Mandibular advancement device (MAD)
A mandibular advancement device (MAD) or mandibular advancement splint (MAS) is a device worn in the mouth that is used to treat obstructive sleep apnea (OSA) and snoring. These devices are also known as "dental devices" "sleep apnea oral appliances," and "sleep apnea mouth guards."
The device treats snoring and sleep apnea by moving the lower jaw forward slightly, which tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep. The tightening created by the device also prevents the tissues of the upper airway from vibrating as air passes over them – the most common cause of loud snoring.
Where appropriate, they are considered a good therapy choice as they are non-invasive, easily reversible, quiet, and generally well accepted by the patient. The focus of improvement in appliance design is in reducing bulk, permitting free jaw movement (i.e., yawning, speaking, and drinking), and allowing the user to breathe through their mouth (early "welded gum shield"-type devices prevented oral breathing).
There are a number of oral devices available to patients suffering from obstructive sleep apnea and snoring. The efficacy of these devices varies greatly, as does the quantity and quality of the research behind them. Many professionals believe CPAP is the most effective treatment, although MAD is easier to use. While MAD may be a valid treatment for those with mild sleep apnea, the devices seem to be less effective at treating moderate to severe sleep apnea.
Many health plans do not cover mandibular advancement devices because they are a relatively new form of treatment. Patients often pay upwards of $2000 out of pocket to secure these devices. These devices can also be somewhat uncomfortable, although many patients find them less bothersome than CPAP mask treatment. Improperly fitted devices can cause teeth to shift over time, leading to significant dental problems. Regular dental checkups and adjustments to the oral device can prevent these problems. Morning jaw exercises can reduce pain and jaw dislocation, helping patients to retain a normal bite pattern.
I want to share a good news story regarding Mandibular Advancement Appliances. I have been on CPAP therapy since the late '80's. CPAP was my best friend, took it everywhere. About 5 years ago, I started finding that I was not getting a quality sleep. I have a fairly good overbite. The mask was holding my lower jaw back. In an wake sate, sitting or standing, with my closed normally; any attempt to inhale rapidly caused my throat to collapse. If I move my lower jaw forward, a quick inhale is effortless. In discussing with my pulmonary specialist, he had nothing to offer. I started looking into alternatives. My overbite 27mm - was not effectively treated using products such as SnoreRX or SleepPro. This may be why many have experienced extreme jaw discomfort. If I move my lower jaw 1 mm forward, I start to feel the misalignment. I tried 25mm for awhile and really messed up my bite. I was stuck for awhile and had to use a SnoreRX. I inverted it and survived for a few days. I think they are OK for a more "normal" bite. My first experience in Nov 2013, was with a Somnomed appliance. It certainly positioned my jaw to open the airway. I started feeling much more refreshed in the morning. For about a year my biggest issue was discomfort from sucking my cheek linings into the hard plastic. Otherwise, I was sleeping great. In the fall of 2014, I came across a device called Panthera Digital Sleep Apnea Device. It is made of a nylon compound. Is adjusted by changing the length of the titration arms. Similar to the Resmed Narval.
In January 2015 I had a Level 1 Polysomnography using the appliance. Sleep Efficiency: 96% Total Sleep time 7hrs 48 minutes Hypopneas: 6 Apnea index: 0/hour Apnea-hypopnea index: 0.77/hour
AHI in: NREM Sleep: 0.8/hour REM Sleep: 0.8/hour
My last readings from Oct 2013, over 371 days: ResMed S9 Average Hours/night: 6:51 Compliance: 98% AHI: 0.32 Obstructive Index: 0.11 Hypopnea Index: 0.06 Clear Airway Index: 0.15
Average Pressure: 13.38 Average EPAP: 11.38
Pros: I am still sleeping very well. The Panthera offers no relief from sucking my cheek tissue into the various nooks and crannies. Maintenance is minimal. Cleaning is a brushing followed by soaking all day in Novadent - a 7 day cleanser. No hose No mask Travelling is a dream. Can even use it on the plane. Reduced costs of ownership. I believe this device (Panthera) could have a very good life expectancy. The only wearing parts are the titration arm connections. They will usually provide 2 pairs with the unit. No mask or hoses to replace. Can be used even when not sleeping a long as you are not eating or talking. Then, if you fall asleep on the couch, you do not wake up with a roaring headache.
Cons: I can not think of any serious ones. Sometimes I wake up with some stiffness in my jaw, but very seldom over the past 4 years. Non device related CON The Somnomed provider was a dentist who had switch to full time Somnomed services. He had some monitoring equipment to help with monitoring. The Dentist who provided me with the Panthera is a dentist who has sleep apnea. He does not provide any monitoring equipment or serious followup services. This is not a CON for the appliance, but a caution
My titration arms are 27mm. Going to 25mm really messed me up, so in jaw alignment terms a couple of millimetres is a lot. The SnoreRX starts very close to 0, so just figure what that amount of offset would do to me???? I also found that using CPAP with the MAD made me feel less refreshed. I was able to give my CPAP to my stepson. This is making a huge difference in his life.
So there are some positives in this treatment, but it has to be done properly, and you have to be a good candidate. My new pulmonary specialist commented that it was nice to be able to see well into a patient's throat for a change, so I assume the physical characteristics of the patients throat of consequence. Last year I had a series of Fotona Nightlase treatments. This has helped tighten up what is called the oral mucosa tissue - back of throat. This has help my breathing round the clock and I can go one night with out my MAD, but notice a deterioration after 2 nights. The therapist presented treatment as an addition to, not a replacement for CPAP or MAD therapy. It makes sense, but also comes with a cost. But, there really is not a better investment in your overall well being. When I was first diagnosed with sleep apnea, I discussed the whole idea with a fellow who was running his CPAP at 20cm. He said "You can sleep or you can die." Pretty scary statement, but like so many, I had started down a pretty hellish path already. That was over 30 years ago. That is a long time to be married to a pump!
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