ORAL APPLIANCE THERAPY  

 

According to the Practice Parameters of the American Academy of Sleep Medicine, oral appliances are indicated for use in patients who have mild to moderate obstructive sleep apnea and who prefer them to CPAP therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP [1].  Oral appliances increase airway size by moving the lower jaw, tongue and posterior soft tissues forward, preventing them from collapsing in the back of the throat and obstructing the airway. 

A definitive diagnosis by a certified sleep physician, along with a physician recommendation for OAT, is needed to initiate oral appliance therapy. Oral appliances should be fitted by a qualified dentist who is trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion  and associated oral structures.

A follow-up sleep test (PSG or HST) is required to ensure treatment efficacy and may also be needed if symptoms worsen or re-occur.  Although oral appliances have been shown to be as effective as CPAP therapy in reducing cardiovascular comorbidity in OSA patients [2]  and many patients prefer them to CPAP because of the smaller size and ease of wear, in some cases  oral appliance therapy does not result in a full therapeutic response (even when snoring is improved), therefore it is critical to complete a follow-up sleep study in order to confirm the effectiveness of the treatment, and if necessary discuss alternative or adjunctive approaches with the sleep physician. 

Using an over-the-counter appliance is not recommended, since the only way to identify the presence, type and severity of sleep apnea is a diagnostic sleep test and a full evaluation by the sleep physician - while the elimination of snoring alone may continue to mask apneas and significant oxygen desaturations which only a follow up sleep study can detect.



    
                          SomnoDent Seperate Pieces                                   SomnoDent in Patients Mouth - High Res
                                                                                                Somnodent in patient's mouth



There are over 100 types of oral appliances used to treat snoring and sleep apnea (to see examples of some of the most common devices click here). Oral appliances can be classified into two different categories:

1. Devices that move the mandible anteriorly ("mandibular repositioning devices", MRD)

2. Devices that hold the tongue in an anterior position ("tongue retaining devices', TRD)



Mandibular Repositioning Devices (MRD)  are similar in size and appearance to an orthodontic retainer or a sports mouth guard, but include an adjustment and titration mechanism that allow the dentist to precisely calibrate the mandibular position until the subjective symptoms of sleep apnea can be eliminated and a follow up sleep test objectively confirms that the apnea-hypopnea index has been normalized.

MRD's are typically made of acrylic resin or silicone, and may contain metal frameworks, retention hooks or adjustment screws. They can be one piece or made of two separate arches that are connected by straps, screws, ramps, hooks or other adjustable mechanisms.



Tongue Retaining Devices (TRD) are made of silicone and consist of a bulb (suction device) into which the tongue is inserted. Once pressure on the bulb is released, the suction effect holds the tongue forward, opening the airway. These may be useful for patients who have an insufficient number of teeth remaining and are not candidates for implant-supported MRD's.




Will Oral Appliance Therapy Work for Me?

While the success rate with dental OSA devices is considerably less than with CPAP, it is now possible to identify those patients for whom oral appliance therapy is likely to be effective. 

MATRx is an FDA-approved technology that is clinically proven to predict with a high degree of accuracy which patients will respond to oral appliance therapy. The overnight test is conducted in a sleep lab and uses a custom-made tray that is remotely controlled by the sleep technician, who advances the mandible in small increments without disrupting the patient's sleep until all apnea/hypopnea events are eliminated or the maximum protrusion is reached. In addition to its predictive power, the test accurately identifies the ideal advancement position for the device, so that the dentist can construct and insert the appliance at the optimal therapeutic position, considerably shortening the time to effective treatment and avoiding over-titration, which tends to reduce side effects. 



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[1] Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005.
Kushida C, Morgenthaler T, Littner M, Alessi C, Bailey D, Coleman J, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer J; American Academy of Sleep Medicine. SLEEP, 2006 Feb 1; 29(2):240-3.

[2]  Van Haesendonck, G., et al. "Cardiovascular benefits of oral appliance therapy in obstructive sleep apnea: a systematic review." Journal of Dental Sleep Medicine 2.1 (2015): 9-14