Problems and Pitfalls with Oral Appliances
CPAP has long been considered the Gold Standard for treating sleep apnea it is extremely effective. The new guidelines from the American Academy of Sleep Medicine now consider oral appliances to be a first line treatment for mild to moderate sleep apnea and an alternative to CPAP for severe apnea when patients do not tolerate CPAP. This raises two questions: Why do we need an alternative to CPAP if it is almost 100% effective. The answer to this question is compliance. Studies have shown that a majority of patients prescribed CPAP do not use it on a regular basis and even most successful users average only 4-5 hours per night of CPAP use not the 7 ½ – 8 hours recommended. The second question, that is often glossed over is what are the problems associated with oral appliances. Additional information about Dental Sleep Medicine and oral appliances can be found at I Hate CPAP. There is a find a dentist section at that site. If there is not a dentist located in your area I HATE CPAP LLC will attempt to help patients find a Sleep Apnea Dentist.
Before we answer the second question let’s talk about CPAP successes. The 23-45% of patients who receive CPAP and like it and use it regularly do not need appliance therapy. CPAP is an excellent answer for treating obstructive sleep apnea. Patients in this group do not need a CPAP alternative. These patients are sometimes interested in oral appliance therapy due to convenience for traveling or because bed partners object to the machine. CPAP machines can occasionally be a problem for people early in relationships because they are just not conducive to romantic nights. Loud snoring, snorting, gasping, sudden movements and excessive daytime tiredness are also not great for new or established relationships. These are a few of the reasons people who are successful CPAP users may look for alternative treatment.
Oral appliances are well tolerated by patients and a majority of patients offered a choice between oral appliances and CPAP prefer appliance therapy. They are now considered a first choice for treating mild to moderate apnea and snoring along with CPAP not excluding CPAP as a first line of treatment. But there are still many problems associated with oral appliances. While these problems may not affect everyone it is good to consider them. The single most common problem associated with oral appliances is excessive salivation. This problem is almost universal when patients first start wearing appliances but luckily it is almost always a transient problem that resolves by itself. Patients who have previously worn orthodontic appliances, bruxism appliances or sports mouth guards usually do not have this problem. A second frequently reported problem with continued wear is dry mouth. Patients who snore or have sleep apnea often report this symptom before receiving an appliance and welcome the additional saliva that occurs when they first start wearing the appliance. The excess salivation usually stops on its own as the body acclimates to the appliance. This is similar to the famous Pavlov’s Dogs experiments.
Dry mouth when it occurs is usually transient and can often be compensated for by simple changes to the appliance. A small subgroup of patients has persistent dry mouth that is impossible to accept. There are patients with Sjorgren’s Syndrome, medication side effects and other conditions that predispose them to dry mouth and there are many over the counter and prescription remedies available. I have found two products that patients report great success with use. The first is Rinsinol by Oral B. It is not marketed as a product for dry mouth but as a product for treating oral ulcers but it provides excellent coverage of mucosal tissues. The second product is a prescription item made specifically to treat oral mucositis associated with chemotherapy. I use it in an off label method with amazing success. The product is Gel-Clair and it comes packaged in a box of 21 small packages meant to be diluted with two tablespoons of water and rinsed around the mouth. I found the product roughly equivalent to Rinsinol when used in that fashion and very expensive. I have many patients who use this product full strength and apply a small amount to their tissues and find it miraculous in how it controls dry mouth all night long. An advantage to the off label method is one package can be used for several nights making it inexpensive to use. It also works extremely well for oral ulcers in its undiluted form.
I have many patients who alternate between CPAP and oral appliances and they report using the product with their CPAP. Patients with severe nasal dryness have used the product intra-nasally and reported less irritation from CPAP. A less frequent problem shared by CPAP and Oral Appliances users is dry or chapped lips. An excellent solution is the use of a small amount of Lanolin places on the lips before bed. You can go to the Pharmacist and get USP Lanolin without a prescription but it is also available in the pharmacy in products for nursing mothers. It is used to prevent chapped and cracked nipples and is safe for new-born infants. Some CPAP users find it protects them from skin sores and irritations if it is applied before CPAP use. Lanolin is also helpful for chapped lips during the winter.
While oral appliances are very effective they only work when they are used. Compliance with CPAP is low, 23-45% according to published studies compared to approximately 90-95% compliance with appliances by patient report. There is no good method to measure compliance with oral appliances so sleep physicians only have patient reports to evaluate success. Patients cite comfort and fit as the primary reasons for not wearing appliances with about an equal split between too loose or too tight. Problems with fit are almost universally correctable with patience. Some patients find it hard to fall asleep with the appliance in their mouth just as some patients find it hard to fall asleep with CPAP. This problem resolves spontaneously for most patients and is often secondary to increased salivation. Many patients find using 25-50 mg of Benadryl (diphenhydramine) helpful during the initial wearing of an appliance due to the sedative effects of the antihistamine and the side effect of a dry mouth. There is an added benefit of easier nasal breathing for patients with allergies.
Cleanliness is very important for patients using CPAP or Oral Appliances. With CPAP scrupulous cleaning on a nightly basis prevents formation of biofilms that can be carried into the lungs, bronchi, and sinus cavities. Patients who have problems with daily cleaning can have several sets of CPAP masks and hoses. Oral appliances require that the patient be scrupulous not only in cleaning their appliances but also in brushing and flossing their teeth before bed. The appliance does not allow the normal flow of saliva to self-cleanse the teeth and bacteria and plaque will accumulate rapidly if normal brushing and flossing are not done. This extra attention to oral health may save patients from numerous problems with decay and gum disease. The effect on overall health of periodontal disease is similar in magnitude to the problems of sleep apnea. Patients with periodontal disease show a six fold increased risk of heart attacks and strokes as well as increases in diabetes, lung infections and numerous other problems. All Patients using CPAP, Appliances or nothing should follow a similar routine but it is most important for patients with appliances.
A problem frequently seen with oral appliances is pet dogs and cats have an affinity for eating, chewing and destroying them. I have never heard of this happening with CPAP masks and hoses. Patients also are more likely to leave an oral appliance in a motel room because it so small and does not require a special case.
All of the problems listed so far have been problems of convenience and they are usually overcome without major difficulty. Changes of tooth movement come in short-term and long-term varieties. Short-term movement is a fit issue to be corrected by the dentist and is usually not a problem. Changes that occur early will usually self correct by discontinuing use of the appliance. It is rare that patients decide to quit wearing appliances even when they are aware of changes. Long-term changes appear to happen in the majority of patients with long-term use. The changes are usually minor but can be more noticeable in some patients. It is often impossible to see the changes without the use of serial radiographic studies. The most common changes in tooth position are usually retro-inclination of upper anterior teeth and forward tipping of lower anterior teeth. The changes are rarely a concern to patients who often are unaware of them until their dentists notice them.
Bite changes are a more common phenomenon and are also easily reversible early on. When the patient wears the appliance that keeps their jaw in a different position for eight hours healing occurs in joints and adaptation will often occur. Dentists usually give their patients exercisers or positioners to return to their original position. Patients are often not aware of the bite changes. When patients are aware of the changes about 50% find them to be favorable. It is rare to see a patient discontinue use due to the bite changes. Dentists are often more upset with the bite changes than the patients are. Dr Alan Lowe an Orthodontist and a leading dental sleep medicine researcher, educator and professor in Canada summed up his feelings about tooth movement and bite changes as: “ Dentists need to get over it, the life changing and life saving effects of the treatment far outweigh the dental changes.’ This is an amazing statement from an orthodontist. He has stated that under no circumstances should dentists withdraw patients from life saving dental appliance therapy without first reintroducing CPAP.
There is also a subgroup of patients who experience TM Joint problems or muscle pain when wearing appliances. These problems are almost never a reason to not use oral appliances but they need to be addressed and treated by a dentist trained to deal with TMJ Disorders. The American Academy of Sleep Medicine actually advised in their recommendations that oral sleep apnea appliances be fit by dentists trained to deal with TMJ disorders. The groups that are dedicated to the treatment are The International College of Cranio-Mandibular Orthopedics (www.iccmo.org) whose members practice Neuromuscular dentistry. Information on neuromuscular dentistry is available at www.ihateheadaches.org. The American Academy of Craniofacial pain (www.aacfp.org) is another excellent organization that teaches and promotes dental sleep medicine and treatment of TMJ disorders. The Dental Organization for Sleep Apnea (DOSA) www.apneadocs.com also promotes treatment of TMJ and Sleep apnea. The American Academy of Dental Sleep Medicine (www.dentalsleepmed.org) has not developed a comprehensive strategy regarding treatment of TMJ Disorders. The American Alliance of TMD Organizations represents the political interests of patients and dentists who deal with TMJ disorders. A listing of all the major TMD groups involved in teaching and promoting TMD practice belong to this group.
The National Heart, Lung and Blood Institute (NHLBI) of the National Institute of Health (NIH) actually consider Obstructive Sleep Apnea to be a TMJ Disorder. Their fascinating report:
CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS
Can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf
The remarkable fact is that 90-95% of oral appliance users report long- term satisfaction with their treatment. The problems associated with appliance use are usually easily solved or well tolerated by patients. Many patients who start with treating their sleep apnea problems find that correcting the underlying TMJ disorders an advantage not a problem. Similarly, many patients who start seeking treatment for TMJ disorders find that they move on to treating their sleep problems. Because the underlying problems are the same it turns out that treating either problem either usually helps both problems. Women are more likely to initially seek treatment for TMJ problems and men are more likely to seek treatment for snoring or apnea.
Dr Shapira is a Diplomate of the American Board of Dental Sleep Medicine and is a founding member of DOSA, a charter member of the Sleep Disorder Dental Society, which evolved into the American Academy of Dental Sleep Medicine. He is also a Regent of ICCMO and a representative for the organization to the TMD Alliance. He is a member of The American Academy of Sleep Medicine and The American Academy of Craniofacial Pain. He is the Founder of I Hate CPAP LLC and can be contacted thru www.ihatecpap.com