How does your dentist choose the right mouthpiece for your sleep apnea?

Reviewed by Dr. Joseph Salim, DMD (written by the Sutton Place Dental Associates editor)

Introduction

Ever wondered how frequently people talk or inquire about continuous positive airway pressure[1] (CPAP)?

One way to find out, albeit indirect, is to check how many times surfers google the term every month.

According to Ahrefs[2], this number is 138,000/month in the USA.

That is in steep contrast to sleep apnea dental appliances[3], also called oral appliances or oral mouthpieces. They only score an underwhelming 2,800 searches a month.

You may think that it is only reasonable, after all. For CPAP is the most commonly prescribed treatment for obstructive sleep apnea.

Also, it is benign, and it shows great efficacy, as a pneumatic splinter, to keep your airways open. It can, in fact, reduce AHI by about six events per hour[4].

But the above data doesn’t tell the whole story. And it does not do oral devices justice.

There is a hidden side to CPAP, and that is … you tend not to use it in the long term, or you will not accept it outright[5].

Enter oral appliances (for sleep apnea), which you will prefer, despite their lower efficacy. Experience shows that you will discontinue using a mouthpiece for sleep apnea twice less often than CPAP[6].

Yes, twice less often, you understood correctly.

So, the result is that the effectiveness of the two devices is equivalent. CPAP’s greater efficacy is offset by your (likely) lower adherence or use. The opposite is true for dental mouthpieces.

Now, if you are an avid reader of this blog, you probably know already many things about mouthpieces (for oral apnea), namely that:

• There are two major categories, Mandibular Advancement Devices (MADs) and Tongue Retaining Mouthpieces.[7]
• There are OTC devices (also called boil and bite) as well as custom-fitted ones made by your dentist.[8]

Oral devices have been around since the early 1980s. Since they are not exactly recent, then you are probably thinking that your dentist knows which patients may benefit from them, right?

Not so fast.

Selecting the right candidate for dental devices is not easy.

Surprised?

Well, let’s delve into this subject of patients’ selection.

You will discover how new oral devices and fiber-optic pharyngoscopy can help your doctor.

Choosing the right sleep apnea patients and the right oral devices

The first criterium is that you have to accept the nightly use of the appliance.

That is only common sense, don’t you think?

Your expectations must also be realistic because mouthpieces do not cure apnea.[9]

But other than that, there are no patient history criteria that your dentist can use to predict your response.

Though, fiber-optic pharyngoscopy can come to your rescue.

Let’s see how.

Fiber-optic pharyngoscopy and sleep apnea

This procedure allows your doctor to understand how your upper respiratory system’s anatomy influences your sleep apnea.

He may find a major site of occlusion or even multiple areas in your airway that collapse during sleep.

Based on these observations, he will try to identify the best therapy for your sleep apnea: oral device, CPAP, or even surgery.

Curious to learn how fiber-optic pharyngoscopy works?

Here we go.

Your doctor will:

1. Use a thin, flexible fiber-optic tubing with a camera at the end. (The optical fibers will transmit the images to an external screen).
2. Give you a numbing (anesthesia) medication.
3. Introduce the tubing up through your nostrils.
4. Gently push it down your throat.

Now, you will be awake the whole time, and the procedure is relatively painless. Though, you may be gagging despite the anesthesia.

So, this is one solution your doctor can tap into to identify the best treatment for your sleep apnea.

But he has more aces up his sleeve.

If you do not like the idea of tubing traveling through your nose and throat, there are other possibilities. He can use a new type of mouthpiece that he can control remotely.

Let’s investigate…

The remotely controlled mandibular advancement system

This type of oral mouthpiece (MATRx) allows your sleep technician to protrude your lower mandible during your sleep progressively.

So, as you doze off, your lower mandible will be moved forward until respiratory events, due to your sleep apnea, disappear.

Now, if you are worrying that the sleep technician may go too far, be reassured. Your dentist will determine the maximum range of movement of the oral appliance.

All the work I have just described occurs while you are hooked up to a bewilderment of wires and sensors.

This serves to capture all sorts of information (eye movement, blood pressure, heart rate, etc.).[10] It is also referred to as a titration study.

It allows your doctor to determine:

1. whether a mouthpiece could treat your sleep apnea
2. the necessary degree of lower mandibular protrusion that your custom-fitted device will require.

As soon as your dentist has this information, he may prepare a device adapted to your needs.

The remotely controlled oral device (MATRx) weighs a mere 90 grams (3 oz).

While its use in sleep centers is promising[11], the cost may also be an issue.

Besides, you can only use it during a titration study.

“IMAGE NEEDED” https://www.accqsleeplabs.com/what-is-matrx/

So, you may want to consider a cheaper alternative.

Next …

The Apnea Guard®

This oral mouthpiece will also help your dentist understand if you will respond to oral appliance therapy.[12]

Albeit cheaper than the previous device (MATRx), your doctor cannot control it remotely.

Though it is good enough for your dentist to:

• assess whether you will respond to oral appliance therapy;
• How far open and forward your jaw should be. With this information, he will also be able to make an ad-hoc device, ensuring optimal fitting.

“IMAGE NEEDED” https://www.advancedbrainmonitoring.com/apnea-guard/

But do you know the best part?

Unlike the MATRx appliance, you can also use it outside a sleep study, for up to 30 days.

That equates to immediate relief. You do not need your custom mouthpiece to arrive to reduce suffering from frequent respiratory events.

The manufacturer claims that “this temporary oral appliance provides outcomes equivalent to a custom appliance for obstructive sleep apnea treatment.”[13]

Finally, you will also find the Apnea Guard® useful if you have undergone surgery.

Can you guess why?

If you have received general anesthesia, then your muscles may relax and occlude your airway. So, if you already suffer from light sleep apnea, things could get worse (albeit only for some time).

Risks will increase for the same reason (i.e., your muscles will relax) also if you are on pain medications and sedation.

Before we finish, let’s briefly look at 3D printed mouthguards.

3D print technology for sleep apnea mouthguards

The future is now.

An Australian dental company, Oventus[14], and a dental research center, CSIRO, have managed to tame 3D print technology to produce mouthguards for sleep apnea.

By using a CT scan to map a patient’s oral anatomy, a 3D printer can do wonders.

With the help of proprietary software, the company can turn the data from the scan into a highly personalized mouthguard.

The appliance itself is printed from lightweight titanium and coated with a medical-grade plastic.

The company describes the device as having a “’duckbill’ which extends from the mouth like a whistle and divides into two separate airways.”

It also claims^[15] that in clinical trials: “the O₂Vent™ Device showed a 50% to 90% reduction in Apnoea Hypopnea Index (or API, which indicates the severity of sleep apnoea) in 75% of patients. It was found to be more effective than other oral appliances and has an effect on oxygen levels comparable to continuous positive airway pressure technology.”

But references to the clinical study do not (yet) show on the web site.

Final Remarks

We hope you have found this article interesting.

If you’re concerned you have sleep apnea, contact your local sleep clinic to schedule a consultation with a sleep specialist.

You may also talk with your primary care physician or dentist about your sleep troubles.

Be sure to ask them about all the available treatment options, including CPAP and dental devices, and inquire which may be best suited for you.

If you live in Alaska and would like to speak with a sleep educator about your symptoms to determine if a sleep study is right for you, click on the link below to receive a free 10-minute phone consultation.

[1] https://www.alaskasleep.com/blog/what-is-continuous-positive-airway-pressure-cpap-therapy

[2] https://help.ahrefs.com/en/articles/78203-what-is-ahrefs-com Ahrefs provides an approximation of actual googled searches.

[3] https://www.alaskasleep.com/blog/dental-appliances-for-sleep-apnea

[4] Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD: Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015; 11: 773–827. https://www.ncbi.nlm.nih.gov/pubmed/26094920

[5] https://www.alaskasleep.com/blog/dental-appliances-for-sleep-apnea

[6] https://www.suttonpda.com/sleep-apnea-cpap-dental-appliances/#how-sleep-apnea-results-obtained-cpap-compare-obtained-mouthpieces

[7] https://www.alaskasleep.com/blog/dental-appliances-for-sleep-apnea

[8] https://www.alaskasleep.com/blog/dental-appliances-for-sleep-apnea

[9] https://www.suttonpda.com/sleep-apnea-cpap-dental-appliances/#do-dental-appliances-cpap-cure-sleep-apnea

[10] https://www.alaskasleep.com/blog/what-is-a-sleep-study-treating-sleep-disorders

[11] Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD; “Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.” J Clin Sleep Med 2015; 11: 773–827.

[12] Levendowski DJ, Morgan T, Westbrook P.; “Initial Evaluation of a Titration Appliance for Temporary

Treatment of Obstructive” J Sleep Disord Ther. 2012 Jan;1(1). pii: 101. Epub 2011 Dec 24.

Sleep Apnea.” https://www.ncbi.nlm.nih.gov/pubmed/26523244

[13] https://www.advancedbrainmonitoring.com/apnea-guard/

[14] http://www.o2vent.com/

[15] https://www.csiro.au/en/Research/MF/Areas/Metals/Lab22/Mouthguard