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Longevity of Dental Sleep Medicine Paves Way for New Research Trend
Harold A. Smith, DDS
Scientific research in dental sleep medicine has flourished considerably, and, as the field progresses, interest is rising in more studies related to long-term clinical outcomes. A growing amount of research demonstrates that patients who use an oral device for more than 5 years remain effectively treated for obstructive sleep apnea (OSA).1 There has, however, been limited understanding about the potential side effects of wearing an oral appliance for an extended duration. Now, after nearly 30 years of growth in the field, researchers are publishing data on the side effects of oral appliance therapy after 10 or more years of treatment, helping pave the way for improved long-term effectiveness and patient adherence.
Two studies assessing the long-term side effects associated with oral appliance therapy have been garnering substantial attention, recently earning 2017 Research Awards from the American Academy of Dental Sleep Medicine. The first study, led by Mona Hamoda, BDS, MSc, MHSc, titled, “Long-term Side Effects of Sleep Apnea Treatment with Oral Appliances,” is the longest patient follow-up study to date, with an average treatment time of 12.6 years and a range of 8 to 21 years.2 The objective was to evaluate both the magnitude and progression of dental and skeletal changes with long-term oral appliance therapy. Sixty-two patients with primary snoring or mild to severe OSA were treated with a custom-fabricated, titratable oral appliance. A baseline lateral cephalogram was obtained prior to treatment, and a range of two to nine additional craniofacial x-rays were taken of each patient during follow-up evaluations. Cephalometric analysis included skeletal, dental, and soft-tissue changes. Results revealed notable dental changes, particularly reduction in overjet and overbite as well as maxillary incisor retroclination and mandibular incisor proclination. There were no clinically significant skeletal changes related to oral appliance use.
Another recent study, “Dental Side Effects of Long-term Obstructive Sleep Apnea Therapy: A 10 Year Follow-up Study,” with Julia Uniken Venema, BsC, DMD, leading the research team, also demonstrated that oral appliances can cause substantial dental changes, particularly dental occlusion.3 The objective was to compare dental occlusion in patients treated with oral appliance therapy versus continuous positive airway pressure (CPAP) therapy. Twenty-nine OSA patients were fitted with an anterior traction oral appliance, and 34 patients were treated with CPAP therapy. Data were analyzed at baseline, at a 2-year follow-up, and at a 10-year follow-up via dental plaster casts using a digital sliding caliper. At both follow-up evaluations, oral appliances resulted in more dental changes compared to CPAP in overjet, overbite, and anterior-posterior occlusion. Both patient groups exhibited a significant decrease in the number of occlusal contact points in the premolar region.
These studies confirm that significant dental changes occur with prolonged oral appliance therapy, providing compelling support for ongoing patient follow-up by a qualified dentist throughout the duration of treatment. Such long-term research results, combined with efficacy studies, indicate that the positive effects of oral appliance therapy can far outweigh any adverse effects related to dental changes when periodic appointments are scheduled to evaluate dental movement and adjust the device for optimal efficacy.
The interest among dental sleep medicine practitioners in long-term oral appliance therapy follow-up studies has, in fact, been a growing research trend for several years. In 2012, academic researchers from 14 sleep centers in nine countries established an organization focused on long-term outcomes of oral appliance therapy to treat OSA patients. A few of the preliminary goals of the Oral Appliance Network on Global Effectiveness (ORANGE) included the analysis of objective treatment adherence, assessment of the cost effectiveness of treatment, evaluation of side effects, and comparison of different oral appliance models and titration methods.4 Recognizing the need for more large-scale clinical trials with standardized data collection, ORANGE is committed to cohort studies that focus on long-term oral appliance therapy and a shared protocol to help better understand the role and effectiveness of oral appliance therapy worldwide. This research network has helped set the stage for more long-term clinical trials with the goal of providing data to help guide dentists in the ongoing treatment of OSA.
Long-term research efforts will serve as a foundation for developing systematic evaluations of the durability of different oral appliances and the management of side effects, which can help the field establish practice parameters for the frequency of patient follow-up assessments and device adjustments. Ultimately, the increasing commitment to long-term clinical trials in the field of dental sleep medicine will better serve dentists and OSA patients, providing evidence-based protocols for ongoing treatment.
1.Sutherland K, Vanderveken OM, Tsuda H, et al. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med. 2014;10(2):215-227.
2. Hamoda MM, Almeida FR, Pliska BT. Long-term side effects of sleep apnea treatment with oral appliances. J Dent Sleep Med. 2017;4(4). Poster 001. October 10, 2017.
3. Uniken Venema JA, Hoekema A, Doff M. Dental side effects of long-term obstructive sleep apnea therapy: a 10 year follow-up study. Sleep. 2017;40(suppl 1):A219-A220. Abstract 592.
4. Almeida FR, Vanderveken OM, Cistulli PA, et al. Oral appliance network on global effectiveness (ORANGE): start-up and design description. J Dent Sleep Med. 2014;1(1):17-20.