Oral appliances are an important part of the armamentarium necessary for the treatment of sleep-disordered breathing.

They are gaining appeal among patients and health care providers because they are well tolerated by patients.

In February 2006, the American Academy of Sleep Medicine published a review of oral appliance therapy for sleep-disordered breathing.¹ It was the result of an appointed task force who spent two years gathering and analyzing the latest medical evidence of the efficacy of oral appliance therapy. From this review, the AASM published a practice parameters update.²

The new parameters recommend that oral appliance therapy is indicated for patients with mild and moderate obstructive sleep apnea. The evidence showed that using oral appliances in this patient population achieved reliable results comparable to continuous positive airway pressure therapy. In many cases, patients preferred oral appliance therapy over CPAP.

However, the evidence for patients with severe OSA showed that oral appliances were less effective than CPAP. For this reason, patients with severe apnea first should undergo a CPAP trial. If they cannot tolerate CPAP, attempting oral appliance therapy is appropriate.²

Selecting the best device

Oral appliances for sleep-disordered breathing are basically of two types - anterior mandibular positioning devices and tongue retaining devices. Anterior mandibular repositioning devices are the most effective and popular. They are available in many designs, and each employs a slightly different mechanism to move the jaw forward to prevent pharyngeal airway closure during sleep.

Boil-and-bite oral appliances are less effective than studier custom-made appliances.  In one double-blind crossover study, results were so poor for the boil-and-bite appliances that the authors concluded that thermoplastic appliances should not even be used as a trial appliance to see if patients could tolerate oral appliances.³

The dentist's knowledge of the varieties of oral appliance devices is critical in selecting one that is suitable for the patient's oral conditions. If the oral appliance is comfortable, effective, and durable, the result likely will improve the patient's long-term compliance.

Improving compliance rates

Compliance with oral appliance therapy after one year of use averages around 60 percent perhaps but drops off after that. The primary complaints that affect use include lack of efficacy, loss of retention, discomfort of the temporomandibular joint or teeth, and changes in the bite or occlusion.

Follow-up by the dentist can address a patient's concerns about oral appliance therapy. After insertion of the appliance, the dentist should see the patient every six months for two years, and then annually thereafter. This is to determine if the appliance is still efficacious, if it is functioning properly, and if it is in need of repair.²

Overnight titration of an oral appliance in the sleep lab is an excellent method of determining the oral appliance's most effective setting. However, the sleep technologists must have familiarity with the appliance the dentist used. For this reason, it is imperative that the dentist establishes close communication with the centers performing the sleep studies.

If the patient becomes symptomatic of OSA while using the oral appliance long term, the patient must have the appliance readjusted. If symptoms continue, they should be sent back to the referring sleep physician for assessment and possible polysomnography.

Dentists with sleep expertise needed

Another AASM recommendation in the practice parameters is that oral appliances should be placed by dentists who are familiar with sleep medicine, including oral appliances, occlusion, and the temporomandibular joint.²

The American Academy of Dental Sleep Medicine holds an examination annually for those dentists interested in receiving a diplomate status. This is not a recognized specialty. It is only granted by the AADSM to designate to physicians that these individuals can demonstrate excellent knowledge of sleep medicine and the use of oral appliance therapy for the treatment of sleep-disordered breathing. 

To qualify for these exams, dentists must submit a number of patient cases referred to them by sleep physicians. These cases must make evident the dentists' proficiency in the use of oral appliances.

References:

1. Cartwright R, Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244-62.

2. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006;29:240-3.

3. Vanderveken O, Devolder A, Marklund M, Boudewyns A, Braem M, Okkerse W, Vanderveken O, et al. Comparison of a a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea . Am J Resp Crit Care Med. 2008; 178;197-202.

 Jeffrey P. Pancer, DDS, is president of the American Academy of Dental Sleep Medicine.