How To Choose The Most Effective Oral Appliance For Sleep Apnea
Oral Devices to Treat Sleep Apnea
Many oral devices are available for the treatment of sleep apnea. They can hold the lower jaw, tongue, or both forward during sleep to prevent the upper airway from collapsing. These devices work best for those who have obstructive sleep apnea that is primarily located in the lower pharynx.
Jaw Retainers (or Mandibular Advancement Devices, or MADs) Jaw retainers hold the lower jaw forward. They are sometimes called MADs (mandibular advance devices), but they can also be called anterior mandibular positioning devices (AMPs), mandibular rearrangement devices (MRDs), and oral airway dilators (OADs).
MADs are similar to retainers or bite plates that can sometimes be prescribed by orthodontists. They can be made from dental acrylic with metal loops that are placed over many teeth to keep the device in place.
Different manufacturers have created their own MAD versions. Some models can be adjusted to allow for the most comfortable forward position for your lower jaw. MADs are usually custom-made. There haven’t been any definitive studies that can pinpoint which patients will benefit from jaw retainers or which devices are most effective.
Mandibular appliances have been studied in sleep apnea patients. However, the studies used small numbers of patients with different success criteria. Based on the few clinical trials that have been conducted, they appear to be approximately 50% effective.
This means that about half of those who have tried them still suffer from sleep apnea symptoms. Modular models that can be adjusted may prove more useful than those that cannot. It is unlikely that any design will be equally effective for all patients.
People who are interested in an oral appliance for sleep apnea should seek out a dentist who has experience in fitting these devices and who also works with a sleep specialist. After the dentist has fitted the patient, the sleep specialist (not the dentist) should diagnose obstructive sleep apnea.
The dentist should also measure the effectiveness of the device. Contact them to find a dentist in your area who has been trained.
The Academy of Dental Sleep Medicine A MAD can be beneficial to anyone. MAD manufacturers and experimenters have reported positive results in the study of patients with mild to moderate apnea.
MADs concentrate their treatment on the lower jaw or tongue. This means that people with a smaller lower jaw than average (orthodontists call it a “class II occlusion”) will likely have the best results.
MADs have also been successfully used in children with irregularly formed jaws and obstructive sleep apnea. Three-quarters of sleep apnea sufferers have airway obstructions in more than one location. Patients with obstructive sleep apnea that is primarily caused by nasal problems or problems in the upper pharynx (large tonsils, adenoids, and uvula) are unlikely to be treated with a MAD.
They will require further treatment, or even surgery for sleep apnea. To use the retainer, you need to be able to blow through your nose. A person suffering from a blocked nose or an allergy will not be able to wear it. Many people, even those who appear to be good candidates for MADs, still have sleep apnea.
This can be evident by their heavy snoring. It is important to have sufficient teeth to hold the appliance in place. A MAD may be a good option for those who are unable to use CPAP despite their best efforts. If your nasal obstruction prevents you from using CPAP successfully, then you won’t be able to use an oral appliance unless the obstruction can be removed by surgery or medication.
Even if it’s only partially effective, there may still be some use for a MAD.
- If CPAP is not available (backpacking, primitive traveling),
- If the device allows patients to use a lower CPAP pressure,
- Screening patients for mandibular advancement surgery (to simulate possible outcomes of surgery)
These situations do not have objective studies that can prove their benefit. How to get used to wearing a MAD. Getting used to wearing a MAD may take several nights or several weeks. The most common side effect is excess saliva.
Excessive saliva is a side effect of any foreign object, such as a retainer. However, this usually subsides after a few nights. It may take up to 2 to 3 weeks for the jaw muscles and the other muscles to get used to the MAD. It may take you at least three weeks to get used to it and determine if it is worth it.
The MAD has a disadvantage: you can’t rent one to test it out. You can adapt one “do it yourself” brand by heating it in hot water. Although it does provide some indication of effectiveness, it is not very long-lasting.
If you don’t pay to have one made, you won’t know if a MAD is effective. You will be thrilled if it works. MADs are less restrictive than breathing devices, smaller and easier to use, and also cost less. There are other options if it doesn’t work.
What Is The Cost Of MADs?
Although MADs are more affordable than CPAP units, they can still be quite expensive. Do-it-yourself brands cost about $25. There are trained technicians at some sleep centers who can fit an adjustable model for $300 to $400.
A custom-fitted appliance can cost as much as $600 and may even be more expensive due to the markup by dentists. This is about twice the price of an ordinary orthodontic retainer. It does not include the cost of having your dentist or orthodontist take jaw impressions or additional visits to adjust or check the fit of the appliance.
These extra costs can add several hundred dollars to your total cost. To find out if your insurance will cover these costs, check with them in advance. Do you think a MAD is worth your consideration? Here are some questions you should ask your sleep specialist if you think you could be a candidate for MAD success.
- A sleep study was done to determine the baseline of your sleep disorder before you started treatment.
- Is your sleep apnea mild?
- Have you considered CPAP (a more efficient treatment) if your sleep apnea symptoms are moderate to severe?
- Do you experience nasal obstructions that prevent you from breathing through your nose?
- Are you suffering from temporomandibular (TMJ) syndrome? Or are there any other dental issues that a MAD could exacerbate?
- Can your sleep specialist refer you to a dentist who has experience fitting sleep apnea oral appliances if you have TMJ problems or other dental issues?
- Have you been scheduled by your sleep specialist to have a follow-up study of the effectiveness of the oral appliance while you are wearing it?
- Have you compared the cost of an oral device with your insurance agent? This includes fabrication, fitting, and follow-up sleep tests. Is this an affordable treatment option?
These questions are partly based on the American Academy of Sleep Medicine’s guidelines for oral appliances. Does your MAD really work? Once you have become comfortable with the MAD, it is a good idea to return to your sleep center to get a sleep study to confirm that the appliance is effective in eliminating your apnea.
The MAD must be tested in a sleep study to determine if it works when you’re sleeping on your back or on your side. MADs’ effectiveness tends to decrease over time. To ensure that your MAD is still effective in eliminating sleep apnea, consult your sleep specialist.
Other oral appliances
The tongue-retaining device (TRD), made from soft plastic, consists of a tongue-sized suction cup. It is designed to pull the tongue forward while holding it in place. It is held in place by the teeth and gripped by the tongue. The TRD has been moderately uncomfortable for many people who have tried it.
In some experiments, the TRD was only worn for half the night. The TRD is able to reduce the frequency of apnea events by approximately 50%, despite its limitations. This means that the TRD could be about as effective as uvulopalatopharyngoplasty (UPPP), a type of surgery described later. TRD is not a popular choice in sleep research and has not been widely adopted or made available. The TRD is only useful for a select group of patients with obstructive sleep apnea.
People who aren’t obese, don’t have nasal obstructions, and have mild-to-moderate apnea are more likely to benefit from a TRD. This means that the severity of apnea when they sleep on their backs is greater than when they sleep on their sides.
This group may have apnea that strongly affects their tongue position. Therefore, it might be a good idea to hold the TRD forward while they are speaking. TRDs can be used to control severe cases of apnea.
The Oral Positive Airway Pressure Apparatus
The oral positive airway pressure appliance (OPAP) treats obstructive sleep apnea using a mouthpiece rather than a nasal mask. The small mouthpiece can be worn by itself or attached to CPAP tubing and a CPAP machine.
The OPAP appliance is designed to be worn alone. If desired, it can also be used as a jaw retention device to keep the lower jaw forward. It attaches to a CPAP device and holds the airway open using air pressure.
Who Can Benefit From An OPAP Appliance?
The OPAP appliance could be an option for those with mild or severe obstructive sleep apnea. The OPAP appliance can be worn alone and may be used as an alternative to a dental appliance for obstructive sleep apnea.
The advantage of the OPAP device is that it does not require a nasal mask. Many people suffer from nasal obstructions, making CPAP difficult to use. The OPAP appliance also eliminates the problems of CPAP mask fitting and skin irritation caused by wearing the CPAP mask on the face. The OPAP appliance doesn’t require headgear, so it is more comfortable. It also eliminates the “bad hair days” that can occur after wearing CPAP headgear for too long.
What Are The Drawbacks To OPAP?
OPAP is still relatively new. Very few people have tried it. The most significant drawback is the excessive production of saliva. The long-term effects of OPAP are still unknown. There are still questions about the effects of OPAP on the teeth and the temporomandibular (TMJ) joint. Patients with TMJ issues should talk to their dentist about an OPAP appliance.
What is the cost of an OPAP appliance? Currently, an OPAP appliance can only be fitted as a custom-fitted appliance, like a dental device. This can prove costly. It will likely cost around $600. In the future, an off-the-shelf version may be offered at a lower price. You should check with your insurance company to see if they will pay for an OPAP appliance.
How can you get an OPAP appliance? Ask your sleep specialist if an OPAP device would suit you. If she is able to answer your questions, she will be able to refer you to a dentist who has been trained to fit an OPAP device. For a list of dentists who are trained in treating sleep disorders and are familiar with OPAP appliances, please contact the Academy of Dental Sleep Medicine (see appendix).
Orthodontic Treatment to Redesign the Jaw
Orthodontists play an increasingly important role in treating obstructive sleep apnea. Patients with sleep apnea who have a small jaw (class II malocclusion) will have an easily blocked airway.
Orthodontic treatment can be used to modify the jaw by removing teeth and placing implants to fill in the gaps. This can be done alone or in combination with jaw surgery (see below) to enlarge the jaw enough to remove or reduce obstructions to the airway.
Orthodontists are now recognizing the dangers of obstructive sleep apnea. They remove childhood teeth to “make space” in the jaw. This practice can lead to jawbone changes over time due to chewing and tongue movement.
The jaw will become smaller due to fewer teeth taking up space. This can lead to crowded teeth, an overbite, and a narrower airway. Obstructive sleep apnea may result. The future may see a simpler solution to a child’s crowded jaw: preservation of the size, architecture, and function of the jaw.
Drugs for Treating Obstructive Sleep Apnea
Obstructive sleep apnea is generally not treated with drugs. Many of the drugs used to treat central apnea have had mixed results. Some people with Pickwickian Syndrome have found the hormone medroxyprogesterone to be effective. It is believed to improve the patient’s breathing, decrease the frequency of apnea episodes, and improve their symptoms.
Some researchers report no improvement in apneas. Therefore, the results of this drug are mixed. Medroxyprogesterone can have undesirable side effects. Some people may experience fluid retention, nausea, or depression.
It is a sex hormone, so it can cause breast tenderness and extra hair growth. People with liver disease or blood-clotting problems, pregnant women, and people suspected or known to have genital carcinoma should not use it.
Protriptyline, an antidepressant, is effective in mild cases. If the individual’s life is not at immediate risk from sleep apnea, it is not recommended as a treatment.
Protriptyline has some drawbacks. It decreases rapid eye movement (REM) and can cause dry mouth, constipation (mild or intolerable), difficulty starting urine flow, and impotence. Protriptyline can cause confusion in the elderly.
People with high blood pressure, arrhythmias, or prostate disease may not find it appropriate. Obstructive sleep apnea can be treated with oxygen alone. In fact, oxygen can actually make it worse.
- Protriptyline In Obstructive Sleep Apnea — A Double-Blind Trial | NEJM. (n.d.). Protriptyline in Obstructive Sleep Apnea — A Double-Blind Trial | NEJM. https://www.nejm.org/doi/full/10.1056/nejm198210213071701.
- DEFINE_ME. (n.d.). DEFINE_ME. https://journal.chestnet.org/article/S0012-3692(15)45901-X/fulltext#relatedArticles.
- A. (2020, June 5). Bad Breath Causes In Kids | Dentist In Harrisburg NC. Best Dentist Harrisburg, NC | 704-659-5036 | Family Dentistry in Harrisburg. https://icardandstreinfamilydentistry.com/benefits-and-drawbacks-of-oral-appliance-therapy/.
- Efficacy Of Positive Airway Pressure And Oral Appliance In Mild To Moderate Obstructive Sleep Apnea – PubMed. (2004, September 15). PubMed. https://pubmed.ncbi.nlm.nih.gov/15201136/.
- Stick Out the Tongue: Using a Mouthpiece To Treat Snoring And Apnea. (2020, May 15). Verywell Health. https://www.verywellhealth.com/tongue-stabilizing-device-for-treating-sleep-apnea-3015243.
- Mandibular Advancement Device | American Sleep Association. (2021, June 23). American Sleep Association. https://www.sleepassociation.org/sleep-treatments/snoring-mouthpieces/mandibular-advancement-device/.
- An Update On Mandibular Advancement Devices for the Treatment Of Obstructive Sleep Apnoea Hypopnoea Syndrome. (2018, January 1). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803051/.
HealthNip does not provide medical advice, diagnosis, or treatment. Any information published on this website or by this brand is not intended as a substitute for medical advice, and you should not take any action before consulting with a healthcare professional.