Sleep is a natural process that allows us to recover from the energy we spend while we are awake. [1] However, some people suffer from conditions that affect the ability to get the rest that the body needs to be awake and affect the quality of life. Such conditions are called sleep disorders.
Obstructive Sleep Apnea (OSA) is one of the most common sleep-related disorders, affecting approximately 1 billion people worldwide. OSA is a condition that is characterized by repeated partial or complete closures of the collapsible part of the upper airway. It is associated with snoring, poor quality sleep, feeling sleepy during the day, and various cardiometabolic health problems. The causes of OSA are multifactorial. It can be associated with various anatomical, biological, demographic, and behavioral factors.
OSA is a condition that can also have outcomes such as depression, anxiety, and various systemic and metabolic health issues. It is important to diagnose and treat it promptly.Dr. Akshaya S, MDS, Oral and Maxillofacial Surgeon
Symptoms of OSA:
Very loud snoring
The patient wakes up feeling unrest, with headaches upon waking up
Excessive fatigue/daytime sleepiness
Cardiovascular diseases—hypertension, stroke, heart failure, coronary artery disease, atrial fibrillation
Cognitive deterioration
Reduced libido
Although most sleep-related disorders are diagnosed and treated by general physicians or sleep specialists, some sleep disorders might require the involvement of dentists too.
What is Dental Sleep Medicine?
Dental sleep medicine is the discipline concerned with the study of the oral and maxillofacial causes and consequences of sleep-related problems and traditionally focuses on sleep-related breathing disorders like obstructive sleep apnea.
A huge step in dental sleep medicine was the introduction of oral appliances as a treatment option for OSA in the late 1980s. However, it was fully accepted as an effective alternative treatment only in the late 1990s and early 2000s. [2]
The Role of Dental Sleep Medicine in OSA:
The gold standard for the management of moderate to severe OSA is continuous positive airway pressure (CPAP). This is done by applying pressurized air throughout the respiratory cycle to keep the upper airway patent. The effectiveness of CPAP is compromised due to reduced acceptance and adherence by patients. Patients tend to seek alternative treatments due to discomfort from wearing the CPAP mask and the various degrees of pressurized air applied to relieve the obstruction. Surgery could be an option, but in some cases, the risk associated with the procedures is high. In these cases, oral appliances can serve as a treatment option.[3]
Oral appliances are recommended for patients who:
Have mild to moderate OSA
Prefer them to CPAP therapy
Fail to respond to CPAP
Are not suitable candidates for CPAP [4]
MedBound Times reached out to Dr. Priyam Mehta Parikh, Doctor of Dental and Sleep Medicine—Dream Dent, to share her insights.
Dental sleep medicine is a subject within dentistry that focuses on treating patients with sleep-related breathing disorders, mainly snoring and OSA. Oral appliances are arguably less effective than CPAP, but the compliance level of oral appliance therapy is higher. According to a review article published in the Journal of Dental Sleep Medicine, the overall efficacy and health benefits of oral appliance therapy and CPAP remain the same. While oral appliance therapy is usually indicated for patients with mild to moderate OSA, it can also be used in severe cases if the patient is unwilling to do any other treatment. In my experience, oral appliances are very effective in improving both objective and subjective symptoms, and patients find them much easier to accept than CPAP machines. Patients wear the appliance throughout the night and also prefer to use it while traveling, as it is less bulky, hassle-free, and non-conspicuous, and there is no need for electricity, unlike a CPAP machine that requires electricity.Dr. Priyam Mehta Parikh, Doctor of Dental and Sleep Medicine, Dream Dent
The Science Behind Oral Appliances:
Oral appliances work by enlarging and stabilizing the pharyngeal airway to prevent breathing obstructions during sleep. The mechanism of action of oral appliances is by the protrusion of the lower jaw, which is capable of enlarging the airway space and preventing its collapse. These appliances allow the mandible to be retained in a relatively forward position to the maxilla, thereby stabilizing the airway.
The commonly used oral appliances that are used for the treatment of sleep apnea are tongue-retaining/stabilizing devices and mandibular advancement splints/devices. [5]
Mandibular Advancement Devices/Splints:
A mandibular advancement device (MAD) advances the mandible and the tongue to an anterior position, thereby enlarging the upper airway and preventing it from collapsing. MADs can be prefabricated or customized and are available in different designs. Prefabricated appliances are usually available over the counter and are also called “boil and bite” appliances. Customized MADs are usually done by taking dental impressions of the individual that can be adjustable or non-adjustable. Customized MADs are preferred more by patients than prefabricated ones due to their comfort, greater range of movement, and efficacy. [6,7]
Tongue-Retaining/Stabilizing Device:
The tongue-retaining/stabilizing device is a non-surgical technique where the tongue is anteriorly displaced by suction forces during the patient’s sleep. This prevents the tongue from falling back into the pharyngeal airway. However, they are considered less effective than MAD but are still preferred in certain patients who use removable dentures, have limited mandibular protrusion, or suffer from acute temporomandibular disorders and advanced periodontal diseases. [3]
Rapid Maxillary Expansion:
In children, OSA can lead to physical and neuropsychomotor impairment. To avoid this, rapid maxillary expansion (RME) could be used as an alternative. RME is believed to decrease nasal resistance and improve the quality of nasal respiration by increasing the width of the maxillary arch, proper positioning of the tongue, and proper lip seals. However, there is a dearth of data regarding its effectiveness.[8]
Are there any side effects?
Initially, there are possibilities of side effects like:
Excessive salivation
Irritation in the soft tissues
These side effects are usually temporary and resolvable. However, due to the use of oral appliances, there are chances of tooth movement and changes in the bite. Sometimes, these changes could also be due to the design and the type of material used for the fabrication of these appliances. It is recommended to have regular dental visits to check for any of these side effects.[9]
As a dentist, I prefer oral appliance therapy for treating OSA. It has been proven to be a highly successful treatment for managing the condition. The main advantage is that it is a simple, non-invasive procedure with excellent results. It works by widening the upper airway, thereby reducing the severity of the disorder. From the patient's perspective, it is easy to use, effective, comfortable, and less obtrusive as compared to other treatment options.Dr. Ansila S, BDS
Recent Advancements in Oral Appliances:
A recent study found that using a transoral neuromuscular electrical stimulation (NMES) device during the daytime reduces snoring and mild OSA, considering the hypothesis that electrical stimulation of the tongue muscle could improve its function during sleep. However, there are limitations to this study, and further research is required.[10]
Conclusion:
OSA is a global health burden and an independent risk factor for many diseases like hypertension, diabetes, cardiac diseases, etc., and its management can be challenging. Dental sleep medicine can play a vital role in benefitting all patients suffering from OSA with the help of oral appliance therapy when standard treatment methods fail or are ineffective.
References:
1. Lobbezoo, Frank, Gilles J. Lavigne, Takafumi Kato, Fernanda R. de Almeida, and Ghizlane Aarab. "The face of dental sleep medicine in the 21st century." Journal of Oral Rehabilitation 47, no. 12 (2020): 1579-1589. (Accessed on 20 January 2025)
2. Lobbezoo, Frank, Nico De Vries, Jan de Lange, and Ghizlane Aarab. "A further introduction to dental sleep medicine." Nature and science of sleep (2020): 1173-1179. (Accessed on 20 January 2025)
3. Chang, Edward T., Camilo Fernandez-Salvador, Jeremy Giambo, Blaine Nesbitt, Stanley Yung-Chuan Liu, Robson Capasso, Clete A. Kushida, and Macario Camacho. "Tongue retaining devices for obstructive sleep apnea: A systematic review and meta-analysis." American journal of otolaryngology 38, no. 3 (2017): 272-278. (Accessed on 20 January 2025)
4. Scherr, Steven C., Leslie C. Dort, Fernanda R. Almeida, Kathleen M. Bennett, Norman T. Blumenstock, B. Gail Demko, Gregory K. Essick et al. "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." J Dent Sleep Med 1, no. 1 (2014): 39-50. (Accessed on 20 January 2025)
5. Sutherland, Kate, and Peter A. Cistulli. "Oral appliance therapy for obstructive sleep apnoea: state of the art." Journal of clinical medicine 8, no. 12 (2019): 2121. (Accessed on 20 January 2025)
6. Venema, Julia AM Uniken, Boudewijn RAM Rosenmöller, Nico De Vries, Jan de Lange, Ghizlane Aarab, Frank Lobbezoo, and Aarnoud Hoekema. "Mandibular advancement device design: a systematic review on outcomes in obstructive sleep apnea treatment." Sleep medicine reviews 60 (2021): 101557. (Accessed on 20 January 2025)
7. Manetta, Izabella Paola, Dominik Ettlin, Pedro Mayoral Sanz, Isabel Rocha, and Miguel Meira e Cruz. "Mandibular advancement devices in obstructive sleep apnea: an updated review." Sleep Science 15, no. S 02 (2022): 398-405. (Accessed on 20 January 2025)
8. Machado-Júnior, Almiro-José, Edilson Zancanella, and Agrício-Nubiato Crespo. "Rapid maxillary expansion and obstructive sleep apnea: A review and meta-analysis." Medicina oral, patologia oral y cirugia bucal 21, no. 4 (2016): e465. (Accessed on 20 January 2025)
9. Dieltjens, Marijke, and Olivier M. Vanderveken. "Oral appliances in obstructive sleep apnea." In Healthcare, vol. 7, no. 4, p. 141. Multidisciplinary Digital Publishing Institute, 2019. (Accessed on 20 January 2025)
10. Baptista, Peter M., Paula Martínez Ruiz de Apodaca, Marina Carrasco, Secundino Fernandez, Phui Yee Wong, Henry Zhang, Amro Hassaan, and Bhik Kotecha. "Daytime neuromuscular electrical therapy of tongue muscles in improving snoring in individuals with primary snoring and mild obstructive sleep apnea." Journal of clinical medicine 10, no. 9 (2021): 1883. (Accessed on 20 January 2025)
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