ORAL APPLIANCES VS CPAP – Good news for patients who say “I Hate CPAP”
By Ira Shapira, DDS
Patients with sleep apnea often are fitted with CPAP as the first line of treatment for sleep apnea and it is a godsend for many. However, a large number of patients do not tolerate CPAP and search for alternatives. The American Academy of Sleep Medicine (AASM) has changed this outlook forever with its new “Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005”, published in the journal Sleep in February 2006. The new parameters state that oral appliances are indicated for treatment of mild to moderate OSA (obstructive sleep apnea) in patients who prefer them or do not respond to CPAP. At the same time, the AASM still recommends CPAP as first line treatment for severe OSA before considering oral appliances.
A correct diagnosis to determine presence or absence of OSA is mandatory prior to initiation of treatment and the AASM recommends that “Dental management of patients with OAs (oral appliances) should be overseen by practitioners who have undertaken serious training in sleep medicine and/or sleep related breathing disorders”. The guideline specifically suggests that patients treated with OSA should have follow up with polysomnography. This author also recommends that you seek dentists who are diplomates of the ADSM (Academy of Dental Sleep Medicine).
Oral appliances are similar to orthodontic retainers and mouth guards but they are specifically designed to prevent the collapse of the airway during sleep by repositioning and stabilizing the mandible (lower jaw), the jaw muscles, the tongue, soft palate and/or uvula. The primary type of appliance used is a MAD or Mandibular Advancement Device that brings the lower jaw forward using the upper jaw as an anchor. This also brings the tongue forward and tightens the pharyngeal walls and the soft palate. The tongue-retaining device uses suction to bring the tongue and jaw forward.
The advantage of dental appliances in treating apnea is that they are preferred by many patients and have a higher compliance rate, as only 23-45% of patients continue the use of CPAP. Compliance with oral appliances is much higher and people like sleeping without the hose, mask and compressor. Many patients who do not object to CPAP still prefer oral appliances for travel and feel they allow the return of intimacy to their bedrooms.
This author has been using various sleep appliances with patients for over twenty-five years. The TAP appliance is probably the most versatile as it allows titration in the sleep lab while the patient is sleeping. It is the best appliance for locating the ideal position for the treatment and also for treating severe apnea. Spouses appreciate the “volume control” knob that lets the significant other dial down the snoring while opening their partner’s airway. The Somnomed appliance allows one to easily drink water from a straw as does the modified herbst, telescopic herbst and the SAUD appliances, all of which all variations of the same appliance. Please remember it is the jaw position and the soft tissue
tension that are most important, not the appliance that maintains it.
Additional information on appliances can be found at ihatecpap.com.
Ira L. Shapira DDS, FICCMO, DAPM, DADSM has been treating sleep disordered breathing with dental appliances for over 25 years. He is a charter member of the Sleep Disorder Dental Society (SDDS) that later became Academy of Dental Sleep Medicine (ADSM). He was credentialed by the SDDS and is a Dipomate of the ADSM. He was a visiting assistant professor at Rush Medical School in the 1980’s and early 1990’s where he did research on jaw position and sleep apnea and returned in the late 1990’s when he treated patients with oral appliances. He is a Diplomate of the Academy of Pain Management and is a Fellow and former international Regent of the International College of Craniomandibular Orthopedics. He is the dental editor of Sleep and Health newspaper and consultant to numerous sleep centers on Dental Sleep Medicine. His titration protocols are used throughout Chicagoland and across the country. He practices in Gurnee, Illinois. He can be reached at 1-800-TMJoint or at his website Ihatecpap.com.