«INTRODUCTION This position paper is based on a review of the literature which has been prepared by the Dental Oro-facial Special Interest Group for ...»
A POSITION PAPER OF THE AUSTRALASIAN SLEEP ASSOCIATION
REGARDING THE USE OF ORAL APPLIANCES IN THE TREATMENT OF
SNORING AND OBSTRUCTIVE SLEEP APNOEA
This position paper is based on a review of the literature which has been prepared by the
Dental Oro-facial Special Interest Group for the ASA. It updates the previous “Dental appliance therapy for the treatment of sleep disordered breathing” paper published by the ASA in 2010. This review relates to the treatment of obstructive sleep apnoea (OSA) in adults and does not address the role of dentists in the management of OSA in children.
Sleep disorders are increasingly recognised as a major health concern. Snoring and obstructive sleep apnoea encompass a spectrum of diseases that involve upper airway collapse and obstruction during sleep. This may range from a reduction in airflow commonly associated with snoring to complete upper airway obstruction with periodic cessation of breathing (OSA). The gold standard for objectively assessing the severity of OSA is obtained by a sleep study / polysomnogram (PSG), requested and reported by a sleep physician who is responsible for the diagnosis. The Apnoea Hypopnoea Index (AHI) or the Respiratory Disturbance Index (RDI), are indices used to assess the severity of sleep apnoea based on the total number of complete cessations (apnoea) and reductions (hypopnoea) in breathing occurring per hour of sleep. The degree of oxygen desaturation during sleep is an independent measure of severity, though much harder to quantify, for which there are no universally agreed gradations of severity.
Oral Appliance Position Statement 11 June 2013 Obstructive Sleep Apnoea (OSA) is a modern epidemic of great health and economic importance. Young et al1 found twenty years ago that in a population aged 30-60 years, 9% of women and 24% of men had OSA, defined as an AHI 5/hr without excessive daytime sleepiness. Additionally, 2% of women and 4% of men had an AHI 5/hr that was associated with excessive sleepiness [Obstructive Sleep Apnoea Syndrome (OSAS)]. The prevalence is likely to be higher now2 because of the increasing prevalence of obesity over recent years3.
Untreated OSA is an important cause of impaired alertness and daytime sleepiness. Patients with OSA have been found to consume more health care resources than those without, take more sick leave and have more work disability.4, 5 A high proportion of OSA cases remain undiagnosed and untreated, in part due to limited resources for case finding and diagnosis.6 Additionally, the investigation of patients with possible OSA has been driven largely by patients and their attending doctors relying on the recognition of the typical symptoms and signs, (e.g. tiredness or witnessed apnoeas), however, there is now evidence that OSA can commonly be present without symptoms7, 8.
Male gender, increasing age and obesity are known risk factors for OSA.9 OSA is an independent risk factor for motor vehicle accidents10, vascular disease,11 stroke,12, 13 hypertension,14, 15 difficult to control atrial fibrillation16 and probably contributes to glucose intolerance.17-19 Some patients have objective evidence of sleep disordered breathing on polysomnography, but do not have the typical symptoms of snoring, tiredness or altered cognitive function and mood. Such patients have OSA but not the OSA syndrome (OSA with symptoms presumed due to OSA). There are limited data about the benefit of treating such patients. The current Oral Appliance Position Statement 11 June 2013 role of dentists in the identification of patients with OSA is in screening for symptoms of OSA and appropriate onward referral to a sleep physician for further clinical review and diagnostic testing.
ORAL APPLIANCE THERAPY FOR SNORING AND OSAOral appliances of various designs have been used increasingly over the past 15 years to effectively treat snoring and OSA. They have potential advantages over the current first line therapy for OSA, continuous positive airway pressure (CPAP), in that they are less obtrusive, more portable, make no noise, are not reliant on a power source and often more acceptable to the patient and his/her family. Relatively high rates of patient acceptance and adherence are reported 20-25.
Oral appliances generally fall into two main categories, Tongue Retaining Devices (TRD) and Mandibular Advancement Devices (MAD). A TRD uses a pliable silicon bulb fitted over a protruded tongue and held in place by suction, supported additionally by the teeth and soft tissues. The encapsulated tongue is held in a forward posture that prevents it collapsing back into the oropharyngeal airway. This effect helps maintain a patent air passage at the level of the most common site of airway collapse26. MADs are the most commonly used and researched devices. These dentally-retained appliances are either a one-piece (monobloc) design or a dual component device, consisting of upper and lower teeth retainers connected by a coupling mechanism27. Their exact mechanism of action on the upper airway is not clearly understood, but MADs are designed to reposition the mandible forward and support this protrusive posture during sleep28. The mode of action most likely involves a structural Oral Appliance Position Statement 11 June 2013 change to the pharynx enlarging the retroglossal airway via forward displacement of the tongue or lateral airway expansion. This has been shown by MRI studies in awake untreated patients29 and by nasendoscopy in awake treated patients30. The ability to advance or titrate the mandible incrementally, with an adjustable custom-made two piece device, has been clearly shown to be of benefit in both snoring and OSA 31-33.
Indications to treat snoring and OSA Snoring is a very common34 and irritating condition, which is often a marker of OSA. It can lead to social disharmony, relationship difficulties and may have independent effects on the carotid arteries, separate from the effects of any associated OSA35. There are, however, no data on the health benefits of treating snoring.
MADs are a proven treatment for snoring36-39. They have also been shown to be effective in treating mild to moderate levels of OSA36, 38-40. MADs are also recommended for treatment of patients with moderate to severe OSA, who have either failed a trial of CPAP therapy, or are intolerant of it39.
Decisions about using MADs to treat individual patients should be based on individual risk benefit assessments, until more outcome data are available. This applies particularly in those patients with an AHI less than 30/hr. The presence of symptoms and co-morbidities will be important influences on treatment choices, as will the probability of a successful outcome in any individual patient.
Oral Appliance Position Statement 11 June 2013 Side Effects of Oral Appliances No effective therapeutic intervention comes without the potential for some undesirable side effects. The adjustment and the final set position of an oral appliance is a delicate balance between side effects and effectiveness. MADs nightly reposition the mandible during sleep in a protrusive position. After 2 years, self-reported oral appliance usage, ranges from 48% to 84%, with a declining trend over time23, 28 The most common reasons for discontinuing oral appliance therapy were lack of efficacy, side effects and device complications41.
Side effects are relatively common. These include excessive salivation, dry mouth, gum irritation, tooth tenderness/pain, abnormal dental occlusion in the morning, masticatory muscle tenderness and temporo-mandibular joint discomfort and/or stiffness42, 43.
Continued use of an oral appliance has been shown to permanently change the bite or occlusal contacts in many sleep apnoea patients and is mainly related to tooth movement43.
Significant or persistent temporo-mandibular joint dysfunction or an increase in its prevalence has not been found44.
Although side effects may be undesirable they are usually well tolerated 21, 23-25and accepted by patients, particularly when symptomatic relief of their condition is achieved.
1. The role of the dentist
1.1. Dentists can have an important role in screening both for symptoms and treatment effectiveness of OSA. To manage SDB successfully, the dentist must work in cooperation with a sleep physician and the patient’s medical practitioner. The diagnosis of this medical condition is not within the scope of dental practice, but a dentist should be able to recognise and be familiar with the typical signs and Oral Appliance Position Statement 11 June 2013 symptoms, as well as be aware of the predictive co-morbidities (obesity, hypertension, ischaemic heart disease and Type 2 diabetes7), and the fact that OSA
1.2. Dentists should be able to provide patients with explanations and information on the treatment options available, including but not limited to: lifestyle modification, behavioural therapy, sleep hygiene, sleeping position, surgical and CPAP options, as may be recommended by the attending physician. They are not expected to provide a detailed discussion of the pros and cons for individual patients however, as this is the
1.3. If treatment with an oral appliance is medically indicated, the dentist is responsible for determining if the patient is a suitable candidate from a dental perspective and to choose an appropriate device. Routine dental, periodontal health, TMJ, occlusal and radiographic examination, is to be conducted prior to and during the term of the
1.4. Dentists also need to be aware of, and routinely examine for soft tissue and craniofacial morphology that predisposes to OSA, including a disproportionately large tongue45 and the association between sleep bruxism46 and OSA.
1.5. Dentists are the only dental care providers who are qualified to manage oral appliance therapy for SDB. Practitioners who offer these services should be able to demonstrate competency in this field.
1.6. To refer patients suspected of having OSA to a sleep physician, who will determine the need for a diagnostic test (usually a polysomnogram) and all treatment options,
Oral Appliance Position Statement 11 June 2013
1.7. To refer patients requiring more specialized care, such as a pre-existing temporomandibular joint dysfunction or orofacial pain, to an appropriately trained dental
1.8. To refer patients back to their regular dental care practitioner, where the patient’s oral condition requires attention, before a MAD is fitted.
1.9. To follow up patients after the fitting and adjustment of a MAD for both effectiveness, (often in collaboration with the referring physician), and for detecting side effects, particularly changes to the bite.
2. Professional Relationships
2.1. There is now an increasingly prominent role for the dentist in screening for and making MAD to treat snoring and OSA. This has resulted from the development of a range of suitable devices, and the weight of evidence supporting oral appliance
2.2. At this time the ASA advocates a “shared care” approach, where there is close collaboration between a dentist and a medical practitioner (sleep physician or other doctor appropriately trained in sleep medicine), who is the clinical team leader.
2.3. To be responsibly involved in the construction of MADs for management of OSA a dentist must have additional training and experience, ideally evidenced by regular attendance at training courses endorsed by the ASA and the Dental Board of Australia, as well as mentored clinical experience in the selection, fitting, adjustment
2.4. The ASA regards it as essential that there is written professional communication about each patient undergoing dental treatment of OSA between the GP, sleep physician and dentist, and any other involved medical practitioners.
Oral Appliance Position Statement 11 June 2013
2.5. A written report to the referring practitioner, detailing the dental treatment and the patient’s symptomatic feedback is required. A systematic follow-up program should be established between the practitioners to monitor the patient’s progress47. The dental aspects of the treatment are the responsibility of the dentist. The treating physician, who holds the primary responsibility for managing the patient’s medical conditions, should monitor the appropriate health indices. A high degree of collaboration and communication between the dental and medical care providers is expected, to enable optimal patient outcomes to be achieved.
2.6. There may be appropriate referral by the dentist to periodontists, orthodontists and prosthodontists for complications and co-incidental conditions.
3. Code of Practice As this field of dentistry is developing rapidly, dentists practicing in the discipline of
Dental Sleep Medicine must follow “best practice” procedures, including the following:
3.1. Obtain written informed consent from each patient prior to commencing any oral
3.5. Keep comprehensive dental and other clinical records, including relevant dental casts, radiographs and photographs.
3.6. Participate in ongoing education relevant to the practice of dental sleep medicine.
Oral Appliance Position Statement 11 June 2013
3.7. Avoid real or perceived conflicts of interest and in particular, avoid compromising arrangements with industry.
4. Oral Appliances and Devices
4.1. The ASA does not endorse any particular oral appliance or device.