How do Sleep Apnea Mouthguards Compare to CPAP?

How effective are sleep apnea mouthguards when compared to CPAP therapy?  Here we review the current information comparing the effectiveness of CPAP therapy and custom dental apnea mouthguards, a well-researched treatment for obstructive sleep apnea.

What is Sleep Apnea?

Sleep apnea is a fairly common medical condition that can be potentially deadly. The word apnea means “without breath”. During sleep apnea, the upper airway becomes blocked during sleep, reducing or completely stopping airflow for at least 10 seconds. Untreated sleep apnea can have serious consequences: high blood pressure, heart disease, stroke, automobile and work-related accidents, diabetes, depression, and even death.  Sleep apnea occurs during sleep and most individuals are completely unaware of it occurring. This is why it can be so serious.

There are three types of sleep apnea: obstructive, central, and mixed. Of these, obstructive sleep apnea (OSA) is the most common. A person that experiences untreated sleep apnea can have hundreds of apnea episodes throughout the night, sometimes lasting a minute or more.

Many times this condition will go undetected, particularly if the person does not have a bed partner. Often, it is a spouse or significant other that first notices the issue. The bed partner may complain about loud snoring or snorting sounds throughout the night. The person experiencing the sleep apnea may complain of waking with a dry mouth, headaches, and daytime sleepiness. At other times, apnea patients do not experience any additional notable symptoms other than snoring.

There are different methods available today to treat sleep apnea. A person must first be evaluated by a physician through a sleep study (polysomnogram) or a home sleep test to confirm the diagnosis. Once the sleep study is completed and a diagnosis is made, it is then determined what type of treatment may be prescribed.

Continuous Positive Airway Pressure (CPAP) Therapy and OSA

How does CPAP work?

Continuous positive airway pressure (CPAP) therapy is considered the gold standard of treatment for individuals that have been diagnosed with obstructive sleep apnea (OSA). CPAP therapy has been used to treat sleep apnea since 1981 with patients of all ages.

A CPAP device consists of a small motor with a fan that takes in room air, filters it and delivers air at a designated pressure through a mask that fits over the mouth and nose of the user. The effective pressure setting for an individual is determined through the help of a sleep study (polysomnogram). The purpose of this setting is to provide the correct amount of air pressure in order to keep the airway open during sleep, eliminating apneic events.

The use of a CPAP device not only helps to eliminate or reduce apnea episodes, but it also has been shown to improve the quality of life for its users, by allowing the individual to get restful sleep and by reducing the risk of the chronic health consequences of untreated OSA.

Although very effective, many people complain that CPAP masks are cumbersome and uncomfortable to sleep with. For these reasons patients often do not use CPAP therapy as prescribed.

CPAP Use and Compliance

CPAP therapy is only 100% effective when worn as prescribed and fitted properly. However, as many as 40-50% of all OSA patients don’t adjust to sleeping with a CPAP or outright refuse to use it.

The results of a twenty-year study on CPAP adherence reviewed the results of 84 different studies conducted between 1994 and 2015. During this comprehensive review, the CPAP non-adherence rate was determined as anything less than 7-hours of use per night sleep time. With this parameter,  they found that 34.1 % of all patients were non-compliant.

However, many other medical studies on compliance and most sleep care professionals consider adequate CPAP compliance as 4 hours per night average usage and greater than or equal to 70% of nights.  That means the other hours beyond the 4-hour window of sleep time or the 3 of 10 nights the patient may not be using the device at all, they are still considered overall “compliant”. Even with such a short amount of hours required, it has been reported that 46 to 83% of patients with OSA were noncompliant with the treatment prescribed.

Sleep Apnea Mouthguards

The American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) have set guidelines for the use of well-researched sleep apnea mouthguards that are known by health care clinicians as “oral appliances”. The dental service area specifically known as oral appliance therapy involves the fabrication of custom-made dental sleep apnea mouthguards.

A sleep apnea mouthguard maintains an open airway by repositioning the jaw and soft tissues of the throat that block the airway during an apnea event. The devices look much like a sports mouthguard or an orthodontic retainer and are custom-made specifically for that person by a trained dentist.

Oral appliances have several advantages that patients often struggle with in terms of CPAP therapy. Oral appliances or sleep apnea mouthguards do not require electricity, do not produce noises, do not restrict sleeping position, and allow wearers to speak or drink water while wearing their devices.

Most recent oral appliance therapy guidelines state that in order for apnea mouthguards to be properly fitted, they should be prescribed by certified sleep physicians followed by treatment by qualified dentists.

Although not effective for all individuals, decades of research have shown that sleep apnea mouthguards (custom dental appliances) are an effective treatment for many snoring and obstructive sleep apnea sufferers.

Jointly, the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine have recommended that oral appliances can be prescribed for:

• Patients that snore but have no apnea (verified through testing)
• Patients at all levels of apnea that have attempted CPAP therapy unsuccessfully
• Any patient that prefers to seek out oral appliance therapy as an alternative to CPAP therapy

CPAP Therapy vs Sleep Apnea Mouthguards: A Summary of How They Compare on Overall ‘Effectiveness’

Successful treatment of apnea events, whether through CPAP or custom sleep apnea mouthguards, has been found to improve blood pressure, reduce the risk of fatal cardiovascular events, improve daytime sleepiness, and improve quality of life.

Some studies have found that patients that use sleep apnea mouthguards tolerate these devices more easily than CPAP therapy. When patients use a sleep apnea mouthguard, they often keep the devices inserted for most of the night and wear the devices more nights of the week than when they had attempted  CPAP use.

The question of which treatment may be best for an apnea individual depends on a number of factors. One of the biggest factors is the compliance of prescribed treatment.  If an OSA patient cannot tolerate CPAP therapy or refuses to use it, then a qualified sleep medicine dentist can offer help.

Some research has demonstrated that oral appliances can offer very similar overall health outcomes as CPAP therapy when many common factors including patient compliance and preference are reviewed.

Overall there is approximately a 70-85% chance that a custom apnea mouthguard will be effective in treating OSA. Factors such as the experience of the dentist providing the service, limitations of the device chosen, the severity of apnea, natural jaw movements and weight of the individual can all impact success levels.

According to the research article Efficacy versus Effectiveness in the Treatment of Obstructive Sleep Apnea: CPAP and Oral Appliances (Sutherland, Phillips & Cistulli, 2015),  oral devices overall stack up quite high in overall health outcome when compared to CPAP therapy. CPAP therapy may be more effective when used, but oral devices are tolerated more easily and worn for more hours than CPAP therapy.

In other words, for many apnea sufferers, both types of therapies–CPAP therapy and custom sleep apnea mouthguards— may have comparable end results in treating apnea.

References

Almeida, F. R., & Bansback, N. (2013). Long-term effectiveness of oral appliance versus CPAP therapy and the emerging importance of understanding patient preferences. Sleep, 36(9), 1271–1272. https://doi.org/10.5665/sleep.2938

American Academy of Dental Sleep Medicine. (2015). Oral Appliance Therapy.

American Dental Association. (2017). Evidence Brief: Oral Appliances for Sleep-Related Breathing Disorders.

American Sleep Apnea Association. (2017). Sleep apnea information for individuals.

Kribbs, N. B., Pack, A. I., Kline, L. R., Smith, P. L., Schwartz, A. R., Schubert, N. M., … & Dinges, D. F. (1993). Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. American Review of Respiratory Disease, 147(4), 887-895.

Kapur, V. K., Auckley, D. H., Chowdhuri, S., Kuhlmann, D. C., Mehra, R., Ramar, K., & Harrod, C. G. (2017). Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(03), 479-504.

Nico de Vries, M. D., Ravesloot, M. J., Benoist, L., & van Maanen, J. P. (2018). Analysis of CPAP Failures. Sleep Apnea and Snoring E-Book: Surgical and Non-Surgical Therapy, 56.

Ramar, K., Dort, L. C., Katz, S. G., Lettieri, C. J., Harrod, C. G., Thomas, S. M., & Chervin, R. D. (2015). Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. Journal of Clinical Sleep Medicine, 11(07), 773-827.

Rotenberg, B. W., Murariu, D., & Pang, K. P. (2016). Trends in CPAP adherence over twenty years of data collection: a flattened curve. Journal of Otolaryngology-Head & Neck Surgery, 45(1), 43.

Sutherland, K., Phillips, C. L., & Cistulli, P. A. (2015). Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and oral appliances. Journal of Dental Sleep Medicine, 2(4), 175-181.

Weaver, T. E., Maislin, G., Dinges, D. F., Bloxham, T., George, C. F., Greenberg, H., … & Pack, A. I. (2007). Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep, 30(6), 711-719.

Weaver, T. E., & Grunstein, R. R. (2008). Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proceedings of the American Thoracic Society, 5(2), 173-178.