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Tuesday, February 2, 2010



"Treating Sleep Apnea: What's New for CPAP Masks?
For the 18 million people living with sleep apnea, under 50% regularly use their CPAP mask while sleeping at night. Common patient complaints are that the masks, which opens the upper airway with pressurized air through a tube, are uncomfortable, awkward, and claustrophobic. Rates of sleep apnea are rising in the US and many people go undiagnosed.."

The NSF foundation links to a Wall Street Journal Article on Sleep Apnea Treatment that can be found at:
The articl titled
"The New Face of Sleep
As Patients Balk at Bulky Masks, New Efforts to Treat Sleep Apnea" is a worthwhile read. The history of sleep apnea diagnosis and treatment starting in the 1960's. In the early days of apnea treatment cosisted of a tracheotomy. The article suggests there are 18 million patients in the US with Sleep Apnea but many experts consider that estimate to be very low. It is upsetting that the NEW York Times known for its accuracy gave an outdated dfinition of why apnea occurs. "The NY Times reported "Patients with sleep apnea stop breathing during sleep because the soft palate collapses and blocks the upper airway. A tell-tale symptom is chronic and loud snoring." This is actually incorrect. The level of the blockage is actually at the base of the tongue. It was this mistaken belief that the soft palate was the obstruction that led to countless UP3 surgeries (uvulopaltopharyngealplasty) LAUP (laser assisted uvuloplasty) and other surgeries then sometimes relieved snoring but rarely were successful in treating apnea. The tongue actually obstructs the airway and prevents the soft palate from letting air pass. The soft palate acts like a swinging door and the tounge like a door stop that doesn't let the door open. Surgery to the soft palate is like taking an axe to a door instead of removing the door stop.

The times story reports on CPAP, oral appliances (Dental Sleep Medicine), behavioral modification and surgical treatments. It even discusses the didgeridoo and quotes the British Medical Journal's study that learning circular breathing and playing the didg can reduce snoring and sleep apnea. I suggested several years ago in a Sleep and Health Journal article "Didgeridoo and Apnea Too" that medical insurance compnies should cover The didgeridoo as DME or durable Medical Equipment and pay for didgeridoolessons as respiratory therapy.

There is a picture of a "collapsed airway" in the article that is incorrect and does not show how the tounge actually occludes the airway. The article does say there is some evidence compliance is better with oral appliances. Actually 90-95% of patients prefer an oral appliance over CPAP if they are offered a choice. The story overplays TMJ problems associated with oral appliance therapy and does not even mention the newest article that shows no damage to the TM Joint with appliance wear.

While CPAP can give dratic improvement studies have shown that the majority of patients do not use CPAP on a regular basis and even CPAP users average only 4-5 hours a night use.

The following was a letter I wrote to the author of the New York Times author:
I was pleased to read your article on sleep apnea. I would like to point out that the tongue is usually the site of obstruction not the soft palate. Originally ENT's thought it was the soft palate and this led to numerous failed UP3 and LAUP surgeries that had high morbidity and rarely cured apnea. Most patients still needed CPAP. The picture of the collapsed airway is also incorrect.

A major omission in your article is the fact that most patients actually use CPAP only an average 4-5 hours a night of CPAP use a night not the recommended 7-71/2 hours. Patients with untreated Sleep Apnea have a greatly increased risk of heart attacks and strokes and are in fact more likely to die in their sleep then exercising. These heart attacks and strokes usually occur in the early morning hours. Patients utilizing their CPAP for only 4-5 hours have already quit using it before they reach the time apnea causes cardiovascular events.

Thirdly you suggest dentists are prescribing the devices for treating sleep apnea. The American Academy of Sleep Medicine actually recognizes oral appliances as a first line treatment for mild to moderate sleep apnea (along with CPAP) and an alternative for severe apnea. The National Sleep Foundation stated in "SleepMatters" that "oral appliances are a therapy whose time has come." Ideally dentists are working as a team with sleep physicians to treat sleep apnea. It is not within the scope of dentistry to diagnose sleep apnea. Hopefully this will change as the NHLBI considers sleep apnea to be a TMJ disorder. (see http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf) CARDIOVASCULAR AND SLEEP RELATED CONSEQUENCES OF TEMPORO-MANDIBULAR DISORDERS.

You call CPAP the most common (true) and most effective (not true) treatment. The second part of that statement is not true if patient compliance is factored in. It would seem worth noting that CPAP is a gold standard that fails the majority of patients. Approximately 25% of patients love their CPAP from the first day and thereafter but the majority of patients abandon CPAP or use it far less time than recommended.


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posted by Dr Shapira at 9:28 PM

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