleep and Breathing concluded that" long-term usage of an OA does not cause impairment to the temporomandibular joint." The study also concluded that "There was a long-term improvement in the ESS (epworth slepiness scores) values over the years analyzed."

PubMed abstract is included for reference
Sleep Breath. 2009 Nov;13(4):375-81. Epub 2009 May 1.

Systematic assessment of the impact of oral appliance therapy on the temporomandibular joint during treatment of obstructive sleep apnea: long-term evaluation.
Giannasi LC, Almeida FR, Magini M, Costa MS, de Oliveira CS, de Oliveira JC, Kalil Bussadori S, de Oliveira LV.
Institute of Research and Development IP&D, University of Vale do Paraíba, São Paulo, Brazil. odontogiannasi@uol.com.br
OBJECTIVE: The aim of the present study was to evaluate the symptoms of temporomandibular dysfunction (TMD) in patients with obstructive sleep apnea treated with long-term use of an oral appliance (OA) using a questionnaire based on the Helkimo Anamnestic Dysfunction Index. A further aim of the study was to evaluate the presence of daytime sleepiness using the Epworth Sleep Scale (ESS) and otologic symptoms. MATERIALS AND METHODS: Polysomnograms of 34 patients were performed at baseline and after 6 months of OA use. As follow-up, the patients were contacted by telephone interview to answer the same questionnaires after 36.0 +/- 17.0 months. RESULTS AND DISCUSSION: The intensity of TMD symptoms decreased significantly throughout treatment (p < 0.01). ESS values improved from 12.2 +/- 5.0 to 6.9 +/- 2.6 (p < or = 0.05). Tinnitus was present in nine patients at baseline and decreased in intensity in seven patients by the final assessment while remaining at the same level in two patients. CONCLUSIONS: We conclude that long-term usage of an OA does not cause impairment to the temporomandibular joint. The Helkimo and otologic indexes are simple and useful in long-term patient follow-up. There was a long-term improvement in the ESS values over the years analyzed. A follow-up program could increase compliance by motivating patients to use the device regularly.

Labels: effectiviness, ESS, long term oral appliance use, MAD, TMD, TMJ

Patient Inquiry

You can take steps to make using a CPAP mask a more pleasant experience. Here's what I do: I’ve been a snorer for a long time. As I got older, my snoring has gotten more frequent and louder. I also noticed I was tired a lot and liked to take naps during the day. I was overweight. People complained about my snoring and I did not want to sleep in the same room with other people for fear of keeping them awake.Finally, I asked my doctor about the problem. He sent me home with a machine to check my breathing and pulse while I slept. The results really shocked me! The doc said my airway was closing off up to 70 times each hour, and that I stopped breathing for as long as one full minute at a time! I had severe apnea. He strongly recommended I start using the CPAP machine, since I was risking damage to my heart due to lack of oxygen.I had read about CPAP machines before and always thought I would never be able to sleep with one, since I am a little claustrophobic. Surprisingly, it only took me a few minutes to get used to, and I was able to start sleeping comfortably right away.The mask part is just a small nose manifold that covers the nostrils to blow in air. That keeps the throat inflated like a balloon, preventing throat closures and snoring. One problem is the straps over the head that keep the nose piece in place. They can be a little annoying at first, and if you change sleeping positions at night, it is possible for these straps to move, causing the nose piece to slip off. I have been using a Dreamhelmet (a combination sleep mask sound-muffling pillow) for years now, to sleep at night and for napping during the day. I always find it hard to sleep without the Dreamhelmet, and was afraid I would not be able to use it with the CPAP mask, but I was wrong about that too. After using the CPAP machine and mask for a short while, I tried wearing the Dreamhelmet over the CPAP mask, covering up the straps – voila, it worked like a charm! I found that the Dreamhelmet actually helps keep the straps in place when I change positions, so now I can sleep all night in comfort, not being bothered by sound, light, or changing positions. The CPAP combined with the Dreamhelmet are the perfect sleeping combo for me. You can see and buy the Dreamhelmet for under 30 bucks at DREAMHELMET.com. Now I don’t snore, I wake up rested, and I have energy that lasts all day long. I’m still overweight, but I don’t feel so run down all the time or feel like I need an afternoon nap, but I still carry an extra Dreamhelmet in the car with me just in case I do need a nap.

I was not familiar with the Dream Helmet and had to Google it. It appears this response may be commercial in nature but I thought it was worth passing it on as it might be helpful for some patients. I recently spent time in Dallas, Texas with Dr Keith Thornton the inventor of the TAP oral appliance for treating sleep apnea and I am please to report the excellent TAP-PAP combinations which include an integrated TAP 3 appliance and a nasal CPAP mask. This will eliminate leaking masks. Airway technologies is also manufacturing custom CPAP masks for appliance connection that use denture technology for a custom mask.

Patient Inquiry:

Dear Dr. Shapira,

I suffer from both TMJ Disorder and Sleep Apnea. Is this common?


Response to Patient:

Dear____,

It is ver common to suffer from headaches and sleep apnea. The National Heart Lung and Blood Institute say that sleep apnea IS a TMJ disorder. Morning headaches, in particular are almost always related to TMJ, Bruxing, Grinding or Sleep Apnea

Sincerly,
Dr. Ira L. Shapira

From patient:

Already diagnosed and been on CPAP since march. Dr. told me to stop using it about a month ago since I have mild-moderate apnea and the mask disrupts my sleep.

Response to Patient:

DEAR ____,

STOPPING CPAP WITHOUT OTHER TREATMENT IS VERY DANGEROUS AND COULD LEAD TO DIRE OR EVEN LIFE THREATENING CONSEQUENCES. PATIENTS WITH UNTREATED APNEA ARE MORE LIKELY TO DIE IN THEIR SLEEP THAN WHEN EXERCISING. THERE IS UP TO A SIX-FOLD INCREASE IN HEART ATTACKS, STROKES AND MOTOR VEHICLE ACCIDENTS.

WITH MILD TO MODERATE APNEA YOU NEED TREATMENT. IF CPAP IS NOT ACCEPTABLE SEEK OUT AN ALTERNATIVE: ORAL APPLIANCES OR SURGERY.

If you have sleep apnea or someone you know suffers from this condition, you may know the dangers associated with this common, but very dangerous, sleep and breathing disorder. Sleep apnea is a serious, potentially life-threatening condition in which the sufferer stops breathing while he sleeps. The cessation of breathing can go on for several seconds and can occur several hundred times each night. Each sleep apnea patient Dr. Ira Shapira sees in his Gurnee, Illinois dental office presents with a unique combination of symptoms. The most common symptoms sleep apneics suffer are:

Daytime sleepiness
Fatigue
Gastric reflux
Memory problems
Concentration problems
Sore throat
Dry mouth
Depression
Anxiety

One of the most serious problems sleep apnea can lead to is stroke. A study conducted by the American Thoracic Society International Conference showed that people with moderate to severe sleep apnea were 3 to 4 times more likely to have a stroke than people without sleep apnea. The study did not follow those with mild sleep apnea. Moderate to severe sleep apnea, for purposes of this study, was defined as breathing stopping or slowing at least twenty times per hour of sleep.

One reason why sleep apnea may increase your chance of a stroke is that this condition increases your blood pressure; hypertension is the most common risk factor for stroke. For this reason, it is very important to have your sleep apnea treated.

If you live in the Chicago, Illinois area and suffer from sleep apnea (or your partner does), please contact Dr. Ira Shapira today to schedule a thorough evaluation.