TAP-3 Appliance (Snoring, Sleep Apnea, TMJD)

Dr. McFarlane: “So, we came to deliver the TAP-3 appliance, today… to follow-up. We delivered it last week. And now, we’re following up to see, ‘How does it feel?’”

Patient: “It’s great.”

Dr. McFarlane: “OK. Now, tell me a little bit about what you were telling me earlier about sleep. How was your quality of sleep?”

Patient: “Well, before, you know my snoring would wake me up.”

Dr. McFarlane: “OK.”

Patient: “[With this appliance] I could tell the first night that I slept all the way through the night. And I actually woke up, earlier than the alarm. And it felt good! I didn’t feel really tired!”

Dr. McFarlane: “Alert?”

Patient: “Yes.”

Dr. McFarlane: “For the first time in…?”

Patient: “A long, long time – Several years.”

Dr. McFarlane: “And you were comparing that to falling asleep on the couch?”

Patient: “So, when I didn’t have it in… so, I wore it for about a week and then on the weekend I didn’t wear it and I woke myself up in the middle of the night. And I could tell the difference.”

Dr. McFarlane: “And the reality was, you were snoring possibly losing airway function.”

Patient: “Yes. This is so much better than having a tube running around on your face. Like a CPAP.”

Dr. McFarlane: “So, you’re describing a CPAP. What do you think the issue is with a CPAP when you describe that?”

Patient: “Well, I’ve never had one on. But, it just looks like it would be very cumbersome and when I turned over I might jar it loose.”

Dr. McFarlane: “We know the success rate on CPAPs is about 49% at 1-year. People can’t tolerate wearing it. But, you’re not the first person that when we look at the guard has said, ‘Man, that is changing my life.’ (That after wearing it for a few days,) you start going, ‘Man, I am not going back.’ And tell me, you said, ‘it was kind of like biofeedback for you.’ Talk to me about that.”

Patient: “Yes, the first night I wore it I could feel some tension in my jaw. And I’ve had some issues with TMJ. It made me really relax and not hold so much tension in the joint. So, after 3 or 4 days then I was not even really aware of it. It wasn’t like hurt, like deep pain. It was just sore, at first.”

Dr. McFarlane: “At first, you felt some soreness. You’ve been clenching you jaw shut, for who knows how long, to hold your jaw in a certain position when you sleep and that grinding has been associated for you with probably some snoring, (maybe sleep apnea events – we don’t know.) But, what we do know for sure is that your airway (when it’s open,) you can actually relax your jaw. And that’s holding your jaw forward.”

Patient: “And my teeth looked whiter. But, I know that’s not the cause.

Dr. McFarlane: “[Joke] Even whiter teeth – what are you going to do?”

Patient: “Yep. I’m happy.”

Opioids (think: Vicodin, Oxycontin, Codeine)

There is an ongoing opioid epidemic in the USA. This map from the CDC shows US prescribing rates. That map is from the collated prescriptions per 100 people. The CDC shows that the rates of prescriptions are starting to slow down, but, for every 100 people there are 59 prescriptions for opioids, as of 2017. That’s insane. The distribution of these prescriptions skew heavily toward a handful of states: Arkansas, Mississippi, Alabama, Tennessee, Louisiana, Oklahoma, West Virginia, and Kentucky. These states have opioid prescription rates near or above 100 Rx per 100 people.

Texas has remained relatively lower than these other states with an opioid prescription rate at closer to 58 Rx per 100 people, closer to the national average. How has Texas remained somewhat* insulated from the epidemic. According to Ernie Luce, Medicaid reimbursement for these drugs in the state of Texas leaves these drugs essentially uncovered so people get them at a lower rate than in other places. *I say somewhat insulated from the effects of this epidemic because I see this rate of prescriptions (as of 2016, 58/100) as too high and probably not the best medical care.

Opioids have a lower effectiveness than a combination of Tylenol# and ibuprofen# (#if the Tylenol and ibuprofen are taken together at the same time.) When taken together, they have an NNT value of 1.5. What that means is that if you give 3 people 500mg of Tylenol at the same time as 400mg of ibuprofen, within about 30 minutes, 2 of the 3 people would experience a reduction in pain of 50%, for dental pain. None of the opioid drugs comes anywhere close to that in terms of effective NNT. The traditional Tylenol No. 3 with Codeine and Tylenol has an NNT of 12.7, which means that if 13 patients are given Tylenol No. 3, 1 of the 13 will experience a pain reduction of 50% and 12 of the patients will not experience any meaingful reduction in their pain. Ibuprofen alone, is effective in 1 out of 2.5 patients at 600mg and 1 out of 2.7 patients at 400mg.

So, the takeaway message is that for moderate to severe pain a combination of Tylenol and ibuprofen is more effective than most opioid drugs.