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References

Al-Delaimy WK, Harris CD, Herold DL, Shepard JW Snoring as a risk factor for type II diabetes mellitus: a prospective study. Am J Epidemiol. 2002; 155:387-393
Hu FB, Willett WC, Manson JE Snoring and risk of cardiovascular disease in women. J Am Coll Cardiol. 2000; 35:308-313
Lavie P, Herer P, Hoffstein V. Obstructive sleep apnoea syndrome as a risk factor for hypertension: a population study. Br Med J. 2008; 320:479-482
Pataka A, Riha RL. Continuous positive airway pressure and cardiovascular events in patients with obstructive sleep apnea. Curr Cardiol Rep. 2013; 15 https://doi.org/10.1007/s11886-013-0385-z
Balk EM, Moorthy D, Obadan NO Diagnosis and treatment of obstructive sleep apnea in adults.Rockville (MD): Agency for Healthcare Research and Quality (US); 2011
Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008; 5:173-178
Johal A. A review of the use of mandibular advancement appliances in sleep-disordered breathing. Dent Update. 2008; 35:230-235
Johal A, Fleming P, Manek S, Marinho V. Mandibular advancement splint (MAS) therapy for obstructive sleep apnoea − an overview and quality assessment of systematic reviews. Sleep Breath. 2015; 19
Sleep-Related Breathing Disorders. 2012;
Ramar K, Dort LC, Katz SG Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliances therapy: an update for 2015. J Clin Sleep Med. 2015; 11:773-827
Hoffstein V. Review of oral appliances for the treatment of sleep-disordered breathing. Sleep Breath. 2007; 11:1-22
Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Sleep. 1995; 18:511-513
Vanderveken OM, Devolder A, Marklund M Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med. 2008; 178:197-202
Johal A, Haria P, Manek S Ready-made versus custom-made mandibular repositioning devices in sleep apnea: a randomized clinical trial. J Clin Sleep Med. 2017; 13:1-8
Barnes M, Douglas R, Banks S Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med. 2004; 170::656-664
Mehta A, Qian J, Petocz P, Ali Darendeliler M, Cistulli PA. A randomized, controlled study of mandibular advancement splint for obstructive sleep apnoea. Am J Respir Crit Care Med. 2001; 163::1457-1461
Gao X, Otsuka R, Ono T, Honda E, Sasaki T, Kuroda T. Effect of titrated mandibular advancement and jaw opening on the upper airway in non-apneic men: a magnetic resonance imaging and cephalometric study. Am J Orthod Dentofacial Orthop. 2004; 125:191-199
Tsuiki S, Lowe AA, Almeida FR, Fleetham JA. Effects of an anteriorly titrated mandibular position on awake airway and obstructive sleep apnea severity. Am J Orthod Dentofacial Orthop. 2004; 125:548-555
Millman RP, Rosenberg CL, Kramer NR. Oral appliances in the treatment of snoring and sleep apnoea. Clin Chest Med. 1998; 19:69-75
Johal A, Battagel JM. An investigation into the changes in airway dimension and the efficacy of mandibular advancement appliances in subjects with obstructive sleep apnoea. Br J Orthod. 1999; 26:205-210
O'Sullivan RA, Hillman DR, Mateljan R, Pantin C, Finucane KE. Mandibular advancement splint: an appliance to treat snoring and obstructive sleep apnea. Am Rev Respir Crit Care Med. 1995; 151:194-198
Doff MHJ, Hoekema A, Pruim GJ, Huddleston JJR, Stegenga B. Long-term oral appliance therapy in obstructive sleep apnoea: a cephalometric study of craniofacial changes. J Dent. 2010; 38:1010-1018
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The role of dentists in management of snoring with oral appliances

From Volume 45, Issue 5, May 2018 | Pages 408-412

Authors

Ama Johal

BDS, PhD, FDS(Orth) RCS, BDS (Hons), MSc, PhD, FDS, MOrth RCS, DMS, FDS (Orth) RCS, FHEA

Senior Lecturer, Department of Oral Growth and Development, Bart's and The London School of Medicine and Dentistry, Institute of Dentistry, Queen Mary's College, London, UK

Articles by Ama Johal

Aditi Desai

BDS, MSc

President, British Society Dental Sleep Medicine and Dental Consultant, Sleep Service, HCA at The Shard; London Bridge Hospital, 34 St Thomas Street, London SE1; 76 Harley Street, London W1G 7HH, UK

Articles by Aditi Desai

Abstract

Abstract: This paper aims to highlight the importance of dentists in the management of sleep-related breathing disorders through the provision of mandibular advancement appliances (MAAs). An update on the use of MAA therapy is provided with respect to current clinical practice guidelines, their mode of action, selection and an awareness of their relative advantages and disadvantages, along with follow-up and practical aspects to their provision.

CPD/Clinical Relevance: With the increasing recognition of the role of mandibular advancement appliances in the management of sleep-related breathing disorders, the importance of trained dentists in what is recognized as Dental Sleep Medicine is highlighted in this update.

Article

Ama Johal

A recent development in dentistry is the emergence of dental sleep medicine (DSM), which is a recognized branch of sleep medicine that deals with patients who have sleep-related breathing disorders. These can range from ‘simple’ snoring to obstructive sleep apnoea (OSA), which is characterized by repeated collapse of the pharyngeal airway during sleep. Whilst snoring is largely considered to be more of an anti-social problem, with resultant disturbed sleep for bed partners, there is evidence to suggest that this in turn could act as an independent risk factor for Type II diabetes and cardiovascular disease.1,2 OSA and the resultant impaired sleep is associated with a significant cardiovascular and metabolic comorbidity, impaired quality of life and increased risk of motor vehicle accidents.3,4

Dentists are beginning to take notice of their proactive role in this emerging area of special interest in managing patients who have sleep-disordered breathing. First line therapy for symptomatic OSA remains continuous positive airway pressure (CPAP), in view of its proven treatment effect.5 However, the limitations of this therapy relate to significant issues with tolerance, in particular adherence which remains highly variable and has been reported to range from 17−60% and, finally, in a small sample may not resolve the OSA.5,6 There is now an established evidence base for the management of OSA with custom-made, titratable, which permits incremental advancement (3rd generation7), mandibular advancement appliances (MAAs), provided by a dentist with special training.8It is worth remembering that dentists remain the only healthcare providers with both the knowledge and expertise to undertake MAA therapy.

In order to be involved in DSM, dentists need to undergo training in oral appliance (MAA) therapy, have knowledge of sleep-related breathing disorders and established management protocols, as well as having an understanding of how to work as part of a multidisciplinary medical team, in order to build a productive medical and dental collaboration.

It is widely recognized that a large percentage of OSA patients remain undiagnosed and untreated in the UK.9 In this respect, dentists trained in DSM are optimally placed to screen for the presence of signs and symptoms of OSA in their patients. Once identified, dentists can assess for suitability of provision of a MAA and refer to the patient's general medical practitioner (GMP), to help establish a diagnosis. This will entail the GMP referring the patient to secondary care designated Sleep Clinics, where they are likely to undertake an overnight sleep study. The British Society for Dental Sleep Medicine provides this training and access to treatment protocols and a care-pathway, designed to outline this process (www.bsdsm.org.uk).

Clinical practice guidelines

The need for collaborative working between physicians and dentists was recently recognized in the joint publication of the Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy by the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM).10 This first official joint clinical guideline supports increased collaborative practice between physicians and dentists for optimal treatment outcome, recommending the use of MAA therapy in regard to the following sleep-related breathing disorders:

  • Non-apnoeic snorers, who fail to respond to OR are not appropriate for weight loss or positional changes;
  • Mild to moderate OSA, in which patients express preference for MAA; intolerant of OR refuse n-CPAP;
  • Severe OSA, where patients must always undergo a CPAP trial and, only if they are found to be intolerant of OR refuse it, should they be offered a MAA. Furthermore, MAAs should be offered to patients who are not suitable candidates for surgery.

    • Thus, it would appear that the MAA plays a central role in the management of sleep-related breathing disorders, either as first-line or the alternative treatment choice. It remains important that dentists wishing to be involved in this emerging field of Dental Sleep Medicine acquire not only an understanding of the current management of sleep-related breathing disorders and, in the case of OSA, work in conjunction with the Sleep physician, but importantly acquire specialist training to provide MAA therapy. The provision of customized MAAs requires high quality accurate dental impressions of the upper and lower dental arches and, in some instances, a bite registration, with or without a degree of mandibular advancement.

    This knowledge transfer remains two-way, with sleep physicians equally being advised to prescribe titratable MAA therapy for OSA adult patients rather than no treatment, in those instances where CPAP is not tolerated or ineffective. This is particularly in light of the fact that lower rates (56−68%) of discontinuation are observed in response to MAA treatment, when compared to CPAP.5,611

    In terms of the overall treatment objectives for patients with sleep-related breathing disorders, managed with MAA therapy, the American Sleep Disorders Association, reporting on practice parameters, defines these as the following:12

  • To reduce the snoring to a subjectively acceptable level for patients with simple snoring;
  • The resolution of clinical signs and symptoms, with normalization of the apnoea-hypopnoea index (AHI: number of abnormal respiratory breathing events per hour of sleep) and oxyhaemoglobin saturation in patients with OSA.

    • It is of importance that OSA patients managed with MAA therapy are appropriately followed-up to ensure that they are being optimally treated. This assessment can be in the form of validated subjective questionnaires, as well as objective overnight sleep testing. The latter is particularly important when managing failed CPAP treatment or milder but symptomatic OSA. It is important to recognize that both CPAP and MAA therapy are life-long treatments, which are highly dependent on patient compliance and, as such, require periodic follow-up to help ensure maximum comfort and effectiveness.

    Selection of mandibular advancement appliance design

    There is currently little controversy in the literature with respect to the selection of MAA design. The optimal properties of what has been described as a 3rd generation MAA have been well documented previously and include: good retention; sufficient mandibular protrusion to maintain airway patency; minimal vertical opening and full occlusal coverage.7 These have been further supported by the AASM/AADSM guidelines, recommending the use of a custom-made, titratable MAA over a non-customized oral appliance.10 The weight of evidence for the use of a custom-made, titratable MAA is supported by the greater reduction in AHI, oxygen saturation levels, quality of life, daytime sleepiness and, importantly, improved tolerance observed with custom-made, titratable MAA therapy.13,14 Given that there is great individual variation in the degree of mandibular protrusion attainable by patients, appliances that permit incremental advancement (titration) offer clear advantages. These include not only minimizing initial patient discomfort, by avoiding the need to posture the mandible forward excessively, but also in obtaining maximum therapeutic benefit, through gradual adaptation and subsequent self-adjustment (titration). Figures 1, 2 and 3 illustrate three such appliances with proven therapeutic value.15,16 Gao et al17 and Tsuiki et al18 have demonstrated the benefit of progressive advancement of the mandible in order to determine the most effective position to treat sleep-related breathing disorders.

    Figure 1. Sleepwell® (MDSA) customized mandibular advancement appliance.
    Figure 2. Somnodent® customized mandibular advancement appliance.
    Figure 3. Narval® customized mandibular advancement appliance.

    Contra-indications to MAA therapy

    Whilst MAA therapy has a role in managing patients with sleep-related breathing disorders, it is important that dentists involved in the provision of MAA therapy minimize any later potential complications and impaired quality of life for their patient through a careful initial assessment. The provision of MAA therapy is contra-indicated in the following circumstances:

  • Epilepsy: It is not considered appropriate in subjects with epilepsy, for fear of the appliance becoming dislodged during a nocturnal seizure, with resultant airway obstruction.
  • Poor dental and periodontal health: The dental health of the patient needs to be optimal. In particular, the periodontal health should be stable and without any signs of active inflammation and disease, as evidenced by bleeding on probing and mobility. The MAA utilizes the dentition for its support and consequently transmits the reciprocal forces of mandibular advancement to the dentition, risking unwanted tooth movement or accelerated tooth loss in the presence of periodontal disease.
  • Temporomandibular joint dysfunction (TMD): These appliances act by their very nature through forward posturing of the mandible, away from its rest position. It is therefore important that dentists identify any signs and symptoms suggestive of TMD and avoid the provision of such appliances until the symptoms are settled. The subsequent use of incremental advancement appliances, and particularly self-adjustable ones, permit the patient under the careful monitoring of his/her dentist to advance the mandible slowly and monitor symptoms, as well as reverse activation to minimize any loading of the joint.

    • Side-effects of MAA treatment

    The use of these appliances is not without side-effects and they form an essential part of the consenting process, not least because of the long-term nature of their use. In general terms, these can be divided into short term, and of low impact, or long term, with the potential for significant impact.

    Short term

    With the advent of titratable MAA, many of the previously reported effects of discomfort in the muscles of mastication and dentition can be eliminated, as they are permitted to adapt to the level of mandibular protrusion gradually.19 Patients are likely to report excess salivation and altered bite sensation on awakening; these are reflective of the changes in neuro-proprioceptive responses induced by the forward posturing of the mandible.20,21 These effects are short-lived and the patient readily adapts to them within a matter of weeks.

    Long term

    These can have a potentially significant impact on the patient and warrant careful explanation:22,23

  • As a direct consequence of the MAA posturing the mandible forwards, reciprocal forces are transmitted through the facial musculature and directed to the dentition, with resultant unwanted tooth movements and change in the occlusion. A significant body of evidence exists to confirm this change, and in particular highlights the following:22,23
  • Retroclination of upper incisors, with potential dental crowding;
  • Proclination of the lower incisors, with potential dental spacing;
  • A reduction in the number of occlusal contacts.
    •  Furthermore, these changes can be observed within the first year and may persist beyond but demonstrate significant variability with no defined strong prognostic indicators. However, the importance of maintaining an optimal standard of dental and periodontal care cannot be over-emphasized in an attempt to minimize this unwanted side-effect. Furthermore, the design of the MAA per se does not appear to impact significantly on risk, with incremental advancement devices also demonstrating dental movement. However, the ability to titrate an MAA ensures the minimum amount of mandibular advancement to achieve therapeutic benefit is used. It is therefore important that patients are appropriately warned of these invariable risks of tooth movement as part of the informed consent process.
  • Temporomandibular joint dysfunction (TMD): TMD and associated symptoms of discomfort remain a potential side-effect.22,23 However, the key is prevention and, as such, patients exhibiting signs or symptoms of TMD should not be provided MAA therapy (see above for contra-indications) and, following elimination of TMD, the use of an incrementally advancing device is to be recommended and the patient carefully monitored and followed-up.
  • Ensuring therapeutic benefit. Following MAA therapy, patients should be followed-up, initially at a 1−3-month period to assess their adherence and therapeutic benefit. The latter can be assessed both subjectively, through direct questioning and a range of validated questionnaires for symptom improvement, and objectively, with overnight sleep monitoring. The latter highlights the importance of working as part of a multidisciplinary medical team and, in the case of patients referred for treatment of moderate to severe OSA by MAA therapy, the Sleep physician should be contacted to arrange a follow-up overnight sleep study to assess the changes in sleep physiology.

    • Conclusions

    Dental sleep medicine is both an exciting and very rewarding aspect of care, which not only provides the opportunity to improve the quality of life of patients and their families, but offers dentists the opportunity to be part of a multidisciplinary team designed to manage sleep-related breathing disorders.