Adjunct Therapies for OAT

The following document will focus on evidenced based adjunct therapies to improve outcomes with oral appliance therapy (OAT) for sleep apnea. The evidence is drawn from clinical guidelines and studies published in reputable medical journals, including the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM).  

Oral Appliance Therapy (OAT):

Oral appliance therapy (OAT) is an effective treatment for many people with obstructive sleep apnea (OSA). However, OSA pathogenesis is heterogeneous, and in approximately 50% of cases, OAT does not fully control OSA. Here are some adjunct therapies with moderate to high levels of evidence that can be combined with OAT to improve outcomes.

Combination Therapy:

Combination Therapy with CPAP and OAT for patients who do not achieve complete resolution of OSA with OAT alone, combining OAT with continuous positive airway pressure (CPAP) can be effective. This combination has been shown to reduce the required CPAP pressure and improve treatment efficacy.[1][2]  Patient Combination Therapy

Hybrid Therapy:

Positional Therapy:

Positional therapy, such as using a device to avoid sleeping on the back, can be combined with OAT to treat positional OSA. Studies have shown that this combination can significantly reduce the apnea-hypopnea index (AHI) and improve oxygen levels during sleep.[3][4] Positional Therapy Devices for Sleep Apnea and Snoring

Inspire Therapy:

Inspire is a device that stimulates the hypoglossal nerve to keep the airway open during sleep. It can be an option for patients who do not respond to OAT or CPAP. Clinical trials have demonstrated its effectiveness in reducing OSA severity.[5]

Orthognathic Surgery:

Orthognathic Surgery for patients with craniofacial abnormalities contributing to OSA, orthognathic surgery can be considered. This surgery repositions the jaw to enlarge the airway and has been shown to improve OSA outcomes.[6]

Sinus Surgery

Sinus Surgery in patients with nasal obstruction contributing to OSA, sinus surgery can improve nasal airflow and enhance the effectiveness of OAT and other therapies.

Trizepatide:

Tirzepatide is a medication primarily used for diabetes and weight management. While not specifically approved for OSA, weight loss can improve OSA symptoms, and tirzepatide may be considered in patients with obesity-related OSA.

Maxillary Skeletal Expansion (MARPE, SARPE, DOME):

Maxillary skeletal expansion techniques such as Miniscrew-Assisted Rapid Palatal Expansion (MARPE), Surgically Assisted Rapid Palatal Expansion (SARPE), and Distraction Osteogenesis Maxillary Expansion (DOME) can be used to increase the transverse dimension of the maxilla. These procedures have shown promise in improving airway dimensions and reducing OSA severity in patients with maxillary constriction.  

Follow-Up and Monitoring: The American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine recommend regular follow-up visits with a qualified dentist and sleep physician to monitor and adjust treatment as needed.[6]  

Discuss these options with your healthcare provider to determine the best combination of therapies for your specific condition.  


The document now includes adjunct therapies with moderate to high levels of evidence, ensuring the recommendations are both comprehensive and evidence-based. This should provide a robust guide for improving outcomes with oral appliance therapy for sleep apnea.  

References

1. Stepwise Add-on and Endotype-Informed Targeted Combination Therapy to Treat Obstructive Sleep Apnea: A Proof-of-Concept Study. Aishah A, Tong BKY, Osman AM, et al. Annals of the American Thoracic Society. 2023;20(9):1316-1325. doi:10.1513/AnnalsATS.202210-892OC.
2. Combination Therapy With Mandibular Advancement and Expiratory Positive Airway Pressure Valves Reduces Obstructive Sleep Apnea Severity. Lai V, Tong BK, Tran C, et al. Sleep. 2019;42(8):zsz119. doi:10.1093/sleep/zsz119.
3. Mouth Closing to Improve the Efficacy of Mandibular Advancement Devices in Sleep Apnea. Labarca G, Sands SA, Cohn V, et al. Annals of the American Thoracic Society. 2022;19(7):1185-1192. doi:10.1513/AnnalsATS.202109-1050OC.
4. Effects of the Combination of Novel Eye Mask Sleep Position Therapy Device and Oral Appliance on Positional OSA: A Multi-Arm, Parallel-Group Randomized Controlled Trial. Huang W, Li C, Zou J, et al. Sleep Medicine. 2023;102:52-63. doi:10.1016/j.sleep.2022.12.017.
5. A Mandibular Advancement Device Associated With Lingual Control: A New Treatment Option for Obstructive Sleep Apnea?. Caram JM, Guimarães MLR, de Azevedo PG, Silva ALC, Resende V. Sleep & Breathing = Schlaf & Atmung. 2024;28(2):657-663. doi:10.1007/s11325-023-02938-6.
6. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring With Oral Appliance Therapy: An Update for 2015. Ramar K, Dort LC, Katz SG, et al. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2015;11(7):773-827. doi:10.5664/jcsm.4858.

Insertion and Removal

To Insert the Appliance:

1. Place the appliance in your mouth.

2. Position the upper arch onto your upper front teeth and gently push it into place.

3. Use your fingers to move to the back molar region and push the arch up firmly to fully seat it.

4. You may hear an audible “snap” as it engages the undercuts of your teeth. If the appliance loosens, the “snap” may not be heard, but it should still fit snugly.

5. Bring your lower jaw forward and repeat the process to place the lower arch (with “wings”).

To Remove the Appliance:

1. Bring your thumbs together and firmly push up on the edge of the lower arch near the canines.

2. Use your index fingers on the edge of the upper arch above the molars and pull downwards until the appliance releases from your teeth.

The First Week

• No adjustments should be made to the clips during the first week after receiving your appliance. This time is crucial for allowing your jaw and teeth to adjust to the appliance.

• Monitor your symptoms (see the included adjustment journal), including snoring, daytime sleepiness, and sleep quality.

• You may experience increased salivation, drooling, and mild tenderness in your teeth and jaw as you acclimate. If you have concerns, contact our Clinical Treatment Department at 815-599-3082.

After the First Week

• Change the adjustment clips every 3-4 days, unless you experience discomfort or pain in the jaw joint or teeth.

  1. Detach the existing adjustment clip and place it in plastic bag labeled #1.

  2. Take the adjustment clips from plastic bag #2 and snap them into place on the left and right sides.

  3. Continue switching clips every 3-4 days until you reach bag # _______, clip # __________.

Some patients advance through these changes faster than others. If you feel significant tenderness, pause the advancement or revert to the previous clip. When you resume changing clips, do so more gradually by increasing the days between adjustments. Always monitor your symptoms as you progress.

Note: A bag labeled -1 is included, allowing you to return to an earlier setting if you experience excessive jaw discomfort.

Keep track of rod changes and record them in your adjustment journal.

IMPORTANT: We hope you notice immediate improvement in your symptoms. However, advancing the jaw slowly over time is usually necessary for the appliance's effectiveness while maintaining comfort. You have a set number of adjustment rods to use over the next six weeks. Even if you notice improvement early, continue advancing the appliance (unless you experience pain) and document your observations for discussion at your follow-up visit.

WARNING

• Keep the appliance away from all animals. It tends to attract them, and the lab does not cover damages from animal interference.

• Avoid extreme temperatures: Do not use water that is too hot or too cold when cleaning.

• Do not store the appliance in extremely hot or cold environments.

• Avoid abrasive or chemical cleaners that are not specifically suggested by our office.

Warranty

For 36 months from the shipping date, the lab will replace any device free of charge for in-mouth material breakage not resulting from modifications that alter normal use. The warranty is void if new models or impressions are needed due to dental work.

Patients Using CPAP

• If you tolerate CPAP, always start by using it simultaneously with the oral appliance.

• You have been advised to wear the oral appliance alone only during observed naps.

Problems

• Retention Problems: Contact us if you experience retention issues. This may require adjustments or sending the appliance back to the lab. There’s a fine line between too tight and too loose. If the appliance is overly rigid or retentive, adjustments may be needed at your next visit. The appliance may loosen with wear during the first month.

• Jaw Joint Pain: Mild tenderness in the jaw joint, similar to overworked muscles, is normal initially but should not last more than 1-2 hours in the morning. If pain persists into the afternoon, causing headaches or earaches, consult the jaw tenderness handout and contact our office if necessary.

• Tooth Tenderness: Initial tooth tenderness is normal and should not last more than 1-2 hours in the morning. If it extends into the afternoon or lasts all day, contact our office for possible adjustments.

• Increased Saliva Flow: A bit of extra saliva flow is typical at first and will diminish after a few days.

• Dry Mouth: Using rubber bands may help. If dryness persists, consider OraCoat XyliMelts, OraCoat XyliGel, or Biotène Oralbalance Moisturizing Gel. Please call us if the problem continues.

Cleaning Instructions & Infection Control

Hand Hygiene: Hand washing is crucial for reducing infection risk. Follow these steps:

1. Wet hands with warm running water.
2. Apply soap and distribute it thoroughly.
3. Rub hands together for 10-15 seconds, covering all surfaces.
4. Rinse thoroughly to remove soap and dry with a clean towel.

Daily Cleaning: Clean your appliance daily for optimal benefit and longevity:

1. Clean your appliance immediately after removing it.
2. Use a soft toothbrush and antibacterial soap (not toothpaste) to brush the appliance, then rinse.
3. Dry all parts and the storage case with a clean towel, leaving the lid off to air dry.
4. Store the appliance in its case, away from children and pets, and out of direct sunlight.

Weekly Deep Cleaning: Recommended 1-2 times weekly:

1. Rinse and lightly brush the appliance.
2. Fill your sonic cleaner halfway with lukewarm water.
3. Add the cleaning solution and place the appliance in the container. Follow the specific cleaning instructions for your solution.
4. After cleaning, rinse the appliance again with cool to lukewarm water, dry it, and store it in the container.

Allergen Note: Some cleaners may contain allergens. Follow the instructions and warnings for the cleaner used. DentaSoak cleaning solution may be preferable if you suspect an allergy.

Morning Repositioner

30 minutes after removing the appliance, complete the morning repositioner exercises for a total of 3-5 minutes.

Instructions:

1. Insert the repositioner onto the upper teeth.
2. Bite into the grooves on the lower portion, squeezing your back molars together and holding for 5-10 seconds, then release.
3. Repeat this squeezing and releasing for approximately 3-5 minutes, or until the original bite position is achieved.

Cleaning: Always use cool water for cleaning the repositioner, as it is thermally sensitive and will deform in hot water. You can follow the same cleaning instructions as for the oral appliance.

Important Reminders

• Your 90 days of included visits and adjustments begin on the date you receive your appliance. Visits outside this period will be billed to your medical insurance.

Return Visit

Your first follow-up will be scheduled 6 weeks from your delivery to check settings and order your follow-up sleep study.

Sleep Study

An order will be sent to the sleep center for an overnight study with the oral appliance. The order will include the settings to be tested during the study. If adjustments are made to the appliance before the study, please inform our office. The order is valid for 90 days; if the study isn’t completed, an office visit may be required for a new order and to verify appliance settings.

Results

Please ensure that Midwest Dental Sleep Center is included on any release of information from the sleep center to guarantee we receive the results. Our office will contact you to review them. If you have not heard from us within 3 weeks after the sleep study, please call our office. Remember, we cannot assess the appliance's effectiveness until we receive the results; caution is advised when operating vehicles or machinery until then.