I am constantly being asked, “Do oral appliances work?” By physicians, by patients, by friends, by the mechanic, by my barber… Recently, I was visiting a local Ear Nose and Throat Specialist and he expressed the opinion that success rates with oral appliances are the same as palatal surgeries. WRONG!
Let’s compare Oral Appliance success rates to what we know to be the “Gold Standard” of treatments, Continuous Positive Airway Pressure (CPAP). Of late, compliance monitors that are built into the actual appliance have been useful to objectively establish how often and for how long patients actually wear their oral appliance (1). This allows the calculation of“Mean Disease Alleviation” (MDA); a term that takes into account not only “how effective” a therapy is, but also “how compliant” patients are with the therapy (2); providing a more realistic measure of therapeutic effectiveness.
It is clear that CPAP is more effective in lowering AHI, especially with higher severities (3). However, the literature also clearly establishes that patients prefer oral appliances to CPAP and as such wear them more often and for longer periods (3). Oral appliances are worn 6.7 hours per night 2, versus (5) hours per night for CPAP (4).
So, do oral appliances work when compared to the “Gold Standard”? The effectiveness of CPAP has been calculated to be 50% (when adjusted for sleep-time, it’s actual effect and use) in a study of mild, moderate and severe apneics (5). Calculated therapeutic effectiveness, or MDA, for oral appliances has been calculated to be 51.1% in a study of mild to moderate apneics (2). Although the evidence supporting oral appliances continues to mount, it is going to take a while for some to digest these statistics. Do oral appliances really have a higher therapeutic effectiveness for alleviating apnea than CPAP? Clearly, this calls for more studies, and then some more studies. After which, perhaps the right thing to do, would be even more studies.
Recently, a study found the following, “health outcomes in patients with moderate to severe OSA were similar after treatment with CPAP and MAD (mandibular advancement device)…likely explained by the greater efficacy of CPAP being offset by inferior compliance relative to MAD” (1). Do oral appliances actually work you ask? The literature data is telling; when compared to the “Gold Standard” they are not as effective at reducing AHI, but superior compliance results in a similar therapeutic effectiveness (6).
The MDA concept was a main theme at this year’s annual American Academy of Dental Sleep Medicine (AADSM) meeting. Interestingly. The New Guidelines published jointly by the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine state that a Sleep Physician should consider a patient’s preference regarding the use of an Oral Appliance, regardless of their severity of Sleep Apnea (7). This is a huge paradigm shift! Stop banging your head against the wall on this one, it seems that Oral Appliances that manage Sleep Apnea work!
1. Am J Respir Crit Care Med 2013; V187:8, 879–887
2. Thorax doi:10.1136/thoraxjnl-2012-201900
3. Principles and practice of sleep medicine. 5th ed., 2011; Chapter 108:1266-1277
4. Sleep 2006; 29:381
5. Eur Respir J 2000;16:921–7
6. J Clin Sleep Med 2011;7:447–8
7. J Dental Sleep Medicine 2015; 2(3)71-125
John Viviano DDS D ABDSM
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