I previously asked about whether there was updated research on the effectiveness of dental appliance for sleep apnea and never got a response. Do I take that to mean there isn't anything?
What about sleep apnea surgery such as the UPPP and MMA Jaw advancement surgery?
Many people seem to be under the impression that most alternatives to pap therapy don't work very well. But it seems that unless there is updated research that we can refer to, that no one whether they are or not in support of them, has the monopoly on the truth.
This is a great question.
Increasing evidence indicates that dental devices (also known as oral appliances or mandibular advancement devices) can play an important role in the treatment of sleep apnea. In fact, there have been over 70 clinical trials that have evaluated various oral appliances compared to no therapy, compared to alternative oral devices (there are many models), or compared to CPAP. In 2015, the American Academy of Sleep Medicine published an updated guideline on use or oral appliances ( Journal of Clinical Sleep Medicine; 2015: 11(7): pages 773-827). They concluded that while CPAP is generally more effective in reducing the AHI, many patients with mild to moderate obstructive sleep apnea benefit from oral appliances with improved symptoms, better sleep quality, and reduced numbers of apneas during sleep compared to no treatment. Even some patients with more severe sleep apnea may benefit. Custom-fit devices, which can be "titrated" to meet specific patient needs, was recommended over non-custom devices. A summary of the research on this area led to the recommendation that oral devices be considered for patients who do not tolerate CPAP and that use of these devices should be overseen by both a sleep specialist and a qualified dentist. It is important that response to treatment, symptoms and possible side effects are closely monitored, and changes made as needed.
There are also other treatments for sleep apnea--including hypoglossal (tongue) nerve stimulation and various surgeries. The effectiveness of these depends on a number of factors, such as a person's anatomy and disease severity.
In looking to understand your options, speak to your sleep doctor and discuss any concerns about CPAP. Ask about other options and whether your doctor thinks you are a possible candidate to be further evaluated by a qualified dentist (for an oral device) or a surgeon (for surgery).
I will be asking some of our experts in this area to contribute future blogs to further discuss these topics. You can use the search button to see what other patients say about their treatments.
Updated research on the effectiveness of mandibular advancement oral appliances (OAs) is always forthcoming and there is a journal that prints nothing but articles about this form of treatment. The success rate of oral appliances sits consistently at about 50%. That means that half the people who get an OA respond as well to the OA as others do to CPAP. Interestingly, 20% get better, but would not be considered to have controlled their sleep apnea by their sleep physician. A solid 25% do not improve and a few even get worse. After 20 years of research as to who will be effectively treated with an OA, we still cannot predict who that will be. Since we do not know who will respond to an OA and who will not, all people who get an oral appliance MUST return to see their sleep physician and most of these need to have actual sleep testing to make sure the OA is working.
On thing that does make physicians happy, and dentists too, is that the average nightly use of an OA is 6 hours/ night and the average use of CPAP closer to 4 hours / night. That means that people who are only partially treated with an OA, but use it all night may have the same medical improvement as someone who uses CPAP for 2-3 hours per night. All treatments used for the entire sleep time work better than a treatment used only part of the night.
All surgical approaches are less effective long term than CPAP and OAs. Even double jaw surgery (MMA advancement) will eventually fail. CPAP is the only treatment that does not fail with long term treatment.
While it is true that the success rate of oral appliances consistently sits at about 50%, I feel that this is somewhat misleading in that this would be an over-all average for a wide range of appliances. There are definitely oral appliances capable of much better efficacy rates than that. Most notably, the TAP line of appliances. A very well regarded study by Dr. Arnaud Hoekema showed an efficacy rate for the Tap at about 84% for mild to moderate cases of OSA. So it behooves sleep dentists to know the efficacy rates for the various appliances and to select the best. You can certainly do better than 50% for mild to moderate OSA. I know that I do. Arthur B. Luisi, Jr. D.M.D.
Knowing the literature is important when reporting on which device is 'more effective'. Hoekema's data is more than 10 years old and was done looking only at the TAP 1. The TAP 1 was made from pieces supplied by the parent company and actually fabricated to Dr. Hoekema's specifications by his own laboratory...a much more controlled fabrication that seen from most dental laboratories (dental technicians in the US are not required to have any training and there is no requirement that they know what they are doing). One study done comparing the effectiveness of two different appliances (TAP 1 and a Herbst style device) showed an initial advantage of the TAP device ( by a very small number of breathing events) but, by 2 years, the improvement in breathing events was similar and more people had stopped using their TAP appliance. With over 30 studies scientifically comparing one device to another, there is no consistent device that is more effective than another. In Japan , where insurance reimbursement is poor, dentists must make do with prefabricated devices (bought in bulk on line) and fitted by a dentist. Those devices fitted by a dentist are almost as effective as a custom fabricated one provided by a dentist.
As Dr. Luisi states, he is more effective in treating patients with mild - moderate sleep apnea, so is every dentist. Every study has a different definition of success some of which say, that if the number of breathing events is cut in half and ends up under 20 / hour that is 'success'. No sleep physician would accept a residual number of breathing events of 20 (still moderate sleep apnea) when titrating a patient with CPAP. Physicians Titrate CPAP until the number of breathing events is less than 5/hour. This level of breathing events has been shown to resolve all negative complications that occur with untreated sleep apnea. Hoekema's study (2004) showed an excellent response to oral appliance therapy but every patient had more than 2 laboratory sleep studies. If the study showed the patient did not respond well, the oral appliance was adjusted in hope of improving outcomes. This cannot be compared to a normal procedure for a dental provider who does not follow the same rigid guidelines as in the study.
Well, O.K., point made. However, In my practice, I track the results with my appliances very carefully with sleep studies with the oral appliance in place. I am VERY insistent that the patients get these and over the twelve years that I have placed Taps, the results have tracked that of the Hoekema study pretty closely. I know other dentists that have told me that their results have also come close to the Hoekema study long term, too. So I am fairly confident that these appliance can exceed the 50% success level by a pretty significant margin. I do not say this because I am acting as an agent for Airway Management. And I do use a selection of other appliances when indicated so that I am not a one trick pony. The point that I am making is that we should not get comfortable with a 50% success rate. I think that, with more research, and by weeding out some of the weaker members of that over 100 population of oral appliances, we CAN do better than that for the patients. Arthur B. Luisi, Jr.,D.M.D.
As you stated, Hoekema's study(2004) showed an excellent response to oral appliance therapy. It proves that, with top notch technique, properly selected patients, and a better than average titration protocol, much better results CAN be achieved with oral appliance therapy than is being achieved currently in the United States with dentists who, in general, are fairly poorly trained in dental sleep medicine. So, just because the dentists are currently not up to this level of quality, does that mean that we have to accept mediocrity and blame the technology when most of the fault lies with the practitioners. I hope not, for the sake of the patients. Arthur B. Luisi, Jr., D.M.D.
If one references the 2015 joint study by the AADSM and the AASM on oral appliances, as I read it, there is no statistical difference in many of the medical outcomes of CPAP vs. OAs with the notable exception of Oxygenation levels(big win for CPAP) and AHI(big win for CPAP). The question that has to be raised is the following: Is it fair and proper to apply CPAP standards to OAs when evaluating them? I believe that that is still an open question. OAs are not CPAP Lite, they are a different mode of treatment alltogether. A huge difference is that the entire oral appliance experience is much less intense than CPAP and for that reason people's bodies react significantly differently too it. This must be taken into account and is not. As I understand it, the AADSM does not have an official standard for acceptable efficacy for an oral appliance at this time and do not think that it is necessarily correct to just use the CPAP standard. Arthur B. Luisi, Jr., D.M.D.
There is no accepted definition of treatment response for surgery or oral appliance therapy, only CPAP; that is why we often borrow their definition of success. At present, most studies on oral appliances report three outcomes: how many people drop the AHI by 50% (a surgical definition), how many drop the AHI below 15 and how many drop the AHI below 5. The number of breathing events has been used as a measurement for years because we can measure it. There is a significant move to look at the amount of time you spend with an oxygen saturation below 90% as the next new measurement to be used in evaluating treatment outcomes. This is a young field and we are still working out all the bugs and trying to get at the core.
A few more thoughts on treatment standards. The CPAP standard is an AHI reduced to less than 5("normal" people can have a few apneas per hour) and total abolition of symptoms. Let's say that a patient who had a pre-treatment AHI of 20 and was quite symptomatic is reduced by an oral appliance down to an AHI of 9 with a total abolition of symptoms. Would you consider that successful treatment? I would. Long-term cohort mortality studies show increased mortality in OSA patients with an AHI above 20. Let's say that a severe OSA patient has a pre-treatment AHI of 50 and an OA cuts that down to 15 with a total abolition of symptoms. Would you consider that successful treatment? I would. The point is that physicians feel that they must titrate the AHI down to below five for success with CPAP and usually they can do so. Remember that oral appliances are a different mode of treatment than CPAP. Do they have to be titrated down to below AHI of 5 to be successful. Possibly not. TO BE DETERMINED. Arthur B. Luisi, Jr.,D.M.D.
My profuse apologies for not coming back to this thread and thanking everyone for their responses. I am looking for a link to a similar type study that I posted a few years ago on another apnea forum that was from 2011 in which the various AHIs ranges were broken down as to how well the dental appliance had been in getting the AHI to 5 or below.
Dr. Luisi, your point is well taken that someone who doesn't reach an AHI of 5 or below with a dental appliance may still be considered to be successfully treated depending on their situation. Still, I think a study like the updated 2011 would be nice to access. If I remembered where I got it from, I would post the link but unfortunately, I don't,
Dr. Demko, any links you can provide that proves that surgical advances don't hold up long term? And when you say long term, what is your definition of that? Even if someone can't tolerate pap therapy and a dental device but needs treatment, having surgery still might be worth having depending on the situation.
And just so folks know, I have tried repeatedly searching to find what I am looking for to no avail. Perhaps I am not looking in the right place.
Surgical therapy for sleep apnea is a big field. There are multiple options of soft tissue throat surgery, (most of which have fallen out of use over the past 20 years), implantable pacing for the nerves that control the tongue, or surgical movement of both the upper and lower jaw called maxillomandibular advancement surgery or ‘telegnathic’ surgery. Ear nose and throat doctors do the soft tissue and implant surgery while specially trained oral surgeons do the movement of the jaws.
Soft tissue surgery has been known to be less effective than oral appliances therapy for more than a decade and this was reviewed in an article by Adam Elshaug and others in the journal of Sleep in 2007. Simple in-office procedures using a laser or a procedure called radioablation have been shown to be somewhat effective for the treatment of snoring but ineffective in the treatment of sleep apnea. (Camacho et al published a review of laser surgeries in 2007 and one of their conclusions was that they did not believe laser assisted uvulopalatoplasty should be done at all because 44% of patients got worse.) Caples and his coauthors wrote in 2010 that previous styles of throat surgery were poorly studied (who wants to have pretend surgery to see if a procedure really works?) but that newer techniques appeared promising. Van Maanen did a study in 2012 where the AHI dropped from 36 to 25. I know of no sleep physician that would accept that as a final number of breathing events per hour and call that ‘success’. Implantable devices show much promise, but insurance companies do not, as of yet, cover this surgery because they consider it experimental. Ear nose and throat doctors are working more with newer procedures and doing a great deal of patient evaluation to try and ‘hand pick’ patients who are more likely to be effectively treated. Many studies suggest not treating anyone over 55 years of age or who are significantly overweight. When looking at jaw surgery, I was lucky enough to lecture in Korea with Kasey LI, MD, DDS (a very impressive surgeon in California) and he said in his lecture that it appears as if jaw surgery fails around 15 years and he has patients comping back to do the whole thing again. Look at his website for more information: www.SleepApneaSurgery.com Bariatric surgery is the best option for patients who are more than 100 lbs. overweight. While all the studies show that weight loss does not cure sleep apnea, it will seriously improve it. To go from very severe apnea to mild or moderate sleep apnea will allow previously ineffective treatments to become effective. Weight loss / weight control should be part of any treatment plan for sleep apnea.
As far as the literature shows, there is no treatment except CPAP that does not fail with time. It seems much easier to increase CPAP pressure over the years than to go through repetitive surgeries. This is why there is such a push to have patients try CPAP. While many patients feel they cannot tolerate it, sleep physicians and technicians work every day to try and help you find a set-up that works and is comfortable. The future holds a team approach for every patient to help find what will be optimal treatment for each individual. This will include sleep physicians, Ear Nose and Throat doctors, dentists, psychologists and others. Those of us in the field wish we could figure out how to predict which patient will be successful with any single treatment option. Only CPAP works for 90-95% of patients.
There are no websites of which I know that talk about treatment failures. I have a library of more than 2000 medical and dental articles that I access when discussing treatments and 27 years of experience.
I am not sure what you mean by updated research on the effectiveness of oral appliances. Last count, there were more than 700 articles on oral appliance therapy (from 1986- to present) all of which show a statistical improvement in all studied outcomes (AHI, oxygen saturation, quality of life, blood pressure, you name it.) Research is ongoing to look at the impact appliances have on diabetes and A1C. To date, looking at 30 years of data, CPAP is effective in 90-95% of patients, jaw surgery in 75% of patients, oral appliances in 55-50% of patients and soft tissue surgery, less than that. These are studies over only a 1-year period. Long term impact is less well studied. But CPAP has been around since 1981 and I have read posts from those who have used it fir more than 20 years. That speaks volumes right there. I have only one patient who has used his oral appliance for > 20 years.
Sleep Apnea never goes away. It gets worse with age, weight gain and other medical conditions. It is like diabetes and requires daily treatment.
Now we look to reviews of the literature and improved study design.
The high level of success with CPAP in reducing the AHI to acceptable levels is, indeed, tantilizing. But, as one of my earliest patients said, no matter how good a treatment is, it won't help you if you can't stand it. Of course, the big problem is the compliance rate, especially over time. And CPAP does have a long list of potential side effects, certainly a much longer list than oral appliances have. I might sound cavalier in saying this, but there has to be a better way. And I am not saying that oral appliances are that better way. Arthur B. Luisi, Jr., D.M.D.
