Candidate patients for the intraoral prosthesis
The guidelines, issued by the American Academy of Sleep Medicine and published in the February 2006 edition of the journal Sleep, shows that "the use of oral appliances are indicated in patients with mild to moderate OSAHS, to those, who prefer them instead of continuous positive airway pressure (CPAP), those who did not respond to treatment,or are not appropriate candidates or have failed attempts with CPAP. Oral appliances should be installed by qualified dental personal, who are trained and experienced in the overall care of oral health, temporomandibular joint, dental occlusion and oral structures; as it's the best and most recommended sleeping apnea solution.
A sleep study is needed to verify the effectiveness, and may be necessary, when symptoms of OSA worsen or persist. Patients with OSA, who are treated with oral appliances should follow-up visits with the dental clinic specialist regularly to monitor the proper development of treatment by the patient, to assess the damage of the device, and to assess the health of the intraoral structures and integrity of the occlusion. Regular monitoring is also necessary to assess the patient and to discover signs and symptoms of OSA worsening. The application of oral appliances are indicated for the vast majority of patients with OSAHS. The improvement in the design and mechanism and the effectiveness of existing devices on the market ensure effective treatment in all patients with few exceptions. The American Sleep Asociation provides a generic protocol to establish a profile of candidates for treatment with oral appliances.
The recommendations on the use of intraoral appliances for the treatment of choice is intended to:
- Snoring patients, whose primary symptom is snoring.
- Patients with mild OSAHS.
- Patients with mild-moderate OSAHS with low BMI.
- Patients with IRSUA.
- Patients, whose lifestyle includes frequent travel.
As an indication of second choice it is recommended to:
- Patients with rejection or intolerance to CPAP.
- Patients, where surgical treatment has failed.
- Patients, who use nasal CPAP or oronasal masks and also maintain an intraoral appliance in the mouth.
First we consider, that the majority of apneas are those considered mild or moderate, that means not exceeding 40 events per hour. Even if it is true, that treatment with nasal continuous positive airway pressure (CPAP) consists of administering a continuous flow of air that "opens the airway", which is a highly effective treatment, it is also noteworthy, that the rate of abandonment of long term therapy is very high (about 70% use it less than four hours per night). This lack of compliance is primarily due to the drawbacks of this therapeutic option referred by patients such as dry mucous membranes, irritation of the mask mismatch, the limitation of movements in bed, discomfort to turn over during sleep or by psychological reasons like increased anxiety and claustrophobia.
In the case of oral appliances, crossover studies have highlighted, that the levels of abandonment of therapy by the users of CPAP base on exactly these significations. The default rate in patients with intraoral devices is higher in those, without the possibility of a mandibular advancement, 24% with respect to those, who have it and only 5%, who don't. Studies of long-term monitoring of the use of intraoral appliances include a prevalence of 6.8 hours per night. Among the most recurrent factors for the patient to stop using the device are the discomfort and lack of motivation. Given these limitations, it should be emphasized in making an appliance with a material as comfortable as possible and perform a series of controls for check the alignment and the proper use of the equipment. On the other hand, it is appropriate to work on the effectiveness of the devices realizing policardiografic studies to assess, that the AHI is normal, which means, less or equal than 5. At this point it should be noted, that the design differences between these and other devices is not a negligible aspect in the record of the therapy. The type of required device significantly influence the acceptance of patients, who get better used to devices of the next-generation such as Orthoapnea,which include laterality, openness and millimeter progress and are better rated by the users, because the discomfort of remaining stationary monoblock or the bulky machines disappear.
The indication of CPAP treatment is restricted to a series of patients with AHI greater than 30 within the range 15 to 30, who manifest symptoms related to hypopnea and cardiovascular risk (hypertension, obesity ...). The correct action is to individualize treatment compared to each patient and to use dietary measures previously administered to loose weight. Finally, for patients with AHI> 30 without symptoms, or hereditary factors or cardiovascular risk, which would not be indicated with CPAP treatment, the intraoral appliances could be the therapy of choice.
The criteria of sleep units to send a patient to a qualified professional in oral sleep medicine to perform an intraoral appliance treatment are:
- The primary symptom is snoring.
- Rescue surgery (uvulopalatopharyngoplasty).
- Rejection or intolerance to CPAP.
- Frequent disturbances, or psychological reasons with the mask.
In those cases, where it would not be indicated the use of oral protheses would be:
- Primary symptom Drowsiness.
- Teething inappropriate, active periodontal disease without treatment.
- Important obesity.
- If there is significant desaturation.
In short, being the most striking symptom, for snoring (not having excessive hypoxemia) intraoral devices are the treatment of choice, but if there is a significant sleepiness the response with CPAP is highly valued and with oral devices patients are not sufficiently treated. In some cases, patients may benefit from both treatments for example, when patients travel, they can wear the intraoral appliance and can use CPAP as an individual therapy. The lack of teeth is not a disadvantage, cause the development of mechanisms make this appliance viable in any type of dentition, including patients with edentulous prosthesis or, even in patients with dental implants. The clinician will have to conduct a thorough review of the patients dentition, and in the presence of periodontal disease or any other conditions, he shall treat them before prescribing a prosthesis. The patient should have the capability to advance the mandible forward and open it without significant limitations. Serious problems in the TMJ or insufficient capacity of protrusion may be contraindicated for the therapy with oral devices although not all TMJ problems are an exclusion to the prescription of oral therapy and require an evaluation by a dental specialist.