Who treats OSA?

While a dentist may be the first practitioner to identify patients who have sleep apnea, they seldom treat these patients without medical guidance.  Pulmonologists and sleep specialists are qualified to document and treat the disorder, however dentists are becoming more and more accepted by the medical profession as qualified OSA treatment providers.  

The proscribed medical treatment for OSA is "Continuous positive airway pressure" or CPAP (pronounced "C-Pap") and a newer variation called BiPap.  These machines have a high flow fan, a hose and a sealed nasal mask to which the patient is attached while sleeping.  Clinical studies have shown that CPAP is effective in relieving most apnic episodes.  In addition to the CPAP machine, physicians prescribe a weight  loss regimen, and abstinence from tobacco and alcohol.   Unfortunately patient compliance is a problem due to the noise of the air compressor, the constriction of movement caused by the hose attachment, stuffy nose, skin irritation from the nosepiece, and having less intimacy with a bed partner. 

In the early 1990's, OSA research projects were carried out on mandibular advancement devices (airway dilators, or "snore guards") .  These projects resulted in a 1995 review by the American Sleep Disorders Association entitled "Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances".   The review concluded that oral appliances are a good alternative to CPAP in cases of mild to moderate obstructive sleep apnea.  "Although not as efficacious as continuous positive airway pressure (CPAP), oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep-position change." 

The dental treatments for obstructive sleep apnea are simpler than CPAP from the point of view of patient compliance.  Dentally oriented treatments for this problem fall into two groups; Removable appliances that advance the lower jaw while the patient is asleep, (airway dilators, better known as snore guards) and surgical solutions, some of which advance the lower jaw permanently.  

If a true case of obstructive sleep apnea is suspected, the dentist generally uses his skills in conjunction with the help of a qualified physician specialist who can assess the need for, and ultimately the success or failure of the treatment.  This makes sense since it is the physician who can order and interpret the medical tests involved in the establishment of the diagnosis.

The removable OSA appliances (Snore guards) 

In the schematic diagrams seen at the top of the page, notice that the lower jawbone (the mandible) is connected to the tongue.  Anything that advances the lower jaw forward (brings it into protrusion) will tend to lift the tongue and epiglottis away from the back of the throat relieving some of the constriction caused by the relaxation of the muscles during sleep.  In order to wear such an appliance, it is imperative that the patient have sufficient numbers of healthy teeth in both upper and lower arches for the appliance to attach to. If the patient lacks healthy teeth, dental implants may still make it possible to wear a removable snore guard.

Note that removable snore guards separate the upper and lower teeth and thus perform the functions of a bruxing guard in addition to those of the snore guard.  Thus a snore guard may not only treat snoring and obstructive sleep apnea, but it will treat the symptoms of TMJ as well.  However, in severe cases of organic joint dysfunction due to TMJ, the forward repositioning of the lower jaw may exacerbate the damage to the jaw joint and thus a snore guard may be inappropriate for these patients.

Impressions are taken of both the top and bottom teeth, and models are poured in plaster.  Then the patient may be instructed to bite into a slab of wax with his lower jaw protruded as much as possible without straining.  This is called a protrusive bite registration.  Both the models and the protrusive bite registration are sent to the lab.  The laboratory returns the finished appliance which can take a number of different forms depending on  what the dentist orders.  

Three types of Snore Guard

While I mention specific types and brands of snore guards, many orthodontic laboratories have their own proprietary brand of appliance.  The SilentNite ® mentioned below is one such appliance.  It is franchised, marketed nationally and fabricated in a number of dental labs around the country.  This site does not endorse any specific brand or type of snore guard.  Nor does any appliance's absence from this page suggest that it will not perform as advertised.  You and your dentist must decide on the correct type of snore guard for you.

Snore guards are frequently quite effective at relieving the obstructions causing OSA, but they are limited by the ability of the TMJ to move forward.  As a rule, the maximum advancement of the lower jaw that can comfortably be achieved with a fixed-jaw-relation snore guard is on the order of 3 to 5 millimeters.  This is frequently enough to relieve the airway, and will work quite well for most people.   The disadvantage to a fixed relation guard is that the appliance cannot be adjusted to bring the lower jaw further forward as the joints (TMJ) relax over time.  Adjustability is desirable since obstructive apnea is a progressive disease and further jaw protrusion often becomes possible as the joint ligaments stretch. 

1. Fixed-jaw-relation snore guard

• Prefabricated appliances

A fixed-jaw-relation type snore guard is the least expensive appliance available for the treatment of snoring and obstructive sleep apnea.  A number of manufacturers make very inexpensive prefabricated appliances in which the patient is instructed to bite into a double sided prefabricated plastic tray lined with flexible thermal plastic.  The patient bites with the lower jaw thrust out (protruded) and when the thermal plastic cools, impressions of both the top and bottom teeth remain behind and the tray, along with the thermal lining becomes an "immediate" snore guard.  I have found that this type of "quick and dirty" device works reasonably, but is generally is not very durable and not always very comfortable.  They have proved most useful as provisional (non permanent) appliances for emergency or experimental purposes to see if a patient can tolerate a jaw protruding device.  You don't have to go to a dentist to try one.  Several such devices can be found by clicking here, here, here, or click here for a Google search of the current crop of prefabs. . 

• The Elastomeric appliance

  More durable and permanent appliances are custom made in a dental laboratory.  One of the least expensive and most popular types is called an elastomeric snore guard.  Impressions of both upper and lower teeth are taken by your dentist, and plaster models made from those impressions are sent to the lab along with a protrusive bite registration.  (The patient is instructed to bite into a horseshoe of soft wax with his lower jaw protruded as far as he can comfortably extend it.  Dentists click here to order a George gauge to help in this task, and here to learn how to use one.)  The lab sends back a finished appliance made out of a silicone rubber which looks like the one in the images below.  These are surprisingly comfortable, and the patient can breath freely through the holes seen in the front view below.  Actually, once the patient gets used to having the appliance in place, the "panicky"  feeling that he or she has to be able to breathe through the mouth vanishes and the patient spends the night breathing through the nose, so the holes are mostly a temporary "psychological" necessity.  One of the unsung advantages of this type of snore guard is its indestructibility.  It cannot break under pressure and the fit, with a few adjustments, is generally perfect.  They never break, even under the extreme pressures placed upon them by the worst bruxers.  Since they are also the least expensive laboratory constructed bruxing guard, patients may be able to afford a new one every so often in order to advance the lower jaw.  Probably the most important advantage to the elastomeric bruxing guards is that it is the type of snore guard least likely to cause serious shifting of the teeth over time.

   

Fixed jaw relation snore guard made of elastic silicone rubber (elastomeric appliance)

• The NAPA Appliance

The NAPA appliance has been in use since 1983 and ranks as the oldest snore appliance in continuous use.  Like the Elastomeric appliance above, it is built in a fixed jaw relationship which cannot be changed.  It is made out of hard acrylic and is held in place by eight clasps which firmly grasp the teeth.  The extension in front is a breathing tube which keeps the lips apart.  Over the years, it was found that this arrangement was unnecessary since patients tend to breathe through their noses when asleep and block the breathing tube with their tongue.  However, many patients like the security of an airway which is always open and unobstructed.

2. Semi Adjustable Snore guards

• The SilentNite ® Snore guard

One of the more commonly prescribed semi adjustable snore guards is called the "SilentNite".  This appliance is really a proprietary form of standard orthodontic device called a Herbst appliance.  In this case impressions are taken by the dentist and poured with plaster to make models of the upper and lower teeth.  The models are sent to the lab, in this case without a protrusive bite registration.  The lab sends back an appliance composed of two separate plastic bite trays, one each for the bottom and top teeth.  These trays are attached together with a pair of plastic hinges which keep the lower jaw in protrusion while allowing the patient to open and close his mouth. 

Notice that in this type of appliance the bar that connects the top and bottom trays may be lengthened or shortened to accommodate the needs of the patient.  The shorter the bar, the more the protrusion.  

This type of appliance is more expensive than the fixed relation snore guard, partly because the lab costs are higher, and partly because there is more service necessary in replacing the connecting bars.

My experience with this device has been less than outstanding.  Although the lab has been very helpful in remaking the device when it has failed, I feel that the materials out of which it is constructed are too difficult to fit properly, and too fragile to withstand prolonged usage.  I now prefer to prescribe a standard elastomeric appliance, or a Herbst appliance since it seems to hold up better to wear and tear, is much easier during initial fitting, and making adjustments in jaw protrusion is much easier, and can even be made by the patients themselves.

3. The fully adjustable snore guards

The fully adjustable snore guard is the most versatile of all the snore guards because it contains a jack screw assembly or some other orthodontic arrangement which allows the dentist to progressively increase the jaw protrusion over the course of several weeks.  This usually results in a much greater jaw protrusion with consequently greater relief of the symptoms of snoring and obstructive sleep apnea. 

• The Klearway ®

One of the most frequently prescribed fully adjustable snore guard is a Canadian invention called the Klearway, and is shown in the four images below.  The lower right image shows only the top arch and provides a detail of the jack screw that that allows for minute adjustment of the appliance. The two wires that project forward would be attached to the lower arch in a complete appliance.  

This type of snore guard is the most expensive, not only because of the more complex design and hardware requirements, but especially because it is quite labor intensive on the part of the dentist who must see the patient on numerous visits subsequent to the initial insertion in order to adjust the jack screw, progressively advancing the jaw.   

The Herbst has been around for a very long time as an orthodontic appliance. Recently, it has been adapted to the role of snoring appliance, and it has since become one of the most commonly prescribed devices for the relief of snoring and obstructive sleep apnea.  It consists of two hard, acrylic trays, one for each arch (upper and lower).  The inside of the trays are formed to fit tightly over the teeth.  The upper and lower trays are attached together by two bars that are placed along either side.  They allow the lower tray to be advanced using 1, 2 and 3 mm shims which extend the stop at the end of the bar.  The Herbst is available with either  thermoflex trays, which are pliable when heated in warm water and can be more easily adjusted to fit the teeth, or hard acrylic trays, which are not as easily adjusted, but are more durable and hygienic.  

The Herbst is similar to the Silent Night in that it allows some vertical and horizontal movement without disengaging the appliance.  It is more expensive than the silent night, but much sturdier.  The elastic bands on either side are to close the jaw once the patient is asleep in order to keep the lower jaw from opening which would reduce the amount of  protrusion and decrease the effectiveness of the appliance. 

 

The Snore-Aid ® The Snore-Aid is another proprietary form of snore guard which is suitable for persons who wear an upper full denture (in other words have no upper teeth), but still have sufficient lower teeth to retain a plastic tray which can protrude the lower jaw.  This snore guard uses an extra oral lip shield (engaging the outside of the upper lip) to hold the lower jaw forward.  It too can be adjusted to increase the jaw protrusion over time.

The TAP® appliance This appliance is fairly new and is compliant with the federal standards applying to oral medical devices.  It can be prescribed and fabricated by any licensed dentist.  It should not cause unwanted tooth movement because of its design, however it limits the ability to open the mouth while wearing the appliance.

Other commercial snore guards and why you should not buy them over the web.

If you run a Google search for Snore Guards, you will come up with literally hundreds of pages of products promising relief from snoring and sleep apnea.  The point to remember about purchasing anything over the internet that promises to relieve snoring or sleep apnea is---DON'T!!:

• You do not have enough information to diagnose your condition!
  • Even after reading this website, you do not have the education to make a diagnosis.  That requires medical expertise.
  • After all, you are asleep when the problem is occurring.  You don't have the slightest idea of what is happening to your body while sleeping.
  • Sleep apnea is a VERY DANGEROUS condition which can lead to stroke, heart attack or death.  Sleep apnea may also be only one symptom of an even more serious underlying medical problem.  If you are wrong about your condition, you could be making a fatal mistake!

     

• Any appliance you buy over the web without a prescription from a physician or dentist is NOT medically approved to treat any condition. 
  • The people marketing these appliances may have no medical knowledge at all!  Often, they are hucksters trying to sell a modern form of snake oil using up-to-date terminology.  Some of these things will actually make your condition worse!
  • You should not consider purchasing any sleep apnea appliance unless it complies with the requirements of directive 93/42/EEC concerning medical devices.  Federal (U.S.) law restricts these devices to sale by, or on the order of, a dentist or physician.

   

• If you are a severe snorer, or suspect that you are a victim of sleep apnea, you should visit a qualified physician (Ear, Nose and Throat specialist preferably), or at least a dentist who has had some training in diagnosing and treating snoring and sleep apnea. 
  • He or she will often prescribe a sleep study to confirm the severity and identity of your sleep disorder.
  • He or she may also order tests to see if your sleep disorder is connected to other underlying causes.

Are snore guards covered by insurance?

Snore guards are not covered by dental insurance, however, some medical policies will cover them if they are prescribed by a physician on your plan.  Below are some of the CPT codes that the physician can use to submit a sleep apnea device.

The problem of tooth movement with tooth borne snoring appliances

The down side to snore guards is that constant pull of the muscles of the lower jaw places forces upon the entire dentition, both upper and lower.  Over time, some limited tooth movement tends to take place so that eventually the upper and lower teeth do not seem to "bite" together properly.  The upper and lower teeth are "splinted together" because each arch of the snore guard acts as a bite splint and tends to hold the teeth in their original positions.  Thus, there is no visible movement of individual teeth.  However, there may be some minor tilting of all the teeth in each arch over time, as well as a tendency for the TM joints to "prefer" a more anterior position thus causing the lower jaw to protrude slightly, even when the guard is not in place.  This may cause the upper and lower teeth to feel as though they do not properly come together.  

This change in bite is generally of little consequence during normal functioning, (i.e. eating and talking)  however it may be a problem for persons who tend to brux (grind and clench their teeth---see my page on TMJ).  In bruxers, this change in the bite may often be compensated for by a gentle "occlusal adjustment" (selective grinding of the tooth surfaces by a dentist).  This will not completely correct the bite, but it may even-out the contacts to make biting feel less abnormal, and will not affect the fit of the snore guard.  In a few cases, the movement of the teeth may necessitate the abandonment of the snoreguard.  The elastomeric fixed guard is the least likely of all to produce tooth movement because of the hugely retentive nature of the tooth indents and because of the springlike resilience of the material which tends to shift teeth back into their original position.  

Where can you find a dentist that fabricates snore guards?

There are several ways to get referrals to dentists near you who prescribe snoring appliances.  

1. First try contacting your state dental or medical society.  Run a Google search (there's a box at the bottom of this page) for, say, "Texas Dental Society" to get the main phone number and call an office near you.  
2. Call local otolaryngologists (ear, nose and throat specialists) to see if they work with dentists in your area.  
3. Look up an orthodontic lab near you to see if they make snoring appliances.  The larger orthodontic labs make these appliances for doctors all over the country.  If you call one, you may be able to get a referral to a dentist in your area who treats snoring with these types of appliances.  One lab I use all the time is Great Lakes Orthodontics, LTD.  Email them at info@greatlakesortho.com.  Glidewell Labs makes the SilentNite appliance.  Click here for their website (and their telephone number).
4. Finally, QuietSleep.com is an excellent internet site which further explains snoring and sleep apnea.  It  also has a search engine for finding local dentists and the various laboratories that make snore guards.

The surgical OSA treatments.

There are several surgical options available for the relief of snoring and obstructive sleep apnea. 

• The oldest and most frequently performed type of snoring related surgery is called a UPPP  (UvuloPalatatoPharyngoPlasty or "U-triple-P" or "uvulectomy" for short).   It is performed by an ear, nose and throat specialist (Otolaryngologist).  This procedure relieves obstructive sleep apnea well if the major obstruction lies behind the soft palate.  Overall, the UPPP alone will relieve obstruction in about 41% of the cases in which obstructive apnea is a factor over and above snoring.   However, the procedure works quite well at relieving simple snoring in a majority of patients since an over-sized soft palate is the most frequent cause of snoring.  It is still one of the least expensive, most effective, and simplest forms of surgery to relieve snoring and mild to moderate obstructive sleep apnea. 

  The procedure involves the removal of parts of the soft palate, the uvula, tonsils and sometimes parts of the sides of the walls of the throat.  Although it sounds major, it is a relatively simple surgery lasting under an hour and requiring very little recuperative time.  The surgery itself comes in two varieties; "standard surgery" done with cold steel techniques in an operating room under general anesthesia, and "laser surgery" done in the office under local anesthesia.  The U-Triple-P, in combination with a snore guard is generally quite effective in treating both snoring and obstruction.  Unfortunately, medical insurance rarely covers the U-Triple-P surgery unless a sleep study links the snoring with obstructive sleep apnea.

   

  Download a scientific study (PDF format for Adobe Acrobat Reader)--You must have the Adobe reader Plug-in to download this file For an excellent scientific study on how well devices like the ones discussed above work when combined with the U-Triple-P surgery, please see this article reprinted from Chest Journal "The Efficacy of Oral Appliances in the Treatment of Persistent Sleep Apnea After Uvulopalatopharyngoplasty".  In this study, 24 patients who were unsuccessful in treating their obstructive sleep apnea with the U-Triple-P surgery were later treated with the Herbst appliance.  The study assesses their success and is quite honest about the failures as well.  It is complex and loaded with technical terminology, as well as statistical analysis, but even those without a scientific background will get a fair idea about how well the combined therapies work.

    

• The newest form of OSA surgery is a major surgical procedure that advances the genial tubercle (a bump on the inside of the tip of the chinbone) along with its associated muscle attachments and the Hyoid bone (the Adams apple).  The procedure is called a GAHM procedure (Genioglossal advancement with hyoid myotomy/suspension), and in combination with the UPPP has an overall 61% success rate.  The GAHM procedure may be done in conjunction with modifications to the back of the tongue (laser midline glossectomy and lingualplasty) to further open the airway.

• The Orthognathic solution is a major surgical technique in which both the upper and lower jaws are advanced forward together drawing the tongue and soft palate with them.  This option is the most radical, and it does change the overall appearance of the face.  It is rarely performed, but it is a very effective treatment for obstructive sleep apnea.  The advancement of the mandible can be on the order of 10 to 12 millimeters which is almost certain to relieve the obstruction.  

For more information on Obstructive Sleep Apnea, please see the Food and Drug Administration position paper "Breathless no more"

QuietSleep.com

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