Dear Dr. Doe, 

Our patient John Breathless came to me requesting he be fitted for a dentally supported anti-snoring/anti-obstructive sleep apnea device known as Nocturnal Airway - Patency Appliance (NAPA).

The NAPA, which has been approved for marketing by the FDA, resembles an orthodontic retainer.  It snaps on the teeth and is worn only while sleeping.  The NAPA was designed to prevent constriction of the heavy airway during sleep by several mechanisms: 

Protruding the mandible to move the tongue away from the posterior wall of the pharynx; 

Stabilizing the mandible since this allows the geniohyoid muscles to protract the hyoid and tongue, rather than opening the mouth; 

Preventing movement of the muscles of mastication which stimulate proprioceptors that initiate an anti-tongue-biting reflex that retracts the tongue; and 

Increasing vertical dimension which via the TMJ initiates another reflex which activates the genioglossus muscle and tends to protrude the tongue. 

In a retrospective polysomnographic study of 20 patients with an average respiratory disturbance index (RDI) of 41.7 the NAPA demonstrated an average reduction in apnea index of 80.7%, with a range from 49% to 100%.  Subjective comments indicate the NAPA’s anti-snoring effectiveness is, at least, equal to its ability to reduce the obstructive apneas and hypopneas. 

Mr. Breathless’ score on the Epworth Sleepiness Scale (ESS), a questionnaire to differentiate simple snorers from those with obstructive sleep apnea syndrome (OSAS) by determining daytime somnolence, was_____.  The following are average ESS scores:

  The range for snorers with severe OSAS is 10 to 23.  Mr. Breathless’ ESS score and his responses to the enclosed questionnaire indicate that he has (no, mild, substantial, severe) signs and symptoms of obstructive sleep apnea.  This, of course, can only be substantiated by polysomnography. 

Please let me know if you would like to reexamine Mr. Breathless prior to using the NAPA, or would you suggest he come in after being fitted for the devise so that you may determine if the NAPA is an adequate solution to his sleep/breathing disorder.  If you believe polysomnography is indicated for Mr. Breathless, I believe it would be most practical and economical if you would prescribe the test be done half night with and half night without the NAPA. 

I am hopeful that this device will substantially reduce your patient’s snoring and probable OSAS.  Please contact me with your instructions concerning Mr. Breathless.

Sincerely,