Oral Appliance for Sleep Apnea

INTRODUCTION
Device inserted into the mouth for treatment of snoring or OSA.
2 main types; Tongue retaining device and Mandibular repositioning appliances
They improve airway by moving tongue and or mandibular forward, hence increasing posterior airspace

Indicated for – primary snoring, mild to moderate OSA

EVALUATION OF PATIENT
Should be done by a dentist to see if a good candidate
Focus on TMJ, history of bruxism, quality of dental occlusion and overall dental health

A – Skeletal class I occlusion – nearly ideal balance
B – Skeletal class II occlusion – retrognathia
C – Skeletal class III occlusion – prognathia

EXCLUSIONS / CONTRAINDICATIONS
Atleast 6-10 teeth in each arch is needed, if less, contraindicated
Inability to open jaw
Moderate to severe TMJ dysfunction
Moderate to severe bruxism

Note – mild TMJ and bruxism may actually benefit from MRA

EFFECTIVENESS
May improve AHI in mild, mod and severe, however less effective than CPAP, hence CPAP should be first considered in moderate and severe OSA
Success is AHI <10/hr

AASM Guidelines
OAs can be used to treat mild-mod OSA as well as snoring
In severe, considered 3rd line after PAP and surgery

OAs success
Mild to Mod OSA → 57-81%
Severe OSA → 14-61% / but rarely AHI <10

Factors Predicting Effectiveness
Severity of OSA – better in mild to moderate
Amount of protrusion by the OAs
Positional sleep apnea component
BMI
Compliance

FOLLOWUP TREATMENT
Repeat oximeter or PSG after final adjustment
Then followup 6-12 months with dentist and sleep physician

SIDE EFFECTS
Minor and Temporary:
TMJ pain, myofascial pain, tooth pain
Excessive salivation
Dry mouth, gum irritation
Morning after occlusal changes
Chronic and Severe:
Tooth movement
TMJ dysfunction
Gum disease

References:
Berry R. Fundamentals of sleep medicine. Chapter 20: Oral Appliance and Surgical Treatment for OSA 2012. 349-373