In August 2014 a respiratory therapist asked my opinion on the marketing of oral devices as a substitution for PAP therapy. At the time, I wrote a lengthy post about the pros and cons of oral appliance therapy (OAT), with a particular focus on how dental devices can supplement PAP therapy.
As HST America strives to build its integrated sleep program and connect sleep apnea patients with dentists who provide oral appliance therapy, I want to revisit some of the important issues from the previous post. In my comments I will borrow some of the language and points made at that time to use as a springboard for additional commentary.
I know that oral appliance therapy has great potential for many patients as I used one every night from 1998 to 2001 and gained excellent results. When we consider means of treatment, we must take into account whether or not the patient would have adapted to PAP or rejected it. As I said then and will repeat now “some treatment is better than no treatment.” Sutherland and colleagues’ spelled out in great detail the value of OAT from the standpoint of cost-effectiveness,1 which in this circumstance refers to a more efficient way to use healthcare resources by determining in advance the patients who should start with OAT instead of PAP.
The three main issues that must be addressed when considering oral appliance therapy are how well it works (efficacy), how the patient responds to the treatment (measurable outcomes such as sleepiness or insomnia), and adverse side effects (for example, jaw discomfort). Here, I want to make a few brief points:
Oral appliance therapy efficacy remains controversial only because the sleep medical field resists paying attention to respiratory effort-related arousals (RERAs). As dentists must take their lead from referring sleep medicine physicians, this particular issue is not likely to be addressed in a comprehensive fashion in the near term. The good news, however, is that increasing research on OAT devices clearly demonstrated a considerable degree of benefit will be gained, even when focusing only on reductions in the apnea-hypopnea index (AHI).
Sutherland and colleagues’ explained how these devices clearly improve symptoms.1 In a more recent work on veterans using oral appliance therapy, more than 30% of the respondents to a follow-up survey reported their OSA was effectively managed with their device and they were confident in their ability to use the device. Regardless of their outcomes, 65% of patients expected to keep using their OAT device regularly.2 This latter figure is of considerable interest, because it may not be as common to find a similar proportion of CPAP patients committing to use their devices. In another area of research, investigators are looking at more sophisticated ways in which to predict who will benefit the most from using oral appliance therapy.3 In their study, they found patients with modest obstructive anatomy and less collapsibility of the airway responded better to OAT. And, patients with less reactive breathing to changes in CO2 (a process referred to as ‘loop gain’) also responded better.3 In a study published last year, Japanese researchers demonstrated OAT resulted in lower blood pressure readings, most notably in sleep apnea patients who presented with hypertension at baseline.4
The number one serious concern remains exacerbation of temporo-mandibular joint (TMJ) dysfunction. Yet, a recent study describes jaw opening exercises that might decrease this problem if the exercises are performed prophylactically. Compared to a placebo-exercise control group, the genuine jaw-opening exercise group reported essentially no pain once they started using oral appliance therapy, and they demonstrated better outcome scores at the end of one month.
These three areas, efficacy, outcomes and side-effects, will continue to be the most important areas to monitor in the development of OAT devices and their burgeoning expansion into the sleep apnea market.
Sutherland K, Vanderveken OM, Tsuda H et al. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215-227.
Carballo NJ, Alessi CA, Martin JL, Mitchell MN, Hays RD, Col N, Patterson ES, Jouldjian S, Josephson K, Fung CH. Perceived Effectiveness, Self-efficacy, and Social Support for Oral Appliance Therapy Among Older Veterans With Obstructive Sleep Apnea. Clin Ther. 2016 Nov;38(11):2407-2415. doi:10.1016/j.clinthera.2016.09.008. Epub 2016 Oct 15.
Edwards BA, Andara C, Landry S, Sands SA, Joosten SA, Owens RL, White DP, Hamilton GS, Wellman A. Upper-Airway Collapsibility and Loop Gain Predict the Response to Oral Appliance Therapy in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2016 Dec 1;194(11):1413-1422.
Sekizuka H, Osada N, Akashi YJ. Effect of oral appliance therapy on blood pressure in Japanese patients with obstructive sleep apnea. Clin Exp Hypertens. 2016;38(4):404-8. doi: 10.3109/10641963.2016.1148159. Epub 2016 May 9.
Ishiyama H, Inukai S, Nishiyama A, Hideshima M, Nakamura S, Tamaoka M, Miyazaki Y, Fueki K, Wakabayashi N. Effect of jaw-opening exercise on prevention of temporomandibular disorders pain associated with oral appliance therapy in obstructive sleep apnea patients: A randomized, double-blind, placebo-controlled trial. J Prosthodont Res. 2017 Jan 4. pii: S1883-1958(16)30107-4. doi: 10.1016/j.jpor.2016.12.001. [Epub ahead of print].
About the author
Dr Barry Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr. Krakow started in sleep research in 1988 and helped pioneer innovative therapies for chronic nightmare patients. Since 1995, he has practiced sleep medicine full-time and currently operates Maimonides Sleep Arts & Sciences, Ltd., a private sleep medical center specializing in the treatment of sleep disorders such as insomnia and sleep apnea in mental health patients. He is also principal investigator of the Sleep & Human Health Institute, a non-profit research center that focuses on the complex interplay between physiological and psychological sleep disorders.