What is a sleep apnea mouthpiece?
The sleep apnea mouthpiece is an oral dental device designed to bring the lower jaw and tongue muscles forward, especially when sleeping on your back. This prevents the lower jaw from being pushed back as the muscles relax, ensuring that the upper airways remain open during sleep. The sleep apnea mouthpiece is most often made of acrylic plastic. The pieces are both single and double-piece. In a two-part device, the parts coming to the tooth arches are connected to each other by means of frames or similar structure. Sleep apnea mouthpieces are both completely custom-made and semi-finished pieces that are shaped to fit in the mouth. The recommended lower jaw forward import volume is 50-75% of the jaw protrusion capacity, ie the maximum of the lower jaw forward import volume. The sleep apnea mouthpiece can be used to treat both normal weight patients with mild to moderate sleep apnea and mildly overweight patients with mild symptoms. Instrumental therapy can also be used to treat snorers and possibly also patients who, for one reason or another, have failed CPAP therapy.
Positive effects of sleep apnea mouthpiece
According to one study, in sleep apnea mouthpiece treatment, an average of 52% of patients achieve a good response (AHI equal to or less than 10). There are also indications that the use of a sleep apnea mouthpiece significantly lowers the apnea / hypopnea index (AHI) and significantly increases arterial oxygen saturation. The use of a sleep apnea mouthpiece also significantly lowers systolic and diastolic blood pressure in both arteries. However, the apnea mouthpiece has not been found to have a significant effect on heart rate
Furthermore, the use of a sleep apnea mouthpiece improves the result of the Epworth Sleepiness Scale (ESS), i.e. reduces the sleepiness of patients. The use of a sleep apnea mouthpiece also improves quality of life and reaction speed. The sleep apnea mouthpiece has been found in some to even alleviate the symptoms of temporomandibular disorder (TMD) symptoms compared to the initial situation of users. In other patients, however, no significant change in TMD symptoms was observed with apnea mouthpieces. The positive effects of sleep apnea mouthpiece, such as improvement in nighttime breathing, somnolence, blood pressure, fatigue, sleep quality, and quality of life, have been shown to last for at least about 2.5 to 4.5 years after initiation.
What are the side effects of sleep apnea mouthpiece?
According to studies, the short-term side effects of using an apnea mouthpiece are e.g. tooth tenderness, gingivitis, jaw discomfort, bite change, bite dysfunction, dry mouth and increased salivation. Such mild subjective side effects are common. Over time, these symptoms often worsen and patients who decide to continue to use the sleep apnea mouthpiece, feel that the symptoms are insignificant.
Long-term side effects, in turn, include changes in the bite in the teeth, such as a tendency for the horizontal and vertical overbite to decrease and the bite to open laterally. According to a study by Doff and partners, after two years of CPAP or sleep apnea mouthpiece treatment, the number of upper and lower tooth contact points had decreased in the premolar and molar regions in both treatments. One study found that two years of use of the apnea mouthpiece causes palate tilt of the upper incisors and labial tilt of the lower incisors. There was no significant change in tooth constriction. The protrusion of the sleep apnea mouthpiece, i.e. the amount of jaw forward import, was found to have a significant effect on the reduction of overbite. However, no significant changes in horizontal or vertical overbite were observed in other similar studies. This difference is thought to be due to different types of apnea mouthpieces.
Prolonged use of the sleep apnea rail has also been found to cause downward and backward rotation of the lower jaw. After two years of follow – up, apnea mouthpiece users had an increase in lower face height and overall front face height compared to CPAP users. However, the height ratio of the front faces had not changed significantly between user groups.
Clinical experience has shown that changes in the bite are often reduced when treatment is stopped. Bite changes can be prevented by the design of the instrument as well as by restricting the use of the instrument.
Can everyone use a sleep apnea mouthpieces?
There are only few contraindications to the use of a sleep apnea mouthpiece. Lack of teeth may be an obstacle to sleep apnea mouthpiece treatment. There is no exact information about the number of teeth needed, but 6 to 10 teeth in each dental arch would be desirable. If a sleep apnea mouthpiece is used in a toothless mouth, it puts considerable pressure on the toothless ridge and creates pressure points. The teeth and periodontium, the supporting tissue surrounding the teeth, must be in good condition in order for sleep apnea mouthpiece treatment to be carried out.
The patient’s severe bite dysfunction can also be a barrier to sleep apnea mouthpiece treatment. Especially if opening the mouth or bringing the lower jaw forward is limited, sleep apnea mouthguard treatment cannot be implemented.
Further, severe bruxism can also prevent the implementation of sleep apnea mouthpiece therapy. Bruxism can cause damage to the mouthpiece or increase the pain felt by the patient, because the mouthpiece usually holds the teeth and jaws firmly in one particular position throughout the night. Poor treatment motivation of the patient can also be considered a contraindication, because if the apnea mouthpiece is not used or its use is irregular, it will not help in the treatment of sleep apnea. Even then, getting used to the device is more difficult. Panic disturbances, depression or acrylate allergies can also be an obstacle to the use of an apnea mouthpiece.
Custom made sleep apnea mouthpiece compared to the factory-made sleep apnea mouthpiece
An individually made apnea mouthpiece is an acrylic plastic device individually sized and made for the patient’s mouth based on dental casting. The prefabricated device is a partially preformed piece of plastic and is made suitable for the patient’s mouth and teeth by first warming it in hot water and then biting into the device so that the lower jaw is approximately 50 percent of the maximum import of the lower jaw.
The factory-made device has not been found to affect nighttime breathing breaks, while the individually manufactured apnea mouthpiece significantly decreased the value of the apnea / hypopnea index, i.e., significantly reduced nighttime breathing breaks. The custom-made sleep apnea mouthpiece also reduces snoring more than factory-made products. Patients clearly favored the custom made sleep apnea mouthpiece, and the individual sleep apnea mouthpiece was also used more than average: both on several nights and for several hours at a time.
Sleep apnea mouthpiece compared to CPAP device
CPAP treatment is the primary treatment, especially in moderate to severe sleep apnea. Although CPAP provides a good response in most cases, treatment is not for everyone. After the CPAP trial period, approximately 70-80% are suitable for treatment. In those who are unable to continue CPAP treatment, the causes are often, for example, local symptoms such as persistent rhinitis, nasal congestion, sneezing, dry mucous membranes in the nose and mouth, nosebleeds, and accumulation of mucus in the throat. In addition, noise and discomfort from the device or mask, a feeling of suffocation, or an inability to sleep when connected to the device may interfere with CPAP therapy.
Local symptoms can be reduced with a humidifier connected to the device. The sleep apnea mouthpiece is not as effective in lowering the apnea / hypopnea index as the CPAP device. In addition, the CPAP device is more effective than the sleep apnea mouthpiece in improving blood oxygen saturation and reducing snoring. In addition, the advantage of a CPAP device is that there is hardly any absolute contraindication to its use. Nevertheless, the sleep apnea mouthpiece has been found to be a competitive form of treatment relative to the CPAP device in the majority of patients with obstructive sleep apnea.
No overwhelming compliance with either device has been observed; in some studies, patients preferred the sleep apnea mouthpiece, in some the CPAP device. The advantage of the sleep apnea mouthpiece is that the device is easy to take along, which makes the use efficient. Furthermore, when comparing the CPAP device and the apnea mouthpiece, the long-term use of the CPAP device has not been found to have an effect on the facial ratios, while the sleep apnea rail has been found to increase the lower face height. Both the sleep apnea mouthpiece and the CPAP device have been found to improve both quality of life and subjective drowsiness as measured by the ESS drowsiness survey. In some quality-of-life metrics, the apnea mouthpiece was even better than CPAP.
Although CPAP has been found to be more effective in reducing breathing breaks than apnea mouthpiece, therapies may be just as effective in treating sleep apnea because the utilization rate of sleep apnea mouthpiece is often higher than that of CPAP.
Sleep apnea mouthpiece compared to surgery to dilate the upper airways
Studies have shown that the sleep apnea mouthpiece reduces the apnea / hypopnea index more than UPPP pharyngeal surgery. This difference has been observed in both one- and four-year follow-up. Treatment success, i.e., a halving of the apopnea index, was significantly more common in those using a sleep apnea mouthpiece than in those using UPPP surgery.
The researchers studied the effect of tonsil removal on sleep apnea. Ten patients in the study had sleep apnea and at rest had a maximum distance of 5 mm between their tonsils. After removal of the tonsils, good treatment outcome (AH1 decreased by> 50% and AHI postoperatively <20) was achieved in 9/10 of the sleep apnea patients.
In children, tonsillectomy is most often the best treatment for obstructive sleep apnea, but it also works as a treatment for adult patients with enlarged tonsils.
Multilevel radiofrequency therapy (RFA), in which different areas are heat treated simultaneously, has been found in the pharyngeal area to reduce symptoms and improve quality of life in mild to moderate sleep apnea. However, no effect on the apnea / hypopnea index has been observed.
Compliance with sleep apnea mouthpiece
The measure of the effectiveness of sleep apnea mouthpiece treatment is not only the effectiveness of the treatment but also the compliance with the treatment and the use of the mouthpiece. The utilization rate of the apnea mouthpiece has been found to decrease over time. It is due to a small improvement and / or worsening of the expected subjective symptoms over time. Transient, short-term side effects do not require interruption or discontinuation of treatment if the side effects remain under control. Patients believe that the benefits of a sleep apnea mouthpiece outweigh the side effects of the rail. It has also been interpreted that intraoral devices that allow the jaw to move laterally and the jaw to open vertically may reduce side effects and thus increase patient compliance. In addition, it has been found that patients prefer sleep apnea mouthpieces with as little bite opening as possible. The amount of bite opening has not been found to have an effect on the treatment outcome.
In one study, 82% of sleep apnea mouthpiece users used the device regularly during a three-month follow-up. These regular users used the apnea mouthpiece for an average of 6.7 hours per night. The results were obtained from a microsensor attached to a sleep apnea mouthpiece by patients without knowing its purpose. These results did not differ significantly from the device utilization rate reported by patients subjectively. In a five-year follow-up study, 62% of patients who used a sleep apnea mouthpiece who responded to the survey were still regular users, 21% were irregular users, and 17% had discontinued the use of a sleep apnea mouthpiece. 82% of regular apnea mouthpiece users were satisfied or very satisfied with sleep apnea mouthpiece treatment. 17% of irregular users also felt this, but none of the users who discontinued treatment were satisfied with sleep apnea mouthpiece treatment. The study found that snorers and those with mild sleep apnea were more likely to continue their sleep apnea treatment with a mouthpiece than patients with more severe sleep apnea.
A ten-year follow-up survey conducted found that 66% of patients who responded to the survey continued to use a sleep apnea mouthpiece. Of these patients, 47% used the device every night. Of those who no longer used the rail, half found the apnea mouthpiece very uncomfortable. To summarize the reported studies, it can be concluded that the sleep apnea mouthpiece is an effective long-term treatment for sleep apnea and snoring.