In a recent discussion with a group of advanced clinical dentists and specialists, a topic was raised regarding the efficacy of Mandibular Advancement Devices (MADs) and at-home Sleep Study Screening and Diagnostic Devices, as well as their respective relationships to the treatment and diagnosis of Obstructive Sleep Apnea (OSA). I have spent many years developing my knowledge in these areas and know that it is very relevant to the sizable sector of the population that suffers from OSA and other forms of Sleep Disordered Breathing. At one point during our discussion, it was opined that MADs do not work. However, based on my years of experience studying and treating Sleep Disordered Breathing, I have to fervently disagree.
At Saco River Dentistry, my associates and I have been practicing dental sleep medicine for years, including screening for and treating OSA. I am willing to stake my professional reputation on the following claim: MADs absolutely work. In addition, dentists are obligated to play a more direct role in this arena of Sleep Disordered Breathing (SDB), with the American Dental Association’s (ADA) Council on Dental Practice having released a clear position statement on this topic. This position statement makes the point that MADs are effective, and I doubt the ADA would put out a position statement for an “ineffective” treatment.
The ADA states that MADs and other Oral Appliance Therapies (OATs) are perfectly acceptable and effective forms of treatment for mild to moderate OSA and Upper Airway Resistance Syndrome (UARS). MADs are sometimes even recommended in cases of severe OSA where the patient is not compliant with the regular use of Continuous Positive Airway Pressure (CPAP) therapy. At Saco River Dentistry, we work closely with sleep physicians (who provide the diagnoses) and local sleep centers to treat patients with mild and moderate OSA and UARS. In addition, we get referrals and fabricate appliances for the 60% of severe OSA patients that are not compliant with wearing their CPAP devices as recommended. If the qualified sleep physicians are prescribing MADs, there is clearly utility in their use.
Is a MAD better than a CPAP? No. MADs are approximately 65-80% as effective as a properly-worn CPAP device. However, in studies that compare the two in accordance with their user-compliance rates, the MAD wins every time. At times it is said in the dental community that MADs don’t work, but this is like saying a partial denture doesn’t work because a dental implant is “better.” One treatment may yield superior results, but the inferior treatment still has its place under the right conditions and for the right patients.
While many readers may be familiar with OSA, they may be wondering what the referenced UARS is. Well, UARS is the lesser-known “cousin diagnosis” to OSA. It affects a different kind of patient than those typically affected by OSA. This is relevant to this topic and, at times, more important than OSA because this condition goes largely undiagnosed in the medical community. That said, we in dentistry are very well-positioned to recognize the signs of UARS intra-orally. There is a growing body of research pointing to the fact that UARS is related to nocturnal bruxism, or nighttime teeth grinding. For patients with UARS, airflow is being impeded in the nasal passages. There are airflow sensors in our nose, and when these sensors are not activated during sleep, the body induces a sympathetic response in hopes of waking itself up to restart proper breathing. This sympathetic response has been connected with masseter hyper-activity and the aforementioned bruxism. Treat the airway, and you treat the bruxism. This is a newer, more controversial, and less well-studied concept, yet it represents an important aspect of the role of dentistry in identifying and treating Sleep Disordered Breathing. With that said, the use of MADs to treat UARS is well established. For those seeking further information, the Stanford University Medical department has released information on Upper Airway Resistance Syndrome and the possible treatments, including OATs.
At Saco River Dentistry, we’ve had the opportunity to treat numerous medical professionals who work at sleep centers with OATs, and it has oftentimes changed their lives for the positive. We’ve also treated many more patients that wore their CPAP machines for a few months and then grew non-compliant with that treatment. I myself have been wearing an oral appliance for several years and it has improved my life dramatically. Call this evidence anecdotal, but those are just a few examples from a multitude of cases where a patient’s life has been dramatically changed through a simple oral appliance. Do OATs cure everyone? No, they do not. However, how many treatments have a 100% success rate? What is more important is that OATs can provide relief from sleep-related disorders for many of those that have found CPAP treatments ineffective or difficult to comply with.
For the sake of offering a complete perspective, there is a new procedure designed to treat OSA called Inspire, which is performed by ENTs. It is an implantable device inserted in the thoracic region that stimulates the hypoglossal nerve during sleep, resulting in a more open airway. This device may someday replace both CPAP machines and OATs, but for now, all treatment methods remain relevant.
Another relevant point to discuss is the efficacy of Home Sleep Testing (HST). In our role as dentists treating OSA and UARS, we are 100% at the guidance of Board-Certified Sleep Physicians. Those physicians are the providers that recommend these tests, and dentists should be screening and collecting data; the physician orders the HST and provides the diagnosis, and the dentists fulfill the treatment. Sure, there are patients that end up getting “In-lab” sleep studies, but these are typically reserved for patients with a very specific profile that arises during the screening process. 85% of patients are sufficiently tested with the extremely advanced Apnea Risk Evaluation System (ARES™). This device measures oxygen (de)saturation, brainwave activity (EEG), airflow, body movement, HR variability, snoring volume (in Dbs), and so on. This device is not a Fitbit or an Apple Watch, it is an expensive piece of advanced technology that has a 96% concordance rate to “In-lab” Polysomnograms (PSGs) in diagnosing OSA and UARS. The only things this device cannot do are measure advanced heart conditions through an EKG and measure leg movements separate from body movements, but neither of these measurements are data points we are typically interested in when diagnosing OSA and/or UARS (unless the patient has cardiac issues or restless leg syndrome). This is why HST is becoming increasingly popular. Not to mention the fact that “in-lab” sleep studies do not replicate the normal sleep environment for the subject, raising questions as to the validity of data collected during these tests.
I want to add that I am also in disagreement with any statement that positions that HSTs “don’t work.” If it wasn’t for this technology, many lives would be much worse off, as many patients either do not know that they need to or refuse to go into a “Sleep Lab.” My father was one of these people, and he passed away due to OSA. This evidence may be anecdotal, but it is also real. Had my father had the opportunity to undergo HST, he might still be alive today. I encourage any readers who are skeptical about this anecdotal evidence to peruse the attached bibliography below, which can provide more clinical studies in support of my conclusions.
As a final thought, I would like to discuss advances in both sleep medicine and the accompanying technologies used during diagnosis and treatment. To improve the efficacy of the MADs we prescribe here at Saco River Dentistry, we utilize a device called a “pharyngometer.” This is an acoustic-sonar device that maps the constriction points in the airway. Unlike CT or MRI scans, this device maps the airway under conditions of collapsibility, which is what happens when airways get obstructed during sleep. We use this tool to find the optimal 3D position of the mandible (when collapsed) to maximize patient outcomes. Historically, there was a high degree of “trial and error” when it came to finding the correct position of an MAD. As a matter of fact, Spear Education—a leading dental continuing education provider—has an entire video series on their laborious “trial and error” method. This fact might be contributory to why one might believe “MADs don’t work”. However, by utilizing the pharyngometer, we can more precisely find the ideal position for the appliance right from day one. We can also determine which patients are unlikely to respond to MADs, as the advancement of the mandible only affects certain depths of the oro-, velo-, and hypopharynx. As a result, we can guide those patients for whom oral appliances may prove less effective towards alternative therapies (surgery, Inspire, CPAP, etc).
I hope that you find this information enlightening and that it adds to your knowledge of the potential options available to patients experiencing sleep-related breathing disorders. This is a rapidly evolving area of patient care that can be significantly enhanced by dentists’ observations and their profound knowledge of intra-oral healthcare.
Sources for Efficacy of MAD’s
Sources for Efficacy of At Home Sleep Study Testing