DENTAL SLEEP MEDICINE OF CONNECTICUT

Oral Appliance Therapy Compared to CPAP

Mode of Operation

Each therapy works in a very different way.  Obstructive sleep apnea (OSA) occurs during sleep when the tissues of the airway close fully or partially to interfere with breathing.

CPAP therapy uses a regulated air pressure, mechanically generated, to blow open or force air through the obstruction. 

Oral appliance therapy (OAT) physically opens the airway by repositioning and strengthening the structures that form the airway so that the individual can breathe in a normal manner.

History

CPAP therapy has been developed by large multinational companies that have historically supplied respiratory products for assisted breathing to hospitals and health care centers. Oral appliances have been developed more recently by independent dental practitioners.  CPAP machines are mass produced but the masks are usually custom fitted to the individual from "off the shelf" inventory.  Oral appliances are custom made at dental laboratories and are adjusted for each patient.

Popularity of CPAP

CPAP is generally acknowledged to be bulky, uncomfortable, noisy, inconvenient and to have numerous unpleasant side effects. Despite this, CPAP is much more widely used than oral appliances for a variety of reasons. Tests of large groups of OSA patients will show that on average, CPAP is slightly more effective.  Insurance coverage for CPAP has been good while coverage for OAT was poor and usually limited to individuals who could not use CPAP.  Initiating CPAP treatment is relatively easier and quicker for the patient. The CPAP machine can be tried and adjusted during the first sleep study and the patient is for the most part treated.  Oral appliances require  the referral to another practitioner and additional visits for adjustment of the appliance. For the most part, people who are using oral appliances today were started on CPAP but were unsuccessful with it.

Oral Appliance Use is Growing

In the past 10 years, a great deal has been learned about oral appliances. Recent research has compared oral appliances to CPAP for effectiveness on daytime sleepiness, sexual dysfunction, cardiac functions and sleep study data. For mild and moderate OSA, treatment outcomes are similar. (When the test data for mild/mod OSA is separated out from the overall data, some reports show that OAT is actually superior.)  For severe OSA, however, CPAP superiority is well documented.

Based on accumulated research, in 2006 the American Academy of Sleep Medicine (AASM) issued new guidelines for the use of  oral appliances.  These guidelines state that oral appliances are recommended as a first line of treatment for mild to moderate OSA if the patient prefers oral appliances to CPAP. It also states that oral appliances should be recommended to patients with severe OSA that can not use CPAP. As is prudent practice, patients who are diagnosed with mild to moderate OSA should thoroughly investigate their treatment alternatives.

Since the new recommendation by the AASM, insurance coverage has greatly improved and dentists who practice in the field of OAT report approximately 90% coverage for oral appliances.  As OAT experience has grown, treatment time and the number of visits have been reduced.  Patients can be guided through adjustments at home and with recent improvements in technology, these adjustments can be conveniently evaluated by a home sleep study.  Final evaluation, however, is determined by a well controlled overnight sleep study.

Conclusion

Patients overwhelmingly prefer OAT to CPAP.  Since OAT is more user friendly, many researchers recommend that OAT be tried initially for mild and moderate OSA patients.  One study showed that 46-83% of CPAP users do not use their machines over 4 hours per night and at least 6 hours are necessary for a therapeutic effect.  Using current patient selection criteria, an 80% success rate with OAT has been demonstrated whereas it has been shown that it is not possible to predict which patients will comply with CPAP therapy.

Each mode of therapy has its advantages and disadvantages; the decision of which therapy to choose should be carefully considered by patient and physician.

THE BEST TREATMENT OPTION IS THE ONE THAT YOU WILL WEAR ALL NIGHT EVERY NIGHT!

See Physician's Section for references