Oral Appliances

Oral appliances are becoming more common in the treatment of snoring and mild sleep apnea. This is a hotly debated topic, particularly between groups who dispense CPAP devices and groups who fit oral appliances. The short answer to the question “Do oral appliances work?” is yes…. maybe.

CPAP treatment is considered a gold standard treatment of obstructive sleep apnea, because it addresses most of the levels of the airway that collapse during an obstructive event.  However, CPAP therapy may be overkill for some patients with less severe sleep apnea.  Oral appliances are devices that fit in the mouth and using parts of the mouth as a fulcrum, push the lower jaw out and therefore move the tongue out of the airway.  Some devices also pull the tongue out alone without any effect on the jaw, or depress the tongue.  For some, this is enough to improve their obstructive problems.  However, the common limitation with this device is that the oral device works in the mouth, not in the throat or nose.  This is why oral devices are called alternative CPAP therapy options.

They may be perfectly suited to control sleep apnea, but only in the right person.  One person with mild sleep apnea might get complete control with an oral device, while another with mild sleep apnea might not, based on their anatomy.  You should check with a dentist or oral surgeon TRAINED in sleep apnea management.

The following are excerpts from the Cochrane Collection, a series devoted to sifting through state of the art research, weeding out the bad studies and putting together recommendations for health professionals to follow.

1. Oral Appliances for Obstructive Sleep Apnoea.  Lim, Jerome et al.  Cochrane Review. June 2009

Nutshell:  [OSA] is characterized by recurrent episodes of partial or complete upper airway obstruction during sleep, leading to a variety of symptoms including excessive daytime sleepiness. The current first choice therapy is CPAP that keeps the upper airway patent during sleep. However, this treatment can be difficult for some patients to tolerate and comply with on a long-term basis. [Oral appliances (OA)] are now widely used as an alternative to CPAP therapy. They are designed to keep the upper airway open by either advancing the lower jaw forward or by keeping the mouth open during sleep. This review found that OA should not be considered as first choice therapy for [OSA], where symptoms and sleep disruption are severe. There has not been a sufficient amount of research that examines the effects of OA compared with CPAP in terms of symptoms and quality of life. Although CPAP was clearly more effective at reducing the disruption to sleep, some people with [OSA] may prefer using them if they are found to be tolerable and more convenient than CPAP. When an active OA was compared with an inactive OA , there were improvements in daytime sleepiness and apnoea/hypopnoea severity. OA may be more effective than corrective upper airway surgery. Further research should consider whether people with more distinctly severe symptoms respond in a similar way to those patients represented in the studies we have included in the review.

2. Continuous Positive Airway Pressure for Obstructive Sleep Apnoea in Adults.  Giles, Tammie et al.  Cochrane Review.  October 2008.

Nutshell: Obstructive sleep apnoea is the term used to describe the interruption in normal breathing of individuals during sleep. It is caused by collapse of the upper airways during sleep and is strongly associated with obesity. The mainstay of medical treatment is a machine used at night to apply continuous positive airways pressure (CPAP). The machine blows air through the upper air passages via a mask on the mouth or nose to keep the throat open. We searched and reviewed all randomised controlled trials that had been undertaken to evaluate the benefit of CPAP in adult patients with sleep apnoea. Some of the trials had methodological flaws, although more recent studies have begun to use appropriate forms of control. The overall results demonstrate that in people with moderate to severe sleep apnoea CPAP can improve measures of sleepiness, quality of life and associated daytime sleepiness. CPAP leads to lower blood pressure compared with control, although the degree to which this is achieved may depend upon whether people start treatment with raised blood pressures.

The final message is that one particular therapy is not perfect for everyone.  Obstructive sleep apnea is a condition that involves facial / throat anatomy, throat muscles and soft tissue bulk (from possible obesity) causing obstruction, while other co-existing conditions like high blood pressure, low thyroid state, depression and diabetes can all contribute to fatigue and sleepiness.  Oral appliances may work in some and not others, while CPAP may work in some and not others.

 
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