Clinical ReviewTreatment of snoring and obstructive sleep apnea with mandibular repositioning appliances
Introduction
Obstructive sleep apnea (OSA) is a very common disorder, affecting approximately 4% of men and 2% of women in the middle-aged workforce.1 Snoring, a precursor to OSA, is even more common affecting 40–60% of adults.2 These disorders result from sleep-related narrowing of the upper airway, which is thought to be due to varying combinations of anatomical and neuromuscular factors that culminate in an imbalance of forces acting on the airway. This causes airflow limitation (snoring), partial (hypopnea) or complete (apnea) closure of the upper airway, with consequent adverse effects on sleep quality and gas exchange. Daytime consequences of OSA include a range of symptoms related to excessive sleepiness, neurocognitive impairment, and mood disturbance, which affect quality of life. There is also growing evidence linking OSA to long-term cardiovascular morbidity, including hypertension, myocardial infarction, and stroke, and an increased risk of motor vehicle accidents. It is now recognized that OSA is a serious public health problem. Snoring, either as an accompaniment to OSA or in isolation, also imposes a social burden to patients and their bed partners.
In broad terms, the treatment of snoring and OSA is aimed at reducing the vulnerability to upper airway collapse during sleep. In the case of OSA, the most commonly used treatment is Continuous Positive Airway Pressure (CPAP), involving the administration of pressurized air to the upper airway via a nasal or face-mask during sleep. This pneumatically splints the airway, thereby preventing collapse. Prior to CPAP, the only effective treatment was tracheostomy to bypass the upper airway obstruction. Whilst CPAP is a highly efficacious treatment in terms of preventing snoring and obstructive events, as well as producing positive outcomes in terms of sleep quality, daytime function and blood pressure, criticism has been leveled at its expense, obtrusive nature and consequent effects on compliance.3 This has prompted a search for simpler alternatives.
One such alternative that has emerged particularly over the last decade is oral appliance therapy, which relies on repositioning of the tongue and mandible in a way that reduces the tendency of the airway to narrow or collapse during sleep. Two broad appliance classes have emerged, namely mandibular repositioning appliances (MRA) and tongue retaining devices. The former are far more commonly used in clinical practice, and the quantity and quality of scientific literature supporting their use is greater than for tongue retaining devices. Hence, this review will focus on the use of MRA in the treatment of snoring and OSA.
Section snippets
Rationale for use of MRA in snoring and OSA
Whilst details of the mechanism of action of MRA in the treatment of snoring and OSA remain uncertain, preliminary studies suggest that the tongue, soft palate, lateral pharyngeal walls, and mandible interact to control airway size, and that mandibular advancement induces complex changes in these structures, resulting in improved airway stability (see Fig. 1). Specifically, MRA have been shown to increase the lateral dimension of the upper airway,4 to improve velopharyngeal obstruction,5 and to
Efficacy and effectiveness of MRA treatment
Whilst interest in the use of MRA as a treatment for snoring and OSA has been sparked since its inception in the early days of dentofacial orthopedics, its efficacy in the treatment of sleep-disordered breathing has only been rigorously investigated during the last decade. Randomized controlled trials (RCTs) have been undertaken with MRA comparisons made in the short term against no treatment,10., 11., 12., 13., 14. both active12., 14., 15. and non-active oral appliances,14., 16., *17., *18.,
General indications
The prescription of any treatment for OSA, including MRA, follows both subjective and objective appraisal. A clinical history, which preferably includes bed partner input, reveals most frequently the presence of nocturnal habitual snoring, nocturnal witnessed apneas, and excessive daytime sleepiness, which often prompt medical consultation in the first instance. However, these features are not solely relied upon for a definitive diagnosis of OSA, as they lack diagnostic sensitivity and
MRA designs
A multitude of MRA designs have been reported in the literature and are available commercially. It is not the intention of this review to describe specific MRA, but rather to consider general design principles. Most use traditional dental techniques to attach a one- or two-piece appliance to one or both dental arches and vary in design from relatively simple acrylic moldings to appliances incorporating metallic rod and tube fittings, interarch elastic, metal or plastic connectors, or even
Side-effects and complications
The reported adverse effects associated with MRA have so far been of limited magnitude.*22., 56., 57., 58., 59., 60. Almost 90% of patients who continue treatment on a regular basis consider that the treatment benefits outweigh any adverse effects.61 Nevertheless, discomfort from the appliance is the major cause for discontinuation of treatment or poor compliance for about 20–50% of initially treated patients.*32., 61., 62. This may be exacerbated by using a single position appliance or too
Treatment compliance
The acceptance rate of MRA is moderately high and this appears to be related to the simplicity of the treatment itself.15., *17., *18., 19., *20., *21., *22. However, the interpretation of adherence rates is subject to limitation by over-inflated figures reported as a result of a lack of intention to treat analyses and most importantly, unlike CPAP, a lack of objective data for verification. The main reasons for patient refusal to initiate or continue with treatment are a lack of self-perceived
Comparison with other treatments
The overall benefit of a treatment is related to the product of its effectiveness and the patient's adherence to treatment, the latter being determined to a large extent by the acceptability of the treatment to the patient, and often the bed partner. Whilst CPAP is unquestionably a more effective treatment for OSA, there is now strong evidence from RCTs that patients find MRA a more acceptable treatment than CPAP*20., *21., *22., 24., 25. and that for an important subset of patients (30–40%)
Clinical pathways and education
Integrative care appears to be central to the successful management of patients with snoring and OSA for whom MRA therapy is indicated. This involves a multidisciplinary approach involving a proficient sleep and dental team. Interdisciplinary communication and treatment planning via a coordinated care pathway would most likely enable an efficient process in the care of these patients. Patient access to and knowledge of such a process is essential in optimizing patient outcomes. Moreover, the
Trends in usage
Anecdotal evidence suggests increasing awareness about MRA for snoring and OSA, both among clinicians and patients. This trend appears to apply to North America, Europe, China, Japan, and Australia. In Sweden, the number of prescribed MRA for sleep apnea per annum has increased 3-fold since 1999. During this period, medically indicated MRA treatment has become incorporated in the general health care system, resulting in lower fees for the patients and registrations of MRA treatments. In some
Acknowledgements
Peter Cistulli and Helen Gotsopoulos have received research support from the National Health and Medical Research Council of Australia. Marie Marklund has received research support from The Swedish Association for Heart and Lung Patients and the Swedish Dental Society. Alan Lowe has received research support from various Canadian provincial and federal granting agencies.
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- 1
Peter Cistulli has agreed to act as a medical advisor to an Australian start-up company that intends to commercialise an oral appliance for snoring and sleep apnoea. It is anticipated that the company will become operational some time in the second half of 2004. Royalties from Kleenway sales are paid directly to the University of British Coloumbia.
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The most important references are denoted by an asterisk.