- Why OSA and snoring need to be treated.
- What treatment options exist, in addition to the oral devices that represent the focus of this piece.
- Why dentists are the medical professionals who are often the first to spot snoring/OSA problems.
- The advantages and disadvantages entailed by the various treatment options.
- Clinical trial-based evidence concerning the efficacy of oral appliances for OSA.
- How you should go about finding the proper form of dental treatment for your OSA.
What is OSA and why should you treat it?
…also: is snoring really something you should treat? Snoring is common and people seem to live with it fine.
The problem is that the root causes of Obstructive Sleep Apnea and snoring are the same. If you snore, you experience a restriction of your upper airway. More precisely, the obstruction occurs at one or several of three critical sites: the nose, the velopharynx, and the hypopharynx.
When you breathe in, you exert negative pressure on your upper airway. While you are awake, the pharyngeal dilator muscle counters this pressure. During sleep, this muscle relaxes and the airway collapses. As air is forced through the collapsed airway, it starts to vibrate. This is snoring.
If you fail to draw a breath for a set amount of time while snoring, OSA occurs. Being overweight and having a thick neck are OSA risk factors. Abundant pharyngeal tissue is always a problem.
Weight loss is, therefore, a natural first remedy. Some OSA risk factors are out of your control, however:
- Elongated palate
- Large tongue
- Facial bone structure peculiarities
- Thick lateral pharyngeal walls
- Longer pharynx (men usually have longer pharynxes than women)
Why you should not leave your snoring/OSA untreated
Sleep apnea, which is a consequence of snoring, results in blood oxygen desaturation. It also causes several micro-awakenings during the night. It thus deprives the sufferer of quality rest.
According to a 2015 study, by Melissa Knauert, Sreelatha Naik, M. Boyd Gillespie, and Meir Kryger, the health implications of OSA are enormous. If left undiagnosed and untreated, the condition can cause:
- Daytime sleepiness conducive to workplace- and vehicle accidents
- Myocardial infarction
- Morning headaches
- Frequent nocturnal urination (nocturia)
- Loss of libido
A substantial body of additional scientific evidence supports these findings.
Untreated snoring and OSA can result in death. The economic costs caused by untreated sleep apnea are also significant.
Snoring/OSA Treatment Options
Among an abundance of other scientific evidence, a 2016 study published at PubMed proves beyond doubt that Continuous Positive Airway Pressure (CPAP) treatment can increase the quality of life of OSA sufferers.
CPAP is widely regarded as the most efficient treatment solution for OSA. By forcing air into your collapsed upper airways, it eliminates the risk of choking. It also helps with snoring.
CPAP machines are somewhat cumbersome, however. They consist of a motor that generates air pressure, a face mask, and a tube connecting the two. Most CPAP machines are lightweight enough, so you can take them along when traveling.
Despite the apparent advantages of CPAP, you may find that you cannot get used to this type of treatment. People have reported scores of side effects. While some of these problems are tolerable, many pose real challenges to users.
According to WebMD, CPAP machines can cause:
- Discomfort and a sense of confinement from the mask.
- Dry mouth and sore throat.
- Chest muscle pain.
- Bloating and digestive discomfort.
- Sinusitis and even nose-bleeds.
- Sores on the bridge of the nose, where the edge of the mask rests.
Please note that if you happen to suffer from such side effects, you should contact your physician and have your device adjusted. Do not discontinue CPAP treatment in favor of an alternative solution on a whim.
Your care provider can recommend cushioned face masks or even heated humidifiers. Such solutions can alleviate many of the above-mentioned side effects.
Perhaps the biggest shortcoming of CPAP treatment is the fact that it does not lead to a permanent cure. To achieve that, a more radical approach is needed.
At first glance, surgery may not seem like an attractive option for many. It is more expensive than CPAP and dental appliance-based solutions. It is naturally intrusive as well.
On the other hand, unlike CPAP, surgery offers a permanent cure for OSA as well as snoring. It alters the airways, therefore it is a very effective treatment option. In addition to addressing the problem head-on, surgery also deals with maxillofacial and skeletal irregularities which also act as OSA triggers.
That said, you will likely require lifelong follow-up if you do go through such a surgical procedure.
If nasal obstruction is to blame for your snoring/OSA, surgery is a very effective option. It bears pointing out that in such cases, prosthetics are highly effective as well.
A 2012 study by Bettina Carvalho, Jennifer Hsia, and Robson Capasso provides a bevy of useful information on surgical procedures targeting OSA.
According to this study, OSA and snoring can be addressed through the following surgical procedures:
- Surgical procedures aimed at the nasal cavity can target soft tissue or skeletal structure. Polypectomy and ablation of turbinate are soft-tissue surgeries. Septoplasty is skeletal surgery.
- The procedure aimed at the Nasopharynx is called Adenoidectomy.
- Procedures targeting the Oropharynx can also be skeletal or soft-tissue surgeries. Tonsillectomy is one of the most popular such soft-tissue surgeries. Rapid Maxillary Expansion is the skeletal approach to Oropharynx surgery.
- The Hypopharynx can be targeted through Midline Glossectomy and tongue base reduction. Both are soft-tissue surgeries. Mandibular Advancement and Genioglossal Advancement are skeletal options.
- Maxillomandibular Advancement targets the Oropharynx and the Hypopharynx.
- Tracheotomy is the more radical solution of bypassing the airway.
It is up to the surgeon to decide exactly what type of surgery you require.
The main disadvantage of surgery is that having your airways rearranged in such an intrusive manner is problematic. It may provoke post-surgical complications.
There are OSA-sufferers for whom neither CPAP therapy nor surgery is a reasonable option.
For such patients, dental appliances represent an alternative treatment path.
Dentists and OSA/Snoring
It may be surprising that often, the earliest diagnosis of sleep apnea is delivered by dentists. It makes perfect sense, however.
Some dentists are trained to draw sleep-related conclusions from the dental condition of their patients. That said, only a qualified sleep specialist can set an official diagnosis in this regard.
Your dentist may still recommend a sleep study based on his/her observations.
Often, teeth-grinding (bruxism) is the first sign of OSA – according to WebMD. Bruxism leaves some telltale signs on people’s teeth. Dentists know exactly how to interpret the worn tooth surfaces that result from tooth grinding.
In addition to worn surfaces, tooth grinding also results in inflammation, receding gums, as well as an uptick in the number of cavities.
Once he/she has spotted these signs, your dentist can look for redness in your throat, caused by snoring. Other telltale oral signs of OSA are scalloped tongue-edges and a small jaw.
Why is bruxism often associated with Sleep Apnea? The act of clenching your jaw generates a wake-up signal for your brain. This signal allows you to awaken from an OSA choking episode, and to draw a breath.
If your OSA/snoring treatment does take the path of oral appliances, you will find yourself in the hands of a dentist again.
Oral Appliances for the Treatment of OSA/Snoring
Treating your snoring and sleep apnea through an oral appliance means much more than picking up a random mouthpiece online.
In a 2006 study, published in the Journal of Clinical Sleep Medicine, and updated in 2015, authors Kannan Ramar, Leslie C. Dort, Christopher J. Lettieri, and others, have defined a set of guidelines for oral appliance therapy.
According to this guide:
- If a sleep physician prescribes an oral appliance for OSA, the appliance should be custom-made by a specialist dentist. It should also be titratable.
- Sleep physicians should prescribe oral appliance treatment for non-OSA snoring. Leaving the condition untreated should not be an option.
- For OSA sufferers who do not tolerate CPAP therapy and are not willing to undergo surgery, sleep physicians should prescribe oral appliance therapy.
- Follow-up oversight for oral appliance therapy should be provided by a qualified dentist.
- Sleep physicians should follow up oral appliance treatment with sleep testing. This way, they can assess the efficacy of the treatment.
- Dentists, as well as sleep specialists, should invite oral appliance-treated patients for regular check-ups.
The problem with studies such as the mentioned one is that they provide no efficacy assessment for OSA of various degrees of severity.
How do oral appliances help with OSA? What about scientific evidence in this regard?
Dental appliances aim to keep your airways from collapsing through a handful of solutions. Some retain your tongue, others advance your mandible, and still others target your palate.
According to a 2014 study published in the European Respiratory Journal by M.M.M. Eisvogel, M.G.J. Brusse-Keizer, and L. Visscher, the efficacy of oral appliances is comparable to that of CPAP in regards to mild OSA.
The study draws this conclusion from the Dutch National OSAS guideline. It does not provide clinical evidence to support it.
For severe OSAs, the study still recommends the use of CPAP over dental devices.
Before I get to the advantages of dental appliances over other forms of OSA treatments, let me put forth that oral appliances should constitute a backup plan. These devices should not replace CPAP therapy for patients who tolerate/respond well to the latter.
- Cost efficiency has to be one of the top advantages of oral appliances. Most such devices are covered by medical insurance.
- Portability may not seem like a major asset but active people will likely not ignore it.
- Throughout this article, I pitted CPAP therapy against oral appliances. I did so intending to compare the two. CPAP can work extremely well with oral appliances, however. If you use your CPAP device at high pressures, an oral appliance may allow you to lower the pressure. Such a solution can greatly improve your comfort. By extension, it can also improve your CPAP adherence.
- Dental appliances are suitable for OSAs of varying degrees of severity.
- A 2018 study by AlRumaih, Baba, et al. concludes from relevant literature that OSA sufferers prefer oral appliances to CPAP due to convenience.
There are several conditions/features which impact the success rate of dental appliances.
- Retention or the accurate, comfortable, and lasting fit of the device is important. The appliance needs to stay in the required position all night. Rigid appliances can be a handful in this regard. Soft, heat-sensitive materials adhere and fit better.
- Adjustability refers to the possibility of adjusting mandibular position through the device.
- Adaptability defines the ability of the device to adapt to denture changes. Tooth fillings, crowns, etc. are some examples in this regard.
- Your weight. The more you weigh, the more severe your OSA symptoms tend to be.
- Your age. With age, muscles atrophy. Pharyngeal muscles included.
- Pharyngeal and nasal inflammation.
- Sleep hygiene.
- Sleeping position. The supine position is conducive to more severe OSA symptoms.
Unfortunately, the disadvantages of oral appliances are numerous. The most obvious shortcoming is the fact that these devices are not efficient at treating severe OSA. Other problems exist too.
- For some, oral appliances can be just as uncomfortable to wear as a CPAP mask.
- A qualified dentist has to custom-fit every device. The “self-adjusting” devices sold by various online operators are useless.
- Drooling can be a major problem with tongue-retaining devices.
- Oral appliances are hard on the temporomandibular joint. Once pain occurs at this potential point of failure, devices can become intolerable.
Medscape lists several other problems that may arise from the long-term use of oral appliances.
- Mouth sores and a host of dental problems can occur. These include, but are not limited to loose teeth, cracked/broken teeth, destroyed dental work, and root resorption.
- Muscle spasms.
- The permanent migration of the mandible, which can lead to a permanent change of bite.
- The accidental swallowing of broken pieces of the device.
- Soft palate implants can cause many other problems, such as ear and jaw pain, difficulty swallowing, possible extrusion, as well as difficulty swallowing.
The above points make it clear that you should accompany your oral appliance use with frequent follow-up trips to your doctor. One the one hand, you need to make sure you avoid the complications listed. On the other, you need a thorough progress assessment. Only through such a report can you establish the efficacy of the treatment you are following.
Progress analysis may consist of polysomnography and pulse oximetry sessions. Make sure you are well instructed in the proper use of the device. Have the integrity of your dentition and device checked regularly as well.
Types of Oral Appliances
While there are several options available in this regard, most oral appliances advance the mandible. Theoretically, such devices target three upper airway areas: the soft palate, the tongue, or the mandible.
- Soft palate advancement is likely to trigger the gag reflex. Such an approach is, therefore, less tolerable.
- Isolated tongue advancement is also a seldom taken route of treatment. It too may stimulate the gag reflex.
- Most devices either rotate the mandible downwards or advance it. Such devices also advance the tongue in addition to enlarging the upper airway.
- Fixed oral appliances come in the shape of implants. Palatal implants are embedded into the soft palate muscles, thus stiffening them. Such a solution is a permanent one. According to a 2008 study by Steward DL, Huntley TC et al. completed at the University Cincinnati College of Medicine, the efficiency of palatal implants for the treatment of OSA is limited at best.
Prefabricated, one-size-fits-all oral appliances have acquired a bad reputation. Some manufacturers have struck a compromise in this regard.
VitalSleep is a prefabricated mouthpiece. It comes in two sizes: medium for men and small for women.
It has a couple of tricks up its sleeve though. It comes with custom molded teeth impressions. This allows individual wearers to achieve a theoretically perfect fit, regardless of the peculiarities of their dentition.
Additionally, VitalSleep also features an Accu-Adjust System, which lets users fine-tune mandibular advancement. Accu-Adjust is a fancy name for a couple of screws that allow for adjustment.
The device has accrued an overwhelmingly positive score at TrustPilot. Most users seem to love it. Those who logged complaints decried bad fit and discomfort.
Unlike most prefabricated appliances, VitalSleep is not a mono-bloc solution. As such, it might be worth a shot. Costing ~$70, price-wise it is an interesting proposition.
Some anti-snoring device makers have turned to radically different solutions. PeaceSleeper uses electric impulses to stimulate pharyngeal muscles. Thus, the device is not a dental appliance.
Electric impulse-based muscle stimulation has been around for decades. People have used such devices to work out abdominal muscles etc. Now Peace Sleeper takes a similar approach to battle snoring.
The device needs to be applied to the throat, under the chin. It detects snoring. When snoring occurs, PeaceSleeper activates, sending electric impulses into the pharyngeal muscles.
The solution seems devilishly clever. If it does work as it is supposed to, it may even strengthen atrophied pharyngeal muscles over time, offering a permanent cure.
There are hardly any user reviews available on PeaceSleeper. The jury is still out on this one.
Clinical Trial Evidence
There is plenty of scientific literature available on the subject of the dental treatment of OSA. In addition to what I have covered in this article, there are quite a few clinical trial papers available.
A 1999 study by Jeffrey Pancer et al. has successfully demonstrated the effectiveness of the Thornton Anterior Positioner for snoring, as well as various degrees of OSA. Indeed, the appliance was deemed useful even in cases of severe OSA.
Some 86 percent of trial participants stuck with the program long-term. 32 percent of them reported experiencing discomfort. 60 percent of the participants were “very satisfied” with the results. Only 13 percent were moderately- or very dissatisfied.
A 2013 study by White DP and Shafazand S, at the Harvard Medical School, compared mandibular advancement devices to CPAP. The testing period was one month.
Surprisingly, the study found no difference between the impact of a MAD and CPAP, in adults treated for moderate to mild OSA. The variables tracked were daytime sleepiness, the general quality of life, and 24-hour mean ambulatory blood pressure.
Both treatments proved equally effective.
A 2016 literature review at the University Clinical Hospital in Valencia, Spain, by Serra-Torres, Bellot-Arcis et al., concluded that mandibular advancement alleviates the main symptoms of OSA.
The study found custom-made, adjustable devices superior to prefabricated, mono-bloc solutions.