Practical Aspects: Sleep Apnea Questions
Snoring and sleep apnea: do I really need a sleep test?
Where do I start? How can I get a sleep test? Do I have to spend the night in the lab?
I could not tolerate my CPAP. What do I do now?
Are you really controlling your sleep apnea? Make your CPAP work for you!
Who can order a dental device for snoring or sleep apnea?
Will my insurance cover a sleep apnea dental device?
I have a commercial driver license and was diagnosed with obstructive sleep apnea. Can I wear an oral appliance instead of CPAP?
FMCSA useful links and updates
Snoring and sleep apnea: do I really need a sleep test?
Q: My spouse says I snore, but I don’t want to go get a sleep test. Can you just make me one of those appliances I’ve seen advertised on TV?
A: Snoring is a symptom: in some patients it is benign, without any significant airway obstruction; however in a very large proportion of cases it hides something much more serious (obstructive sleep apnea) which needs to be diagnosed, staged and treated appropriately. Because the only way to differentiate between benign snoring and obstructive sleep apnea is through a sleep study, it is always necessary to complete this step before deciding whether an oral appliance is the appropriate treatment.
According to the practice parameters of the American Academy of Sleep Medicine, an oral appliance is indicated for patients with primary (benign) snoring, patients with mild to moderate sleep apnea who prefer a dental device to CPAP, and severe sleep apnea patients who do not respond to CPAP, are not appropriate candidates for or failed CPAP treatment. A patient with severe sleep apnea, significant cardiovascular risk, central/mixed apneas or deep, persistent oxygen desaturations is better served by CPAP, Bi-PAP, ASV and related forms of treatment – so working closely with a local board-certified sleep physician is essential to manage these cases safely and effectively.
Another important aspect to consider is that without a baseline and follow-up sleep study we do not know whether our oral appliance is treating the problem effectively. Even if the snoring disappears, the airway obstructions may persist, with all their associated morbidity/mortality risks: masking the smoke does not necessarily put out the fire.
Where do I start? How can I get a sleep test? And do I really have to spend the night in the lab?
As a first step we recommend that you schedule a free, hour-long consultation with our office, so that we can determine your current status, answer all your questions and most importantly, provide the “roadmap” without which so many patients tend to fall through the cracks, especially if they are CPAP-intolerant. There are many treatment options, but understanding the timing of the different steps involved in this process is critical to a successful approach to sleep apnea therapy, both in terms of efficiency and maximizing insurance benefits. Also, because studies show that combination therapy can successfully rescue a majority of patients who would otherwise fail CPAP, it is essential that we are able to collaborate with your primary care provider or sleep physician from the very beginning of treatment, especially if you have severe apnea or significant cardiovascular risk, so we can intervene if necessary before you lose access to the trial CPAP and to this important treatment alternative.
If you haven’t had a sleep test within the past few years, we will then make a referral to one of the board-certified sleep physicians in Spokane for a consultation and sleep study. Although most sleep studies are done in the convenience of your own home, sometimes the sleep consultation may reveal additional concerns that require more detailed data which can only be collected in the lab.
If your primary care physician refers you to our office on the basis of a current, pre-existing sleep study, we do not usually need to repeat that study.
Q. I have been diagnosed with obstructive sleep apnea but I could not tolerate my CPAP. What choices do I have now? I am worried about leaving my sleep apnea untreated and my wife says that my snoring is getting worse. How do I get back into treatment?
Unfortunately this is an all too common scenario, as the vast majority of patients who fail CPAP tend to fall through the cracks, unaware of other treatment options or unsure about how to pursue them. We also know that obstructive sleep apnea is a progressive disease – without treatment it predisposes patients to metabolic changes and additional weight gain, which in turns makes the apnea worse - so the sleep quality and daytime sleepiness can deteriorate significantly within a few years, in addition to considerably increasing the risk of hypertension, stroke, diabetes and heart disease.
If you have a current sleep test and have already failed CPAP, your primary care physician, cardiologist, endocrinologist or any other member of your health care team can write an order for an oral appliance and refer you to our office for this alternative therapy.
Are you really controlling your sleep apnea? Make your CPAP work for you!
Are you wearing your CPAP every night, throughout the night – or is it just sitting on a shelf for most of the week? If you recognize yourself in this latter scenario, then realize that you are not treating your sleep apnea adequately. Studies show that you need at least 5.6 hr of CPAP use per night in order to derive its full cardiovascular benefits – however the reality is that at 3 years, only 1/4 of patients are “regular users” of CPAP (Sutherland et al J Dental Sleep Med 2015; and American Academy of Dental Sleep Medicine 25th Annual Meeting). To protect your brain and your heart, “having a CPAP” or wearing it on and off is very different from building the discipline to wear your CPAP every night, preventing those drops in oxygen saturation - especially during the second part of the night, when you experience your deepest, longest REM sleep, which is precisely when your CPAP (or oral appliance) are needed most.
So maybe you should see your sleep physician for a follow-up – he or she might decide that they should adjust the settings on your CPAP; or maybe it’s time to try a new mask; or maybe you should consider a dental appliance / CPAP combination therapy, which some studies have shown can rescue up to 70% of CPAP failures (Sanders Sleep Review 2015)
There are many new treatment options and approaches to sleep apnea – and as we learn more about oral appliance therapy, adjunctive tools and combination therapies, your chances of finding a successful long term solution are better than ever!
Q. I already had a sleep study and the diagnosis came back as benign snoring/mild/ moderate obstructive sleep apnea. I would like to see if a dental device will work for me before considering CPAP. Can my primary care physician write an order for an oral appliance?
As long as there is adequate clinical documentation of relevant signs and symptoms and the sleep study was interpreted by a board certified sleep physician, your primary doctor can write this order, based on the current AASM guidelines. The prescription must include the date, your name, physician’s name, OSA diagnosis, order for a “mandibular repositioning appliance”, length of need (lifetime or 99 months) and doctor’s signature.
Please note that while most cases of mild or moderate sleep apnea are uncomplicated, on occasion we may decide that the safest course of action is to consult with and co-manage your case with a local sleep physician, such as when combination therapy may be anticipated in cases of obesity hypoventilation, or where the cardiovascular risk factors are significant.
Oral appliance treatment for sleep apnea is covered by approximately 90% of medical insurance plans, including Medicare (this is a medical procedure, so it is not covered under your dental plan).
This is only one aspect of a very controversial topic and unfortunately there are no clear answers for the time being. Studies show that between one third and three quarters of commercial drivers suffer from some form of sleep-disordered breathing, which has created significant concerns for the drivers, their employers, medical examiners, sleep medicine providers and regulatory agencies. All of these stakeholders have recently participated in a series of public discussions, in an effort to update and clarify the existing protocols used to identify, test and treat at-risk drivers. Because the FMCSA (Federal Motor Carrier Safety Administration) has so far only issued recommendations, rather than universal rules, it is up to the individual medical examiners to decide which treatment guidelines they want to use – and there are several guidelines available, some of which allow the use of an oral appliance for mild to moderate apnea, while others discourage it.
As the articles below explain, “FMCSA does not require specific diagnostic testing/treatment, but the agency permits the ME to use medical best practices to govern his/her decisions” (Papp). However, this has created considerable confusion and frustration, so it is generally hoped that within the next year the agency will be able to issue clearer, definitive guidelines to be followed by everyone, addressing which drivers are at the greatest risk of sleep-related accidents and which treatment options/ protocols are acceptable in order to maintain one’s commercial driver license.
The use of oral appliances to treat mild and moderate sleep apnea is very well established by the current practice parameters of the American Academy of Sleep Medicine in the general population – however for CDL purposes the protocol may also need to incorporate compliance-tracking technology such as the Braebon Dentitrac chip, which can be embedded into Somnomed and other appliances and record up to 6 months of wear data, just like CPAP monitors. Of course a follow-up efficacy study demonstrating that the appliance can reduce the AHI below 5 (or 10 with elimination of daytime sleepiness, according to some guidelines) is also an essential requirement to prove successful treatment, just as in the general population.
Here are a number of useful links that may provide further information on the topic:
Sleep Review October 26, 2016
http://www.sleepreviewmag.com/2016/10/fmcsa-panels-advance-sleep-apnea-recommendations/
Full text: http://www.ttnews.com/articles/printnews.aspx?storyid=43664
Sleep Review April 4, 2016
http://www.sleepreviewmag.com/2016/04/8-fmcsa-rulemaking-myths-debunked/
Sleep Review June 30, 2015
Chest. 2006 Sep;130(3):902-5.
Hartenbaum N1, Collop N, Rosen IM, Phillips B, George CF, Rowley JA, Freedman N, Weaver TE, Gurubhagavatula I, Strohl K, Leaman HM, Moffitt GL; American College of Chest Physicians; American College of Occupational and Environmental Medicine; National Sleep Foundation.
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.683.3627&rep=rep1&type=pdf