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Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a condition that develops from the obstruction of the upper airway during sleep and necessitates awakening to resume breathing. Recently developed oral appliances, fabricated to maintain upper airway patency during sleep, are proven to be effective when treating patients with OSA. This article outlines the role of the dental professional in the diagnosis and treatment of OSA, including patient education on the use of oral appliances, as well as intervention strategies to prevent dental diseases from occurring during oral appliance therapy.

Introduction

Obstructive sleep apnea (OSA) is caused by reduced upper airway size and altered upper airway muscle activity, which leads to an obstruction and cessation of breathing for longer than ten seconds. The primary symptoms of OSA are snoring, nocturnal awakenings, failing to feel refreshed in the morning, and feeling excessively sleepy during the day. The patient's spouse or partner often reports apneas, choking, and gasping for breath. In general, the patient is unaware of these events, but may complain of dry mouth on awakening, which can be an indication of repeated episodes of gasping and mouth breathing. The impact of OSA on daytime function (eg, excessive daytime sleepiness, consequent increased risk of motor vehicle accidents, and cardiovascular complications) has been associated with morbidity. Premature mortality is also increasingly evidenced in OSA patients, but may be a result of obesity and/or cardiovascular disease, which is often present in these individuals. Although snoring is a key symptom of the condition, not all snorers have OSA. Significant snoring is most prevalent in 10% to 40% of overweight, middle-aged men, and approximately half as many women. The more common "primary snoring," however, is not accompanied by apnea, hypoventilation, or excessive sleepiness. Snoring may also be associated with hypertension, ischemic heart disease and stroke, although its etiologic role in these conditions is controversial.

 

Diagnosis of OSA

The presence or absence of OSA must be determined before treatment is initiated. The condition is considered "obstructive" when there is absence of airflow despite continuing respiratory effort; "central" when both airflow and respiratory effort cease; and "mixed" when there is an initial period of central apnea that becomes obstructive within the same episode (Figure 1). Documentation of OSA identifies those patients at risk of complications of sleep apnea and provides a baseline to evaluate the subsequent treatment. Polysomnography is used to record EEG, EMG (of chin and legs), airflow, chest and abdominal movement, oximetry, and EKG. The severity of OSA is categorized by the apnea-hyponea index (ie, the frequency of apneas and hyponeas per hour of sleep related to blood oxygen saturation during sleep), and some measure of oxygen desaturation, such as the minimum oxygen saturation during the sleep period. Other indices have been developed to evaluate the effect of OSA on sleepiness and daily functions (eg, the Epworth Sleepiness Scale-a questionnaire used to aid in evaluation of sleepiness).

 

Treatment of Snoring and OSA

The treatments of snoring and OSA are directed at the upper airway and include nasal continuous positive airway pressure (CPAP) (eg, sleeping with an oxygen mask and tank by the bedside), and various surgeries (eg, tracheostomy, uvulopalatopharyngoplasty, [UPPP]), reconstructive surgery of the facial skeleton, medication, and weight reduction). Some treatments are limited by a low and unpredictable success rate (ie, UPPP, medication, weight reduction), inconvenience (ie, tracheotomy, CPAP, patient expense [reconstructive surgery]) and/or patient noncompliance (CPAP). While CPAP is the most effective and widely used treatment, many patients do not accept this solution or use it optimally.

(Continued from page 1 )

Types and Mechanisms of Oral Appliances

In response to the recent interest in OSA, various types of oral appliances have been designed and investigated to treat snoring and sleep apnea. The goal of oral appliance therapy is to modify the position of upper airway structures to enlarge the airway or reduce its collapsibility.     

Among the appliances devised are mandibular-advancing devices and tongue- retaining devices (Table 1). Mandibular devices use traditional dental techniques to attach the appliance to one or both dental arches and to advance the mandibular posture (Figure 2). Tongue retainers are designed to keep the tongue in an anterior position during sleep by means of negative pressure in a soft plastic bulb. Recent research has indicated that this device shows minor success rates.

Construction of the oral appliance requires impressions and bite registration to be recorded, and study models and appliances to be fabricated in a dental laboratory. A thermoplastic device is now available in a prefabricated form, however, and can be adapted to the patient's teeth in the clinician's office (Figure 3). Several appliances allow readjustment of the mandibular position after initial construction, but other devices require prefabrication of the entire apparatus. Some bi-arch appliances may restrict mouth opening by means of clasps and elastic bands, whereas others allow relatively unhindered mouth opening. Some designs include tubes for breathing or pressure relief.  

 

Effectiveness of Oral Appliances

Studies have demonstrated that snoring and OSA are reduced when oral appliance therapy is utilized. In addition, most patients have reported an improvement in daytime sleepiness.

The adverse effects of wearing an oral appliance include TMD and tooth discomfort, which may be alleviated with further occlusal adjustment by a dentist. Initially, most patients experience pain, excessive salivation, and occlusive changes for the first month of appliance use, which may lead to a discontinuation in therapy. Analysis by the American Academy of Sleep Medicine has suggested that oral appliances are a useful alternative to more aggressive approaches, especially for patients with no medical complications linked to snoring ("simple snoring") and those with moderate OSA who cannot tolerate nasal CPAP. Additional clinical studies are necessary, however, to better define the efficacy of oral appliance therapy across the spectrum of OSA severity.

Effects on the Periodontium

Since the oral appliance is worn for many hours each day, it seems feasible that this type of therapy may have a deleterious effect on an individual's periodontal health. A randomized crossover study has recently been conducted on the oral appliance's effect on the periodontium. Over an eight-month period, the researchers conducted an evaluation made at the baseline and following treatment with each appliance. This study suggested that the use of oral appliances has no effect on periodontal diseases or occlusion. Since patients may use OSA appliances for longer periods, however, further studies are required to determine long-term efficacy.

 

The Practice’s Approach to Oral Appliance Therapy

Since the dental hygienist is a primary provider of dental care, she or he is often the first practitioner to discuss the patient's health history. Consequently, the dentist and the dental hygienist should have a thorough understanding of OSA and a predetermined protocol by which they will engage such patients. Questions about snoring and sleeplessness can alert the hygienist and patient to the need for assessment by a physician (Table 2). In many cases, the dental hygienist may not gather information about OSA symptoms during a health history, but rather during a subsequent conversation. In fact, since OSA-afflicted patients may receive repeated hygiene care, it is possible that patients may more readily discuss the socially embarrassing symptoms of OSA (eg, snoring and sleeplessness) with dental hygienists, rather than with other healthcare providers.    

In addition, the dental hygienist can play an important role in the fabrication of the oral appliance by making impressions, performing bite registration, and pouring and trimming models during a routine dental hygiene appointment. The dentist is then responsible for making necessary occlusal adjustments to the oral appliance. The most important function of the dental hygienist, however, is patient education. Patients receiving oral appliance therapy will need customized oral hygiene techniques designed to clean the appliance and prevent dental diseases. The utilization of a toothbrush and nonabrasive toothpaste is recommended. The entire appliance and any retention screws should be brushed thoroughly and rinsed well with cool water. Although it is not necessary to store the oral appliance in water or mouthwash, soaking solutions are currently available and are proven to be safe and effective.

 

Conclusion

OSA is a common condition caused by reduced upper airway size and altered upper airway muscle activity. The relationship between the dental hygienist and the patient is crucial in the diagnostic formulation and treatment of OSA. With a thorough understanding of this condition, the hygienist can educate the patient about the benefits of an oral appliance and whether or not a referral is necessary. In addition, the hygienist can instruct the patient on the proper techniques to prevent periodontal diseases during oral appliance therapy to ensure optimal treatment success.

 

*Associate professor; University of New Mexico. Graduate Program Director and Clinic Manager; UNM Division of Dental Hygiene. Coordinator; UNM Division of Dental Hygiene.  

**Associate Professor and Director, Division of Dental Hygiene, University of New Mexico.

***Associate Professor of Medicine Emeritus, University of New Mexico, Sleep Medicine Institute, Presbyterian Hospital, Dallas, Texas, and President, American Sleep Disorders Association.

 

References

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