Oral appliances cause bite changes.
The literature reports that bite changes can occur with patients wearing an oral appliance for long periods of time, anywhere from 3% to 40%. As a result, we have developed an exercise program for our sleep apnea patients. This involves having the patient clench on the back teeth in the morning after the appliance has been removed, four times per minute, until the back teeth interocclude. We have been utilizing this technique for five plus years now. In patients who have been using this exercise program, we have almost never seen any bite changes. In virtually every case where a bite change has occurred, the patient has not followed through on the recommended exercise protocol.
Recent literature seems to indicate that bite changes are related to the development of additional fibrous tissue in the temporomandibular joints, which has created a mandible in a more anterior position. As a result of this anteriorization of the mandible, the bite has changed resulting in a posterior open bite. This exercise program seems to stimulate the tissue within the temporomandibular joint and prevent such changes.
Oral appliances cause teeth loosening.
Teeth loosening clearly can be an issue in the long-term wearing of an oral appliance. Basically, the dentition is what is preventing the mandible from retruding and holding the base of the tongue in a forward position. We carefully examine the patients at their initial evaluation. As periodontists, training is devoted to the maintenance of this support apparatus of the tooth. Therefore, we are acutely aware of this possible risk. In isolated cases, splinting of teeth may be necessary to prevent loosening. We monitor these patients during active treatment and annually to avoid any significant issues related to tooth loosening. To date, we have not found any significant problems related to this issue.
Oral appliances are only for mild cases of OSA.
As we are sure you are aware, the position of the American Academy of Sleep Medicine (AASM) states, “All appliances are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond, or who are not appropriate candidates for, or who fail treatment attempts with CPAP”. We have been treating patients with both moderate and severe degrees of obstructive sleep apnea. Many of the moderate cases have completely resolved their sleep apnea and have used this as their only treatment modality. Some of the advanced cases of sleep apnea have also completely eliminated their sleep apnea. In a recent case, a patient presented with an AHI of 61 and was reduced to 8.1 with an oral appliance. Other cases who are completely CPAP intolerant have had substantial reductions in their sleep apnea. At that point, additional modalities such as uvulopalatopharyngeal surgery or CPAP at lower pressures can be utilized. Some of these patients who refuse other treatments have simply had their degree of sleep apnea reduced substantially.
There is only one appliance that is used and can be used for OSA.
This is clearly false. At present, we have the ability to utilize five different appliances in our office. Briefly, they are:
All of these appliances have different advantages and we attempt to utilize the appropriate appliance to the specific needs of the patient.
Oral appliances cause Temporomandibular Joint issues and muscle pain.
One of the primary subspecialties in our office for the past 35+ years has been the treatment of patients with temporomandibular joint disorders. We carefully examine all patients at their initial visit for any temporomandibular joint symptomatology. These symptoms can be pain in the temporomandibular joints or the muscles that move the mandible. The patients are apprised of the degree of temporomandibular joint involvement and the effect of this involvement on their ability to utilize a sleep appliance. The appropriate sleep appliance is constructed for these patients and is carefully monitored. When difficulties occur in the temporomandibular joint region, changes in our advancement protocol and/or referral for physical therapy modalities are often utilized to allow these patients to function with oral appliances. Most of these patients are successful in the long term to utilize their appliances. On occasion, some patients have advanced temporomandibular joints that do not allow them to wear oral appliances successfully; however, these are the exception rather than the rule.