Brady Wood, assistant professor of medicine, Division of Education and Innovation, Department of Medicine, McMaster University, joins Dr Roman Jaeschke, professor of medicine, McMaster University, to examine the idea of mouth taping during sleep through the lens of evidence-based medicine.
This is a new episode of the Not Quite Evidence Based talks, where a nonclinician and a physician-methodologist scrutinize the facts behind health news that make the front pages.
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Brady Wood, MA, MCM: Welcome to the McMaster Perspective series, a part of the McMaster Textbook of Internal Medicine. This is our second episode of Not Quite Evidence Based, and today we are discussing mouth taping.
I’m very pleased to introduce my colleague, Dr Roman Jaeschke, one of the leaders of the McMaster Textbook of Internal Medicine and also a faculty member in the Department of Medicine and Department of Health, Research, and Methods at McMaster University. I am also a faculty member in the Department of Medicine in the Division of Education and Innovation.
We started this series because clinicians are often asked to comment on remedies recommended in popular media. Sometimes these remedies have been evaluated to some degree in the literature. Our quest here is to examine which remedies may or may not be evidence based and also lead to a broader discussion of evidence-based medicine (EBM).
As Roman noted, health-care practitioners often have to react to unexpected questions from folks visiting them. Our objective is to explore what is actually evidence based and to take a methodological look at the problems that we’re raising here.
Roman, mouth taping has been in the popular media, on blogs, in the lifestyle sections of newspapers, in the realm of influencers, and it’s being pushed for its sleep improvement, sleep apnea improvement, reduction of asthma, general health benefits, etc. Folks have even been wearing a mouth tape to exercise. You and I were looking at an article called “The Impact of Mouth-Taping in Mouth-Breathers with Mild Obstructive Sleep Apnea: A Preliminary Study.” Roman, do you want to kick us off by what you thought of this topic and how you might have approached looking at it through the lens of EBM?
Roman Jaeschke, MD, MSc: Well, not only through the lens of an EBM practitioner but maybe through the lens of a general practitioner who’s confronted with a topic that is, at least for me, completely new. You mentioned that it’s popular in different areas and different media, and I have to say it was not popularized enough to reach me. So, I’m trying to pretend I’m a health-care practitioner who is confronted with it. The easiest way to say is “OK, go to the specialist and talk to them,” but let’s try to mimic real life and, after an hour or 2 spent exploring the topic, try to provide some comments. The other comment that I wanted to make here is that when I’m talking about the area of my expertise, I speak a bit faster. Here is the area which I’m not as familiar with, so I have to be quite careful so that I don’t say something completely not true. In this sense I encourage our listeners to listen to our podcast at double speed if we seem to be talking not fast enough. That’s number one.
Number two, you asked the question about the paper that you provided; it was about the use of mouth taping in sleep apnea. As usual, I wanted to clarify what we are talking about. The first thing for people who will listen to this presentation is what sleep apnea is. It takes a little bit to orient yourself. There are medical definitions of what sleep apnea is.
As we sleep, we take breaths in and out and there’s a certain amount of air that is being moved. On some occasions, when the airways narrow—or collapse when it’s happening in more severe forms—the amount of air may come down to <10% of the usual and we call it apnea, or it will come down by <30% of the usual and we call it hypopnea. Then we count the number of such episodes and put them into an index that is called the Apnea–Hypopnea Index (AHI) [and denotes] the number of such episodes per hour.
There are some other situations in which the flow of air doesn’t drop that dramatically, ie, 90% for apnea or 30% for hypopnea, but it drops enough so that the sleep is disturbed and then it is called respiratory disturbance.
The number of such episodes per hour dictates how we call it. If there are >5 and <15, we’ll call it mild obstructive sleep apnea (OSA); between 15 and 30, moderate; and >30, [severe], which really means you drop the flow through your airway either by 90% or 30%, which means it happens more [often] than every 2 minutes for a specified period of time, which is usually 10 seconds. Usually in the physiology of human beings, it’s difficult to say exactly what is normal, because suddenly we call 5 per hour abnormal but that really means that 4 per hour is normal and 6 per hour will be defined as abnormal. That’s the first thing we have to know when we talk about the underlying disease, so to speak.
Then, in terms of what mouth taping is, I had to reorient myself and for that I would like to share my screen for a second and show people...
Brady Wood: Yes, please do.
Roman Jaeschke: I think I’m sharing it now to show people what mouth taping may mean because it may mean these types of tape. I found this type of tape, or I found this type of tape. In reality I want to say that there may be a difference between this taping and this taping, and possibly even this taping. However, the paper that I received would need some context from what I was talking here about. Number one, they had to use the tape in this fashion [vertically] to close the mouth.
Brady Wood: For someone just listening to audio: that is just a top-to-bottom strip, so not across the entire mouth. The top-to-bottom strip.
Roman Jaeschke: The top-to-bottom strip, but it could be across, or it could be 2 strips crisscrossing each other. Now, the obvious question is why it should work in those variety of situations that you mentioned: sleep apnea, snoring, asthma, exercise. The most likely or theoretical reasoning behind it is that once the mouth is open, the pressure in the pharynx equalizes, or equilibrates, with the pressure outside. In effect, there is no positive pressure, so the tissues are kept separate by their own elasticity, if you wish. If you close your mouth and you breathe in and out, there is a certain degree... You could consider it like having a small balloon, with which, as you are moving air through, you are generating positive pressure, which spreads the tissues apart. Now, you could imagine and people may argue that in OSA the problem is the collapse of the tissues on each other.
Similarly, in snoring you also have the collapse of tissues on each other and in order to open the airway, you have to generate a lot of pressure to keep the tissues separate. During this process the tissue vibrates and generates different sounds, which are collectively labeled as snoring.
Brady Wood: Roman, if I understand you right, as someone’s breathing through their mouth, the tissues in the throat are reverberating and falling inward and that’s what’s causing the snoring or the complete obstruction of the airway?
Roman Jaeschke: Essentially you are right, but the first—the egg, so to speak—is the collapse of the tissues, and then you are trying to open them by generating vigorous enforced, or enhanced flow through it. This major pressure and flow affect the tissues, which try to separate from each other through the pressure applied to the passages and then go into vibration. It’s interesting that in the paper that you provided, which effectively dealt with snoring, they did not define what snoring is. It’s one of those things where everybody recognizes what it is, but it’s very difficult to provide a reproducible definition. That takes me now to the paper itself. The title of the paper [refers to] “the use of mouth taping in people with OSA,” but effectively when you read the paper, it turns out that all those people were seeking advice regarding snoring. Snoring may be associated with OSA, but they may be 2 different processes, which are associated with each other but not causally related. Association and causation may be 2 different things.
Is that enough about the background of what OSA is, what snoring is, and what mouth taping is?
Brady Wood: Roman, I think that was very effective. You’ve answered any questions I had.
Roman Jaeschke: OK, so let’s assume that I’m confronted now by a patient who comes to the office, puts the paper in front of me, and asks, “What do you think, doctor? Should I use it for OSA?” The way to approach it, or the way a methodologist would approach it, is to divide the topic into segments. One is population, one is intervention, one is comparator, and one is the outcome of interest.
I will start with population. If my patient is suspected of OSA or has it diagnosed, I would say that the paper looked at people on average 40 years of age, from 20 to 60, who were referred due to snoring, whose average body mass index was 24 kg/m2, and there was very little comorbidity. This is completely different from the usual [patient with] OSA, who would be much older, much heavier, and who would have a number of other diseases including diabetes, hypertension, or whatnot, which are by the way frequently associated with OSA. Again, where is the chicken, where is the egg, is it association or is it causation—it is a different story. That’s in terms of population.
In terms of intervention, it was quite interesting that they described the tape and took a very tiny picture. I believe this was a tape going from the upper lip to the lower lip, which was 1 inch in diameter and which was tolerated by patients. That’s again a big story: as we advise some interventions to our patients, they have to be able to tolerate them. I could imagine a number of people who would be offered such tape and for a variety of reasons they would not be able to tolerate it, or the facial hair would be in the way, or their partners would look at it with dismay and say, “What the heck are you doing here?” That’s in terms of intervention.
In terms of comparator, I want to stress that we are trained—for good or for bad—in a situation where we want to see the effect of a comparison. This particular study had no comparator and it had a small number of patients. It had 20 relatively young people who were snoring and who happened to have mild OSA, and the highest AHI was 12. The average one was somewhere around 6 or 7. So this was very mild OSA—the type of sleep apnea in which we are not sure if it needs any treatment to start with, unless [it has been found] that [patients] are extremely symptomatic, because in a lot of those areas we are really talking about quality of life. Somebody with an AHI of 7 may have zero symptoms and presumably you cannot improve their quality of life by any type of intervention. On the other hand, this person may have very disturbed sleep, wake up in the morning feeling tired, fall asleep during daytime, so the technological measurement of some parameters is not the gold standard, or not a carved-in-stone solution. You have to effectively look at the patients.
But as I mentioned, this study was less about OSA, it was more about snoring. When I started to surf the Internet, I saw that those 3 tapes, which I was showing you by the way, were all for snoring. I looked at the outcome measure in this particular study as being snoring, and frankly it was quite impressive. The average snoring episode was 300 per hour, so I can just imagine it was a fairly vigorous snoring exercise, because a snoring episode was defined here as ≥3 snores, if you wish, in a row, with <10 seconds in between. It sounds to me like these people were snoring almost constantly. Three hundred per hour means 5 such episodes per minute, and each of those episodes would last 30 seconds, so it occupies essentially the entire sleep. These were heavy snorers. One of the evidence-based areas of importance is to point out to people that what we are presented the evidence talks about is not necessarily what the subject really is. The subject here was heavy snorers who had a bit of OSA. Taping the mouth—remembering that these are not only heavy snorers but these are people who also could tolerate the tape and agreed to it—seemed to decrease the intensity of snoring by at least half. There is no comparator here and maybe there is some... we call it regression to mean. That means if you have some abnormal results somewhere and you remeasure it a week or 2 weeks later, there will be regression to mean, there will be less abnormality. But to go from 300 snoring episodes per hour to 100 episodes per hour... It obviously would be nice to have a control [group consisting of] even some of these people who would simply repeat the measurement without taping the mouth, but it sounded quite impressive in terms of snoring itself.
On the basis of what I’ve seen, I cannot comment on asthma or exercise, or OSA, which seemed to be decreased slightly as well—the number of hypopnea/apnea [episodes] or respiratory disturbances was lowered by close to a half, but it was lowered from the level that I’m not sure that it required treatment in the first place and which would have any health benefit.
But cutting down on snoring after experiencing snoring of different people in my life, including very tiny sheds in the mountains when one snoring person could keep everybody else awake the whole night, is something that seems real and quite relevant. Does that answer your question about how I look at the paper?
Brady Wood: It does, Roman. In summary, it sounds like the paper’s findings—if I’m reading you correctly—are actually quite limited in terms of a clinician’s thinking about application.
Roman Jaeschke: Well, they are limited, and we better be limited, as when we approach the patient’s problem, we have to be fairly specific about what the problem is. Using this paper, I would react differently to a person who comes with OSA versus a person who comes with heavy snoring. If that’s what you mean by limited, I would agree.
On the other hand, there are a lot of people snoring heavily in this world, so maybe it’s not a limited scope of application, if you wish.
Brady Wood: Yes, I’m more thinking about the situation where a patient comes to, say, the respiratory institute/clinic and says, “You know that I’ve got sleep apnea. I’ve read this paper and I think it shows that I should be taping my mouth every night.” How should a clinician respond to that? I’m sure that happens all the time with people bringing an article.
Roman Jaeschke: Right. The first thing is probably not to get emotional, because people have all kinds of ideas. That’s number one.
Number two, you would need to look at the degree of OSA. If this person has mild OSA, you almost say, whatever you do is fine, if you wish. If the person has severe OSA—because there are other things associated with severity: there will be desaturations, there will be dropping oxygen concentration, there will be prolonged periods of not breathing at all, all of which are right out dangerous—applying an unproven intervention in this setting is dangerous.
But there are wrinkles here. Look at the following situations. Look at the person who is outside advanced health-care settings, who has no access to a sleep clinic, not to mention a sleep specialist. Look at the person who cannot afford the usual treatment prescribed for sleep apnea, which is a mask that applies external pressure to the airways—it’s called continuous positive airway pressure (CPAP), which is the pressure applied with 5, 10, or even 20 cm H2O intensity. But these are things that require both expertise and finances, so it’s possible that people may have no access to it. They may have sleep apnea, which causes symptoms: daytime sleepiness, waking up with headaches and without feeling rest, and so forth. These would be situations in which I would not recommend it, but I would not put my body in front of the door and say, “Don’t go there,” because that may be the option to the patient, which is the only available.
Look at the people who have access to all those technologies but cannot tolerate CPAP masks, either through the nose or through the full-face mask covering both the nose and mouth. Look at the people who have a nasal CPAP [machine], which is easier to tolerate, but as you could imagine, as you apply the pressure to the nose to keep the airway open but you open your mouth, the effectiveness of this extra pressure disappears, because whatever goes into your nose is coming straight out of the mouth.
There are some situations, which... Again, I’m not a specialist in it, but it would not strike me as completely unreasonable to a person who either has no access or cannot tolerate, or maybe has access but has no finances to apply some of the more advanced solutions.
I would also be very clear that it is unproven. One of the biggest things about EBM [is that] you’re trying to be honest, and you try to recognize what you know that you know from what you know that you don’t know. The effectiveness of mouth taping in some of the situations that I just mentioned is unproven. The only proof... Maybe I will introduce an element of methodology: we have something called n-of-1 randomized trials, which are situations where the patient repeatedly uses or does not use a specific intervention. You can tape your mouth for a week, you can leave it untaped for a week, you can tape it again for a week, and then the question is how to judge the effectiveness. If you’re convinced that the taping works, your own judgment of whether it helped you or not may be blurred.
On the other hand, if the person who is in a position to judge your snoring says, “Hey, this last week was the best in 2 years,” and then you take the tape off and suddenly they want to move out to a different house, that would be a fairly convincing way. Again, this [may incline one] to make very definitive statements. It depends on the context. I’m sorry to use the phrase “it depends on the context,” but today I feel reasonably safe to use it. It depends on what you are trying to cure, what you are trying to treat, how you are measuring it, and what access to more advanced forms of treatment you have.
Brady Wood: Roman, it strikes me, as we talk about these things, that EBM and determining sort of best practice and truth—it is always on this very nuanced spectrum. I think that maybe what’s helpful to the public also is to say how they make sense of seeing an article like that.
Is the best approach to be generally skeptical? Because I do think that an article like the one we reviewed, or on virtually any topic, may seem to have the imprimatur of truth—like this article—when you read the conclusion section on PubMed, it says, “it showed this benefit.” And one might deduce then, “Well, if it’s showing this benefit in this paper, that means that maybe in this case mouth taping is good for sleep apnea.” I think it’s not quite that clear.
Roman Jaeschke: When you look at PubMed, it simply reproduces what the [journal] is publishing. There is no official scrutiny, if you wish. If you look at today’s publication, maybe I will bring another point. There is a whole array of publications in which authors pay for the right to publish. Then it’s an obvious conflict of interest on the part of the [journal] not to publish it. The quality of believability of evidence or confidence that we have clearly varies. I believe the title of this particular paper was “a preliminary study.” When you see a statement where the authors are themselves putting “preliminary results,” it usually means it’s not ready for widespread use or widespread recommendations.
From the perspective of a practitioner, maybe I will summarize it this way: if I’m myself a heavy snorer, I may read this paper and say, “OK, I will try it myself for a few days, use this hypoallergenic 3M tape and see what will happen.” Am I ready to start recommending it to my patients? I would probably not initiate the discussion on it. If the person were to come to me saying, “Listen, I have this heavy snoring that interferes with my life. What could I do?”, I’d probably first go to a reputable review type of publication and say what different people advise about snoring, and they may well talk about OSA and the need to investigate for it, about obesity, about diabetes, about lying on the side rather than on the back, because snoring would be much worse for that. There are situations, which I also ran through over the last little while, when people were putting something in the back of the pajamas, for example, a tennis ball, to prevent them from lying on the back so that they have to lie on the side and this way keep the airway open and cure the snoring.
Am I ready to recommend it as a public health policy? Absolutely not. Am I ready to start asking my patients if they snore and [suggest that] they should tape their mouth? No. If the patient comes and tells me, “Listen, I snore heavily. What do you think about using it?”, we could talk about a positional change, but I could say, “You know what, if you have a way of judging how severe your snoring is, try and tell me what happens.” Maybe if I hear from 10 consecutive patients that it’s the miracle cure, it will make me design a study on it or start advising it to people. Again, the context is relevant.
[Now I will refer to] another comment that you made, which strikes me as very relevant. I remember when we started the EBM movement, so to speak. We thought that if we only had a good enough way of searching publications, we’d be able to answer any questions. It’s clear that we do not and that we frequently base our advice and our recommendations on imperfect evidence. Clearly, mouth taping and snoring is in this category of imperfect evidence as well.
Brady Wood: Roman, on that point, it strikes me... Do you have a way of describing where is the tipping point on an issue like that? Where does something actually become firmly evidence based? What would it require in this case?
Roman Jaeschke: Unfortunately, as usual, it’s a judgment. The judgement depends on... unfortunately I have to use this discredited phrase of “it depends on the context.” Because it depends on the disease itself: how severe it is, what the consequences of not treating it are. Is it something that can kill you, that can put you in a wheelchair, that can [make you bedridden], or that disturbs your sleep a little bit? That’s number one.
Number two, what are the alternatives? If there is no alternative and the disease is awful, your threshold may be a little bit lower. If the disease is not awful and there are reasonable alternatives, you’d better have good evidence that your intervention is better than those alternatives. Especially if this intervention is, say, much more expensive or has severe side effects.
When I was thinking about this tape, the question was how expensive it is. By the look of it, you can buy the tape for about CAN$0.20, so you spend CAN$0.20 a night. I don’t think you can reuse it, but it’s very inexpensive. Now, what are the downsides of it? What could be the side effects of it? Obviously, if somebody squeezes your nose and you cannot breathe through the mouth or nose, you’ll die, but I don’t think it’s a reasonable complication. I think the downsides of it, unless you rip off your facial hair when you take it off, which may be very painful, are probably very low.
Then, the questions are what the alternatives are. If the alternative is trying to sleep on your side, maybe it’s worthwhile to try to sleep on your side first, if you can do it. On the other hand, if the alternatives are to use the CPAP mask, which is expensive, cumbersome, requires cleaning, and so forth, well, maybe it’s something to try.
I’m sorry for the situations where being an evidence-based practitioner requires you to precisely establish the question, including alternatives, costs, and downsides, and whom it should be applied to, and then use a series of judgments, which go from evidence to recommendation. In fact, we have a formal process that leads from evidence to recommendation, and all those factors—severity of illness, alternatives, what you are measuring, how expensive the interventions are—have to be taken into account.
Brady Wood: I wonder too, Roman, as we think about the public—some members of the public may see this, well… the first thing I’d say is obviously you and I are not recommending any intervention without folks consulting their medical practitioner directly. I think that’s an important point.
Roman Jaeschke: Yeah, that’s covering our backside.
Brady Wood: Yes, I probably should have put that in the preamble or the opening statement. But the other thing here, Roman, is there is an effect of commerce here, which I think the public should be aware of. I wonder if you wanted to comment on that as well.
I recall I found the article... the first time I read about this was a New York Times article in December of 2022. I’m just going through my history here and it says… [there’s]someone, one person, claiming mouth taping gives them more energy, another a sharper jaw line, improved skin, mood, and digestion, reduced brain fog, cavities, gum disease, and bad breath... and a strengthened immune system. Really pitched as a cure-all. Spoken about in the popular media. Then, as you found and you showed us earlier in the episode, there’s a lot of commerce, there’s a lot of private business that has been spun off of these findings, and there’s a bit of a “chicken and egg” effect here too. How many companies are now selling very specific mouth tape for this practice...
Roman Jaeschke: One thing that makes me less concerned about it is that these are relatively really inexpensive interventions. I don’t know how big business can be made out of CAN$0.20. Mind you, if one million people in New York will use it, it would be CAN$200,000 a night, so I guess it could be a big business, but obviously the issue of vested interests in this situation is very important. If something were to make me feel much better and more rested, and having more energy, even if it’s a placebo effect and it costs CAN$0.20, I would not be terribly distressed. On the other hand, if this intervention takes 5% of your monthly income, that obviously becomes a big issue.
Brady Wood: I see here online, by the way, Roman, some of the mouth tape companies—I won’t name any of them for fear that they’ll think we’re endorsing them—are charging up to the equivalent of a dollar a night for the little sticker, so I think folks are getting quite creative on marketing and pushing this, and telling us all of the benefits, proven or otherwise.
Roman Jaeschke: Well, yes. Again, in the end, the judgment in today’s health care is made by a combination of a health-care professional and the patient, the subject, or a person—whatever way we want to call it today. In this sense, I think the professionals are less emotional about interacting with these situations. Our role is to provide the judgment, provide the assessment the best we can, and the final decision whether and which tape you want to buy in today’s marketplace will be up to the person.
Brady Wood: Well said, Roman. Any other parting thoughts for us today?
Roman Jaeschke: The big thing for me is the preponderance of evidence and claims that we are confronted with. I wonder if artificial intelligence (AI) will be able to help us down the road, but clearly, approaching it from the health-care professional perspective—approaching a new topic and new intervention even for a disease that you know quite a bit about is quite time- and effort-consuming. Let’s see how we will proceed.
Obviously, the option would be to ask a high-level specialist to express an opinion, but I can almost guarantee that different high-level experts have very strong opinions on almost anything and we’ll always get a singular opinion on something where the evidence is not perfect. We have to get used to living with it.
Brady Wood: Thank you, Roman. As always, it’s good to speak to you, my friend, and we’ll wrap there and thank viewers for tuning in, and encourage folks to look for more content in the McMaster Textbook of Internal Medicine, which can be downloaded on all of the app stores currently and also found online, currently as a free resource [in Canada and the United States]. Anything you wanted to add, Roman?
Roman Jaeschke: I would but I have taped my mouth. Alright, take care.
Brady Wood: Thanks, Roman.
Roman Jaeschke: Goodbye.