It can be confusing when you do a search for oral appliances for sleep apnoea online, due to the myriad of devices listed. Their functionalities and purposes also differ, which add to the confusion. In this post, we share everything you need to know about oral appliances for sleep apnoea – specifically for obstructive sleep apnoea, as central sleep apnoea is a neurological condition that requires a different approach.
The Type of Sleep Apnoea - It Matters When It Comes to Oral Appliance Therapy
Sleep apnoea in general refers to sleep-disordered breathing where the individual stops breathing for periods of time, and is often unaware as they are asleep. A polysomnography (sleep test) is the gold standard for measuring and testing for sleep apnoea, which can range from mild to severe.
These sleep tests usually need to be done in a clinical facility overnight, which some patients might find uncomfortable due to the change in environment, and equipment hooked up to them. An alternative is a portable home sleep test, which we provide and follow up on at our clinic, Nourish Dental Sleep & TMJ Care.
There are also a few different types of sleep apnoea, namely central sleep apnoea (CSA) and obstructive sleep apnoea (OSA). Complex sleep apnoea syndrome (CompSAS) is a rare combination of both CSA and OSA (Wang et al, 2013).
Central Sleep Apnoea
The symptoms in CSA can be similar to OSA, such as daytime sleepiness, snoring, insomnia, irritability and more. However, the root cause is vastly different. Central sleep apnoea is a neurological condition where the brain does not transmit signals to the muscles required for breathing.
According to the International Classification of Sleep Disorders – Third Edition (ICSD-3) (Sateia, 2014), CSA can be classified into the following categories:
- Primary CSA
- CSA with Cheyne-Stokes Breathing (CSB)
- CSA due to a medical disorder without CSB
- CSA due to a periodic high-altitude breathing
- CSA due to a medication or substance
- Treatment-emergent CSA
CSA appears on sleep tests as pauses in breathing in the thoracic and abdominal regions, and also as a reduction of nasal-oral airflow of at least 10 seconds.
According to Rana and Sankari (2022), the cause of central sleep apnoea is primarily cardiovascular (related to the heart), and can occur in patients with atrial fibrillation, heart failure, ischaemic strokes, spinal cord injuries, renal failure, chronic opioid use and more.
Treatment for CSA thus differs from OSA, and may include the use of a continuous positive airway pressure (CPAP) machine, adaptive servo-ventilation (ASV), bilevel positive airway pressure (BPAP), supplementation or medications. Most importantly, the root cause should be addressed and managed for better treatment outcomes.
Obstructive Sleep Apnoea
OSA on the other hand, is the most common type of sleep apnoea and consists approximately 90% of all sleep apnoea cases (Lee, 2022). In fact, many individuals are unaware that they have OSA, and usually learn about it from partners whose sleep might be disrupted due to snoring or gasps for air during the night. In fact, nearly 50% of respondents in a survey done in Singapore said that they practiced this – a term known as “sleep divorce”.
Unlike CSA, the cause of the individual’s pauses in breathing in obstructive sleep apnoea is due to a collapse of the upper airway; each episode can last up to 10 seconds. Contributing factors of OSA include: age, lifestyle (such as smoking), genetics, endocrine disorders, menopause, craniofacial morphology, sex (males being more prone to OSA) and obesity (Shah and Roux, 2009).
It is also worth pointing out that having a stroke does not immediately equate it to central sleep apnoea. We have seen a patient at our clinic who suffered from recurrent strokes that were linked to obstructive sleep apnoea and TMD (temporomandibular joint disorder).
Obstructive sleep apnoea is often connected to TMJ and orofacial pain disorders as well, and a trained orofacial pain specialist should be consulted to differentiate and diagnose each disorder. For more information, you can read the following posts:
- Is There A Connection Between Sleep Apnoea, TMD & Orofacial Pain?
- A Plethora Of Pain From 6 Different Headaches, TMJ Disorders & Obstructive Sleep Apnoea (Plus A Rare, Painful Syndrome) (Case Study #13)
- Sleep Apnoea Treatment
Thus, it is important not to self-diagnose, but to seek professional help from an orofacial pain specialist or sleep doctor, as misdiagnoses can incur unnecessary costs, surgeries, and/or lead to a worsening of outcomes.
What are Oral Appliances? Why are There So Many Different Types?
In the most basic of terms, an oral appliance is a device inserted into the mouth to help reposition a part of the oral cavity. The purpose of the oral appliance varies for each patient. Oral appliances can be used to help manage and treat TMD/TMJ disorders, obstructive sleep apnoea, bruxism (teeth grinding), snoring and other sleep-disordered breathing (SDB) issues. Often, a patient has a combination of these sleep disorder issues as well.
How Do Oral Appliances for Sleep Apnoea Work?
Oral appliances are primarily grouped into two categories – mandibular advancement devices (MADs) and tongue stabilising devices (TSDs). The former protrudes the mandible (lower jaw) and tongue, whilst the latter holds the tongue forward (National Guideline Centre (UK), 2021). A third type of oral appliance is a soft palate lifter, but these are hardly used anymore due to a lack of evidence as to their effectiveness. Out of the three types of oral appliances for sleep apnoea usage, MADs are the most common (Dieltjens and Vanderveken, 2019).
There are also many options within each oral appliance category. Whilst there are prefabricated ‘boil and bite’ oral appliances available on the market, research has shown time and again that these are inferior to custom-made oral appliances for multiple reasons (Dieltjens and Vanderveken, 2019). Our individual craniofacial morphology, lifestyle factors, medical history, comorbidities, tolerance and preference all differ widely.
You can learn more about mandibular advancement devices for obstructive sleep apnoea in this post.
Types of Oral Appliances for Obstructive Sleep Apnoea
There are different types of mandibular advancement devices, such as monoblocs and duoblocs. Monoblocs restrict mandibular movement and are fairly rigid. Duoblocs on the other hand, are titratable.
Oral appliances for obstructive sleep apnoea come in a variety of materials as well, such as: acrylic, plastic, medical-grade silicone, cobalt chromium hardware, stainless steel, titanium, polymer and PMMA (pre-polymerised, milled poly-methylmethacrylate).
They also work differently; some oral appliances require clasps or adjustment mechanisms, whilst others work like a mouthguard. For the latter, your orofacial pain specialist will generally use a mould or 3D dental model to get an impression of your bite.
You can view this chart from Sleep Review magazine, for an overview of oral appliances for obstructive sleep apnoea. Regardless of material or construction, the ultimate aim is to hold the mandible forward in order to open up the upper airway.
How Can an Orofacial Pain Specialist Help Me to Select the Most Suitable Oral Appliance for Sleep Apnoea?
Training & Knowledge of the Orofacial Region
Apart from conducting clinical and physical examinations, orofacial pain specialists have an intimate understanding of the orofacial region and related pain disorders. If they are also trained in oral medicine, they then have a further insight into medical conditions related to the oral and maxillofacial region. Oral Medicine specialists are also trained in oral pathology and oral radiology, and can order and interpret these test results. You can learn more about Orofacial Pain and Oral Medicine specialists in this post.
This diverse training and experience leads to not only a better-informed overall picture, but additional knowledge into potential causes and treatments for your sleep and/or orofacial pain disorder(s). For example, an orofacial pain specialist might be able to determine if you have a TMJ disorder and what type, whilst an oral medicine doctor is familiar with medical conditions or symptoms such as diabetes and certain autoimmune diseases that can affect your oral or dental health.
Individualised Adaptation & Follow-Up
The amount of mandible protrusion is highly dependent on the patient’s orofacial structure and tolerance, which can also change over time. A trained orofacial pain specialist can help to adjust your appliance for obstructive sleep apnoea, in order to gain maximum benefit at your personal comfort levels. They will also be able to advise you as to which type of oral appliance is most suited to your needs, and follow-up with you on a regular basis in order to determine if any modifications need to be made.
MADs are generally unsuitable for edentulous patients (those who lack teeth) as well, but might work with dental implants, depending on the patient’s oral and dental health, as well as the position of the missing teeth. You can learn more mandibular advancement devices with dental implants in this post. It is crucial to note that dental implants can be placed by dentists without any special licensing. Thus, it is best to consult a trained orofacial pain specialist who is more knowledgeable in regards to such conditions and procedures.
Oral Appliances for Sleep Apnoea - What Nourish Dental Sleep & TMJ Care Can Do for You
Dr. Eric Chionh runs the practice at Nourish Dental Sleep & TMJ Care in Singapore, together with a dedicated team. He is formally trained in Oral Medicine and Orofacial Pain, and holds a Singapore Dental Council approved qualification in these areas. He also focuses on Dental Sleep Medicine, which includes Sleep Apnoea.
He has over 20 years of hands-on experience, and is an American Board of Orofacial Pain (ABOP) board-certified specialist in orofacial pain/TMD, which is recognised by the American Board of Dental Specialties (ABDS) and the American Dental Association (ADA).
In addition, Dr. Chionh is a *qualified sleep dentist under the European Academy of Dental Sleep Medicine (EADSM) and American Academy of Dental Sleep Medicine (AADSM), and holds a Diplomate (International Certificant) under the American Board of Dental Sleep Medicine (ABDSM).
Dr Chionh keeps himself abreast with the latest evidence-based dental and sleep apnoea research, with the aim of helping to improve his patients’ quality of life. To him, every individual is unique, and he takes the time to examine and discuss their medical history, symptoms, and any other related concern they may have. Our clinic also uses suitable technology to assist with the proper diagnosis and management of sleep apnoea, TMD and orofacial pain.
Visit our About page to learn more about Dr. Eric Chionh and his credentials, and our Services page to view all services provided at Nourish Dental Sleep & TMJ Care.
References:
Dieltjens, M., & Vanderveken, O. M. (2019). Oral appliances in obstructive sleep apnea. In Healthcare (Vol. 7, No. 4, p. 141). Multidisciplinary Digital Publishing Institute. https://doi.org/10.3390/healthcare7040141
Lee, Y. H. (2022). Implications of obstructive sleep-related breathing disorder in dentistry: Focus on snoring and obstructive sleep apnea. Dental research and oral health, 5(4), 74. https://doi.org/10.26502/droh.0051
National Guideline Centre (UK). (2021). Oral devices: Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s: Evidence review G. National Institute for Health and Care Excellence (NICE). http://www.ncbi.nlm.nih.gov/books/NBK574350/
Rana, A. M., & Sankari, A. (June 11, 2023). Central sleep apnea. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK578199/
Sateia, M. J. (2014). International classification of sleep disorders. Chest, 146(5), 1387-1394. https://doi.org/10.1378/chest.14-0970
Shah, N., & Roux, F. (2009). The relationship of obesity and obstructive sleep apnea. Clinics in chest medicine, 30(3), 455-465. https://doi.org/10.1016/j.ccm.2009.05.012
Wang, J., Wang, Y., Feng, J., Chen, B. Y., & Cao, J. (2013). Complex sleep apnea syndrome. Patient preference and adherence, 633-641. https://doi.org/10.2147/PPA.S46626