Do you have an opinion on the use of dental devices versus PAP therapies?

We have had an increase in radio advertising aimed at the obstructive sleep apnea (OSA) community of patients, insinuating the use of oral/dental devices for patient with mild to moderate OSA. As a respiratory therapist, my job with CPAP and BiPAP patients and their subsequent compliance is often hampered by non-professional noise like this. Do you have an opinion connecting the use of these devices versus PAP therapies? Am I overreacting? Thank you for your time. 

You may or may not be overreacting, so let’s go through the salient issues that influence decision-making on types of therapy presented to OSA patients. As someone who has used oral appliance therapy (OAT) every night from 1998 to 2001 with excellent results, I firmly believe these devices work wonders in some patients. When OAT provides an exceptional response, we are observing not only the best case scenario, but also we must admit that the patient might not have received as great a response from PAP therapy due to potential intolerance problems (mask, leak, pressures, etc). And, we must be especially mindful some treatment is better than none. Sutherland and colleagues’ recent update in JCSM spells out in considerable detail the value of OAT from the standpoint of cost-effectiveness and is a worthy read if you are unfamiliar with the potential role of these devices.(1)

With that backdrop, certain problems with OAT may be overlooked, perhaps because some sleep professionals accept PAP therapy failure too readily and then find OAT (or even surgery) as the path of least resistance. Or, as you have indicated, marketing of OAT may be picking up steam, and marketing always emphasizes the positive. Still, it is entirely plausible that some sleep professionals choose this paradigm and provide quality care to their patients. The question that should arise, in my opinion, is whether or not there is an appreciation for attaining a higher quality of care for their patients if additional strategies to increase PAP acceptance are pursued.

The problems with OAT comprise three main areas: efficacy issues, outcomes, and adverse effects. Once we go through these areas, I believe you will understand why my enthusiasm for OAT has diminished somewhat during the past decade, albeit I remain considerate of those patients needing alternate treatment pathways.

1. Efficacy. OAT efficacy is a huge problem, because the device frequently (some might say always) cannot treat respiratory event related arousals (RERAs). Of the 50-plus cases of repeat diagnostic studies we have observed where the patient was using their definitively adjusted OAT device, only one PSG showed near full resolution of RERA breathing events or the normalization of the airflow signal. Many more patients refuse to return for a repeat study so perhaps we are seeing skewed data. Regardless, flattening on the inspiratory limb of the airflow curve was pervasive in nearly every single case. Thus, to my knowledge there is no OAT device that actually meets AASM standards for an “optimal” titration, because the RDI (apneas+hypopneas+RERAs) is unlikely to dip below 5 events/hr. By way of comparison, a high quality PAP titration can radically reduce the RDI and eliminate most RERAs when the sleep technologist applies a strategy to normalize the airflow signal. OAT from the standpoint of efficacy, then, is clearly not a first-line therapy if the goal is to aggressively treat all breathing events, a point we recently discussed in JCSM.(2)

2. Outcomes. There is no doubt OAT improves sleep outcomes, and some of these gains are directly related to easier use. This point should not be underestimated and is highlighted in Sutherland and colleagues’ update.(1) A problem arises, however, for a sizeable proportion of patients who sense a modest to moderate improvement with OAT, yet were expecting something more impressive. In our experience, many of these patients often decide within a year or two and sometimes sooner to recommit to PAP therapy for another trial, and some then use PAP for more hours than on prior attempts. In contrast, among patients with sub-optimal responses, a “ceiling effect” emerges where patients start OAT, appreciate some gains, and then never wonder whether or not there are more gains to be had. The same effect occurs with PAP. In either case, the sleep center must make a concerted effort to follow-up and communicate with patients to analyze whether or not the current response to treatment is optimal. The ceiling effect may emerge rapidly in some OAT patients, because they do not want to find themselves needing to consider PAP therapy. For the PAP patient, the ceiling effect provides them with an excuse for refusing to return to the lab for a retitration study. Overall, outcomes present a tricky and subtle aspect when managing a substantial proportion of OAT patients, because at virtually every encounter you may want to discuss whether PAP therapy should be reconsidered.

3. Adverse Effects. OAT has obvious side-effects that ultimately make the device intolerable. The most problematic side-effects are exacerbation of temporo-mandibular joint (TMJ) dysfunction and change in the bite. No question, an OAT device improperly fitted or prescribed in a patient with TMJ can make things considerably worse. The smart move regarding TMJ patients is to forego OAT, unless the patient is working with a dentist who has expertise in both TMJ and OAT devices. Changes in bite are commonplace among OAT users, and eventually many patients develop an open bite in the region of the molar or posterior teeth. Changes in bite may be one of the most common factors triggering a return to PAP therapy, only second to patients who are experiencing diminishing results from OAT.

Despite all these potential problems that might steer someone away from OAT, the devices really can prove an invaluable intermediary treatment. With that in mind, here are some tips I have learned from personal use and managing OAT patients.

1. In the morning with the device removed, sit on a toilet or chair and rest your chin at the base of each palm. As you sink the weight of your head into your hands, you can feel the mandible moving back to its original position. A “thinker’s pose” may accomplish the same result. Either way, hold for at least 5 minutes; you might try longer and see more benefit.
2. Consider newer OAT devices that provide at least two features: a) adjustment capability; and b) smaller size and style that permits forward positioning of the tongue (“anterior separation”) between the top and bottom pieces. In Albuquerque, my friend and colleague Dr Tom Meade, who first fitted me with a device in 1998, has recently invented the Thera-Som Cast. The device is half the size of most other devices and provides space for the forward positioning of the tongue between the upper and lower components of the device.
3. Do not feel obligated to wear OAT every night. Instead, an excellent approach to difficulties with either OAT or PAP is to alternate therapies. For example, use OAT during the work week as time pressures may dictate, and then look forward to even better sleep on the weekends with PAP. Such an approach may eventually transition the patient into PAP all nights with OAT then becoming a reliable backup.

In sum, I feel your concerns may be warranted, because it is not out of the question that those who advertise OAT may not attend to some of the points above, particularly its failure to address RERA events in particular and UARS in general. From a cost-effectiveness approach, however, we must appreciate that some sleep apnea patients, perhaps many, just will not give PAP therapy an honest try. For these individuals, OAT is a very credible alternative, and it may provide real benefits for a few years or longer in some patients.

REFERENCES

1. Sutherland K, Vanderveken OM, Tsuda H et al. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215-227.
2. Krakow B, Krakow J, Ulibarri VA, McIver ND. Frequency and accuracy of "RERA" and "RDI" terms in the Journal of Clinical Sleep Medicine from 2006 through 2012. J Clin Sleep Med 2014;10(2):121-124.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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