Oral appliances are increasingly recognized to play a role in managing sleep apnea. There will soon be a new "practice parameter" published by the American Academy of Sleep Medicine that I will share with you when out. This guide reviewed all of the available evidence. The guide noted there is still a need for more research but based on the existing data made a number of recommendations.
Here are some key points about oral appliances: Oral appliances are generally not as effective as CPAP in lowering the AHI compared to CPAP when each device is used for the same duration. However, some people tolerate oral appliances better than CPAP and wear them longer, so that the overall improvement in sleep apnea (AHI) averaged over the entire night and across nights can be similar to to CPAP when worn for a shorter time. Some studies show that oral appliances can reduce blood pressure and improve sleep apnea symptoms, sleep quality and quality of life, too. However, oral appliances are not without side effects--some people may have problems with their jaw or teeth with this treatment. Oral appliances can only be fit in people with a minimal number of teeth and who dont have problems opening their mouth.
The best oral appliances are those that are customized by a dentist and "titrated" to provide the right amount of jaw opening needed for the individual patient. Generally, oral appliances are recommended when patients do not tolerate CPAP. They are also often used to treat snoring that is not accompanied by sleep apnea. If you are interested in an oral appliance, talk to your sleep doctor and review what is best for you.
More research on oral appliances is needed so better decisions can be made on when to use them and who is likely to get the most benefits.
thanks for this question and let me know if you need more information.
Hi All, Im on my second appliance. The first, an EMA worked good for me. I had some dental work done shortly after receiving it, and that led me to my second appliance, the TAP-3 Elite. Just started wearing this for one week now. Unfortunately, I do not know if this will work out for me or not. I am still waking up VERY tired in the morning, and I do not know why. I believe the TAP-3 is doing its job, and there may be something else causing my tiredness in the mornings. I have an app on my phone that I turn on prior to going to sleep and it monitors my snoring levels. So far, and it shows very little snoring, so I do not believe there are any obstructions and the TAP is doing its job.
My Bio: 5'1; 119lbs;health: good shape (could be better with more exercise! :) ); age: 52; diagnosed CPAP intolerant
I am a new forum member here and my goal is to talk with others and share ideas and stories. Feel free to contact me here with any questions.
Interestingly, snoring often goes away before the sleep apnea does. Snoring is controlled in over 80% of the people who get an oral appliance. So it may indicate an effective device, but not always. The TAP family of devices is often made starting at a natural jaw position and you then moves the jaw forward. Since the TAP allows around 10 mm of movement, this may be inadequate to get you to an effective position. The EMA is normally fabricated at an advanced position to start and it may be easier to get your jaw out further. Just to muddy the water, some people can move their jaw too far and, get worse. See if you can compare the two appliances to make sure they are the same forward position. Then look to see if the distance between the front teeth is the same. Your dentist may need to alter the position of the hardware on your new appliance. The dental work must have been extensive because an EMA can usually be adjusted around changes in dental work (as can most hard appliances) unless the crown was way too bulky on the tongue side or cheek side.
Well, Airway Management specifies that bites to guide construction of Taps be set typically at 60% of maximum protrusive position, which would typically be well forward of the typical "habitual closing" position and would make the device capable of reaching maximum protrusive position for the vast majority of people. Never-the-less, it is up to the dentist to be skilled enough to compensate for that. Best practice is to use a George gauge to determine maximum protrusive position ahead of time, so that the Tap can be built forward enough to make that position attainable. It is easy to do. One problem with the EMA and also with the Silentnite appliance, which are somewhat similar in construction is that the bases are made of only one thin layer of material. The upside to this is that the appliances are very thin and comfortable for people who are bulk averse. The down side is that there really is very little thickness for adjustment and unless the dental work is pretty minimal, adjusting the bases is tougher than on other appliances with thicker bases. Everything is always a trade off. Another problem with the EMA is that the adjustment straps tend to stretch and break over time, creating an ongoing maintenance problem. Other devices, like the Somnodent, the Taps, the Micro2, and others have sturdier, more trouble free adjustment mechanisms. Arthur B. Luisi, Jr., D.M.D.
I have tried every treatment under the sun, and only use a manibular advancement appliance for about 2 years now. While not perfect, I would say it is 50% effective. I did have a second sleep test after fitting the appliance and it was as effective as cpap for me, but everyone is different. My biggest side effect is my bottom jaw is permanently moving forward. I am seriously considering surgery at the end of this summer if i dont find a better solution soon.
Carl G, I have been using a dental appliance for probably 10 years now. My first provider was a maxillofacial surgeon who knew the device well and knew that the lower jaw would move forward but thought that was the price to pay. And my jaw did move. Now my second provider who specializes in only sleep apnea dental devices is very concerned about lower jaw movement. I have a mold called a morning positioner that I can use to move the jaw back in to position. I hardly use it because I find it easier to just rest my lower jaw on my hand while working on the computer in the morning. However, that is easy to forget. There are all kinds of exercises that you can do to correct this. Your dentist should be able to advise you.
In all this time I have never had a second sleep study to titrate my appliances. I tried to do one a couple of years ago but the setup was so uncomfortable that I could not sleep enough to get it done. Now at the five year point on my second device (Medicare only pays for one every 5 years) I will need to get a sleep study. I am hoping they will accept a home study because I cannot stand those labs, especially the last one.
for those folks here that have used a dental appliance, what is the issue(s) with the jaw moving forward ?? Approx how far forward is the advancement? Can you or someone else see the movement or is it that you feel your teeth mis-align. I am supposed to be fit for a dental appliance. I can not tolerate CPAP.
My large tongue base is my OSA issue. I am 62, 180 lbs and have a 16 neck. No health issues except slightly high BP. I am undergoing a series of 6 treatments on the base of my tongue. High frequency ablation of my tongue base is done outpatient in my ENT's office, under local anesthesia. It supposed to reduce the tongue base 10-15% and stiffen the tongue base tissue, which relaxes and collapses during sleep. Causes my nasty snoring at night also.
Jaw advancement is dependent on each patient. Some move a lot, some not at all. In the only study evaluating patients wearing an oral appliances for 15-20 years showed tooth movement in all of them. So 2 things can happen: 1. Tooth movement and 2. Movement of the entire jaw. Research is ongoing as to whether jaw repositioners help or if the results I want to see are really there. I have patients who, after 20 years, have moved their jaw almost 1/2"; in dental terms that is scary but he doesn't care. He eats fine, speaks fine and continues to be productive at work. I have others at 10 years who have no changes.
An unusual type of device for large tongues is a Tongue Retaining Device (Not covered by Medicare). This holds your tongue forward in a suction bulb and was developed years before the jaw movement style that most of us dentists use today. I started doing oral appliances in 1989 and limited my practice to sleep dentistry in 1997...in all that time, only 3 patients were able to tolerate a tongue device long term.
Since the tongue is only one part of sleep apnea, surgical procedures are less effective long term than CPAP or an oral appliance which address many more blockage locations than behind the tongue. Recent studies done at hospitals working with Harvard Medical School have shown that the tongue does not collapse as much as was once thought. These studies will help us better predict who will benefit from an oral appliance based on data collected from your laboratory sleep study.
I my clinical experience, I have also found that there is a wide variation in how far forward patients can advance their mandibles. The clinically significant number is the range of motion from maximum retruded position(as far back as the patient can move the lower jaw) to maximum protruded position(as far forward as the patient can move the lower jaw). I have seen this vary in my practice from 0mm(no movement possible) to around 15-16 mm. The average is probably about 8-10mm(have seen studies quoting averages in this range). Generally, more range is better than less. Arthur B. Luisi, Jr., D.M.D.
Chuck, I believe the issue with the jaw moving forward (and staying forward if you don't do the corrections) is that it screws up your bite. As I said, my first provider either did not care or did not know that the advancement could be corrected. In my case, getting the sleep apnea under control was the primary motive for getting a dental device and the heck with the jaw. The jaw advancement can be seen in the mirror in my case, it is a little like Marlon Brando in The Godfather but not as extreme. The advancement is not much, a few millimeters at time. And it has to be done gradually not all at once. Once the device is removed from the mouth most of the Marlon Brando appearance is gone, i.e. the jaw does not stick out much. I can feel the stiffness in the morning and if I do my excercises that goes away pretty quickly.
It would be interesting to find out how often and how many hours per night CPAP is commonly used. I use my dental device all night, every night. I don't think every CPAP user can say that. It would be interesting to hear some comments on that issue, I have not read the other forums so there may well be that discussion going.
Oral appliance therapy is best done with a dentist trained in the field. The American Board of Dental Sleep Medicine (www.ABDSM.org) oversees a rigorous examination and submission of completed cases (with sleep studies before and after) and has a list of qualified dentists in the US and Canada. While the list is quite limited at the moment, more than 100 dentist have already signed up to take the next exam.
Important data to know about oral appliance therapy is that they do not always work. Unlike CPAP which can open the entire collapsible airway (4" in women and 5" in men), oral appliance are site specific. Since your physician does not know where your blockage is, there is no way to predict if oral appliance therapy will be successful; this can be a very expensive trial and error adventure. Medical insurance will often cover the cost of an oral appliance if you have been diagnosed by a physician with sleep apnea. There are many rules that are unique to each insurance company. An example is that Medicare requires that you have a sleep study that is no more than 1 year old at the time of oral appliance therapy. Seems as if dentist have to follow the rules laid down for CPAP companies.
Oral appliances are more effective in patients with mild to moderate sleep apnea, who are of normal weight and who needed CPAP pressure lower than 13.
Side effects are related to the fact that the oral appliances in use belong to a class of orthodontic devices developed over 100 year ago to permanently move forward small lower jaws in children. Where the children had to wear the device 24 hours / day for 5 years, patients with sleep apnea only have to use the appliance during sleep. While some patients can have permanent jaw movement (I guess this is good if you have a small lower jaw), many dentist have developed various ways that can help you maintain normal jaw position. Switching between CPAP and oral appliance use could be one way of limiting side-effects.
As Dr. Demko said, the list of officially certified dentists is extremely limited at this time. There are not nearly enough to cover the current needs of patients in the USA. There are a much larger number of dentists who do have sufficient experience to be effective, but are not certified. I think a good way to find them is to ask for a recommendation from your sleep physician or the head of your local sleep disorders testing lab. They have typically established a relationship with local dentists experienced in dental sleep medicine and can give you the name(s). Arthur B. Luisi, Jr., D.M.D.
Dr. Demko, your statement that oral appliances are more effective in patients who needed CPAP pressure lower than 13 surprises me. I have always been under the impression that there was no known correlation between the level of CPAP treatment pressure in cm's H2O and the success rate of oral appliances. Could you offer some research data on this topic? Arthur B. Luisi, Jr.,D.M.D.
There are two studies that looked at this exact topic. Interestingly they showed a significant racial differences, the cutoff point for Asians is 10.5 cm.
Sutherland et al 201. CPAP pressure for prediction of OAT response in OSA (Sleep Vol 10, No 9 943- 949)
Tsuiki 2010. Optimal positive airway pressure predicts OAT response to sleep apnea. (Eur Resp J 2010 35: 1098-1105)
As with all treatments, there are outliers and people who respond when not expected to.
I reviewed both studies and also a third, Journal of Dental Sleep Medicine Vol:03 Number:04 10/10/2016. Does CPAP Pressure Predict Treatment Outcome with Oral Appliances. My take-away would be this: Clearly, lower CPAP pressure is predictive of success with oral appliances, to some extent. I would keep this in mind and probably discuss it with patients. Do I feel comfortable enough with it to put a number(13) in a list of factors for OA success on the forum at this time. Probably not. It is a judgement call. Arthur B. Luisi, Jr., D.M.D.
Thank you Dr. Demko for the excellent posting on oral appliances found: https://myapnea.org/blog/oral-appliances-an-experienced-dentist-shares-her-perspective
Obviously, It would be nice to know just how many people in the USA actually use oral appliances to treat OSA. Unfortunately that figure is not available. I do have some idea about what the production figures are for some of the more popular appliances. If one takes the often quoted success rate at 50%, I would estimate the number of people using oral appliances at 250,000 to 500,000 and probably closer to the higher end than the lower. Arthur B. Luisi, Jr., D.M.D.
One must not forget that almost 50% of patients who get an oral appliances, and for whom they are successful, discontinue use within 2 years. Many patients with chronic diseases are NOT perfectly adherent with therapy. This includes high blood pressure medication
Well, that is certainly a depressing statistic. If that is the case, one must assume that large numbers of both CPAP and oral appliances users eventually conclude that it is more trouble than it is worth. I would speculate that it is the less symptomatic patients that may be doing so. At least, in my own practice, the very symptomatic patients, who can then perform and feel much better using either CPAP or OAs tend to stick with it. They get a lot of positive reinforcement for putting up with the discomfort of treatment. I can understand why many people with other chronic diseases and conditions tend to have better rates of compliance. How tough is it to pop a couple of pills a day? I guess the take away is that we need to continue to find new ways to treat OSA that are more comfortable and require less commitment, if such ways are possible. Arthur B. Luisi, Jr., D.M.D.
They work in most people (more that 55%) . There are 4 major reasons people get sleep apnea, only 2 of them are related to the patient's anatomy, and abnormal anatomy is what an oral appliance fixes. This does not mean what the patient looks like to the physician or dentist, but how the muscles work and how well the brain controls breathing. An effective appliance is based on an action used during anesthesia to keep the airway to the lungs open prior to placing a breathing tube.This does not work in people who have throat blockages close to their voice box or in those people who have the throat close from all sides rather than just front to back or side to side. That being said, More than half of the people tested completely controlled their sleep apnea when using an oral appliances. Another 25% had a good response, but not perfect.
These appliances are most effective in thin, young patients, but what isn't? CPAP does not have these limitations. Medical insurance (not dental) covers oral appliances, even Medicare. All insurance companies require a trial of CPAP if you are diagnosed with severe sleep apnea.
People love their oral appliances (and yes, there are large numbers of people who love their CPAPs). It is important to offer patients choices in the treatment of their sleep apnea.