snoring, UARS, Partial airway collapse

I tried SilentNite sl for my OSA – Here’s what Happened

In the 20 years I have been involved in the treatment of sleep disordered breathing I have talked to hundreds of dentists their staff and their patients about daytime sleepiness and sleep quality. Frankly I was starting to feel a little judgy. How is it possible that people cannot tell that they are sleepy and that they need to get treatment. Well then I noticed I was falling asleep at my desk in the afternoon and I noticed that I was closing my eyes while driving home (very dangerous). I realized I needed to get treated with a SilentNite sl oral appliance if possible or CPAP if necessary. I have become the guy I have been describing in talks for over 20 years middle age, moderate snorer, sleepy and in need of treatment.

My first step was to fill out a questionnaire I chose the STOP-Bang and I scored a 5 out of 8 which means I have high risk of OSA. Interesting but not a huge surprise. The questionnaire is an interesting tool however being a male over 50 with a neck size over 17” would make me a 3 out of 8 so, while an indicator of risk I still was not very alarmed or surprised.

This is the scoring key for the STOP-Bang questionnaire.
All wired up for my home sleep study with the Nox T3

Next step was to do a home sleep study. I set myself up with a Nox T3 which has 18 channels and since I am in the dental field I also added EMG leads to look at Bruxism, tooth grinding and clenching. It is important to remember that Bruxism is the dental sleep disorder, and in many cases sleep disordered breathing shows up in the dental area as worn broken and chipped dentition (more about that later). The study went pretty well, all the leads stayed on and I was able to put the two RIP belts, Nasal cannula and pulse oximeter on. I even remembered to turn the Nox T3 home sleep testing device on. I did wake up earlier than usual so the length of the study was not as long as I would have liked.

Pre therapy HST report showing an AHI in the high Mild range

Above is the report from my initial home test. I was pleased to find that my condition was still mild but at the upper register AHI is the threshold for moderate apnea. I made a dental appointment that day to have a Silent Nite sl made so that I could manage my airway by changing my jaw position. I took advantage of the one for Home one for Travel option so that I can keep an appliance in my suitcase for travel and leave the my home appliance in the same spot every morning (this is a popular option).

SilentNite sl is a Mandibular Advancement Device (MAD) that is custom fabricated by Glidewell Dental Lab it is made on the prescription of a dentist and has an FDA indication for use for snoring, gasping and mild obstructive sleep apnea cases. The mechanism of action for this device is similar to a Herbst device, an EMA device or a Narval device. These appliances engage the upper and lower teeth and hold the jaw forward through the use of plastic, metal or elastic arms. All of these devices can be titrated 10 to 15 mm so the therapeutic range of the device can be calibrated as needed. Other sleep appliances include the EMA, Oasys,and the DreamTAP.

Provisional Mandibular Advancement Device
SilentNite sl mandibular positioning device for the treatment of snoring and sleep apnea

I received my Silent Nite sl and resolved to start wearing it that night. The appliance comes with 6 sets of different length connectors 21mm to 26mm the shorter the arms the more jaw advancement. The appliance arrives with the 25mm connectors in place. These connectors are easy to change and some dentists allow their patients to make their own adjustments.

I went to bed the first night wearing the appliance and slept pretty well, I thought. In fact I was celebrating complete victory for about 5 nights. I felt better and was sleeping well. That was when my wife broke it too me that in fact I was snoring like crazy with the appliance in my mouth. Snoring is the sound that a partially collapsed airway makes. Time to adjust the connectors to open my airway more. I adjusted my jaw forward 1 mm by changing to the 24mm connectors.

Adjustable slide link connectors come in several different lengths. In order to adjust the therapy the slide link arms are changed

When you change your jaw position even by a small amount it feels different and some people need time to get comfortable. It turns out I am not one of those people. I slept great. I was concerned that my subjective reports of success might happen again so I took the home sleep test to confirm that the treatment was going in the right direction.

Nox T3 Report Post Treatment with SilentNite sl AHI 7.1

I was pleased to find that my Apnea was almost cut in half while using the appliance. My snoring was cut from 4.4% of the night in the first study to a manageable 1.7% of the night in the second study. I found the appliance comfortable and easy to use. AHI of 7.1 still indicates mild OSA however and now I wanted to try the next set of arms to see if I could get my apnea under an AHI of 5 which is considered normal. I changed the connectors a third time to the 23mm connectors. My sleep study changed again. I had achieved my goal of a normal sleep AHI but you will see that my snoring actually increased.

Nox T3 study post treatment AHI 4.6

So the big question is what happened to my perceived daytime sleepiness. I would say it has resolved, I am not as sleepy late in the day and more importantly I seem to have recovered my ability to bounce back from a single late night or an early morning. In the past it was very difficult for me to recover after one of those events. Now it seems to be fairly easy.

The effect of bruxism on the case was very interesting. In the dental world bruxism is really the new frontier. The effects of mouth activity during sleep are well known, and tooth protection strategies are a standard part of any dental visit. The question is why do patients grind tap and clench their teeth during sleep? This is still a matter that is under investigation.

Bruxism is a repetitive jaw-muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible.

Principles and Practice of Sleep Medicine (Sixth Edition), 2017

I mentioned earlier in this article that I measured the muscle activity in my masseter and my temporalis while I collected my sleep data. I used EMG device which was part of the Nox T3 HST monitor. The images below are excerpts from the auto scored bruxism report that is generated by Noxturnal software.

In my untreated study I had 308 bursts of muscle activity. This included 6 phasic (rhythmic) bruxism episodes and 11 tonic (clenching) bruxism episodes in all with the bruxism bursts I experienced 37 episodes that could be categorized as tooth contact or bracing and thrusting behavior.

I do have a history of cracked and broken teeth. I do not experience headaches or have jaw pain which may be attributed to bruxism. I did find it interesting that with an Apnea to Bruxism index of .2 it seems that my bruxism is in fact idiopathic in nature and not associated with my coexisting sleep disordered breathing issue.

Bruxism FIrst measurement AHI 13.5

In my first treated study I was really surprised to see the huge spike in muscle activity. Muscle activity almost doubled to 608 bursts. If you remember my AHI was cut in half here and my Apnea to Bruxism Index stayed exactly the same. It is possible this jaw activity was simply a reaction to having an appliance in my mouth. There may be some other factor.

Bruxism Second Test AHI 7.1

My final Study where my AHI is now under the normal limit and from a sleep disordered breathing perspective I am fully treated my bruxism has also resolved somewhat to 282 bursts. It is interesting to note that more events are related to sleep disordered breathing, in this study, my Apnea to Bruxism index (ABI) increased to .3. If you go back to the earlier report on the last study you will see that this study has the highest flow limitation of the three studies at 24.6% as compared to an untreated flow limitation of 14.6%. This last point may be a contributor to the increase in snoring in the last study as well.

Bruxism Final w Normal AHI 4.6

The process I used above to calibrate my SilentNite sl is not the standard of care for any but a very small number of patients. Post treatment followup can be expensive but I feel it is critical to achieve and monitor treatment efficacy.

I would suggest that this level of diagnostic testing and followup to confirmation of treatment efficacy is currently only available to industry insiders. The requirement is high level of patient education and access to low cost diagnostic services that can be used to direct the course of treatment. I plan on testing myself annually to monitor and adjust my SilentNite sl therapy. I will keep you up to date on my progress.

From The Literature

Randy Clare

Randy Clare

Randy Clare brings to The Sleep and Respiratory Scholar more than 25 years of extensive knowledge and experience in the sleep and pulmonary function field. He has held numerous management positions throughout his career and has demonstrated a unique view of the alternate care diagnostic and therapy model. He is considered by many an expert in the use of oral appliances like Silent Nite, EMA and TAP to treat snoring and sleep apnea in the dental office. Mr. Clare's extensive sleep industry experience assists Sleepandrespiratoryscholar in providing current, relevant, data-proven information on sleep diagnostics and sleep therapies that are effective for the treatment of sleep disorders. Mr Clare is director of business development for Glidewell a dental solutions company his focus is on dental treatment for sleep disordered breathing.

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