Do Oral Appliances to Manage Sleep Apnea Work?

Notwithstanding the wealth of literature demonstrating how successful oral appliances are in managing Sleep Apnea.  I am constantly being asked, “Do oral appliances work?”  By physicians, by patients, by friends, by the mechanic, by my barber…

Herbst by Gergens Lab, Arizona, USA

So, let’s compare it to what we know to be the “Gold Standard” of treatments; CPAP. Of late, compliance monitors that are built into the actual appliance have been useful in objectively establishing how often and for how long patients actually wear their oral appliances (1). Of course, this information has been available for CPAP for some time (2). This allows the calculation of  “Mean Disease Alleviation” (MDA); a term that takes into account not only “how effective” a therapy is, but also “how compliant” patients are with the therapy (2);  providing a more realistic measure of therapeutic effectiveness.

It is clear that CPAP is more effective in lowering AHI, especially with higher severities (3). However, the literature also clearly establishes that patients prefer oral appliances to CPAP and as such wear them more often and for longer periods (3). Oral appliances are worn 6.7 hours per night (4), versus 5 hours per night for CPAP (5). 

So, do oral appliances work when compared to the “Gold Standard”? MDA for CPAP has been calculated to be 50% in a study of mild, moderate and severe apneics (2). MDA for oral appliances has been calculated to be 51.1% in a study of mild to moderate apneics (4). Although the evidence supporting oral appliances continues to mount, it is going to take a while for some to digest these statistics. Do oral appliances really have a higher therapeutic effectiveness for alleviating apnea than CPAP? Clearly, this calls for more studies, and then some more studies. After which, perhaps the right thing to do, would be even more studies.

This year, a study found the following, “health outcomes in patients with moderate to severe OSA were similar after treatment with CPAP and MAD (mandibular advancement device)…likely explained by the greater efficacy of CPAP being offset by inferior compliance relative to MAD” (1). Do oral appliances actually work you ask? I guess the jury is still out; for some. However, the literature data is telling; when compared to the “Gold Standard” they are not as effective at reducing AHI, but superior compliance results in a similar therapeutic effectiveness (6).

1. Am J Respir Crit Care Med 2013; V187:8, 879–887

2. Eur Respir J 2000;16:921–7

3. Principles and practice of sleep medicine. 5th ed., 2011; Chapter 108:1266-1277

4. Thorax doi:10.1136/thoraxjnl-2012-201900

5. Sleep 2006; 29:381

6. J Clin Sleep Med 2011;7:447–8

John Viviano BSc DDS D ABDSM