Are Dental Appliances Effective for Overcoming Sleep Apnea?
By Dr. Cory Herman
The human brain is remarkable and generally senses when it doesn’t have enough oxygen; it alerts the body to wake up. However, if this occurs too often a person suffering from obstructive sleep apnea can end up sleep-deprived, which may trigger additional issues. This is when you know that effective dental appliances can help you overcome sleep apnea symptoms.
According to Harvard Health, “25% of men and nearly 10% of women have obstructive sleep apnea (OSA)”. If you are suffering in this regard, and are one of the individuals who heard of the 2021 Philips CPAP Recall, you may well want to know about more conservative and effective dental appliances.
Obstructive sleep apnea can be associated with several life-threatening conditions. Given it is prevalent, this medical condition merits an early multi-specialty diagnostic and treatment approach. Ongoing research holds the promise of new and improved treatment and management approaches for this common, persistent health condition.
This article will help you become more familiar with your choices. To assist, we’ll first provide a clickable content list to jump to specific topics that provide basic definitions and answers.
Table of Contents
- Are Dental Appliances Effective for Overcoming Sleep Apnea?
- How is Obstructive Sleep Apnea Different from Central Sleep Apnea?
- What is an Oral Appliance?
- What does CPAP stand for?
- What are the Benefits of Oral Appliance Therapy?
- Who is most likely to Benefit from a Dental Device for Sleep Apnea?
- What are Common Types of Dental Devices for OSA?
- Why Some Patients Prefer Oral Appliances over CPAP for OSA Treatment
- Efficacy of Oral Appliances in Treating OSA
- What is the Long-Term Success Rate in Oral Appliance Use for Sleep Apnea?
- What are some of the Best Oral Appliance Brands?
- Possible Treatment Options for Severe Cases of Obstructive Sleep Apnea
Are Dental Appliances Effective for Overcoming Sleep Apnea?
What we know today is that early evaluation and primary care in the form of oral appliances in managing the OSA population seems easily justified. It has both potential short- and long-term benefits of getting more sleep and involves low risks for the patient.
How is Obstructive Sleep Apnea Different from Central Sleep Apnea?
Obstructive sleep apnea (OSA) is when you can’t breathe properly due to upper airway obstruction. Central sleep apnea occurs less frequently than obstructive sleep apnea and is diagnosed when your brain fails to send normal signals to the muscles that control your breathing. The onset of apnea is accompanied by the upper-airway muscles becoming lax and should have a professional diagnosis to determine the type and treatment.
What is an Oral Appliance?
An oral appliance (OA) is a custom-made, adjustable dental device that decreases obstructive sleep apnea, snoring , and possibly restless leg problems. With appropriate treatment, we avoid impacting daytime sleepiness and improve the quality of life for people who struggle with daytime sleepiness, snoring, or mild to moderate sleep apnea.
Their use has proven effective for people getting lower quality sleep when suffering from TMD. If you loss of sleep is due to an TMJ issues, myofascial release may help. It can help release muscle knots that are keeping you up at night.
What does CPAP stand for?
CPAP is short for “continuous positive airway pressure” and is used to treat sleep apnea and can help treat prolonged tiredness during the day. Many individuals find that it is an effective treatment for daytime sleepiness and sleep apnea. However, frequent adherence problems render them ineffective as a result of nasal stuffiness, claustrophobia, and the risk of disturbing a spouse or partner in the same room. These accompanying issues limit the overall usefulness of this therapy. According to cpapsupplies.com, “most CPAP manufacturers specify their decibel (dB) ratings for each breathing device; the average CPAP noise is rated at 30dB”.
Positive airway pressure (PAP), is a bedside machine that blows air through a mask to avoid your airway from collapsing. But it is not your only choice. Dental devices or oral appliances are an ideal treatment option for many people suffering from sleep problems.
Oral appliances are an effective alternative to CPAP, most especially for patients with mild to moderate obstructive sleep apnea. Oral appliance therapy is a good option for those who aren’t candidates for CPAP, don’t respond well or have failed treatment attempts with CPAP , or just who prefer oral appliance therapy over CPAP. Because the general effectiveness of CPAP therapy depends on a patient’s acceptance of, tolerance for, and adherence to the treatment, oral appliances are often the better option.
What are the Benefits of Oral Appliance Therapy?
Some of the many benefits to oral appliance therapy are:
- Oral appliances are well tolerated.
- They are noninvasive.
- OA therapy devices are easy to care for.
- They are easy to take with you anywhere and don’t require electricity.
- They are silent versus the sounds of a CPAP machine.
A CPAP means using a mask that covers either your nose or both your nose and mouth. It has straps that hold the mask in place and a motor that is continuously streaming air into your lungs.
In contrast, an oral appliance has only two small devices that are similar in appearance to retainers or mouthguards. They’re held together by a tiny hinge and snap onto a person’s upper and lower teeth. This device moves the jaw forward and into an alignment that keeps your airways open, and keeps the tongue from blocking the airway passages. Unlike the CPAP’s mask and straps that can slide out of position, oral devices tend to remain put and cause fewer sleep disturbances.
Who is most likely to Benefit from a Dental Device for Sleep Apnea?
A person who needs their upper airway opened may find a dental device for sleep apnea that helps to reposition their jaw or tongue. However, expectations should be discussed in advance to be aware that they don’t always work. Individuals experiencing milder OSA and slight symptoms are ideal users. People with severe OSA who lack tolerance for PAP benefit as well. Check here if you are specifically looking for a temporary tmj mouth guard.
What are Common Types of Dental Devices for OSA?
1. Mandibular advancement devices / PAP therapy.
They are constructed of molded hard plastic and overlay your lower and upper teeth. Equipped with metal hinges, your dentist or orofacial pain specialist can recommend adjustments that will help move your lower jaw forward if needed. You may want to request a custom mandibular advancement device from a pain specialist who is certified by the American Academy of Sleep Medicine and has professional experience treating sleep-related breathing disorders. Positive airway pressure (PAP) therapy is a generic term applied to all sleep apnea treatments that use a stream of compressed air to support the airway.
2. Tongue-retaining devices.
These oral devices are a soft plastic splint meant to surround your tongue and secure it throughout the night in a protective, forward position. Patients report experiencing mouth dryness and some find it to be uncomfortable.
You may want to talk with your insurance company in advance so you have an idea of how much is covered before you have a device made. Commonly, these devices are partially covered if used for OSA treatment, but less likely if requested just for snoring issues.
3. Combination CPAP/Dental Sleep Device Therapy
Combined OA therapy can use a CPAP in addition to an oral appliance. A patient can try actually wearing both at the same time. The oral appliance fits over the teeth and slightly encourages the jaw to move forward to open up the airway, and a patient wears a special CPAP mask that only fits over the nose versus the full facemask. These two methods work effectively hand in hand to deliver a more comfortable yet effective treatment with the oversite of professional care.
if CPAP, OA therapy alone, or combination therapy are either ineffective or intolerable surgical intervention may be necessary. Surgery is typically only necessary if there is some type of physical blockage in the airway (such as excessively large tonsils or adenoids).
Why Some Patients Prefer Oral Appliances over CPAP for OSA Treatment
In July 2021, the FDA classified the Philips CPAP recall as a Class I level recall. The reason behind the recall is the identified, potential risks associated with recalled devices. These include:
- Irritation (skin, eye, and respiratory tract)
- Chest pressure
- Sinus infection
- Inflammatory response
- Organ problems (e.g. kidneys and liver)
- Carcinogenic effects (risk of various cancers)
Understandably, this has generated a number of calls inquiring about the use of OA’s instead. You may read more about which models are part of the CPAP Recall.
Efficacy of Oral Appliances in Treating OSA
NIH  also reports that OA reduces the severity of sleep apnea, and the effect is maintained at the 1-year point. Additionally, oral appliance therapy appears to reduce systolic blood pressure in hypertensive OSA subjects at 3 months and 1 year.
”OA is considered to be the most viable and accessible treatment option for patients with OSA. OA mechanically enlarges the pharyngeal space by moving the mandible and/or the tongue in a forward position. Currently, there are more than 60 different OAs in use, with considerable variations in design. However, none has achieved the position of “Gold standard.” The present clinical technique focuses on a novel OA named “customized maxillary oral appliance (CMOA),” to provide a new therapeutic option for managing moderate OSA.” – Oral appliances for obstructive sleep apnea: Emerging issues, upcoming challenges, and possible solutions by the Journal of Family Medicine and Primary Care
The NIH United States Library of Medicine provides the following table of sleep apnea study group participants and their interventions and/or treatments:
|Active Comparator: Mandibular advancement device (MAD)
an MAD is placed in the mouth prior to sleep. After waking up in the morning, the appliance is removed.
|Device: Mandibular Advancement Device (MAD)
This oral appliance keeps the mandible and the tongue in a protruded position. This results in an upper respiratory tract widening and/or reduced collapsibility of the upper airway, thereby preventing the upper airway collapse during sleep.
|Active Comparator: nasal CPAP
The device is turned on, and the nasal mask is placed on the nose prior to sleep. After waking up in the morning, the device is turned off and the mask is removed
|Device: nasal CPAP
The CPAP machine delivers a stream of compressed air via a hose to a nose mask, splinting the airway (keeping it open under air pressure) so that unobstructed breathing becomes possible, reducing and/or preventing apneas and hypopneas
|Placebo Comparator: placebo
the placebo appliance is placed in the mouth prior to sleep. After waking up in the morning, the appliance is removed.
as a placebo, a thin (< 1 mm), hard acrylic-resin palatal splint with only a partial palatal coverage was used
What is the Long-Term Success Rate in Oral Appliance Use for Sleep Apnea?
In March 2007, NIH reported that “the success rate, defined as the ability of the oral appliances to reduce apnea hypopnea index to less than 10, is 54%. The response rate, defined as at least 50% reduction in the initial apnea/hypopnea index (although it still remained above 10), is 21%”.
The Journal of Clinical Sleep Medicine’s August 1, 2021, Mandibular advancement device use in obstructive sleep apnea: ORCADES study 5-year follow-up data article provides more current data. “Five-year treatment success rates were 52% overall and 25%, 52%, and 63%, respectively, in patients with mild, moderate, or severe OSA. This reflects a decline over time vs 3–6 months (79% overall) and 2 years (68%).”
At the 5-year follow-up appointments, 96.5% of deprived sleep patients reported wanting to continue MAD therapy. Long-term MAD therapy remained effective after 5 years in over 50% of participating patients, which demonstrates good levels of patient satisfaction and adherence.
What are some of the Best Oral Appliance Brands?
An orofacial specialist may aid in determining which brand is most appropriate for each unique patient. Just as every smile is unique, so every sleep apnea sufferer may respond to the same oral appliance therapy differently. At Minnesota Head & Neck Pain Clinics, we see a variety of oral appliance options used to treat any patient.
A few Oral Appliance Brands:
This includes SomnoDent Sleep Appliances, SomnoDent Herbst Advance™, and SomnoDent Avant. Each offers a unique use case.
A custom fit is required for a Custom ProSomnus Device. Many users report it as the least intrusive, most comfortable OA therapy. There is no metal material used while creating the ProSomnus EVO™, ProSomnus [IA], or ProSomnus [IA] SELECT device.
* The Panthera D-SAD
The Panthera is among the smallest, lightest, and most durable sleep appliances available. This Digital Sleep Apnea Device is custom-created using computer optically scanned information, then 3D printed leveraging advanced technology and material. Made from biocompatible polyamide medical grade nylon, it avoids BPA, phthalate or resin materials.
DynaFlex® manufactures a number of high-quality superior Oral Appliance Therapy (OAT) devices for patients who suffer from sleep issues. The four more commonly OA patient devices with airway obstruction are the DynaFlex® Dorsal, Adjustable Herbst, TAP, and EMA.
* The MicrO2
The MicrO2 sleep and snore device is a more recent oral appliance. It utilizes CAD/Cam technology to mill a comfortable, custom appliance. Unlike other brands that clip or snap together, the MicrO2 is crafted as one, seamless unit. Patients report maximal comfort and care, and the high-quality PMMA materials make the appliance compact and comfortable while retaining optimal strength and durability.
* EMA (Elastic Mandibular Advancement) MAD
For jaw pain patients who have mild to moderate obstructive sleep apnea and don’t tolerate or haven’t found CPAP to be beneficial, oral appliances are often an effective treatment option. These devices, typically fitted by a dentist or dental sleep specialist and may include a Mandibular advancement device (MAD).
The Zyppah Pro is a temporary oral appliance that is FDA approved. It is a boil-and-bite oral appliance that is considered to be effective, safe, and easy to use. It claims the ability to adjust the lower jaw advancement. This device can only be applied by a Sleep Certified Dentist.
* Thornton Adjustable Positioner (TAP)
TAP is a mandibular advancement sleep help device that shifts the jaw forward during sleep. These appliances have 3 parts: an upper and lower dental tray, as well as a connector piece. Based on the optimal positioning of the throat during CPR, TAP appliances shift the jaw forward to open the throat and permit air to easily pass through. They can be adjusted by the patient at home with the intent of gaining optimal comfort and effectiveness.
In addition, positional therapy and/or lifestyle therapies for sleep apnea may include losing weight, stopping smoking, avoiding alcohol or surgical options. While rarely recommended, you may be wondering what surgical options look like. It is important to understand how to find a qualified practitioner for dental sleep medicine, appliances, and freatment.
Possible Treatment Options for Severe Cases of Obstructive Sleep Apnea
One can quickly see why using an oral sleep device is much less invasive and easier.
* Upper-Airway Stimulation
Severe sleep apnea patients may undergo a surgical procedure to implant an upper-airway stimulation system. The stimulation electrode is placed on the hypoglossal nerve to recruit tongue-protrusion function; the sensing lead is positioned between a person’s internal and external intercostal muscles to detect ventilatory factors.
* Stimulation Therapy for Apnea Reduction (STAR)
A pivotal clinical trial was conducted that tested the safety and efficacy of the new stimulation therapy. It concluded that patients experienced a significant reduction in sleep apnea events and significant improvement in quality of life measures. Results were published in the New England Journal of Medicine.
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About the Author
Cory Herman DDS, Doctor of Dental Surgery, treats adults and children with sleep issues, TMJ, and Orofacial pain disorders within the Minnesota Head and Neck Pain Clinic. He is known for his non-surgical orofacial pain management with an emphasis on collaborative, integrative, mind-body rehabilitative care.