In 2016, Prehn and Colquitt published a fabrication technique for a custom face mask for the treatment of obstructive sleep apnea. Intended for severe OSA patients, the custom face mask is fabricated from an impression of the face and is screwed onto the mechanism of the TAP 3 (Thornton Anterior Positioner). This prosthesis is designed to improve the seal to the CPAP device, decreasing mask leakage, which is a main reason for discontinuation of CPAP treatment. Table 2: Possible Ways to Increase Adherence to CPAP Treatment • Better communication and education. • Attention to how the mask fits. • Follow-up to find out if the patient is comfortable and if there are any problems. • Monitoring of compliance. • Check-ins to be sure the mask (or other equipment) has not worn out or broken. • Attention to humidification. • Physician attention to the need for antihistamines or decongestants. • Formation of a support group for CPAP users (There has been research into group cognitive behavioral therapy). • Discuss and medical or mental health issues which could impede compliance with CPAP therapy. • Incorporate relaxation exercises to decrease anxiety about the use of CPAP therapy. • Use cognitive behavioral or motivational strategies to improve adherence. • Use CPAP telemonitoring with automated patient- messaging feedback. Adapted from Sunwoo, et. al., 2020; Brooks, 2017. 6. The appliance maintains a stable retentive relationship with the teeth, implants, or edentulous ridge. An oral appliance must prevent dislodging. 7. The appliance retains the prescribed setting during use and maintains its structural integrity for at least 3 years. 8. All oral appliances must be made of biocompatible materials. (Mogell, et al., 2019) In 2015, the AASM and the AADSM published specific guidelines for the use of OAs for OSA (Laratta, et al., 2017). Tongue repositioning devices (TRDs) are designed to hold the tongue forward with suction, using a flexible oral bulb. There is insufficient evidence that these devices are beneficial in the treatment of OSA (Semelka, et al., 2016). Indications Oral appliances are generally recommended for patients with mild to moderate OSA (Cistulli, 2017 or patients with severe OSA who are poorly compliant with CPAP (Pavwoski and Shelgikar, 2017; Laratta, et al., 2017). Oral appliances are less effective than CPAP in patients with severe OSA (Dietltjens and Vanderveken, 2019). These patients receive CPAP as first-line therapy. A sleep study with polysomnography or, if the former is unavailable, an at-home sleep study is essential to establishing the diagnosis and severity of OSA (Kline, 2021). Patients must also undergo a comprehensive dental examination before starting OA treatment (American Dental Association 2021). Candidates for OAs require adequate dentition or alveolar ridges, an absence of temporomandibular joint disorder (TMD), and the ability to protrude the mandible (Dieltjens and Vanderveken, 2019; Cistulli, 2022). Examples A variety of OAs are commercially available. According to a systematic review of the effect of design features on the efficacy of OA. There are several brands of MAD which are available for
CPAP for longer than 4 hours a night compared with those who used CPAP for fewer than 4 hours a night or who did not receive treatment. Research on the effects of CPAP on Type 2 diabetes (i.e., insulin resistance) have yielded conflicting results (Mok, et al., 2017; Reutrakul and Mokhlesi, 2020). Insulin sensitivity has been shown to improve within 2 days of starting CPAP therapy in non- diabetic, non-obese patients; improvements were seen after 3 months in patients with diabetes, irrespective of weight (Xu, et al., 2019). Although there is no debate regarding the positive therapeutic effects of CPAP, compliance with treatment is problematic. Only 60% to 70% of patients are compliant with CPAP (Gabryelska, et al., 2022). The increasing use of appliances in the treatment of OSA is largely a result of these compliance issues with CPAP. Researchers have found several reasons for failure to adhere to CPAP therapy, among them nasal drying and congestion, allergies to the mask materials, physical discomfort, claustrophobia, and worry over appearing unattractive or grotesque to the sleeping partner when wearing the mask (Harward and Speer, 2019). Patients and their reasons for noncompliance are so varied, it is probable that educational and behavioral interventions are the most likely to encourage adherence among persons for whom CPAP has been prescribed especially during the initial stages of the use of CPAP (Patil, et al., 2019). It is worth noting that the Centers for Medicare and Medicaid Services considers the first 90 days on CPAP to be a trial period. If a patient is noncompliant, and thus cannot prove that he or she has received any benefit from use of the machine, payments under Medicare Part B for the rental of any of the CPAP equipment will stop (Medicare.gov, n.d.). Table 2 offers suggestions for increasing CPAP compliance. Oral appliances (OAs) are intraoral devices designed to alter mandible and tongue position, thereby improving upper airway configuration and preventing airway collapse (Stanford Health Care, 2021). According to the American Academy of Dental Sleep Medicine (AADSM), this device protrudes and stabilizes the mandible to maintain a patent upper airway during sleep (Summer and Vyas, 2022). The most commonly used OAs are mandibular advancement devices (MADs), also known as mandibular advancement splints or mandibular repositioning appliances (Basyuni, et al., 2018). Mandibular advancement with OAs enlarges the upper airway space, particularly in the lateral dimension of the velopharyngeal (soft palate and pharynx) area (Basyuni, et al., 2018). In February 2013, The American Academy of Dental Sleep Medicine (AADSM) convened a consensus conference to determine a definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring which were updated by the (AADSM) in March 2019. The following are among the key elements of this updated definition: 1. The most common OA is the MAD, which is the most effective OA for sleep apnea and the most widely used in clinical practice. 2. The function of such an appliance is to protrude and help stabilize the mandible to maintain a patent upper airway during sleep. 3. The OA is custom fabricated using digital or physical impressions and models of the patient since these are superior to prefabricated devices. 4. The OA has a mechanism allowing mandibular advancement in increments of 1 mm or less, with a protrusive adjustment range of at least 5 mm. These advancements must be reversible. 5. The appliance can be removed by the patient or caregiver. Oral appliances Definition and features
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