Selecting an oral appliance for the treatment of snoring and sleep apnoea.

Range of oral appliances

Snoring can often be a sign of sleep apnoea. Oral appliances, along with the CPAP machine, are one of the two proven, effective treatments for snoring and obstructive sleep apnoea (OSA), a medical disorder with significant morbidity and increased mortality rate. 

Following diagnosis of OSA, and recommendation of an oral appliance by a medical specialist, selection of an appropriate appliance for the individual patient needs to be considered. Which snoring, or sleep apnoea mouth guard dentists recommend will depend on a number of factors.

The important first step in deciding to proceed with treatment, is selecting an oral appliance for sleep apnea. However with over 100 different choices, not all oral appliances are equal, and this can be a confusing area – particularly for dentists new to the field.

At SleepWise Clinic we are often asked, “What is the best oral appliance to treat snoring and obstructive sleep apnoea?”

This article will discuss a basis for choosing a mouth guard for sleep apnea, and then review some of the appliances available in Australia.

Guidelines for selection of an oral appliance to treat snoring and sleep apnoea.

  1. The appliance should have demonstrated effectiveness and safety in scientific studies published in refereed journals. The use of appliances lacking supporting evidence-based studies demonstrating effectiveness and safety cannot be justified.
  2. The appliance should comply with the definition of an oral appliance as outlined by the published expert consensus of the American Academy of Dental Sleep Medicine (AADSM)1 .
  3. The appliance design should be of minimal dimensions and result in minimal side effects. A recent study2 demonstrated that the main reason patients stopped using an appliance was side effects, dry mouth and an inadequate lip seal. This can be related to the bulkiness of the appliance. The correct choice of mouthguard for sleep apnea by dentists can minimise unpleasant side effects like these and enable patients to use an appliance very comfortably.

Material of construction

Another important factor that needs to be considered is the choice of material from which the dentist snoring device is constructed. Acrylic resin and hard/soft laminate materials have been traditionally used, and while they can be forgiving of technical errors during the fitting, they tend to be less durable and often result in significant discolouration. They are also quite prone to fracture.

A revolution in materials

The advent of 3D Nylon printing and CAD CAM technology has allowed for the use of extraordinarily thin materials thereby maximising comfort. These materials have exceptional strength and are virtually unbreakable with regular use. 3D printed nylon will be resulting in the traditional acrylic materials becoming obsolete.

What is the best appliance

It is generally accepted that there is no one appliance that is suitable for each and every patient.  It is important that a dentist can choose from a range of appliances in order to select the one most appropriate for the individual patient.

The choice of appliance may depend on factors such as number and configuration of teeth, the relationship between the upper and lower arch, the presence and degree of 

bruxism( clenching and grinding), presence of TMJ (jaw joint) dysfunction and the amount of intra oral space.

Despite claims by manufacturers, there is no such thing as the “best appliance”. Each of the different designs has positives and negatives, and a different side effect profile.

It is through carefully considering these factors that a choice can be made in selecting an appliance to ensure that the mouth guard for sleep apnea from the dentist is the best one for the individual and can be used comfortably and effectively for the longer term.

Review of available oral appliances in Australia

The following is a review of some of the available, custom made, dentist fitted, sleep apnea appliances, classified into different categories based on design.

All the recommended appliances have published research studies demonstrating effectiveness and safety.


Recommended oral appliances

1 – Lateral wing design

This includes the:

Pros

  • Upper and lower components are not connected, or joined, allowing the jaw to open and close with ease in swallowing, jaw movements and even speaking.
  • Allows for fine calibrated titration-down to 0.1mm increments in order to get the jaw in the ideal position to overcome all the snoring and symptoms.
  • Published scientific data demonstrating effectiveness.
  • Conforms to the AADSM definition of an oral appliance.

Cons

  • May be prone to fracture in severe bruxers when made from acrylic resin.
  • May not prevent the jaw from dropping for those patients for which this is an issue.

2 – Side connectors design

a) With plastic or elastic connectors.  This includes the:

Pros

  • Silensor and EMA have minimal dimensions- particularly suitable for gaggers.
  • Published data demonstrating effectiveness.
  • Conforms to the AADSM definition of an oral appliance.

Cons

  • Less robust -connectors can stretch or break, particularly in the presence of bruxism.
  • Prone to fracture unless made from 3D printed nylon, such as the Oventus mouth guard
  • Difficult to perform fine titration – limited to 0.5 or 1mm increments based on available connectors.
  • Retention needs to be optimal due to displacing forces with jaw movements.

b) With metal connectors-telescopic arms.  This includes the:

Pros

  • Robust-suitable for bruxers.
  • Allows for fine calibrated titration-down to 0.1mm increments.
  • Published data demonstrating effectiveness.
  • Conforms to the AADSM definition of an oral appliance.

Cons

  • Retention needs to be optimal due to displacing forces on mandibular movements.
  • Mandible needs to be prevented from dropping in certain patients.
  • Metal side connectors may impinge upon the inside of the cheeks causing irritation and ulceration.

3 – Anterior connector design

This includes the:

Pros

  • Simple one point titration. Allows for fine calibrated titration-down to 0.1mm increments.
  • Robust-suitable for bruxers.
  • Published data demonstrating effectiveness.
  • Conforms to the AADSM definition of an oral appliance.

Cons

  • May be more difficult to minimize the vertical opening and achieve a lip seal.
  • Tongue irritation may be a problem for some patients.
  • Increased loading on front teeth, and resulting tenderness may become a problem for some patients.
  • Retention needs to be optimal due to displacing forces on mandibular movements.

Summary

Despite the claims by manufacturers, based on comparison studies, all appliances are very similar in regard to effectiveness.

When selecting an appliance, it is important that the dentist is familiar with, and able to select from a range of appliances that conforms to the AADSM definition. Clinical decisions should be based upon published studies in reputable peer-reviewed scientific publications.

Choosing a best appliance

Given that scientific studies are demonstrating that the various custom made, titratable appliances are quite similar in effectiveness, the main criteria for choosing an appliance should be based largely on comfort and strength.

The dorsal design is generally regarded by dentists as the one easiest to use and with the least side effects. This is largely because it is the only design in which the patient can open and close, sip water, speak and swallow. When coupled with 3D printed nylon manufacture, it is extremely thin and unbreakable.

In conclusion, one should be wary of claims in effectiveness, via unpublished clinical trials, carried out by those promoting a particular product as treatment for OSA.


1 “Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnoea and Snoring

“A Report of the American Academy of Dental Sleep Medicine”
S Scherr; Leslie C. Dort, F Almeida, K Bennett; NBlumenstock. G Demko, G Essick; S Katz P McLornan; K Phillips; R Prehn;

R Rogers; T Schell; R Sheats; F Sreshta,
Journal of Dental Sleep Medicine
Volume: 2 Number: 3 July 2015

2 “Determinants of Objective Compliance During Oral Appliance Therapy in Patients With Sleep-Disordered Breathing: A Prospective Clinical Trial”
Dieltjens M, Verbruggen AE, et al
JAMA Otolaryngol Head Neck Surg. 2015 Oct;141(10):894-900