What’s the best Anti-Snoring Device? (Sleep-expert reviews top 13 criteria)

What’s the best Anti-Snoring Device? (Sleep-expert reviews top 13 criteria)

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What’s the best Anti-Snoring Device?

The best anti-snoring device is only prescribed after you’ve been screened for Obstructive Sleep Apnoea / Apnea (OSA).

The best one:

  • Stops your snoring
  • Costs you the least money (because it isn’t a false economy)
  • Creates the least side-effects (and helps you sleep and breathe at the same time)

So, if you’re wondering what’s the best anti-snoring device then read this independent (no advertisements or affiliate links!) sleep-industry expert review.

Despite the lack of prior screening for sleep apnoea, anti-snoring devices (Mandibular Advancement Devices – MADs) or ‘gumshields for snoring‘ are big business on the internet and in the pharmacy.

Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I’m a sleep-industry insider with a quarter of century of sleep medicine experience.

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Good to know:

Snorer.com is independent. We don’t sell anti-snoring devices, chin straps or whatever! And we don’t benefit from affiliate deals.

So, the challenge as a hasty snorer is:

How to choose one that actually works?!

Snoring aids and cures are increasingly popular as we recognise the impact poor sleep has upon our health, daytime functioning and work performance.

A news article “Ten Snoring Cures” reviewed 10 ‘cures’ available in the UK. The journalist tried to stop his own snoring, with chin straps, sprays, pillows, and ‘gumshields’, aka anti-snoring devices.

He had little success and concluded his review by quoting a snoring expert, Consultant Respiratory Physician, Dr Tom McKay, from Edinburgh Royal Infirmary Sleep Centre, UK, as saying:

‘Sprays don’t have any great effect although nasal steroids have a small role if you’ve got nasal congestion. It can help to lose weight or avoid alcohol last thing at night or to sleep lying on your side. Various forms of gumshield are reasonably successful – maybe 50 or 60 per cent.’

So, its a reasonable question to ask….

Which Anti-Snoring Devices really work?

‘Gumshields for snoring’ could more accurately be described as mandibular advancement devices (MAD). They are also known as intra oral devices, mandibular repositioning devices (MRDs) or even sometimes mandibular advancement splints (MAS) !

But there are essentially just two categories:

  Over-the-Counter (OTC) ‘gumshields’
  Prescription, Custom-Made Dental Appliances

In this updated for 2019 review, I examine how both categories of anti-snoring device measure up against my Top 13 criteria for choice (see call out box) to determine which ones really work, and if they’re safe and effective.

And the best bit?

Each section concludes with my verdict and there’s a free bonus at the end!

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If you are looking for impartial advice about snoring from an expert in the field, the highly respected Adrian Zacher should be your go to. We applaud Adrian’s work, to raise awareness about the health implications of snoring, and the importance of custom-made devices for long-term success.

Lucie Ash Director Somnowell How to choose the best anti-snoring device September 7, 2018

CAUTION: Snoring may be a symptom of Obstructive Sleep Apnoea / Apnea (OSA)

Snoring may be a symptom of obstructive sleep apnoea/apnea (OSA).

Without first being screened for OSA your purchase of an OTC anti-snoring device, could harm you and if you snore because you have undiagnosed Obstructive Sleep Apnoea (OSA) the OTC gadget delays effective (and free on the NHS!) treatment that will prolong your healthy life.

Get signposted to the most appropriate professional (it’s free!)

The professional will screen you for OSA and decide if you’re ‘just’ a snorer or if your snoring needs investigating.

Your GP may be able to help you – but they may not know much about sleep apnoea as sleep is not part of core medical training. We provide expert written GP Guidelines to help.

In the UK, you can also find sleep-trained dentists who can screen you and recognise Obstructive Sleep Apnoea/Apnea (OSA) symptoms2, make custom anti-snoring devices for snorers, without a prior medical diagnosis, or if they suspect OSA refer you on for further investigation.

Clinical evidence (proof) that the MAD works

No. 1. Clinical evidence (proof) that the Anti-Snoring Device works

What does 'clinical evidence' actually mean?
Medical and dental experts review medical devices (clinical research) to establish if they work. Their research produces data and information which can be thought of as ‘proof’ that something does or does not work, and how well it works in certain circumstances. The evidence they create is also judged for quality.

Judging Anti-Snoring device (MAD) research quality

When selecting an anti-snoring device, it’s important to look at this clinical evidence. To judge the quality of a mandibular advancement device’s (MAD’s) clinical research evidence, you need to look past the headlines claiming “Clinical research– tick”.

What was the outcome of the research?!

Typical patient-centred measures of outcome

Measurement of what patients perceive as important effects from wearing an MAD typically include:

  • Partner reported snoring (derrr… a no-brainer!)
  • Daytime sleepiness
  • Quality of life
  • Adherence (long-term use)
  • Device preference
Gumshields for snoring
Gumshields or ‘Boil-and-Bite’ anti-snoring devices, have been clinically researched head-to-head against custom-made, prescription, adjustable anti-snoring devices and found to be lacking.

Our results suggest that the thermoplastic device cannot be recommended as a therapeutic option nor can it be used as a screening tool to find good candidates for mandibular advancement therapy.3

…patients overwhelmingly found the ready-made MRD difficult to tolerate…4

…96% of patients reported minor adverse events, which related predominantly to discomfort.4 [referring to a study by Dr. Tim Quinnell 5

Prescription, custom made MADs
Today, clinical research has established that custom made MADs are first-line therapy (the default first option) for snoring and mild obstructive sleep apnoea / apnea.

MAD research now focuses on:

Predictors of satisfactory outcome before purchase (who will benefit and why) and which type of custom made MAD is most effective for a given genotype (which MAD is best for YOU as opposed to a vanilla approach).

Expert’s verdict on clinical evidence for MADs
It is not enough to say that an MAD has been clinically researched. Such research may have proved the MAD didn’t work!

A positive outcome from clinical research can be thought of as a ‘guarantee’ of sorts.

My advice is to do your homework (grab the Bonus Mouthpiece Guide at the end) and be guided by a sleep-trained dentist. You can find one on via our Links new window page.

[Note: Below is an advanced topic about typical MAD research metrics. So, if you’re new to clinical evidence, feel free to skip this tip].

Typical Mandibular Advancement Device (MAD) research quality metrics include:
  • Total sample size (the ‘N’ or number of patients who used the device)
  • Could they tolerate it in their mouth (known as tolerance)
  • How many hours they used it for each night (known as compliance)
  • How many nights they used it for per week (part of the compliance metric)
  • Partner reporting of cessation of snoring
  • Perceived sleepiness before and after use
  • Before and during use blood oxygenation level
  • Before and during use AHI (apnoea hypopnea index – an index used to indicate the severity of sleep apnea. The number of apnea and hypopnea events per hour of sleep)
  • Whether a placebo was used with a control group
  • Whether patients crossed over to a different therapy / device
  • Whether the researchers and/or patients were ‘blind’ (who was aware which device was a placebo or an actual MAD?)
  • Has the research been published in a high profile and peer-reviewed journal? (This means other experts in the field judge it for quality)

No. 2. Anti-Snoring Device costs

OTC gumshields and ‘treatments’ might appear cheaper than custom-made, prescription appliances & dentist fees, BUT…

Are they a false economy?

Why use a dentist to get an Anti-Snoring Device (MAD)?

Financially, its tempting to cut out the dentist.

After all, a large part of the cost to you when purchasing a mandibular advancement device, is their clinical time.

The device fees vary, but what are you paying for?

Dentists know about teeth, gums and jaw-joints
That is what they do.

While Dentistry may initially seem expensive, the risks of not using an expert are considerable. Remember, you are relying on the anti-snoring device to hold open your airway while you sleep. Think carefully before you choose.

Some dentists are specially trained in snoring and sleep apnoea / apnea, known as sleep-related breathing disorders (SRBD) and work closely with medics. Dentists with a special interest in sleep, can help you find the correct balance of benefits versus side-effects.

If you have certain medical conditions, or grind your teeth, you might break an OTC ‘gumshield’ whilst you’re asleep. When you are asleep you cannot spit out pieces of a broken gadget. You could INHALE or SWALLOW pieces.

You can find sleep-trained dentists on our Links page. In the UK, look for the British Society of Dental Sleep Medicine.

Expert's verdict on whether to cut out the dentist
Don’t do it.

The terrifying thought of bits of MAD breaking off and being inhaled while you sleep, should surely make you realise you need to see a sleep-trained dentist and use a prescribed custom-made, adjustable anti-snoring appliance, made to quality standards.

In case you’re wondering, I’m not a dentist.

Anti-snoring device (mandibular advancement device - MAD)

Example of a custom-made Mandibular Advancement Device (MAD). Image above used with permission from SomnoMed.

Mandibular Advancement Device (MAD) made from metal

Example of a custom-made Mandibular Advancement Device (MAD). Image above used with permission from SomnoWell.

over the counter: anti-snoring devices

Tired of the sleepiness and the snoring?

Then read our free, definitive step-by-step how to stop snoring Guide.

This comprehensive Guide walks you through self-help, signposting, screening, professional assessment and diagnosis, the three categories of prescription treatment, follow-up and rounds off with a substantial FAQ.

When you’re serious about not snoring read this.

No. 3. Comfort and bulk of Anti-Snoring Devices (MAD)

An MAD that is so uncomfortable to wear, soon ends up being thrown across the bedroom or just left in the bathroom at bedtime…

Both the design and clinical expertise in how an anti-snoring device is supplied, directly impacts your likelihood of successfully wearing it (and therefore whether it stops your snoring) – particularly during the first two weeks of use.

This is when most people who aren’t going to get on with them, quit. It might seem obvious:

but if you don’t wear it – it doesn’t work.

OTC gumshields for snoring (Boil-and-Bite)
Generally OTC gumshields for snoring are “one-size-fits-all”.

They have to be bulkier in size to adapt to your teeth than custom-made devices. This would mean it feels like you are squeezing a tennis ball into your mouth – Oh, and then you’re expected to sleep!

Custom-made MADs
A sleep-trained dentist will ensure that your MAD fits properly and doesn’t hurt.

They will also ensure you know how to put the device into your mouth and get it out again.

Expert's verdict on comfort and bulk
As a general rule, custom-made anti-snoring devices are less bulky than ‘gumshields’.

Due to the lack of accuracy of the ‘fit’ and one-size-fits-all approach of gumshields, they may be too large, too small or take up so much room in your mouth you can’t close your lips and you find yourself dribbling attractively!

Warning! Is this the best anti-snoring device for you? UK expert review

No. 4. Will an Anti-Snoring Device (MAD) damage my teeth and gums?

You wear these things in your mouth.
What impact will it have?

Gumshields for snoring (So called 'instant anti-snoring devices')
Its quite possible that a gumshield will place excessive load upon an individual tooth/teeth.

Over time your teeth will move. It will hurt.

And you will either stop wearing the mandibular advancement device and accept the financial loss (good luck trying to get a refund on a used product), or under duress from your partner and family, continue wearing it and risk losing the tooth or an expensive crown/cap/bridge.

Prescription, custom-made MADs
Prescription Mandibular Advancement Devices on the other hand, can be designed to avoid certain teeth if they are identified as at risk.

An expert sleep-trained dentist can help identify (and save that tooth) if it could not withstand the lateral loading required.

A dental technician would ‘block out’ the identified tooth and not include it in the custom-made device.

Expert's verdict on risk to your teeth and gums

All anti-snoring devices will aggravate your oral hygiene. 

However, a sleep-trained dentist would ensure BEFORE you had an MAD, that your hygiene and oral condition (teeth, gums and jaw-joints) were satisfactory before you began to use it.

Try to keep the device as clean as possible. Use your toothbrush and toothpaste on it each morning. Don’t use chlorine based denture cleaners on gumshield based devices – it makes them hard and brittle (unusable) rapidly. Instead, use a baby bottle sterilising fluid (follow the manufacturer’s instructions).

Brush and floss your teeth carefully and consider using a chlorhexidine mouthwash. If you spit blood when you clean your teeth consult a dentist/hygienist.

‘Boil-and-Bite’ devices will flex when worn and over time, this will procline (tilt forwards) your lower incisors and retrocline (tilt backwards) your upper incisors.

Certain custom-made anti-snoring devices are designed to avoid this tooth tilting movements.

Consult your sleep-trained dentist.

No. 5. Will an Anti-Snoring Device damage my jaw-joints?

Jaw pain is truly horrible and once you have a jaw pain problem it persists.

All types of mandibular advancement device (MAD) work by moving your lower jaw forwards, and the amount it does this to be effective, and not hurt too much, is specific to you.

Gumshields for snoring
Some gumshields for snoring are only adjustable in large increments, while others you have to fit the device – rather than the device actually fit you (again you may lose your money).
Custom-made MADs
Custom made, adjustable, prescription MADs really win when considering your jaw joint. In fact, it’s possible, with some of the custom made ones to start off wearing it with no (or very little) change in your jaw position.

While of course it won’t initially prevent snoring in this position, the dentist will gradually advance your jaw until you stop snoring over a matter of weeks or perhaps even longer (this is known as titration). This gives you, your device (and your jaw joint) time to get accustomed.

Which means you STOP SNORING!

And don’t permanently harm yourself. Yay!

Expert's verdict on jaw-joint risk
Your sleep-trained dentist will screen you for sleep apnoea, assess your teeth, gums and examine your jaw joints.

They will take X-rays and put things right beforehand if necessary. If it doesn’t look like its a good idea, they’ll suggest:

  • You DON’T have one,
  • Explain why,
  • And direct you to appropriate help.

If everything is OK, they’ll monitor the effect the MAD is having upon your teeth, gums, jaw joint and snoring.

If your jaw joint isn’t healthy before you start using an anti-snoring device then it may cause irreversible harm. (The exception is when a specialist sleep and jaw joint pain [Temporo-Mandibular Joint Dysfunction or TMD] dentist prescribes a device for BOTH issues.)

A sleep-trained dentist would know what to avoid and ensure you did not experience premature posterior contact (see call out box) that would damage your jaw-joint.

Premature posterior contact

This gets a bit technical.

A common problem particular to ‘gumshields’ occurs when the device is adjusted forwards known as ‘protrusion’ (you might do this in an attempt to increase the effect – and stop the snoring noise). The upper and lower parts of the device may then come into contact on just your back teeth.

This acts like a ‘bit’ for a horse – it gives you something to chew on. It ‘gags’ open the bite (keeps your jaws more open than they should be) and this uneven bite places enormous load on your jaw joints.

It would be even worse for your jaw joint, if this was on one side only, and as you close your mouth, your jaw has to ‘rotate’ around this ‘premature contact’. What the above means, is that your jaw has to move in unnatural ways.

This hurts. And if you use the device in this position (because you’re trying to appease your partner) you will irreversibly damage your jaw joint.

No. 6. Retention /  Fit of your Anti-Snoring Device (MAD)

How well your anti-snoring device fits, is known in dental terminology as ‘retention’.

But retention has two meanings in Dental Sleep Medicine (DSM is the term for MADs used to help with sleep-related breathing disorders, including snoring and OSA).

The first meaning is how well it keeps hold of your teeth, or to put it another way, how well it ‘clips on’ or stays in place. 

Most MAD designs rely upon its ability to ‘clip’ into place to then be able to hold your jaw forwards – and stop you snoring.

The second DSM interpretation of ‘retention’ relates to the MAD’s ability to hold open your airway, retain it in a forward position, and prevent you from snoring.

So, the right amount of retention (or fit) is essential for it to work.

Over-the-Counter ‘gumshield’ vendors make their money by relying on you being too lazy to seek a refund when it doesn’t work.

Read my review of ways they separate you from your money. ↗

Gumshields and retention
This is unavoidably technical. So, feel free to skip to my verdict.

Due to the necessary choice of thermo-plastic (it softens and becomes adaptable to you, when heated in boiling water) material used in ‘boil and bite’ devices, getting and keeping the right degree of retention, for the long-term is nigh on impossible.

The material ‘wants’ to go back to its original shape as it cools down, which is technically due to both the elastic memory and elastic recovery of the material. There’s more about the material used in the Lifespan or ‘Cost per wear’ section below.

Custom-made MADs
Custom-made dental devices for snoring are made for you (on prescription) from raw materials by a registered dental technician. While the materials used vary, they usually only become thermoplastic (soften when warmed up) when heated over 100 deg C.

On the other hand, ‘Customised fit‘ devices are the ‘Boil-and-Bite’ gumshield type of MAD (and I know you know water boils at 100 deg. C!).

Expert's verdict on retention of Anti-Snoring Devices
Boil-and-Bite gumshields for snoring as a general rule, cannot provide good retention.

Without good retention or ‘clip’ to your teeth, gumshields will not stop you snoring. End.

No. 7. Can I adjust the position of my Anti-Snoring Device (MAD)?

The ability to adjust the forward position of your jaw (adjust the protrusion to prevent snoring) impacts upon both comfort and how well it works.

The optimum position is unique to you. It has to be just far enough forward to prevent you from snoring, yet not so far forward, it hurts your jaw joints.

Fixed devices (sometimes called ‘monobloc’ devices) take an arbitrary approach to the forward position of your lower jaw. This primitive design (exhibited by both over-the-counter gumshields and some old tech custom-made ones) is likely to be less than ideal for comfort and effect.

Gumshields for snoring
For the MAD to prevent snoring it must prevent your mouth from falling open.

You should NOT need a chinstrap in addition to your anti-snoring device. If a chin straps is suggested then:

You need a different MAD.

If you’re trying to ensure you breathe through your nose and stop your mouth falling open, then read Chinstraps for snoring? Safe, Effective or Dangerous? [new window]. In my chin strap review, I examine if they have a role for snoring and obstructive sleep apnea (OSA).

If you can only breathe through your mouth and/or sometimes struggle to breathe through your nose, then consult your GP and seek an ENT assessment.

Custom-made, adjustable MADs
Custom-made, adjustable MADs are inherently adjustable (the clues in the name!)

The important thing to understand about adjustable MADs relates to their range of movement, and:

  • Whether this is sufficient
  • Whether it dictates a hard to tolerate initial position

The most modern custom-made adjustable MADs have between 8-10mm range of movement. If more is needed – you will most likely need a remake (more money).

Expert's verdict on ability to adjust the protrusion
Clearly, fixed or monobloc devices fail this test 🙂 A new anti-snoring device would need to be made if the jaw position was incorrect. Adjustable anti-snoring devices need to have sufficient range of motion to coincide with your jaw range of motion – or you must start in a forward jaw position, which may impact your ability to get along with the MAD initially.

No. 8. Life-span or ‘cost-per-wear’ of your Anti-Snoring Device

To ensure your purchase of an anti-snoring device (MAD) is not a waste of money or a false-economy, you have to consider:

  • Its outright price (don’t forget the clinical fees) and VAT (if its for snoring)
  • Its length of useful life

Amongst other things…

Gumshields for snoring
A material that softens in boiling water called ‘Ethylene Vinyl Acetate (EVA) or EVA’ is commonly used in gumshield type anti-snoring devices.

  • This material absorbs saliva from your mouth (and also any cleaning chemicals that may then leak back out into your mouth overnight – nice).
  • They are damaged if you grind your teeth because the material is soft and elastic.
  • Their typical lifespan is 6 months to 1.5 years before the EVA constructed gumshield becomes too smelly and unpleasant to use.
  • They also distort and place high lateral loads on your front teeth – making them very sore in the morning.
Custom-made Anti-Snoring Devices
Some early design variants of custom-made anti-snoring devices, are also made from EVA ‘blow down’ or vacuum formed blanks of CE marked material by a registered dental technician.

However, most are typically made from a type of denture acrylic (polymethylmethacrylate) or ‘PMMA’, and as such are stronger and less likely to absorb saliva than EVA materials. Some new variants are made from a type of ‘Nylon’ (polyamide) and are very strong in thin section (see Comfort and bulk above). This means they will last longer and therefore the ‘cost per wear’ may be reduced.

In the UK, it is also possible to obtain a custom-made anti-snoring device manufactured entirely from metal (known as ‘Chrome’ = Cobalt chrome wiki link: http://en.wikipedia.org/wiki/Cobalt-chrome new window ) While this type of manufacture may cost more (they are more time consuming to make) the material cross-section is extremely thin (fractions of a millimetre are possible) making the bulk in your mouth minimal (see comfort and bulk above). Additionally, the metal device does not absorb saliva or cleaning agents.

The downside is that any adjustment of ‘fit’ of metal devices may be problematic and over time the clasps (bits that wrap around your teeth to hold [retain – remember that?] the device in your mouth) may ‘relax’ and need adjusting.

Expert's verdict on lifespan of MADs
Broadly speaking its a sliding scale of cost versus lifespan.

The high-end devices using nylon or chrome are thinner and less bulky but are also difficult (if not impossible) to adjust. This does not mean to say its a problem, they just have to be perfectly made.

So, if its not – then it needs to be remade: Do not accept a poor fitting custom made anti-snoring device.

No. 9. Control of mouth opening (Does the MAD do it?)

When using a mandibular advancement device (MAD) it is essential to prevent your mouth from falling open for effective snoring relief and to avoid making your airway narrower than it would be without a mandibular advancement device.

It should not be necessary to resort to a chin strap to control this. Yes, I’ve been over this point in Retention above, but…

Why does vertical opening matter?

The lower jaw rotates backwards as it opens which further narrows your airway and makes snoring worse (or if you have sleep apnoea / apnea may increase the severity and duration of apneaic episodes).

If your jaw is protruded with a mandibular advancement device (MAD) and your jaw falls open your airway may be narrower than without using an MAD.

See the three X-ray diagrams below, to understand why vertical opening with an MAD should be avoided. The red dots highlight how the airway increases / decreases with protrusion and vertical opening.

Images courtesy of Dr Ulrich Huebers DDS.

The diagram (below left) shows the size of the airway in your throat without a mandibular advancement device (MAD).

The diagram (below centre) shows the ideal situation. The mandibular advancement device advances the jaw and opens the airway in your throat.

The third diagram (below right) shows how the airway becomes narrower with both protrusion and vertical opening. Disaster.

rest position before a mandibular advancement device
Mandibular Advancement Device (MAD) with NO vertical opening in protrusion
mandibular advancement device
Gumshields and custom-made MADs
Both categories of MAD (Boil-and-Bite gumshield and custom-made MADs) can fail when examined against this important test metric.

  • Jaw advancement must increase as the mouth opens (protrusion must increase proportionally [to maintain the same effect] if vertical opening occurs).
  • Less protrusion correlates with:
    1. Less side-effects (including less risk of tooth movement and jaw pain)
    2. Increased tolerance and improved long-term compliance.

An interincisal opening (the distance measured between the upper and lower front teeth) of more than 5 mm has been associated with lower patient adherence (long-term use), perhaps as a result of discomfort.6

Expert's verdict on mouth opening
Minimal vertical opening (as in just sufficient to permit the lower jaw to advance without the upper and lower teeth hitting each other) should routinely be considered ideal. More than this may be necessary in selected cases where:

  • the tongue is large
  • the jaw is small

However, opening beyond 5mm (measured between the incisors) is uncomfortable, inhibits lip closure and detrimentally impacts long-term use. A design principle for MADs is control of vertical opening (note my previous comment about not needing a chin strap).

No. 10. Ability to move side-to-side (lateral movement)

It might seem obvious, but unless the MAD is worn, it cannot stop your snoring.

As such, it must be comfortable to use. Part of this comfort equation is the MAD not creating a ‘trapped’ sensation.

This may occur when the lower jaw is unable to move from side-to-side.

Gumshields and custom-made MADs
Some MADs (both custom-made and ‘Boil-and-Bite’) exhibit the capability to move laterally (side to side) while some do not. My viewpoint is that you should look for one that does permit movement.
Expert's verdict on lateral movement
If you grind your teeth (brux) then this will significantly impact the life-expectancy of your MAD. In fact, you may work harden metal components necessitating their earlier replacement, than would otherwise be expected.

Finally, while it is perhaps a contentious area, if you routinely ‘brux’, then an anti-snoring device that does not permit side-to-side (lateral) movement may actually disrupt your sleep. One theory suggests that this is because your attempts to move are hindered.

The opposing theory suggests you will no longer brux when your apnea is resolved. The jury is out.

No. 11. Does the Anti-Snoring Device mechanism invade your tongue-space?

Ever had a filling or a crown? You may recall how you were very conscious of it. You probably explored it with your tongue and it felt alien. Every anti-snoring device will feel huge in your mouth when you start to use it.

Consequently, less is more!

 

Less physical presence in your mouth, squashing your tongue, enhances your ability to initially accept it and keep using it – and stop snoring…

The concept behind an MAD is to advance the jaw, and in turn, move the tongue forwards and away from the back of your throat.

This increases your airway dimensions and improves tissue tone, which stops you snoring.

So, when an MAD is too bulky, it squashes your tongue. Which is self-defeating.

Gumshields and tongue space
Typically, gumshields are bulky and squash your tongue. They may even have rough or sharp edges which may cause tongue ulcers.

Technically, this may occur with ‘gumshields’ at the junction between two materials, typically with devices that have a hard-outer shell and a softer thermoplastic liner, or when they are crudely ‘adjusted’ with home equipment i.e. scissors!

Prescription, custom-made MADs

Construction

Some primitive custom MADs are bulky and invade tongue space. Materials technology is continually improving, and thinner cross-section devices are now appearing on the market using laser sintered polyamide (a type of nylon).

While traditionally manufactured metal (known as ‘chrome’) devices are available. These may be expensive to make (as they are labour intensive) and may necessitate plastic and metal combined devices, which builds in failure points (because dissimilar materials exhibit different mechanical properties).

Placement of the adjustment mechanism

The placement of adjustment mechanisms in the tongue space is uncomfortable and counter-productive (see concept note above in introduction to this point). Some early custom MADs used orthodontic screw mechanisms in the palate or inside the lower jaw (lingually).

A sleep-trained dentist will guide you when you choose. To get informed for that conversation download our free, evidence-based How to Choose a Mouthpiece Guide. new window

Expert’s verdict on tongue space invasion
If you can’t wear your MAD, then its pointless having it. Consequently, comfort has to be a pivotal deciding factor when selecting one.

Anything placed where your tongue can contact it, is a negative. Remember less is more, when it comes to MAD design.

No. 12. Easy to Keep Clean (Extend useful life, hygiene)

Consult your dentist and the MAD manufacturer’s instructions on how to clean your MAD.

I would suggest that broadly speaking you should (every time you remove it in the morning) use a toothbrush and toothpaste on the device before/after cleaning your teeth. Floss if you have the enthusiasm and discipline… and consider using a chlorhexidine mouthwash too.

Having worked in this industry for longer than I care to remember, I know that MADs must be:

  • Easy to keep clean
  • Not absorb cleaning fluid or saliva
  • Ideally not have intricate mechanisms to retain food and bacteria
  • Be entirely made of one material

Bacterial biofilm (a slimy film of infectious microbes) will form on the device. It’s important to pay extra attention to your oral hygiene (and keep the MAD clean with a toothbrush immediately you remove it in the morning).

Gumshields for snoring
These materials absorb saliva (and cleaning fluids) so bacteria are drawn into the material itself – not just on the surface. Ewww.
Prescription, Custom MADs
The use of materials with better properties, more suited to long-term use in your mouth, should have less detrimental impact. You will of course need to keep them clean and remove the biofilm – and keep your teeth and gums really clean.

See a dental hygienist if you need assistance keeping on top of this. Its an investment.

Expert’s verdict
Prescription, custom-made MADs utilise materials that are better-suited to long-term use. They are inherently easier to clean and keep clean. This is vital when you consider the number of people who have gum disease (gingivitis) whose condition would be aggravated by an MAD, perhaps to such an extent that they risked losing a tooth.

Top Tip

If you are lucky enough to have a marble bathroom, make sure that the MAD cleaning fluid does NOT splash out (powder or granule type cleaning products are commonly a type of acid that permanently damages marble). Ideally, clean your MAD elsewhere! (Voice of experience! Customer reported the above to me when I ran Zacher Sleep Appliances).

No. 13. Side-effects of Anti-Snoring Devices (Mandibular Advancement Devices)

There’s always a down-side!

Or in ‘English’:

“You don’t get nowt for nowt”

side-effect
The most common side-effect from Anti-Snoring Devices (MADs)
The most common initial side-effect from using anti-snoring devices is related to saliva. Some people find they dribble while wearing the device during the first few weeks of use. Others may find they have a dry mouth.
The next most common side-effect is jaw ache
This is normally transient and may arise during the ‘titration’ period (where the device is adjusted to gradually advance your lower jaw and stop you snoring).

If this occurs, the correct advice is to speak with your dental clinician. It normally resolves itself but do not suffer in silence.

Longer term, changes in the position of your teeth may occur
This is due to the weight of your lower jaw (think gravity) and the muscles attached to it combining to attempt return of your jaw to its normal position. These forces are all transferred to your teeth and their roots.

This is why even the most wonderful anti-snoring devices are NOT suitable for children – because they would act like an orthodontic device and move their teeth in uncontrolled ways (exceptionally an orthodontist may prescribe an anti-snoring device for certain children with particular needs).

Expert's verdict on side-effects
It is really important to keep things in perspective: Not snoring, breathing and sleeping at the same time or perhaps minor tooth movement?

However, as I have highlighted throughout this review all anti-snoring devices have side-effects.

A sleep-trained dentist would screen you for sleep apnoea, help you stop snoring and minimise (and if necessary correct) any side-effects. They also carry professional indemnity insurance and use prescription anti-snoring devices made to quality standards by registered dental technicians.

FREE BONUS

Download our free, NHS England’s Information Standard accredited, evidence-based, expert-written and jargon-decoded Guide

(that’s a mouthful!):

> How to Choose a ‘Mouthpiece’ to Stop Snoring

You’ll learn about your options and be able to make more informed choices.

No registration is required.

They’re also free on Google Play:

google play

If you snore and self-help isn’t cutting it then don’t self-diagnose. Get signposted to the most appropriate professional to help you. Its free, evidence-based and a simple way to find out if snoring is actually a symptom of sleep apnoea.

NHS England's Information Standard UK
top-selling anti-snoring devices

Summary

This review has examined the best anti-snoring devices, both Over-the-Counter and custom-made, against my top 13 criteria, to help you choose an anti-snoring device that works, and is safe and effective.

My final verdict is that while a ‘boil-and-bite’ gumshield may prevent snoring for a short while (if you fit the gadget) they are ultimately a false economy and won’t work for long (if at all).

Longer-term, if you were to persevere with a ‘gumshield’ for snoring, it would:

  • Create unpleasant and sometimes permanent, unmanaged dental side-effects
  • Potentially irreversibly damage your jaw-joints
  • And it delays potential OSA diagnosis and effective treatment

In conclusion, clinical research3 has established that ‘boil-and-bite’ gumshields are not valid as either a trial or treatment device.

But this is not a definitive guide to OTC anti-snoring device manufacturers’ claims. This is.

 

The real question

The real question is:

Why do you snore?

My advice is to:

  • Get signposted to the most appropriate professional
  • Get screened for sleep apnoea before you dive into any treatment and learn why you snore

And then you will know how to stop.

Here’s the next step:

Found this review useful?

Write a review below, and let me know.

Reviews

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Really helpful when I was worried about my OH’s snoring. Gave me info on what to worry about. Next stop the GP.

Mrs P Really interesting stuff! May 24, 2018


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If you are looking for impartial advice about snoring from an expert in the field, the highly respected Adrian Zacher should be your go to. We applaud Adrian’s work, to raise awareness about the health implications of snoring, and the importance of custom-made devices for long-term success.

Lucie Ash Director Somnowell How to choose the best anti-snoring device September 7, 2018

Found this useful?

Let others know what you think.

1 - 5 out of 5, where 5/5 is the best and 1/5 is the worst


Expert reviews and ‘How-to’ Guides related to Anti-Snoring Devices:

Here are some more expert reviews about anti-snoring devices, snoring and sleep apnoea / apnea products, cures and aids!

Glossary

Anti-Snoring Device – generally considered a product worn in your mouth to stop you snoring.

Boil-and-Bite – a type of gumshield for snoring that may be adapted to you by softening the material in boiling water. See OTC below.

Custom-made – a bespoke device made exclusively for you by a registered dental technician, working to prescription, using CE marked materials. In Europe working to the Medical Devices Directive  administered in the UK by the Medicines and Healthcare Products Regulatory Authority (MHRA).

DSM Dental Sleep Medicine – the management of sleep-related breathing disorders using dental devices.

Gumshield for snoring – see ‘Boil-and-Bite’ above.

Information Standard – NHS England’s Information Standard. Organisations that join The Information Standard are showing their commitment to producing good quality, evidence-based health and care information.

MAD Mandibular Advancement Device – Jaw advancing device, worn at night while asleep to hold forward the lower jaw to stop snoring and prevent obstructive sleep apnoea / apnea.

MAS Mandibular Advancement Splint – See ‘MAD’.

MRD Mandibular Repositioning Device – See ‘MAD’.

OSA Obstructive Sleep Apnoea – (also spelt apnea) When an individual is unable to sleep and breathe at the same time. Visually, a repetitive pattern of breathing interruptions (apnoeas) occurring while the individual sleeps, due to a physical obstruction in the airway.

OTC – Over-the-Counter product sold over the pharmacy counter or on-line without prescription, medical or dental assessment and without a review of medical/dental history.

Signposting – Is the medical term for directing people to the most appropriate professional to help them based upon their answers to some high-level questions.

Sleep-trained Dentist – A dentist that has undergone special interest training in sleep. As such they are able to obtain professional indemnity insurance.

TMD – Temporo-Mandibular Joint Dysfunction. Jaw-ache or pain, due to abnormal or impaired movement.

References

  1. Snoring cures success ‘exaggerated’ http://news.bbc.co.uk/2/hi/health/1701735.stm new window [accessed 16th Oct 2016]
  2. Stradling, J. and Dookun, R. 2009, Snoring and the role of the GDP: British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol, British Dental Journal, 206, 307 – 312. Available here: http://www.nature.com/bdj/journal/v206/n6/abs/sj.bdj.2009.214.html new window [accessed 12 April 2017]
  3. Vanderveken OM, Devolder A, Marklund M, et al, 2008. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med; 178: 197–202. Available here: http://www.atsjournals.org/doi/abs/10.1164/rccm.200701-114OC#.V9ukcFT_rio new window [accessed 12 April 2017]
  4. Ready-Made Versus Custom-Made Mandibular Repositioning Devices in Sleep Apnea: A Randomized Clinical Trial, Johal A, Haria P, Manek S, Joury E, Riha R. Ready-Made Versus Custom-Made Mandibular Repositioning Devices in Sleep Apnea: A Randomized Clinical Trial. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2017;13(2):175-182. doi:10.5664/jcsm.6440. Available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263072/ new window [accessed 18th June 2018]
  5. A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO). Quinnell TG, Bennett M, Jordan J, Clutterbuck-James AL, Davies MG, Smith IE, Oscroft N, Pittman MA, Cameron M, Chadwick R, Morrell MJ, Glover MJ, Fox-Rushby JA, Sharples LD. Thorax. 2014 Oct; 69(10):938-45. Available here: http://thorax.bmj.com/content/68/Suppl_3/A4.1  new window [accessed 18th June 2018]
  6. Pitsis AJ, Darendeliler MA, Gotsopoulos H, et al: Effect of vertical dimension on efficacy of oral appliance therapy in obstructive sleep apnea. Am J Respir Crit Care Med 166:860, 2002. Available here: https://www.ncbi.nlm.nih.gov/pubmed/12231498  new window [accessed 18th June 2018]

Created by Adrian Zacher | Page last updated 24th June 2019

How to prescribe oral appliances for snoring (Ultimate Guide 2019)

How to prescribe oral appliances for snoring (Ultimate Guide 2019)

Healthcare
Professional
information 

HOW TO PRESCRIBE ORAL APPLIANCES FOR SNORING

The Ultimate Guide

By Adrian Zacher

2019 edition


This Ultimate Guide for dentists, will show you exactly how and when to prescribe oral appliances for snoring patients. Supplemented with multiple real-life examples, downloads, videos, photos of impressions and 13 intra-oral images.

It could equally be titled ‘When to prescribe…” as there’s a right and a wrong time to prescribe a Mandibular Repositioning Appliance (the technical name).

The best part? If you’re a UK dentist, I will show you how to prescribe oral appliances for snorers without a prior medical diagnosis (and stay indemnified).

Sound good? Let’s dive right in…

Snorer.com
Rated 5/5 based on 16 customer reviews
How to prescribe oral appliances for snoring and sleep apnoea / apnea

Peer review and about the Author

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Looking into snoring solutions can be an intimidating process, with so many different options and treatments available. The How to prescribe oral appliances for snoring: Ultimate guide provides in-depth, impartial advice, looking at all the options available, so the practitioner can offer the best service. Well done!

Lucy Ash (Director at Somnowell. Ltd) An excellent resource for both, snorers and healthcare professionals. October 10, 2018

Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I’m a sleep-industry insider with a quarter of century of sleep medicine experience.

Google Scholar

Click to jump to each chapter:

Finding suitable patients for oral appliance therapy for snoring

CHAPTER 1

Finding suitable patients: referrals, screening, recognition and diagnosis

Dental clinical signs and symptoms of sleep-related breating disorders

CHAPTER 2

Dental clinical signs and symptoms of sleep-related breathing disorders

Can I prescribe oral appliances for snoring?

CHAPTER 3

Can I prescribe oral appliances for snoring / sleep apnoea?

What training do I need to prescribe oral appliances for snoring?

CHAPTER 4

What training do I need? How to judge quality dental sleep education

Dental lab requirements to make an oral appliance for snoring

CHAPTER 5

What does the lab need?

How to choose the best oral appliance for snoring

CHAPTER 6

How to choose the ‘best’ oral appliance for snoring?

Oral appliance titration, follow-up and duty of care

CHAPTER 7

Titration, follow-up, your duty of care

FAQs about oral appliances for snoring

CHAPTER 8

FAQs, tools and resources

Before we begin… is this you?

A patient has asked me about an Anti-Snoring Device…

STOP.
Unless you’re sleep-trained do NOT prescribe an anti-snoring device.

  • You’re not insured (both the Dental Defence Union and Dental Protection Ltd. have position statements on this)
  • You may delay your patient’s diagnosis by inadvertently disguising their symptoms: snoring may be a symptom of obstructive sleep apnoea (OSA) and the first-line therapy for OSA is not an oral appliance

I’ve received a referral (patient has sleep apnoea): Now what?

STOP.

While you’re medico-legally ‘OK’ to prescribe an anti-snoring device (the patient has a medical diagnosis and has been referred to you for oral appliance therapy) ask yourself:

Do you feel sufficiently informed to treat?” 

Intrigued? Read on…

CHAPTER 1:

 

Finding suitable patients


Starting right now, I’ll show you how to find enough patients, to make a fulfilling business from helping snorers.

Beginning with networking, referrals and building your credibility, we then navigate how to accelerate the process through screening and recognition (I will also cover diagnosis).

Finding snorers who need help

Finding patients

Helping someone stop snoring, I’m sure you’d agree, is a great aim. Happily, the market for oral appliance therapy for snoring (i.e. prescription, custom-made anti-snoring devices) continues to grow.

Indeed, 20% growth in European unit sales (2017) was reported by one of the few listed companies1 that provide such details.

So, its perhaps surprising then, that in my experience, dentists get very excited, train how to prescribe oral appliances for snorers… and then….

Nothing.

Nothing at all.

If you’re reading this, then maybe you have a snorer in mind (you or your other half perhaps?).

Well you’ve found one snorer, so how hard can it be, to find some more?

After all, it seems just about everyone snores…2

40% of the UK population regularly snore

Perhaps a slight exaggeration to say EVERYONE snores, however, in a telephone interview of 4972 people (UK population sample, aged 15 -100 yrs) 40% reported snoring regularly and 3.8% reported breathing pauses during sleep. BMJ, 1997; 314:860 (Ref. 2)

Yet, dentists once sleep-trained either:

  • Don’t know how to find these snorers
  • Or perhaps it’s just too darn hard (or slow) to make a real go of it

Why is that?

(Don’t worry – I will tell you why – and how to get snorers knocking on your door).

How to receive referrals of snorers?

Dentists around the world are facilitators in sleep medicine. They facilitate provision of a therapy for a sleep and respiratory condition:

  • Snoring (and Obstructive Sleep Apnoea / Apnea).

The choice of treatment (in this case a mandibular repositioning appliance or MRA) is not made by them.

Which is not such an alien situation as it may at first appear…

For instance:

You may as part of your oral health assessment (with training) suspect the patient has an oral tumour and proceed to refer them for expert assessment, diagnosis and a treatment plan.

Perhaps you’re involved in the long-term management of the patient?

Treatment for snoring or OSA follows diagnosis, and the diagnosis of obstructive sleep apnoea / apnea (OSA) is the exclusive preserve of the Consultant Respiratory Physician (after amongst other things an overnight sleep study) – but we’ll get to that in a moment.

It might seem obvious but to receive referrals, you need to be known to the referrer!

JARGON ALERT!

Oral Appliance, Device, Mouthpiece, ‘Gumshield’, Splint…
MRA (Mandibular Repositioning Appliance)
MAS (Mandibular Advancement Splint)
MAD (Mandibular Advancement Device)
MRD (Mandibular Repositioning Device)

These are different names (acronyms) for the same thing: an oral appliance which holds the lower jaw forwards to improve breathing while asleep.

JARGON ALERT!

A sleep study is an overnight test that (while the patient sleeps) includes measurements of oxygen saturation, body position and the amount of effort required to breathe.

Treatment for snoring follows screening for sleep apnoea

When can dentists treat snorers?

Snoring may be a symptom of OSA, in which case the sleep-trained dentist is faced with a situation that is more or less delineated by this extract from the American Academy of Sleep Medicine’s Clinical Guideline3 (yes, OK, this is a US Guideline but it’s broadly similar to what’s found in other parts of the world and it makes my point clearly enough):

The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment.

This is an ideal time to define obstructive sleep apnoea:

What is Obstructive Sleep Apnoea?

Obstructive sleep apnoea (OSA) is a condition where breathing repeatedly stops during sleep4, because the upper airway behind the tongue, has narrowed or collapsed. Sufferers commonly snore.

What are the symptoms of Obstructive Sleep Apnea Syndrome?

Obstructive sleep apnoea syndrome (OSAS) gives rise to unexplained daytime sleepiness as the dominant symptom. Sufferers experience major adverse physiological changes, due to the recurrent asphyxia and micro-arousals that fragment their sleep.5

Other symptoms include:

  • Reduced vigilance
  • Difficulty concentrating
  • Poor at work, home and driving6 performance
  • Snoring

OSAS fragments someone’s sleep to such an extent that they’re unaccountably drowsy and tired when they should be wide-awake.7

How to differentiate between snoring and OSA?

This is the crux of the issue.

Differentiating between OSA sufferers who snore (who would benefit and most likely comply with a Positive Airway Pressure or PAP device) and ‘simple’ benign snorers, who would be most appropriate for an oral appliance is what sleep units ‘do’.

You need to leave this to the professionals in the sleep unit. (Unless you’re a dentist in the UK – we’ll get to how this works later).

JARGON ALERT!

PAP = Positive Airway Pressure therapy.

This is the best option for severe obstructive sleep apnoea (OSA).

Learn more about PAP therapy with this ‘How to choose: PAP therapy‘ ↗ Guide

If you want to understand where MRAs fit with the other treatment options (PAP, soft and hard tissue surgery) for snoring and sleep apnoea, then check out this video from our KnowSleep™ Academy for dentists. ↗:

Snoring or OSA?

How to get referrals from the Sleep Unit, ENT and MaxFac departments?

Active networking is not for everyone.

However, as a sleep-trained dentist wishing to receive referrals, you will need to network with:

  • Your local sleep unit
  • The ENT department
  • The Oro-maxillofacial department
Receiving referrals from the sleep unit, MaxFac dept, ENT

The departments in your local hospital (listed above) need to be aware of your existence and training, for you to receive referrals of patients, in the following circumstances:

  • When snoring patients do not merit treatment with PAP therapy or sleep apnoea patients have refused or failed with it
  • ENT approaches have not been successful or require concurrent oral appliance therapy
  • Oro-maxillofacial surgery is not considered appropriate
Treatment options

It certainly won’t hurt to write to them, yup, good ol’ snail mail.

Also, make sure you attend any continuing education events the units may run, join the available professional societies and go to the national sleep conferences (I can see a joke here – but I’m not going there)

There’s no way around it:

It will take some time and effort.

This rather passive, ‘wait and see’ approach as to when you can prescribe an oral appliance for snoring, is globally applicable – with one unique exception (in the United Kingdom):

Which I hinted at earlier and can now reveal…

How to screen and recognise obstructive sleep apnoea (OSA)

Sleep-trained dentists in the UK, using the British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol8, may screen and recognise obstructive sleep apnoea (OSA) symptoms (and refer for further investigation).

What this means:

You can train to identify snorers who can be treated safely with oral appliances, without a prior medical diagnosis.

Which is a globally unique situation (to the best of my knowledge).

Screening for obstructive sleep apnoea?

Dentists screen for oral conditions every day.

Call it an ‘oral health assessment’ if you like, whether you’re screening for gingivitis, caries or an oral tumour… screening for a condition is simply looking for the warning signs, while it’s in its infancy.

The idea of course, is that a condition in its early stages may be more easily treated or managed.

Warning signs of sleep apnoea

Can I screen for obstructive sleep apnoea?

Screening for OSA is no different to the screening (sorry oral health assessment) that you do routinely.

The conversation begins by adding the important question:

Do you snore?

to your medical history questionnaire. If you ask this question, then I’m sure you will be amazed how many snorers you discover – and how many want to talk to YOU about their condition.

Sleep-trained dentists may recognise (and I use the word ‘recognise’ intentionally) symptoms of obstructive sleep apnoea, including:

  • Daytime sleepiness
  • Obesity
  • A partner witnessing breathing interruptions during sleep
  • Awakenings due to gasping or choking fits
  • Frequent night awakenings to urinate
  • Need to sleep sitting up
  • Snoring

It’s important to note that UK sleep-trained dentists are not diagnosing.

They are assessing according to an agreed, published protocol and acting within the bounds of their professional indemnity insurance9, 10 (which is kind of important!).

Unless you’re a sleep-trained dentist in the UK, you need to refer EVERYONE to their GP (primary care physician – PCP) for the doctor to decide who should be referred for a sleep study after which the most appropriate treatment can be discussed. You might well see the patient again for the fitting of an oral appliance.

The Association of Respiratory Technology and Physiology (ARTP) Standards of Care document, cites the British Society of Dental Sleep Medicine’s pre-treatment screening protocol (as published in the BDJ May 2009, by Prof. John Stradling FRCP and Dr Roy Dookun BDS).

These two documents make up the ‘rules of the game’ for UK sleep-trained dentists.

We’ll get into this some more later (Chapter 4 – What training do I need?).

The benefits of dental screening and recognition of sleep apnoea

OK, so you can’t immediately prescribe an oral appliance for snoring.

But the snorer you refer to their GP (or Primary Care Physician if you prefer) effectively becomes your ‘sales person’. The patients you push through the system the right way, then help to reinforce your networking.

The sleep unit medics will think:

“Here is a responsible, informed professional – lets send our patients to them.”

Tick.

Diagnosis of snoring and / or obstructive sleep apnoea (OSA)

As I said in the paragraph ‘Screening and Recognition’ above, the diagnosis of OSA and what is known as ‘simple’, ‘benign’ or ‘anti-social’ snoring is not something a dentist can do.

Here’s the pertinent extract from Dental Protection Ltd’s position statement (a UK-based professional indemnity insurer):

The diagnosis and treatment of OSA, other sleep disturbances or snoring conditions does not fall within the definition of the practise of dentistry and therefore falls outside the scope of assistance normally provided by Dental Protection. However, dentists can have an important role in the screening of patients for signs and symptoms which may predict the presence of OSA.

Consequently, determining that your patient ‘just’ snores and prescribing an oral appliance for snoring, is likely to get you into ‘hot water’.

And it would comprehensively obliterate any credibility you’ve built up, with all your networking and screening efforts.

Don't just prescribe for snoring

Sleep-Related Breathing Disorders: The Dentist’s Role

There is an expectation that patients see their GP at a frequency, based upon their age and needs.

For example, a new mother would perhaps see their GP regularly (say once a week – a month), whereas young adults perhaps less so (once every few years – or only as necessary). And so on.

Dentists on the other hand, generally see their patients (and look in their mouths) at defined and comparatively frequent intervals.10 i.e. more than 3 months and no more than 24 months apart.

Dental intervals

As such, dentists are ideally placed to play 4 critical roles12:

Treating adults with oral devices for snoring  Treating adults with oral devices for snoring and mild to moderate OSA to slow the progression of the disease
Identifying patients at risk (both children and adults) by looking at their upper airways on a regular basis  Identifying patients at risk (both children and adults) by looking at their upper airways on a regular basis
Treating children with rapid maxillary expansion and avoiding deleterious orthodontic treatments  Treating children with rapid maxillary expansion and avoiding deleterious orthodontic treatments
Recognising the need for bimaxillary osteotomy among young adults with a need for maxillofacial correction  Recognising the need for bimaxillary osteotomy among young adults with a need for maxillofacial correction

Top tip: Sleep-related breathing disorders: Dentists are ideally placed to play 4 critical roles.

So, as a UK dentist with dental-sleep medicine training, YOU can become a valued member of the sleep patient care team.

You just need to find patients…

Have signposted snorers making appointments with you.

Have signposted snorers come to you

CHAPTER 2:

 

What are the dental clinical signs and symptoms of sleep-related breathing disorders?


Picture yourself:

You’re screening performing an oral health assessment and you start to wonder:

“What are the dental signs and symptoms of sleep-related breathing disorders?”

Well, lets have some real-life examples:

What are the dental clinical signs and symptoms of sleep apnoea?

What are the dental clinical signs & symptoms of sleep-related breathing disorders (SRBD)?

Let’s have some examples. You may come across these dental clinical signs and symptoms of possible Sleep-Related Breathing Disorders (SRBD).

Including:

Scalloped tongue  Tongue crenulations (scalloped borders) suggesting perhaps both bruxism and that the patient is regularly pushing the tongue forwards against the teeth to open their oral airway.

Scalloped tongue

open-bite relationship of the opposing teeth may result from tongue posturing  The development of an anterior or lateral open-bite relationship may result from tongue posturing.

Sleep bruxism   Sleep bruxism may develop or increase (see point 1 above)

Gastroesophageal reflux  Dimpling of the cusps and lingual surfaces of the teeth may be an indicator of related gastroesophageal reflux. Reflux may occur due to  ‘pumping’ efforts to breathe bringing up stomach acid.

Incisor damage from stomach acid - perhaps from gastro-oesophageal reflux
Dentinal pooling a symptom of sleep apnoea?

temporomandibular joint (TMJ) dysfunction symptoms  The development of:

  • Orofacial pain
  • Temporomandibular joint (TMJ) dysfunction symptoms
  • Masticatory muscle fatigue noted on awakening
  • Morning headache

These can be related to the positioning of the mandible to open a person’s airway or bruxing after a sleep apnoeaic episode.

large uvula, or a narrow or tongue-obstructed airway  During the evaluation of the oropharynx, prominent tonsils, a large uvula, or a narrow or tongue-obstructed airway may be noted.

The patient’s age may also contribute to loss of tone of the pharyngeal muscles.

mouth breathing while sleeping  Evidence of mouth breathing while sleeping may take the form of drying of the surface of the gingiva.

  Halitosis

What should I do if I suspect the patient has sleep apnoea?

If your suspicions are aroused, then refer the patient to their GP (in writing) for further investigation. Or if you’re in the UK and you’re a sleep-trained dentist, you should screen for OSA and its comorbidities.

And if you look down a patient’s throat and see this – what does it tell you?

This patient has had a UVPPP (sometimes its written UPPP). This acronym stands for ‘uvulopalatopharynogplasty’ and this is the ENT surgery solution for problem snoring.

Read more about surgery for snoring.

CHAPTER 3:

Can I prescribe an oral appliance for snoring?


Now (at last) we can answer your question:

“Can I prescribe an oral appliance for snoring?”

And this is absolutely about WHEN as a dentist you can prescribe.

Time to put the sickle scaler down.

Can I prescribe an oral appliance for snoring?

When to prescribe oral appliances for snoring?

It really is the million-dollar question! So, let’s start positively.

You can prescribe an oral appliance for snoring when:

  The patient has been diagnosed by a sleep unit and referred to you for an oral appliance for snoring or obstructive sleep apnoea.

  You’re a UK sleep-trained dentist, who has screened for OSA, and is satisfied the snorer is a candidate for oral appliance therapy.

Now back to reality with a bump…

If either of the above 2 conditions are not satisfied, then you cannot prescribe an oral appliance for snoring.

Sorry, I don’t make the rules. (Err… Except I did have a hand in making the rules in the UK… but that’s another story).

Onwards…

Case selection

In situation case selection above, the patient has been deemed suitable (from a medical perspective) for an oral appliance for snoring / obstructive sleep apnoea (OSA) and referred to you.

This is now a double prescription situation.

Allow me to explain:

The Consultant Physician has prescribed oral appliance therapy, and YOU as the dentist prescribe which mandibular repositioning appliance (if you consider it dentally appropriate) the patient gets to take home.

JARGON ALERT!

Oral Appliance Therapy is the term for prescription, custom-made medical devices that reposition the mandible to aid breathing while the user is asleep.

JARGON ALERT!

Mandibular Repositioning Appliance, Mouthguard, Device, Mouthpiece, ‘Gumshield’…
MRA (Mandibular Repositioning Appliance)
MAS (Mandibular Advancement Splint)
MAD (Mandibular Advancement Device)

These are different names (acronyms) for the same thing: an oral appliance that repositions the lower jaw to improve breathing while asleep.

Bottom line:

It is down to you as a dentist, to determine if the patient is suitable from your dental, clinical perspective – and then to select the most appropriate oral appliance.

But not like the example shown below:

Unsuitable patient lower impression

Example of an unsuitable patient (lower impression)

Poor case selection upper dental impression

Example of an unsuitable patient (upper impression)
[and yes both impressions are from the SAME patient]

What’s wrong with the above case?

  • Insufficient teeth per arch
  • Of the remaining standing teeth, they are unevenly distributed around the arch
  • Only incisors remaining on the mandible – retaining the MRA and therefore the jaw will be difficult (is this time to consider implants?)

If an oral appliance for snoring were to be prescribed – it would likely prejudice the remaining teeth.

CHAPTER 4:

 

What training do I need to prescribe an oral appliance for snoring?


The Financial Conduct Authority defines independence for financial advisers, and uses wonderful terms like:

“non-independent advice”

My point is, that any rational person seeks a whole-of-market view, and treats ‘one brand sales spiel’ with a degree of caution.

Selecting dental sleep medicine training, is exactly the same.

What training do I need to prescribe oral appliances for snoring?

Training to prescribe oral appliances for snoring: What’s required?

Staying with my financial adviser analogy a moment longer, the ‘tied’ financial adviser is, in dental sleep medicine terms:

The ‘one oral appliance for snoring dental lab‘ provided course.

Such a course provides you with:

Insufficient knowledge  Insufficient knowledge of a broad range of oral appliances for snoring. Just like any other medical device, mandibular repositioning appliances have indications and contra-indications. There is no ideal or ‘best’ device. It all depends upon the patient.

Risk exposure  Professional indemnity insurance risk. Why would you use anything other than an insurer approved way to screen and recognise snorers that are safe to treat with oral appliances (without a prior medical diagnosis)? When selecting education, look out for the British Society of Dental Sleep Medicine’s pre-treatment screening protocol.

What constitutes appropriate dental sleep medicine training?

Happily, in the UK we don’t have to guess what constitutes appropriate dental sleep medicine training. We simply refer to the Association for Respiratory Technology and Physiology’s (ARTP) defined training course content:

Click to read: ARTP - content of courses / documented training should include:

1.7.1 Content
The content of courses/documented training should include:

  • Basic knowledge of sleep physiology/architecture
  • Pathophysiology of relevant sleep disorders (including the parasomnias and dyssomnias which in addition to OSA, are causes of excessive daytime sleepiness)
  • Sleep disordered breathing, OSA, OSAHS
  • Biomechanics of MRD therapy
  • Screening for the signs and symptoms of OSA, patient evaluation and assessment
  • Potential side effects of MRD therapy (short and long term)
  • Varieties of appliance design and manufacture
  • Appliance adjustment and patient follow up/recall
  • The dental practitioner must also be aware of the range of non-dental appliance interventions (both medical and surgical) available for patient treatment as well as an appreciation of the medical co-morbidities associated with OSA, an appreciation of the dangers of excessive daytime sleepiness (EDS), the assessment of EDS and the importance of taking a full and accurate medical and OSA history.

The identification of snoring/OSA predisposing factors needs to be discussed with the patient and along with appliance assessment factors which must also be taken into consideration as these may influence the design of device to be prescribed or even the decision to provide a mandibular repositioning device at all.

Cut to the chase: training to do what again?

Training that means you are confident with the below list:

  • You must be sufficiently informed about a range of oral appliances for snoring: their indications and contra-indications
  • You’re into lifestyle advice, i.e. stop smoking, quit alcohol, lose weight etc.
  • You (or a dental nurse perhaps?) need to record (and monitor for changes) the patient’s:
    • Blood pressure
    • Height
    • Weight
    • Neck circumference
  • You will ideally have examples of different MRA to demonstrate to the patient
  • You must explain the risks and benefits: and it’s a good idea to provide this advice in writing
  • You must ensure you have valid informed consent (grab an example PDF in Downloads)
  • You need to explain the possible side-effects and keep master casts to identify tooth movement – and communicate signs of this immediately to the patient
  • You have a duty of care to follow-up snorers and sleep apnoeaics alike (as their condition may change over time)

Here are the pertinent lines re: different designs of oral appliance from the same document (they use the acronym MRD – mandibular repositioning device):

1.5 Equipment
There are a variety of custom manufactured MRD designs available. Some designs may be deemed more appropriate for the individual patient after assessment.

1.7.1 ……………. The identification of snoring/OSA predisposing factors needs to be discussed with the patient and along with appliance assessment factors which must also be taken into consideration as these may influence the design of device to be prescribed or even the decision to provide a mandibular repositioning device at all.

Which means (if you undertake independent training and use the BSDSM protocol) you’ll stay on the right side of the professional indemnity insurers’ position statements.

How the professional indemnity insurers position statements help you

Fortunately, the Dental Defence Union8 and Dental Protection Ltd.9 have issued position statements (and of course other insurers will refer to these as the industries benchmarks).

I say ‘fortunately’ because we’re not guessing.

The position statements and ARTP Standards of Care make it crystal clear WHAT constitutes appropriate dental sleep medicine training and what does not.

Here’s the deal:

  • Seek comprehensive courses, independent of manufacturer bias – that make you aware of the wide array of oral appliances (and their indications and contra-indications)
  • Screen using the British Society of Dental Sleep Medicine’s protocol or frankly you’re asking for trouble.

Of course, it would be rude at this point not to highlight our KnowSleep™ Academy for dentists, on-demand video courses (that naturally do all of the above):

CHAPTER 5:

What does the lab need to make an oral appliance for snoring?


You might be wondering:

  • "What impressions does the lab need?"
  • "What bite registration is required?
  • "Errr... How do I record a protrusive bite?"
  • "How many teeth are required?"

Fear not.

What information does the lab need to make an oral appliance for snoring?

Lab requirements

Or to put it another way:

What do good, bad (and plain ugly) impressions look like?

The examples below, illustrate what impressions and the typical protrusive bite registration, should look like. Consult the dental lab (of course) for specifics for each mandibular repositioning appliance you consider. 

The impressions shown below are not fictitious. 

Good dental impression for an oral appliance for snoring

'Good' dental impression for an oral appliance for snoring

 

Bad dental impression for an oral appliance for snoring

'Bad' dental impression for an oral appliance for snoring. (If you look closely you will see a BSDSM standing order mandate!)

Ugly dental impression for an oral appliance for snoring

'Ugly' dental impression for an oral appliance for snoring

 

What impression material should I use for a mandibular repositioning appliance (MRA)?

Unless your alginate impressions are cast up within the hour, my advice is to use upper and lower fine detail silicone or polyvinysiloxane impressions of all the patient’s teeth. Use a special tray if required.

> Why include ALL teeth in the dental impression for an MRA?

It's advisable to include the 8s if present, as regardless of whether they are included in the final device, including them aids the lab avoid interference on protrusion and lateral excursions.

> What about sulcal extension?

Pay close attention to the sulcal extension where the device mechanism is to be situated.

What bite registration is needed for a mandibular repositioning appliance?

A protrusive bite registration.

Typically between 50% and 80% of the patient’s maximum protrusion (it may be useful to work back from 100%).

Your protrusive bite registration dictates your choice of oral appliance: Don't have an oral appliance in mind.

How to record the protrusive bite?

The George Gauge video below (click on it bottom right to go full screen) shows you more about how to take a protrusive bite registration with a product called a George Gauge (you can get these from MRA labs).

[YouTube video used with permission from Great Lakes Orthodontics - who I have no commercial connection with.]

How many teeth are required for a mandibular repositioning appliance?

8 teeth per arch (minimum) is a good starting point. However, just as important (if not more so) as the number of teeth, is the arrangement of the remaining teeth:

  • You need teeth where you intend to have the titration mechanism
  • If there are few molars - incisor sensitivity and ultimately proclined / retroclined incisors will result

So that wraps up general lab requirements. Talk to your lab - they may have their preferences and these may vary for a particular device.

Which brings me neatly to how you choose the 'best' oral appliance for your patient:

CHAPTER 6:

 

How to choose the 'best' oral appliance for snoring?


We've covered How?, When? and What? now we'll look at Which?

Which oral appliance for snoring is 'best'? 

When the patient is:

Class II?, Class III? A heavy bruxist? Has edge-to-edge incisors? Has a heavily restored dentition?

Do you mean to say the 'best' oral appliance can't cope?

How to choose the best oral appliance for snoring?

Which oral appliance for snoring do I prescribe?

There's a lot of marketing guff about this or that oral appliance for snoring being the 'best' one.

The 'best' oral appliance for your patient is of course, the one indicated and not contra-indicated.

I've written it before and I will write it again:

"There is no ideal (read 'best') oral appliance"

Here are some examples of what I mean:

Class II, steep condylar angle, step between lower 3 and 4

Situation
Mr X snores. He does not have OSA (referred to you by the local sleep unit), his BMI is 30 but he is otherwise healthy. He is late 30's, fully dentate, with reasonable oral hygiene and no perio. No evidence of TMD. He is Class II skeletal (mandibular retrognathia) with an acute condylar angle and a 'step' between lower 3 and 4. As he protrudes his OVD markedly increases.

Observations

  • An oral appliance that crowds his already cramped tongue is contra-indicated.
  • As the patient protrudes, an adjustment mechanism between the incisors, may no longer connect
  • Gross (and intolerable) vertical opening may develop due to the high condylar angle
  • The posterior parts of the oral appliance may impact upon one another
The heavy bruxist

Situation
Mr S snores. He has moderate OSA and is PAP non-compliant (referred to you by the local sleep unit). He sleeps supine (on his back). He is mid 40's, was a rugby player in his youth and now his BMI is 35 despite exercise. You suspect it relates more to muscle bulk and not so much fat. Neck circumference is 20 inches.

He bruxes and exerts terrific forces on his MRA (which he swears by). He has however found the metal components BREAK. And he has on occasion woken up with the broken part in his mouth.

What do you do?

Observations
Metal components will be work-hardened by his bruxing.

Perhaps consider an MRA where metal components are not subjected to his bruxing forces. Ensure it permits limited lateral movement or be prepared to swap out the metal components at frequent intervals.

Consider offering advice re positional therapy.

Class III or 'edge-to-edge' incisors

Situation

Miss G snores. She does not have OSA (referred to you by the local sleep unit), and she is otherwise healthy. She is mid 30's, fully dentate, with reasonable oral hygiene and no perio condition. BMI 35. No evidence of TMD. She is Class I skeletal. She has a 'firm' incisor relationship (edge-to-edge) i.e. nil overjet / overbite.

Which MRA do you consider is indicated?

Observations
Consider an MRA that neither contacts the labial aspect of the maxillary incisors or lingual aspect of the mandibular incisors to limit and ideally prevent incisor tilting.

Heavily restored dentition

Situation
Mrs B snores. She is a new patient. She does not have OSA (referred to you by the local sleep unit), and she is otherwise healthy. She is mid 50's, fully dentate, with reasonable oral hygiene and no perio condition. BMI 35. No evidence of TMD. She is Class I skeletal. Her incisors have veneers and her molars have bridgework that do not raise immediate concerns.

Which MRA do you consider is indicated?

Observation
Consider perhaps an MRA that is less dependent upon dental retention for its effect.

Here are two examples (and there are many more) of oral appliances for snoring with entirely different protrusive mechanisms.

While they both protrude the lower jaw, they have different indications and contra-indications, range of movement, side-effects and frankly costs!

Which one is 'best!' Hah!

Oral appliance for snoring and sleep apnoea
Oral appliance for snoring

Why does this matter?

Knowledge of a range of MRAs is vital for you to prescribe the most appropriate for your patient. It gives them the best chance of it working and should minimise side-effects.

Finally, I refer you to the 'ARTP Standards of Care for MRDs' document we discussed earlier:

The particular part about:

"...possessing knowledge of a range of oral appliances".

Sadly, time and again, I've witnessed dentists and patients struggling with patently the wrong type of MRA.

 

  • The well-intentioned but misinformed dentist is at a loss. They have nothing else to offer the patient because the 'one trick pony' lab they usually rely on, only sells the 'best' oral appliance.
  • The lab does not have the indicated oral appliance in their portfolio - i.e. they believe their own hype - and are contractually bound NOT to carry competing (shouldn't that be complementary?) appliances.

How to select the 'best' oral appliance for your snoring patient

Earlier I wrote:

"Your protrusive bite registration dictates your choice of oral appliance: Don't have an oral appliance in mind."

To elaborate:

The 'protrusive bite' informs your decision-making process, when it comes to selecting the indicated oral appliance for your snoring patient.

Buckle up, this gets a little complicated

The objective at this point, is to stay within the adjustment 'window' of the mandibular repositioning appliance:

Which is not as simple as it may at first appear...

Let me give you an example:

Assume the (new to MRA) patient's range of protrusive movement is ~15mm, then consider these points:

  1. Typical MRA protrusive range is 8-10mm (if more is required then you're into a remake)
  2. You might think therefore that an initial protrusive bite that is 5-8mm ahead of centric has you covered
  3. You know that patient acceptance, during the critical first two weeks of use, may be impaired by an excessive initial protrusion

Now factor in these points:

  1. With MRA use, the total protrusive range of motion may well increase: Patients don't normally go around protruding their mandible - their perception of 100% protrusion may well be inaccurate.
  2. Posterior interference on protrusion: If your initial protrusive bite and final effective (titrated) bite positions are widely divergent, the occlusal surfaces of the upper and lower appliances will require adjustment, typically over the most posterior molars (also bear in mind that gross vertical opening is associated with lower acceptance rates)
  3. The MRA mechanism does not connect any more: At the limit of MRA protrusion, upper and lower appliances of the 'hook and screw mechanism between the incisors' type MRA, may no longer connect.

I did say it was a little complicated.

Moving past the bite registration, what factors influence oral appliance selection?

What to consider when selecting the 'best' oral appliance for snoring?

Below is a non-exhaustive list. We've discussed the first two points, above:

  • Range of oral appliance motion (starting from nil protrusion to enhance acceptance rates)
  • Protrusion necessary (how much the patient can protrude - the maximum tolerable)
  • Lateral movement (necessity for it?)
  • Bruxism (damage to the MRA verging on destruction in a week or less. Or if they brux and the MRA does not permit lateral movement, the MRA may cause an arousal or the patient may simply not wear it).
  • Bulk - less is more
  • Lip seal - aesthetic considerations and to promote nasal breathing (less vertical opening is associated with higher acceptance and compliance)
  • Tongue space invasion - acceptance and frankly effect!
  • Incisor contact = incisor sensitivity and proclined  / retroclined incisors over time
  • Placement of the adjustment mechanism - you need there to be teeth where you want to put the mechanism.
  • Material choice (galvanic reaction, different expansion rates of the materials its made from = cracks and remakes, absorption of saliva and cleaning fluids)
  • Dexterity of the patient (can they actually adjust it themselves?)
  • Control - do you want the patient to be able to adjust it themselves?! Note: an aggressive (read desperate) rate of adjustment of protrusion, WILL aggravate the patient's TMJs and extend the time it takes to stop snoring

Phew!

Anything else I should look out for?

Yes.

Here are the contra-indications:

What are the contra-indications for an oral appliance for snoring?

Here's another long list to consider. Does the patient have any of these 'red flags'?:

  • Inadequate oral hygiene
  • Poor periodontal condition
  • Insufficient teeth per jaw
  • Edentulous mandible (some - but not many - MRA designs can be made for edentulous maxillas)
  • TMJ locking or other apparent dysfunction
  • Inability to protrude more than 5mm from resting jaw position
  • Mandibular ‘free end saddles’
  • Missing teeth where you would place the titration mechanism
  • Short crown height, or ‘pyramid’ shape / under erupted teeth
  • Extensive bridgework
  • Incompetent or restricted nasal airway
  • Severe ‘gag’ reaction
  • Unmotivated patient
  • Partner motivation for simple snoring (as in they're not really bothered about the noise themselves)

The presence of these 'red flags' does not mean an MRA is out the window. It does mean you need to select the most appropriate oral appliance to prescribe.

Which brings me full circle to:

There is no 'best' oral appliance.

The oral appliance has arrived from the lab: Now what?

Once the patient is comfortably inserting (and removing) the MRA themselves, its time to revisit your discussion about seeing them again.

Its important to point out, that for an oral appliance to stop someone snoring, they're going to need support and encouragement. The first 2 weeks set the pattern for the future.

When do you plan to see them again?

Or perhaps, when should you see them again?

And what's this about your 'Duty of Care'?

Top tip: 'Play' around with a new oral appliance for snoring BEFORE you see the patient. To work out the adjustments (and know which way up it should be!)

CHAPTER 7:

Titration protocols, follow-up, duty of care


Snorers may need motivating to wear their oral appliance (because it won't work immediately) and most patients find that it takes time to become accustomed to its presence.

While those with OSA must be followed up rigorously.

What does this actually look like?

Titration protocols, follow-up, duty of care for oral appliances for snoring

What does Subjective and Objective titration mean?

Adjusting the oral appliance's protrusive position to stop snoring and overcome sleep apnoea, is known as 'titration'.

Titration comes in two forms:

subjective titration  Subjective

objective titration  Objective

Subjective titration

Subjective titration means adjustment ceases when the wearer decides (perhaps with the kind assistance of their partner). No further protrusion is required.

Here's a suggested schedule of follow-up appointments for the benign snorer:
  • 3 days from fit a phone call "How has it been...?"
  • 7 days from fit an ease, adjust 2mm forwards maximum, reassure
  • 3 days later another call "Any improvement?"
  • 14 days from fit: adjust 2mm forwards maximum (look for posterior interference)
  • Repeat until either snoring ceases or no further protrusion can be tolerated.

Should the patient experience TMJ issues the patient should be instructed to immediately cease wearing the device. Refer them to a TMD expert. An aggressive (impatient) rate of titration WILL bring on TMJ issues in just about anyone.

But what if they're sleep apnoeaic?

That's when things get a little more scientific:

Objective titration

Objective titration is when evidence of effect is used, to inform adjustment of protrusion. The patient begins by becoming accustomed to wearing the oral appliance. They then titrate subjectively (see above) and at this point they have a sleep study to see if the MRA is providing effective therapy for their sleep apnoea.

Then a cycle of increased protrusion and repeat sleep studies occurs. Protrusion would cease when one (or more) of these things happen:

  • The MRA is deemed objectively effective (great!)
  • The physiological limit is reached (not so great)
  • Or patient tolerance to the position dictates (tilt!)

Communicate with the patient's GP and the sleep unit

Write and say thanks for the referral. Advise of your intended treatment plan, your review schedule and ask about repeat sleep studies. Ask about supine sleep position (observed by sleep study) as positional therapy combined with an MRA, can be an effective way to control OSA.

Follow-up and your Duty of Care

As a trained member of the sleep-patient care team, you have a duty of care for both the snorer and the sleep apnoeic patient.

This means you need to monitor the patient for a change in their condition - and not just in their mouth. You need to get the patient reassessed with a view to an alternative or adjunctive therapy. The examples below explain further:

The snorer may:

  • Start snoring again - and no further protrusion is tolerable
  • Become hypersomolent (by your assessment informed by the Epworth Sleepiness Scale [see Key sleep terms])
  • Experience other OSA symptoms
  • Be diagnosed with a comorbidity
  • Not improve with increased protrusion

For the diagnosed OSA patient referred to you for prescription of an oral appliance:

Before commencing use they:

  • May not be dentally suitable for prescription of an oral appliance
  • May consider the risk / benefit analysis (of oral appliance therapy) unacceptable
  • They may also find the cost of treatment unacceptable

After commencing use:

  • May inadequately respond to protrusion when measured objectively or subjectively
  • They may discontinue use and / or fail to attend

The diagnosed OSA patient in the situations above needs to revisit the sleep unit. You need to write to the GP and communicate what has (or hasn't) happened.

Longer-term follow-up

Longer-term, tooth movement WILL occur. There is no point in dressing this up.

How important is that tooth movement?

Well that's another thing:

The pictures above are after 21 months of nightly use of an oral appliance for snoring, the patient's occlusion now appears as an anterior crossbite with an anterior displacement of approximately 2.5mm. These post-treatment photos were taken after three weeks of non-use.

Keeping tooth movement in perspective

It is vital to keep tooth movement, as a result of mandibular repositioning appliance wear, in perspective.

As dental professionals we may be shocked at undesired orthodontic tooth movement. But you may be hard-pressed to extract the effective oral appliance from the patient on the grounds of a tilted incisor!

Points to note here:

  • Post-wear exercises e.g. chewing gum in the shower can help the mandible to return to its 'normal' position.
  • The patient had minimal (if any) overbite before MRA use: an overbite is considered 'protective'.

Your Duty of Care to both snorers and sleep apnoeaic patients

As a trained member of the sleep patient care team you have a duty of care. Not just to recognise when to treat or refer new patients.

Certainly, you understand the necessity for follow-up of OSA patients, but its important to identify when an MRA is:

  • No longer effectively treating the (apparently benign) snorer
  • The patient has reached their physiological or maximum tolerable protrusion. Their condition as changed: for example with age, weight gain and lifestyle changes etc.

These patients need your help.

They need you to recognise the change in them (that they may not see themselves) and refer them for further investigation at a sleep unit.

CHAPTER 8:

 

FAQs and resources


This Guide wraps up with an FAQs and resources section.

Have a question that isn't answered in our FAQ? Then let us know! [email protected]

If we don't know the answer - we'll find out if at all possible! - And also add it to the list:

FAQ, Key sleep terms & Downloads re oral appliances for snoring

FAQs

Repositioning or Advancing the mandible?
MRAs aid breathing while the patient sleeps, through anterior repositioning of the lower jaw. There is also an optimum vertical opening.
Is it really: Airway versus Occlusion?
Yes and No.

Yes, long-term use of MRAs will result in occlusal change.

Tooth movement is more likely when:

  • MRAs do not fully utilise the canines and molars (these may be more resistant to movement induced by lateral load)
  • The number and distribution of teeth is less than ideal
  • The MRA design loads the incisors (this will result in retroclined maxillary incisors and proclined mandibular incisors)

Factors that protect against and may limit tooth movement include:

  • Post-wear exercises
  • An overbite (edge-to-edge incisors are prone to incisor tilting)
  • MRA designs that limit the load applied to the incisors
My patient has sleep apnoea and is struggling with PAP - when can I make an oral appliance for them?
When the referring Physician decides. In this circumstance, communicate with the GP and the sleep unit. Explain what is happening, your concerns (i.e. they may use an OTC product) and offer your assistance.
What is patient compliance like with an oral appliance for snoring?
Compared to what? Generally speaking, patients that use prescription custom, adjustable MRAs, use them every night, insert them as they go to sleep and wear them until they wake up.

However, for the sleep apnoeaic patient, the MRA may be less effective (measured using overnight SpO2 saturation) yet used more frequently than PAP therapy (both more hours and more nights a week).

Which therapy is better?

Are MRAs adjustable by the patient, in terms of mandibular advancement?
Yes. While MRA designs vary, patients will find a way.

Further, you may wish to retain control of adjustment (see titration).

Patients may adjust the position in error (typically rapidly increase protrusion) and create TMJ issues that prevent use until the joint has recovered. Ultimately delaying effective therapy.

Should GDPs ask about sleep routinely?
By now you see there is a role (and therapy) ideally suited to the General Dental Practitioner.

It is your choice: do you want to help your patients in this way?

Anti-snoring devices may be categorised as 'luxury items' and your lab may charge VAT
Consult HMRC for the latest guidance.

HMRC (the UK's tax man) considers products for snoring, luxury items and demands 20% VAT.

For patients with diagnosed OSA an MRA is zero rated. You may reclaim 'input VAT'.

'Loose' lower incisors? Has the patient been wearing an OTC anti-snoring device?
OTC oral appliances will damage the patient.

Problems include:

  • Delayed diagnosis and effective therapy
  • Pain
  • Tooth movement or loss due to excessive and uncontrolled lateral loads
  • Posterior open bite
  • Development of a reverse incisor relationship
  • Development of a protruded mandibular posture
Maximum protrusion = maximum effect, right?
If only life was that simple!

The "Law of Diminishing Returns" applies to MRA titration: initially lateral loads are perhaps low (with minimal side-effects) and the effect increases linearly.

However, beyond a patient-defined protrusion, lateral loads significantly increase for non-linear gains in efficacy.

Still further protrusion may cause pain, significant dental side-effects and less effect.

Key sleep terms

  • OSA – Obstructive Sleep Apnoea
  • OSAS – Obstructive Sleep Apnoea Syndrome
  • ESS – Epworth Sleepiness Scale. Patient completed subjective assessment of sleepiness in specified circumstances
  • AHI – Apnoea Hypopnea Index. Index of sleep apnoea severity combining apnoeas and hypopneas:
    • 5–15/hr = mild;
    • 15–30/hr = moderate;
    • and > 30/h = severe
  • MRA – Mandibular Repositioning Appliance
  • PAP – Positive Airway Pressure
  • UPPP/LAUP – UvuloPalatoPharyngoPlasty – Laser Assisted UvuloPlasty

Downloads

PDF

  • Download: Example of an Informed Consent document as a PDF
  • Download: Management of sleep apnoea and snoring, suggested guidelines for General Practitioners and other interested medical professionals. As a PDF.

Now, it's your turn:

Did this Ultimate Guide help?

  • Are you inspired?
  • Concerned?
  • Awake?!

Let me know by leaving a quick comment below right now (scroll down).

Comment or write a review about prescribing oral appliances for snoring

References

Click to view the References
  1. SomnoMed 2017 Annual Report. [Accessed 9th Oct 2018]. Available here: https://somnomed.com/wp-content/uploads/2017/10/SomnMed-Annual-Report-FY17-FINAL-ASX.pdf 
  2. Ohayon Maurice M, Guilleminault Christian, Priest Robert G, Caulet Malijai. Snoring and breathing pauses during sleep: telephone interview survey of a United Kingdom population sample BMJ 1997;314 :860 [Accessed 21 Sept 2018] Available here: https://www.bmj.com/content/314/7084/860.short
  3. Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. (2009). Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine, 5(3), 263–276. [Accessed 19th Sept 2018] Available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699173/
  4. Remmers JE, deGroot WJ, Sauerland EK, Anch AM. Pathogenesis of upper airway occlusion during sleep. J Appl Physiol 1978;44:931-8. [Accessed 20th Sept 2018] Available here: https://www.physiology.org/doi/abs/10.1152/jappl.1978.44.6.931
  5. Issa FG,.Sullivan CE. The immediate effects of nasal continuous positive airway pressure treatment on sleep pattern in patients with obstructive sleep apnea syndrome. Electroencephalog Clin Neurophysiol 1986;63:10-7. [Accessed 20th Sept 2018] Available here: https://www.ncbi.nlm.nih.gov/pubmed/2416530
  6. Stradling J. Driving and obstructive sleep apnoea Thorax 2008;63:481-483. [Accessed 20th Sept 2018] Available here: https://thorax.bmj.com/content/63/6/481
  7. Guilleminault C, Tilkian A, Dement WC. The sleep apnea syndromes. Ann Rev Med 1976;27:465-84. [Accessed 20th Sept 2018] Available here: https://www.annualreviews.org/doi/abs/10.1146/annurev.me.27.020176.002341?journalCode=med
  8. Snoring and the role of the GDP: British Society of Dental Sleep Medicine (BSDSM) pre-treatment screening protocol. British Dental Journal, BDJ volume 206, pages 307–312 (28 March 2009) Available here: https://www.nature.com/articles/sj.bdj.2009.214 ↗ [Accessed 19th Sept 2018]
  9. Dental Defence Union position statement re snoring treatment. Available here: https://www.theddu.com/press-centre/press-releases/snoring-treatment ↗ [Accessed 19th Sept 2018]
  10. Dental Protection Ltd. Position statement: https://www.dentalprotection.org/uk/articles/snoring-and-obstructive-sleep-apnoea-syndrome ↗ [Accessed 19th Sept 2018]
  11. NICE. Dental checks: intervals between oral health reviews. Available here:  https://www.nice.org.uk/guidance/CG19 ↗ [Accessed 28th Sept 2018]
  12. Sleep-disordered Breathing, Adrian Zacher & Michael McDevitt, Carranza's Clinical Periodontology - E-Book: Expert Consult: Online, Elsevier Health Sciences, 2017. Accessible here: https://www.elsevier.com/books/carranzas-clinical-periodontology/newman/978-0-323-18824-1  ↗ [accessed 24th May 2018]

Snorer.me Signposting™ is a CE marked, Clinical Decision Support System, Software as a Medical Device. The Manufacturer is Snorer.com Ltd.

Created by Adrian Zacher and Emma Easton. All rights reserved.

Last updated 22nd Mar 2019.

This page is intended for Healthcare Professionals

This site is intended to provide balanced, scientific, and evidence-based information that is not intended as medical advice. Responsibility for patient care resides with the healthcare professional on the basis of his or her professional license, experience, and knowledge of the individual patient. This resource may include information that has not been approved by the US Food and Drug Administration. For full prescribing information, including indications, contraindications, warnings, precautions, and adverse events, please refer to the approved product labelling.

Dental Appliances for Sleep Apnoea | Snorer.com

Dental Appliances for Sleep Apnoea | Snorer.com

Dental Appliances for Sleep Apnoea

Snorer.com
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What is a Dental Appliance for Sleep Apnoea?

Dental appliances for sleep apnoea / apnea, hold your jaw forwards to aid breathing, while you sleep. They are prescription medical devices, for diagnosed obstructive sleep apnoea (OSA) patients.

If you snore or are worried you may have sleep apnoea (but are not yet diagnosed), then its easy and free to find out, and get signposted to the most appropriate professional to help you.

Go here.

Adrian Zacher MBA

Adrian Zacher MBA

Author, Snoring and Sleep Apnoea Care Navigator

I’m a sleep-industry insider with a quarter of century of sleep medicine experience.

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Dental appliances for sleep apnoea / apnea

How to get a dental appliance for sleep apnoea?

Dental appliances for sleep apnoea are an option for diagnosed obstructive sleep apnoea patients, who are unable to use Positive Airway Pressure (PAP) therapy. PAP therapy is considered the most effective way to treat obstructive sleep apnoea.

Sleep apnoea dental appliances are prescribed by sleep-trained dentists upon referral from a sleep unit.

A dental appliance may also be recommended by the doctor to be used in combination with PAP therapy, when pressures are very high. The idea is for the dental appliance to mechanically open the airway and it is hoped to reduce the PAP pressure required. This is typically for patients with severe obstructive sleep apnoea (OSA). 

Tired of the sleepiness and the snoring?

Then read our free, definitive step-by-step how to stop snoring Guide.

This comprehensive Guide walks you through self-help, signposting, screening, professional assessment and diagnosis, the three categories of prescription treatment, follow-up and rounds off with a substantial FAQ.

When you’re serious about not snoring read this.

Dental appliances for sleep apnoea: an appealing option?

Dental appliances for sleep apnoea may seem a good idea because apart from being far more discreet than PAP (Positive Airway Pressure therapy) what’s that?, there is no need for:

  1. A mask over your face
  2. A pump machine beside the bed
  3. A power supply
  4. A hose connecting you to the pump machine.

But the problem is:

How to know before buying one, if a dental appliance for sleep apnoea, will actually work?

The trouble with a custom-made dental appliance for sleep apnoea, is that you have to wait for it to be made for you.

They’re also:

  Expensive (don’t forget to factor in the dentist’s fees)

  There is no guarantee they will work

  You don’t know if you can even tolerate wearing it in your mouth

 

So, if like me you’re wondering….

Hang on, before I get one, I’d like to know if it works, and if I can wear it!” 

Then keep reading. You’re not alone in wanting to know if they work before they’re used:

The inability to determine BEFOREHAND, who will and who will not find oral appliance therapy effective, has impacted upon wider adoption of dental appliances (by the medical community) for patients with anything other than snoring or mild obstructive sleep apnoea.

So then, you’ll be interested in this brief introduction to the topic of a little known, third category of dental appliance for sleep apnoea.

But first, are dental appliances effective for sleep apnoea?

Can a dental appliance help sleep apnoea?

Yes. Prescription, custom-made, adjustable dental appliances are a valid option for sleep apnoea. They are however, considered second-line therapy (meaning there is a preferred therapy [first-line] i.e. PAP). 

‘Second line’ means that PAP is considered the best option and dental appliances are only considered when a patient fails with PAP therapy.

Can dentists treat sleep apnoea?

A qualified yes:

When a patient has been medically diagnosed and is then referred to a sleep-trained dentist, with a view to the dentist prescribing a custom-made dental appliance.

Such a sleep apnoea patient would require ‘objective titration’. This means that the protrusion (forward movement of the jaw achieved through use of the dental appliance) would be adjusted with reference to data obtained from repeat sleep studies, to ensure the patient’s sleep apnoea was effectively treated.

What is the best treatment for sleep apnoea?

Positive Airway Pressure (PAP) is considered by the medical profession to be the best treatment for sleep apnoea.

However, PAP is an arduous therapy and compliance (those who actually use it) for more than 4 nights a week and more than 4 hours each night are surprisingly few.

Consequently, dental appliances for sleep apnoea, although they may be considered less effective in terms of overcoming sleep apnoea (measured by oxygen desaturation), there is evidence that patients use them more than PAP.

Can dentists diagnose sleep apnoea?

Dentists cannot diagnose obstructive sleep apnoea (OSA). The diagnosis of obstructive sleep apnoea (OSA) is the exclusive preserve of the specialist consultant respiratory physician. 

Uniquely, sleep-trained dentists in the UK may:

  • Screen and recognise obstructive sleep apnoea (OSA) symptoms and refer for further investigation to the GP with a view to a home sleep study.
  • Then in defined circumstances:
    • Provide dental devices without a prior medical diagnosis for those without OSA symptoms

If you’re a dentist interested in training to provide dental appliances for snoring and sleep apnoea patients, then our KnowSleep™ Academy is for you!

How much does a dental appliance for sleep apnoea cost?

  • Some countries in Europe will pay for a dental appliance for a diagnosed sleep apnoea patient.
  • In the UK, this is a grey area. You may be able to obtain an NHS funded dental appliance (don’t expect the best or even a choice) but in my experience, you probably won’t get any help. It’s wrong and it needs to change. A ‘ball park’ price would be anything between ~350 to 1800 GBP for both the dental appliance and dental clinical fees. The price varies for the proximity to London, and of course the sophistication, quality and warranty provided for the dental appliance. Warranties of 5 years plus are available for certain appliances.
  • If you’re in the US and diagnosed with sleep apnea (different spelling) then you should find your dental appliance is a ‘reimbursed therapy’ my advice is to check which dental appliances ARE paid for by Medicare (not all are).

Categories of dental appliance for sleep apnoea

‘One-size fits all’ and custom-made dental appliances comprise two categories of dental appliance for snoring and sleep apnoea:

Category 1: ‘One-Size-Fits-All’

Not a lot positive to say about category 1 dental appliances. Read this if you want to understand more about the ‘interesting’ claims made for them. 

Category 2: Custom-made dental appliances for sleep apnoea

Here are some examples of the 2nd category of dental appliance for sleep apnoea:

The prescription, custom-made, bi-bloc design, dental appliance:

Example dental appliance for sleep apnoea

Figure 1. SomnoWell dental appliance for sleep apnoea. Image used with permission.

Example dental appliance for sleep apnoea

Figure 2: SomnoMed dental appliance for sleep apnoea. Image used with permission from SomnoMed UK Ltd.

How to prescribe oral appliances for snoring and sleep apnoea / apnea
How to stop snoring: The definitive, step-by-step Guide

There is now a 3rd category:

Figure 3, shows the actual predictor prototype ‘in the flesh’ and Figure 2 illustrates where predictor dental appliances fit in the overall taxonomy.

3rd Category of MAD. The predictor / titration MAD

Figure 3:
The Predictor / Titration dental appliance for sleep apnoea
invented by Adrian Zacher MBA.

Taxonomy of dental appliances for sleep apnoea and snoring
Figure 4: Taxonomy of dental appliances for snoring and obstructive sleep apnoea.

Why a 3rd category of dental appliance for sleep apnoea?

Predictor dental appliances for sleep apnoea are not the same as over-the-counter (OTC) anti-snoring devices. OTC anti-snoring devices have been researched (learn how they faired in this definitive guide ↗).

Some years ago (struth it was 2011), I witnessed the competitive emergence of a third category of dental appliance for obstructive sleep apnoea / apnea and snoring:

The Predictor

A Predictor dental appliance is NOT intended to provide long-term therapy. 

Below is short video animation of a prototype sleep apnoea dental appliance (predictor) there is no sound.

Remember, this is an early prototype and it’s NOT intended to be worn for any length of time!

Figure 5. CAD prototype of a predictor dental appliance for sleep apnoea and snoring

What questions do predictor dental appliances answer?

The predictor dental appliance finally emerging commercially, interests me as in 2003, I patented new-window (yup, that long ago) a dental appliance with the design intention being to determine: 

1  Can a patient wear a dental appliance? Something that I consider is an underestimated challenge

2  Does it work? 

This second point means both:

  • Subjectively = Partner reported incidence of snoring (during this time the wearer also has the opportunity to adapt to wearing a dental appliance – or perhaps NOT – and the custom-device will of course feel far more discreet)
  • Objectively = In a sleep lab setting the Physician can feel confident ‘signing off’ that the patient will be effectively treated with a dental appliance in the position determined by the Predictor dental appliance

So what? ‘Building the Bridge’

If obstructive sleep apnoea (OSA) patients’ are to be effectively treated the medical and dental profession must work together in a more patient-centric way.

Predictor dental appliances are perhaps the means to ‘build the bridge’ between the two.

The medical professional knows:

1  If the patient responds to mandibular protrusion prior to referral to a dentist for a dentally prescribed custom-made dental appliance

2  That the patient will be effectively treated with a dental appliance, and is ‘prescribing’ a jaw relationship

And the patient knows BEFOREHAND if a dental appliance will work!

I let my patent lapse. This was over 15 years ago! (2003) Damn.

 

Learn more about dental appliances for sleep apnoea:

Download the free bonus below and train at the on-demand KnowSleep™ Academy from Snorer.training:

Download the 'Mouthpiece' Guide as a PDF

Co-author by Adrian Zacher MBA
Co-author Dr Roy Dookun BDS
Peer reviewed by Dr Shouresh Charkhandeh DDS

In this NHS England’s Information Standard accredited Guide, you’ll learn in jargon-decoded language:

  • About the different types of ‘Mouthpiece’
  • How to get one (that actually works)
  • About the possible side-effects

No signup is required.
No credit card.
Nothing at all in fact.
We do this to help – because we can.

Snoring & Obstructive Sleep Apnoea Overview

Meet the co-authors and peer reviewer

Adrian Zacher. Click for full profile [new tab]

Adrian Zacher MBA

Author and Founder of Snorer.com

Dr Roy Dookun BDS, MFGDP (UK), MGDSRCS (Eng), FFGCP (UK), DIP DENT SED

Co-founder and former President British Society of Dental Sleep Medicine

Dr Shouresh Charkhandeh DDS

Award winning Dental Sleep Medicine Dentist

KnowSleep™ Academy: Snoring courses for dentists

Snoring & Obstructive Sleep Apnoea (OSA) – the role of the dentist.

We provide enhanced CPD (continuing education) training courses for dentists and support staff wishing to further their knowledge and understanding about treating patients who snore and/or may have obstructive sleep apnea / apnoea (OSA).

Our on-demand snoring courses for dentists, teach dentists (and GPs) how and when to prescribe custom-made, dental appliances for sleep apnoea and snoring. 

Reviews and Testimonials

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This is a very comprehensive review of the causes of snoring and how and why it is important to treat certain types. Everyone who is affected by snoring would benefit by following the advice here, possibly more than they could imagine. It will change lives.

Sarah Murphy Overview of snoring and obstructive sleep apnoea June 17, 2019

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If you think you have a sleep disorder please seek appropriate medical advice.
If you’re in the UK you can get signposted to the most appropriate professional to help you for free. Here.
Created by Adrian Zacher | Page last updated 22nd Mar 2019

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