• On snoring, 3

    Chen, H. and Lowe, A.A., 2013. Updates in oral appliance therapy for snoring and obstructive sleep apneaSleep and Breathing17(2), pp.473-486.

    A lot of this is about obstructive sleep apnea (OSA), but a bit is about snoring. Anyway, in general what treats the former also is effective for the latter.

    • “OSA is associated with significant co-morbidities such as cardiovascular, metabolic/neurocognitive complications, motor vehicle crashes, and occupational accidents.” Comment: Causality isn’t so clear from this statement, but for some of these it seems more likely that it runs from OSA to the outcome (e.g., crashes/accidents).
    • “The American National Sleep Foundation 2005 poll based on Berlin questionnaire scores indicated the prevalence of OSA ranged from 16% to 37% in the 18–65+ age groups with the 50–64-year-old group having the greatest chance of being diagnosed with the disease in both gender groups (37% in males and 29%
      in females) [3].” Comment: Dated, but I bet the prevalence has only gone up.
    • “Behavioral modifications for OSA treatment include weight loss, alcohol avoidance, and changes in sleeping
      position.” Comment: Missing from the list is breathing exclusively through the nose. But, to be fair, I have not (yet) read a study that documents doing so can improve or eliminate OSA.
    • “In a recent practice parameters article published by the American Academy of Sleep Medicine (AASM), OAs are indicated for snorers, for mild to moderate OSA subjects, for severe OSA subjects who have not responded to CPAP, who are not appropriate candidates for CPAP, or whose previous attempts to use CPAP failed [5].”
    • “There are over 100 OA [oral appliance] designs available on the market which differ in the fabrication material, location of the coupling mechanism, titration capability, degree of customization, amount of vertical opening, and lateral jaw movement.” Most are mandibular advancement devices (MADs). Tongue retaining devices are not widely used, though are an option for patients who lack enough healthy teeth to anchor a MAD.
    • OAs work by altering the upper airway topology and (somehow) improving upper airway muscle tone.
    • “In a retrospective analysis of 175 male and 156 female patients who received dental care, 67% of the men and 28% of the women were identified as being at risk of at least mild OSA. Over 33% of the men and 6% of the women surveyed were predicted to have moderate or severe OSA [15]. However, a survey [16 (though dated)] showed that 58% of dentists in a group of 192 US practitioners could not identify common signs and symptoms of OSA; 40% knew little or nothing about OA therapy for OSA while 30% learned about it during postgraduate training. Some 54% have never consulted with a physician for a suspected OSA patient in their practice; 75% of dentists have never had patients referred to them by a physician.”
    • “Some researchers advised that pre-fabricated, over-the-counter appliances are less effective, less accepted, and not qualified as a screening tool to predict OA responders [45].”
    • A follow-up sleep test is recommended after adjustment to an OA is complete. However, these are rarely done due to insurance, access to a sleep lab, or (I bet) they’re not the least bit enjoyable for the patient.
    • This paper covers the evidence on effectiveness (they’re generally effective for snoring and OSA), side effects (discomfort and changes to dental structures) and compliance of/with OA. To my reading, long-term compliance rates don’t seem to be that much higher than to CPAP. The difference may be that many people stop using more quickly.

    @afrakt

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