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Selecting an Appliance for the Treatment of Snoring and Obstructive Sleep Apnoea – not all are created equal!

Oral appliances are a proven, effective treatment for snoring and obstructive sleep apnoea (OSA), a medical disorder with significant morbidity and increased mortality rate.
 
Following diagnosis of OSA and recommendation of an oral appliance by a medical specialist, selection of an appropriate appliance for the individual patient  needs to be considered.

The important first step in deciding to proceed with treatment, is selecting an appliance. However with over 100 different not all appliances are equal, and with over 80 available, this can be a confusing area - particularly for dentists new to the field.

We are often asked, "What is the best oral appliance to treat obstructive sleep apnoea?"

 

This article will discuss a basis for choosing an oral appliance and then review some of the appliances available in Australia.

 

Guidelines for selection of an oral appliances

  • The appliances should have demonstrated effectiveness and safety in scientific studies published studies in refereed journals. The use of appliances lacking supporting demonstrating effectiveness and safety. Utilising evidence-based studies cannot be justified treatments is now fundamental in the management of medical and dental disorders.

  • The appliance should comply to the definition of an oral appliance as outlined by the published expert consensus of the American Academy of Dental Sleep Medicine (AADSM)(1).

  • The appliance design should be of minimal dimensions and result in minimal side-effects.

A recent study(2) demonstrated that the main reason patients stopped using an appliance was side effects, dry mouth and an inadequate lip seal. These side effects the main problems. This can be related to the bulkiness of the appliance.

 

Material of construction

Another important factor that needs to be considered is the choice of material from which the appliance is constructed. Hard/soft laminates have been traditionally used, and while they can be forgiving of technical errors during the fitting, they tend to be less durable and often result in significant discolouration. The advent of CAD CAM technology has allowed for the use of uniformly thin materials thereby maximising comfort and durability
 
It is generally accepted that there is no one appliance that is suitable for each and every patient.  It is important that a dentist can choose from a range of several appliances in order to select the one most appropriate for the individual patient. 

The choice of appliance may depend on factors such as number and configuration of teeth, the relationship between the upper and lower arch, the presence and degree of bruxism,presence of TMJ dysfunction, the amount of intra oral space and the tendency towards gagging.
 
Despite claims by manufacturers, there is no such thing as the “best appliance”. Each of the different designs has positives and negatives, and a different side effect profile.
 
It is through carefully considering these factors that a choice can be made in selecting an appliance.

Review of available appliances in Australia
 
The following is a review of some of the available, custom made appliances, classified into different categories based on design.
 
All the recommended appliances have published research studies demonstrating effectiveness and safety.

 

Recommended Appliances

 

1 - Lateral wing design.  This includes the:

 

 

Pros

  • Upper and lower components not connected, or joined, allowing ease in swallowing and jaw movements.

  • Allows for fine calibrated titration-down to 0.1mm increments

  • Published scientific data demonstrating effectiveness.

  • Conforms to the AADSM definition of an oral appliance.

 Cons

  • Mandible needs to be prevented from dropping in certain patients.

  • May be prone to fracture in severe bruxers.

 

2 - Side connectors design

 

a) With plastic or elastic connectors.  This includes:

      Pros

      • Minimal dimensions- particularly suitable for gaggers.

      • Published data demonstrating effectiveness.

      • Conforms to the AADSM definition of an oral appliance.

      Cons

      • Less robust -connectors can stretch or break, particularly in the presence of bruxism.

      • Difficult to perform fine titration - limited to 0.5 or 1mm increments based on available connectors.

      • Retention needs to be optimal due to displacing forces on mandibular movements.

      b) With metal connectors-telescopic arms.  This includes:

       

       Pros

      • Robust-suitable for bruxers.

      • Allows for fine calibrated titration-down to 0.1mm increments.

      • Published data demonstrating effectiveness.

      • Conforms to the AADSM definition of an oral appliance​.

      Cons

      • Retention needs to be optimal due to displacing forces on mandibular movements.

      • Mandible needs to prevented from dropping in certain patients.

      • Metal connectors may impinge upon oral soft tissues.

      c) With nylon and CAD/CAM Construction. This includes:

       

      Pros

      • Minimal dimensions-suitable for gaggers.

      • Robust –suitable for bruxers.

      • Published data demonstrating effectiveness.

      • Conforms to the AADSM definition of an oral appliance.

      Cons

      • Difficult to perform fine titration - limited to 0.5 or 1mm increments based on available connectors.

      • Retention needs to be optimal due to displacing forces on mandibular movements.

      • Not possible to reline or make additions as may often be required when teeth are restored.

       

      3 - Anterior connector design

       

       

      Pros

      • Simple one point titration. Allows for fine calibrated titration -down to 0.1mm increments.

      • Robust-suitable for bruxers.

      • Published data demonstrating effectiveness.

      • Conforms to the AADSM definition of an oral appliance.

      Cons

      • May be more difficult to minimize the vertical opening.

      • Tongue irritation may be a problem in some patients.

      • Increased loading on anterior teeth may be a problem for some patients.

      • Retention needs to be optimal due to displacing forces on mandibular movements.

      Appliances currently not recommended

       

      Oventus

      • No independent published studies - only trials carried out by the manufacturer.

      • The claims of being able to bypass airway obstruction via what’s described as a “duckbill” channel, thereby making it more effective than other appliances, have not been substantiated in any studies.​ This channel adds to the bulkiness of the appliance.

      • The current appliance does not conform to the AADSM definition of an oral appliance as there is no mechanism for advancing the mandible.

      DNA

      • No independent published studies.

      • Does not advance the mandible and therefore does not conform to the AASM and AADSM definition of an oral appliance.

      • Leads to considerable tooth movement as a major side effect.

      Summary

       

      Despite the claims by manufacturers, based on comparison studies there is no “best” appliance and none that is suitable for every single patient.
       
      When selecting an appliance, it is important that the dentist be familiar with, and be able to select from a range of appliances that conforms to the AADSM definition.

      Clinical decisions should be based upon published studies in reputable peer - reviewed scientific publications. Fortunately there are now a number of effective appliances available that meet these criteria. 
       
      One should be wary of claims in effectiveness, via unpublished clinical trials, carried out by those promoting a particular product as treatment for OSA. 

        (1) “Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring

        "A Report of the American Academy of Dental Sleep Medicine”

        S Scherr; Leslie C. Dort, F Almeida, K Bennett; NBlumenstock. G Demko, G Essick; S Katz P McLornan; K Phillips; R Prehn;
        R Rogers; T Schell; R Sheats; F Sreshta,
        Journal of Dental Sleep Medicine
        Volume: 2 Number: 3 July 2015

              (2) “Determinants of Objective Compliance During Oral Appliance Therapy in Patients With Sleep-Disordered Breathing: A Prospective Clinical Trial”

              Dieltjens M, Verbruggen AE, et al
              JAMA Otolaryngol Head Neck Surg. 2015 Oct;141(10):894-900

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