While continuous positive airway pressure therapy is the gold standard of treatment, mandibular advancement devices (MADs) can be an effective alternative for a subset of cases. As obstructive sleep apnoea affects almost a third of our population, GPs are crucial to identifying and advising these patients in their care. We share key information about the indications, patient suitability and treatment process for MADs.
OBSTRUCTIVE SLEEP APNOEA
Obstructive sleep apnoea (OSA) is a prevalent and growing global health concern. According to recent findings from the Singapore Health Study, an estimated 30.5% of Singapore’s population suffers from moderate to severe OSA.
Common symptoms include loud snoring, gasping or choking during sleep, and excessive daytime sleepiness.
While continuous positive airway pressure (CPAP) therapy is the gold-standard treatment for OSA, mandibular advancement devices can be an effective alternative for OSA patients who are unable to tolerate CPAP.
WHAT IS A MANDIBULAR ADVANCEMENT DEVICE?
Mandibular advancement devices (MADs) are custom-made removable acrylic plates, worn on the patient’s teeth during sleep, that posture the patient’s mandible and tongue forward. This forward position of the mandible widens and stabilises the airway, reducing its collapsibility and reducing the severity of OSA.
They are similar to dental mouthguards for grinding or removable orthodontic retainers worn after braces, but with the addition of metal or acrylic connectors between the upper and lower plates that push the mandible forward.
While there is great variation in design and construction, custom-made and titratable MADs are preferred. MADs are compact and portable, worn intraorally, do not require a power supply, and can be a good alternative to CPAP for some patients.
INDICATIONS
The indications for MADs include:
Treatment for simple snoring or mild to moderate cases of OSA
An alternative to CPAP for OSA patients who are unable to tolerate CPAP usage
An adjunctive treatment in combination with:
• CPAP,
• upper airway surgery,
• weight management, and/or
• positional therapy
PATIENT SELECTION CRITERIA
Patients should have a healthy and stable dentition and periodontium (Figure 2).
Patients with some missing teeth (Figure 3), who are using partial dentures, or who have replaced some teeth with dental bridges and implants may still be suitable for MAD treatment depending on the nature of their dental prostheses and the number, location and periodontal support of the remaining natural teeth.
Patients who already use a dental splint for night-time grinding, or who are wearing orthodontic retainers after braces or Invisalign treatment, are still suitable for MAD treatment.
Patients who are unsuitable for MAD treatment include:
Edentulous patients using full dentures in either or both the upper and lower arches (Figure 4).
Patients with severe and uncontrolled caries or periodontal disease (Figure 5).
Patients who are planning to have restorations, dental prostheses or implants done in the near future.
Patients who retch easily and are unable to tolerate dental impressions and prostheses.
TREATMENT PROCESS
Initial assessment
Around two-thirds of patients who use MADs will see significant improvements in their OSA. This proportion of responders can be improved with careful selection of patients.
At the SingHealth Duke-NUS Sleep Centre, patients interested in MAD treatment can be seen in combined clinics attended by ENT specialists and dentists for a combined assessment of their suitability.
Nasoendoscopy or sleep endoscopy by ENT surgeons may be used to check the airway response to mandibular forward repositioning (Figure 6).
Fabrication
The condition of the teeth, periodontium and temporomandibular joints will be assessed by the dentist prior to fabrication of the MAD. Once the patient has been deemed suitable for MAD, their dental arches will be scanned and bite taken for custom fabrication (Figure 7).
Review and follow-up
After issue of the MAD, the patient is reviewed to progressively protrude the mandible over four to six months. A follow-up sleep study is then done while the patient is wearing the MAD to ensure that it is effective in treating the OSA. Adjunct or alternative treatment may be proposed if the sleep study shows incomplete management of OSA with the MAD.
LONG-TERM USE
If the MAD is adequate for OSA management, the patient will be reviewed by the dentist once or twice a year to check the fit and condition of the MAD and to review their dental health.
MADs last around two to five years and will be replaced once cracks develop. Some suppliers may provide a warranty period for the device. For heavy clenchers or bruxers, the device may have to be replaced more frequently.
Adjustments or replacements of MADs may be needed if patients subsequently undergo dental procedures such as extractions, implants or restorations.
SIDE EFFECTS
Short-term side effects
Patients may experience:
Retching when inserting, removing or using the MAD.
Drooling and a dry throat when sleeping with the MAD.
Soreness of teeth and jaws while wearing and after removing the MAD.
Difficulty chewing immediately after removing the MAD, following several hours of wear. In general, the patient’s bite and chewing will return to normal a few hours after removing the MAD.
These side effects are generally transient and manageable, and do not require discontinuation of treatment.
Long-term side effects
In some patients, long-term and continuous use of MADs may cause teeth movements and bite changes (Figure 8).
The upper incisors may tip posteriorly and the lower incisors may tip anteriorly, resulting in reduction of overjet, overbite and development of a posterior open bite. Over a two-year treatment period, a decrease in overjet and overbite of 0-3 mm has been reported.
Patients diagnosed with OSA who are interested in MADs for management can be referred to the National Dental Centre Singapore at 6324 8798. GPs who would like more information about this procedure or would like to refer patients for assessment can contact the SingHealth Duke-NUS Sleep Centre at:
- Singapore General Hospital: 6326 6060
- Changi General Hospital: 6788 3003
- Sengkang General Hospital: 6930 6000
- KK Women's and Children's Hospital: 6692 2984
- National Dental Centre Singapore: 6324 8798
- National Neuroscience Institute: 6330 6363
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REFERENCES
Tan A, Cheung YY, Yin J, Lim WY, Tan LW, Lee CH. Prevalence of sleep-disordered breathing in a multiethnic Asian population in Singapore: A community-based study. Respirology. 2016 Jul;21(5):943-50.
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.
Sutherland K, Takaya H, Qian J, Petocz P, Ng AT, Cistulli PA. Oral appliance treatment response and polysomnographic phenotypes of obstructive sleep apnea. J Clin Sleep Med 2015;11(8):861–868.
Alessandri-Bonetti A, Bortolotti F, Moreno-Hay I, Michelotti A, Cordaro M, Alessandri-Bonetti G, Okeson JP. Effects of mandibular advancement device for obstructive sleep apnea on temporomandibular disorders: A systematic review and meta-analysis. Sleep Med Rev. 2019 Dec;48:101211.
Uniken Venema JAM, Doff MHJ, Joffe-Sokolova DS, Wijkstra PJ, van der Hoeven JH, Stegenga B, Hoekema A. Dental side effects of long-term obstructive sleep apnea therapy: a 10-year follow-up study. Clin Oral Investig. 2020 Sep;24(9):3069-3076.
Chen, A., Burger, M. S., Rietdijk-Smulders, M. A. W. J., & Smeenk, F. W. J. M. (2020). Mandibular advancement device: Effectiveness and dental side effects. A real-life study. CRANIO®, 40(2), 97–106.
Dr Ng Jing Hao is an orthodontist at the National Dental Centre Singapore and the SingHealth Duke-NUS Sleep Centre, where he provides oral appliance treatment for obstructive sleep apnoea patients in addition to routine orthodontic practice.
GP Appointment Hotline: 6324 8798
GPs can visit the website for more information about the department.
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