Is a dental device appropriate for treating moderate Obstructive Sleep Apnea (OSA)?

Dental Devices for Moderate Obstructive Sleep Apnea

Dental devices are appropriate for moderate obstructive sleep apnea in patients who prefer them to CPAP, who do not respond to CPAP, or who fail treatment with CPAP or behavioral measures. 1

Treatment Algorithm for Moderate OSA

1. First-line treatment: CPAP therapy

   • CPAP is considered the gold standard for moderate to severe OSA 1
   • CPAP is superior to oral appliances in normalizing respiratory parameters 1

2. Second-line treatment: Oral appliances (OAs)

   • Indicated when:
     • Patient prefers OAs to CPAP
     • Patient does not respond to CPAP
     • Patient is not an appropriate candidate for CPAP
     • Patient fails CPAP therapy 1
   • Custom-made titratable mandibular advancement devices (MADs) are the recommended type 2

Patient Selection for Oral Appliance Therapy

Good candidates for oral appliance therapy:

• Younger patients
• Lower BMI
• Smaller neck circumference
• Female gender
• Position-dependent OSA 1
• Adequate dentition for device retention 1

Contraindications for oral appliance therapy:

• Severe periodontal disease
• Severe pre-existing temporomandibular disorders (TMD)
• Lack of adequate dentition or implants for retention
• Severe gag reflex
• Poor manual dexterity 1

Effectiveness of Oral Appliances

Oral appliances have been shown to:

• Reduce AHI (Apnea-Hypopnea Index)
• Reduce arousal index
• Improve daytime sleepiness
• Improve quality of life measures
• Improve nocturnal oxygenation 1, 3

However, it's important to note that approximately one out of three patients show negligible improvement with MAD therapy 2. This underscores the importance of proper patient selection and follow-up.

Required Evaluation Before Starting Oral Appliance Therapy

1. Sleep evaluation:

   • Diagnosis of OSA must be confirmed before initiating treatment
   • Severity of sleep-related respiratory problems must be established 1

2. Dental examination:

   • Complete dental history
   • Intra-oral examination including soft tissue, periodontal, and TMJ assessment
   • Evaluation for nocturnal bruxism patterns
   • Assessment of occlusion
   • Review of dental records
   • Dental radiographs or panorex survey as needed 1

Follow-up and Monitoring

After fitting an oral appliance:

• Short-term follow-up to assess accommodation, comfort, and adherence
• Polysomnography (PSG) or attended cardiorespiratory sleep study with the oral appliance in place after final adjustments 1
• Regular follow-up visits to:
  • Monitor device deterioration or maladjustment
  • Evaluate oral structures and occlusion
  • Assess for signs of worsening OSA 4

Common Pitfalls and Caveats

1. Overestimating effectiveness: While effective for many patients, oral appliances are generally less efficacious than CPAP for normalizing respiratory parameters 1, 2

2. Long-term compliance issues: Only about 50% of patients continue using MADs after 3 years 5

3. Side effects: Potential for TMJ soreness, masticatory muscle discomfort, and occlusal changes with long-term use 5

4. Inadequate follow-up: Failure to verify efficacy with objective testing can lead to suboptimal treatment 4

5. Improper device selection: Non-custom or non-titratable devices may be less effective 2

In conclusion, while CPAP remains the first-line treatment for moderate OSA, dental devices represent an important alternative treatment option with comparable effects on symptoms and health-related quality of life measures, particularly for patients who cannot or will not use CPAP. The key to success is proper patient selection, using custom-made titratable devices, and ensuring regular follow-up to monitor efficacy and potential side effects.