Oral appliances in the treatment of obstructive sleep apnea in adults
- Peter A Cistulli, MBBS, PhD, FRACP
Peter A Cistulli, MBBS, PhD, FRACP
- ResMed Chair in Sleep Medicine
- University of Sydney & Royal North Shore Hospital
Obstructive sleep apnea (OSA) is a disorder that is characterized by obstructive apneas and hypopneas due to repetitive collapse of the upper airway during sleep. The concept of using an oral appliance to relieve upper airway obstruction was first reported in the 1930s and applied to OSA more than 30 years ago. There has been increasing interest in oral appliances in recent years because of the high prevalence of OSA and recognition of the limitations of positive airway pressure therapy (eg, frequent non-adherence) and surgical therapy.
The management of patients with OSA using an oral appliance is reviewed here. Relevant definitions and the treatment of OSA using other modalities (eg, continuous positive airway pressure) are discussed in detail elsewhere. (See "Polysomnography in the evaluation of sleep-disordered breathing in adults" and "Management of obstructive sleep apnea in adults".)
A multidisciplinary approach is required to effectively manage a patient who has OSA with an oral appliance. This begins with a medical assessment and sleep study to confirm the diagnosis of OSA, determine whether treatment is indicated, and, if so, whether an oral appliance is appropriate therapy [1,2]. Dental evaluation by a qualified dentist or oral surgeon follows, which includes assessment of suitability for oral appliance therapy, device selection, and fitting.
Once oral appliance therapy is initiated, the effectiveness should generally be evaluated by objective testing, since subjective assessment alone is often unreliable. Long-term follow-up should be performed by both a medical and a dental clinician. This approach is described in this section and outlined in the figure (algorithm 1).
Diagnosis — The diagnosis of OSA should be confirmed and its severity determined prior to the initiation of therapy with an oral appliance [1,3]. Disease severity guides the selection of patients for treatment by identifying those who are at greatest risk for developing complications of OSA. It also provides a baseline from which to measure the effectiveness of therapy. The diagnostic approach to OSA in adults is described in detail separately and shown in the algorithm (algorithm 2). (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)
- Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5:263.
- Ramar K, Dort LC, Katz SG, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med 2015; 11:773.
- Kushida CA, Morgenthaler TI, Littner MR, et al. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep 2006; 29:240.
- Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 2006; 29:244.
- Mehta A, Qian J, Petocz P, et al. A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med 2001; 163:1457.
- Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial. Am J Respir Crit Care Med 2002; 166:743.
- Petit FX, Pépin JL, Bettega G, et al. Mandibular advancement devices: rate of contraindications in 100 consecutive obstructive sleep apnea patients. Am J Respir Crit Care Med 2002; 166:274.
- Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Med Rev 2004; 8:443.
- Liu Y, Lowe AA, Fleetham JA, Park YC. Cephalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2001; 120:639.
- Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success. Chest 2004; 125:1270.
- Chung JW, Enciso R, Levendowski DJ, et al. Treatment outcomes of mandibular advancement devices in positional and nonpositional OSA patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109:724.
- Fransson AM, Tegelberg A, Leissner L, et al. Effects of a mandibular protruding device on the sleep of patients with obstructive sleep apnea and snoring problems: a 2-year follow-up. Sleep Breath 2003; 7:131.
- Dieltjens M, Braem MJ, Van de Heyning PH, et al. Prevalence and clinical significance of supine-dependent obstructive sleep apnea in patients using oral appliance therapy. J Clin Sleep Med 2014; 10:959.
- Zeng B, Ng AT, Darendeliler MA, et al. Use of flow-volume curves to predict oral appliance treatment outcome in obstructive sleep apnea. Am J Respir Crit Care Med 2007; 175:726.
- Zeng B, Ng AT, Qian J, et al. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep 2008; 31:543.
- Sutherland K, Phillips CL, Davies A, et al. CPAP pressure for prediction of oral appliance treatment response in obstructive sleep apnea. J Clin Sleep Med 2014; 10:943.
- Tsuiki S, Kobayashi M, Namba K, et al. Optimal positive airway pressure predicts oral appliance response to sleep apnoea. Eur Respir J 2010; 35:1098.
- Pételle B, Vincent G, Gagnadoux F, et al. One-night mandibular advancement titration for obstructive sleep apnea syndrome: a pilot study. Am J Respir Crit Care Med 2002; 165:1150.
- Tsai WH, Vazquez JC, Oshima T, et al. Remotely controlled mandibular positioner predicts efficacy of oral appliances in sleep apnea. Am J Respir Crit Care Med 2004; 170:366.
- Remmers J, Charkhandeh S, Grosse J, et al. Remotely controlled mandibular protrusion during sleep predicts therapeutic success with oral appliances in patients with obstructive sleep apnea. Sleep 2013; 36:1517.
- Vanderveken OM, Devolder A, Marklund M, et al. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med 2008; 178:197.
- Quinnell TG, Bennett M, Jordan J, et al. A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO). Thorax 2014; 69:938.
- Deane SA, Cistulli PA, Ng AT, et al. Comparison of mandibular advancement splint and tongue stabilizing device in obstructive sleep apnea: a randomized controlled trial. Sleep 2009; 32:648.
- Fleury B, Rakotonanahary D, Petelle B, et al. Mandibular advancement titration for obstructive sleep apnea: optimization of the procedure by combining clinical and oximetric parameters. Chest 2004; 125:1761.
- Krishnan V, Collop NA, Scherr SC. An evaluation of a titration strategy for prescription of oral appliances for obstructive sleep apnea. Chest 2008; 133:1135.
- Gagnadoux F, Fleury B, Vielle B, et al. Titrated mandibular advancement versus positive airway pressure for sleep apnoea. Eur Respir J 2009; 34:914.
- de Almeida FR, Lowe AA, Tsuiki S, et al. Long-term compliance and side effects of oral appliances used for the treatment of snoring and obstructive sleep apnea syndrome. J Clin Sleep Med 2005; 1:143.
- Dieltjens M, Braem MJ, Vroegop AV, et al. Objectively measured vs self-reported compliance during oral appliance therapy for sleep-disordered breathing. Chest 2013; 144:1495.
- Randerath WJ, Verbraecken J, Andreas S, et al. Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J 2011; 37:1000.
- Marklund M, Carlberg B, Forsgren L, et al. Oral Appliance Therapy in Patients With Daytime Sleepiness and Snoring or Mild to Moderate Sleep Apnea: A Randomized Clinical Trial. JAMA Intern Med 2015; 175:1278.
- Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial. Sleep 2004; 27:934.
- Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 2004; 170:656.
- Naismith SL, Winter VR, Hickie IB, Cistulli PA. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med 2005; 1:374.
- Iftikhar IH, Hays ER, Iverson MA, et al. Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med 2013; 9:165.
- Povitz M, Bolo CE, Heitman SJ, et al. Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis. PLoS Med 2014; 11:e1001762.
- Hoekema A, Stegenga B, Bakker M, et al. Simulated driving in obstructive sleep apnoea-hypopnoea; effects of oral appliances and continuous positive airway pressure. Sleep Breath 2007; 11:129.
- Schmidt-Nowara W, Lowe A, Wiegand L, et al. Oral appliances for the treatment of snoring and obstructive sleep apnea: a review. Sleep 1995; 18:501.
- Marklund M, Sahlin C, Stenlund H, et al. Mandibular advancement device in patients with obstructive sleep apnea : long-term effects on apnea and sleep. Chest 2001; 120:162.
- Galic T, Bozic J, Pecotic R, et al. Improvement of Cognitive and Psychomotor Performance in Patients with Mild to Moderate Obstructive Sleep Apnea Treated with Mandibular Advancement Device: A Prospective 1-Year Study. J Clin Sleep Med 2016; 12:177.
- Vecchierini MF, Attali V, Collet JM, et al. A custom-made mandibular repositioning device for obstructive sleep apnoea-hypopnoea syndrome: the ORCADES study. Sleep Med 2016; 19:131.
- Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev 2004; :CD004435.
- Hoekema A, Stegenga B, De Bont LG. Efficacy and co-morbidity of oral appliances in the treatment of obstructive sleep apnea-hypopnea: a systematic review. Crit Rev Oral Biol Med 2004; 15:137.
- Tan YK, L'Estrange PR, Luo YM, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Eur J Orthod 2002; 24:239.
- Aarab G, Lobbezoo F, Hamburger HL, Naeije M. Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial. Respiration 2011; 81:411.
- Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med 2013; 187:879.
- Bratton DJ, Gaisl T, Schlatzer C, Kohler M. Comparison of the effects of continuous positive airway pressure and mandibular advancement devices on sleepiness in patients with obstructive sleep apnoea: a network meta-analysis. Lancet Respir Med 2015; 3:869.
- Giles TL, Lasserson TJ, Smith BJ, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006; :CD001106.
- Bratton DJ, Gaisl T, Wons AM, Kohler M. CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. JAMA 2015; 314:2280.
- Walker-Engström ML, Tegelberg A, Wilhelmsson B, Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest 2002; 121:739.
- Rose EC, Staats R, Virchow C Jr, Jonas IE. Occlusal and skeletal effects of an oral appliance in the treatment of obstructive sleep apnea. Chest 2002; 122:871.
- Pantin CC, Hillman DR, Tennant M. Dental side effects of an oral device to treat snoring and obstructive sleep apnea. Sleep 1999; 22:237.
- Pliska BT, Nam H, Chen H, et al. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med 2014; 10:1285.
- Almeida FR, Lowe AA, Otsuka R, et al. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 2. Study-model analysis. Am J Orthod Dentofacial Orthop 2006; 129:205.
- GENERAL APPROACH
- Patient selection
- - Advantages
- - Contraindications
- - Predictors of benefit
- Device selection
- - Mandibular advancement splints
- - Tongue retaining devices
- - Comparative efficacy
- Device titration
- Compared with positive airway pressure
- Compared with surgery
- ADVERSE EFFECTS
- SUMMARY AND RECOMMENDATIONS