Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP.

 

Practice Parameters for the Treatment of Snoring and Obstructive
Sleep Apnea with Oral Appliances: An Update for 2005
SLEEP, Vol. 29, No. 2, 2006

CPAP Failure & Alternative Treatment

Snoring and Obstructive Sleep Apnea

Snoring occurs when there is partial obstruction of the airway behind the tongue and soft palate. Inspired air does not flow smoothly in what is called a laminar flow because of the soft tissue that partially collapses. As a result, the loose soft tissue vibrates and creates the nosie called snoring. Because air flow is diminshed while snoring, the name obstructive hypopnea (diminished airflow) is sometimes used as a more scientific term than snoring.

When the obstruction becomes so complete that all air flow ceases, it is called obstructive sleep apnea. In obstructive sleep apnea the airway in back of the throat is totally closed by collapse of the soft tissues like the soft palate, the uvula, the tongue and sometimes the epiglottis. In obstructive sleep apnea, the sleeper awakens frequently during the night to clear the obstruction often unaware of these awakenings, however, this leads to a substantial loss of sleep and excessive daytime sleepiness.

In both cases, less oxygen reaches vital organs during the episodes leading to thee well-know medical problems associated with these conditions: heart disease, high blood pressure, stroke, diabetes, depression, motor vehicle and job related accidents associated with drowsiness and even erectile dysfunction.

What is CPAP?

CPAP Mask Failure

nCPAP or continuous positive air pressure delivered through a nasal mask is the most commonly applied treatment for obstructive sleep apnea. The air pressure that is forced through the nose creates an air splint in the back of throat that holds the airway open and prevents collapse. CPAP is 100% effective at preventing the collapse and airway obstruction - but it must be worn to provide this function.

There are many variations of CPAP - some deliver various levels of pressure, some work only on demand, some have heated air flow, some moisturize the airflow - but basically they provide the same function, air under pressure delivered through a tube, through the nose to support the soft tissue structures in the back of the throat to prevent collapse.

The CPAP machine itself is an electically powered pump that compresses air, allows the pressure to be adjusted, humidifies and warms the air and delivers it to the patient through a tube and nasal mask. Literally dozens of different machines are available through multiple companies

CPAP machines that deliver pressurized air through a nasal mask

The pressurized air generated by the CPAP machine must be delivered through a mask that fits over the nose and sometimes over the mouth as well. It is the fit and feeling of the mask that patients who object to the CPAP find most of the problem. There are dozens of different configurations and styles of masks and often patients must try several to find one that is comfortable.

Assortment of nasal masks

Let's remember also that the masks must be connected to the CPAP machines with tubing that is long enough to reach from the machine itself to the mask with enough extra length to allow the patient to move around in bed.

CPAP Compliance

While CPAP is 100% effective for those who wear the device, compliance is low. Compliance is simply the number of people who wear their CPAP the recommended hours EVERY night. In an article by Stepnowsky published in 2002* the authors stated "Nasal continuous positive airway pressure (CPAP) is the treatment-of-choice and has been shown to reduce the frequency of nocturnal respiratory events, improve sleep architecture and decrease daytime sleepiness. Patient compliance with CPAP is disappointingly low."

Others, however, offer a more positive outlook and state that with proper education and training, compliance rates cn be improved to 75% and higher.

Whatever the realistic compliance rate may be, there are still large numbers of patients with sleep-breating disorders who cannot, for one reason or anther tolerate the CPAP.

Why some patients hate CPAP

Patient tangled in the tubing of his CPAP machine

Some patients absolutely love their CPAP units and the relief it provides, other simply hate CPAP and cannot get used to the mask, the machine itself and the tubing.

The reasons given by patients who dislike CPAP are varied from non-specific comments like "I just can't stand the thought of something over my nose" to more specific complaints that prevent the patient from accomodating to CPAP:

  • I just cannot wear the mask, it's so uncomfortable
  • I seem to take the mask off at night without knowing it
  • I take the mask off at night to go to the bathroom and find it too much trouble to put it back on
  • The skin around my nose is constantly irritated
  • Air seems to be forced into my stomach and my sinuses
  • The mask leaks air and dries my eyes
  • I can't stand the pressure
  • My wife says the sound of the CPAP keeps her awake
  • I get twisted in the tubing
  • My nose is always stuffy
  • I'm always on the road and in airplanes and can't carry my CPAP everywhere

Alternative to CPAP

But there is good news, there is an alternative that is almost as effective as CPAP and, according to many reports, better tolerated by patients. This is an intra oral appliance that fits over the upper and lower teeth that, when fitted and adjusted properly by a well-trained dentist, can provide the relief you are looking for.

Find Sleep Apnea Dentists who can provide an alternative to CPAP

References

*Stepnowsky CJ Jr, Marler MR, Ancoli-Israel S.Determinants of nasal CPAP compliance. Sleep Med. 2002 May;3(3):239-47