Oral appliances: An odds-on in obstructive sleep apnoea management

INTRODUCTION

Obstructive sleep apnea (OSA) is a sleep-disordered breathing disease that involves repeated obstruction of the upper airway during sleep or reduction/elimination of airflow completely for at least 10 s and in a number of 5 episodes or more every hour of sleep. The common sites affected are the area between the nasopharynx and the larynx, base of the tongue (retroglossal), behind the soft palate (retropalatal).^[1,2] The upper airway is occluded due to the sleep-induced physiologic changes, including structural defects and abnormal muscular activity, sleeping posture in the supine position, edema in upper airway whose etiology may be smoking, hypothyroidism, acromegaly, and nasal obstruction.^[3-7] It is a serious systemic disorder with an incidence of 17% in adult women and 34% in men, which when left untreated may accelerate the development of new comorbidities, fatigue, sleepiness during day time which in turn cause an impaired cognitive performance, a reduced quality of life, an increased risk of occupational and traffic accidents^[8] metabolic disturbances,^[9] hypertension,^[10] cardio and cerebrovascular morbidities, and OSA-related mortality.^[11] Its long-term management is based on:

1. Patient with treatable physiological or structural abnormalities

2. Comprehensive lifestyle interventions such as weight-loss intervention.

Apart from the conventional continuous positive airway pressure (CPAP) therapy to treat the cases of moderate to severe OSA, the automatic positive airway pressure and bilevel therapy have also become a standard option regardless of the underlying mechanisms of apnoea and site of the pharyngeal collapse, or patient phenotype.^[12-17] Noninvasive treatment options like oral appliances (OA) like mandibular advancement devices (MAD) are indicated for use in patients with mild to moderate OSA whose compliance solely depends on the balance between the perception of benefit and the side effects and monitoring throughout the follow up is mandatory.^[18-22]

TREATMENT MODALITIES

Figure 1 shows the various treatment modalities of OSA.

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Figure 1:

Various treatment modalities of OSA.

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THERAPY USING OA

The three broad categories of the OA for the treatment of OSA:

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ORTHODONTIC MANAGEMENT

Some of the other oral appliances for the treatment of OSA are shown in Table 1 [Figure 5].

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Figure 2:

Mandibular advancement splints (Courtesy of http://www.dentalartslab.com).

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Figure 3:

Tongue repositioning or retaining devices (Courtesy of https://www.ebay.ca).

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Figure 4:

Palatal lifters (Courtesy of https://stlouis.smlglobal.com).

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Figure 5:

Orthodontic oral appliances for sleep apnea (Courtesy of https://pacificdentalcare.org/sleep-apnea).

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EFFICACY OF CPAP VERSUS OA

CPAP is no doubt the gold standard Non-surgical treatment as it is highly potential in preventing OSA. However, its compliance rates have declined despite its effectiveness^[12] due to the fact that the systems involved are noisy. Discomfort on wearing the mask, sometimes, causing claustrophobia in some users is a major drawback. As non-invasive devices, OA which are as efficient as CPAP, stand as its better alternative and are prescribed in patients who refuse conservative treatment, who prefer them to or those who do not respond to or those who have failed to CPAP therapy.^[12]

CONCLUSION

Despite the developing approaches to OSA, many unresolved problems linked to their treatment modalities still remain a question mark. Diagnosis and treatment of OSA aim at improving the quality of life for patients whose compliance depends on the stability between the idea of benefit and the side effects of the therapies performed. Constant communication and follow-up is essential for an effective OSA management. Currently, the primary motive of OSA should be on terminating apnoeas with personalized therapy for each subject with an ultimate goal of maintaining the quality of life and managing the onset of comorbidities. The patients are motivated to participate in healthier lifestyle modification programs associated with increasing physical activities and exercises to reduce weight so that the overweight or obesity is reduced among the individuals.