Think Before Sinking Your Teeth into Oral Appliance Therapy

T treatment of obstructive sleep apnea (OSA) has been undergoing a steady shift over the last decade. Whereas continuous positive airway pressure (CPAP) was more or less the sole effective treatment for many years, the landscape is changing with a growing number of treatment alternatives of varying effi cacy, and a move toward personalized care. Oral appliance therapy is increasingly recognized as a viable treatment alternative for OSA. Mandibular advancement splints (MAS) are the most common form of oral appliance used in clinical practice and are currently indicated for treatment of mild to moderate OSA patients and severe OSA patients who are intolerant or refuse CPAP therapy. This clinical shift toward increasing usage of MAS is underpinned by a growing evidence base that has identifi ed good treatment effi cacy for patients across the spectrum of mild to severe OSA and higher patient preference for this form of treatment. While this augers well for enhancing treatment adherence and treatment outcomes, some unease exists among clinicians and patients about long term side effects. A number of studies have demonstrated the appearance of minor, usually subclinical, changes in the dentition over time.1,2 The details surrounding the appearance and time course of these changes have been poorly understood. Hence, the paper by Pliska and colleagues3 in this issue of JCSM is a welcome addition to the literature. This landmark longitudinal study, representing the longest follow-up published to date, documented clinically signifi cant changes in occlusion that were progressive over an average of 11 years of MAS use, based on dental study cast analysis. 77 patients (62 males, mean BMI 29 kg/m2) including snorers and patients with a broad spectrum of OSA severity were evaluated and found to have signifi cant decreases in overbite (2.3 ± 1.6 mm), overjet (1.9 ± 1.9 mm) and mandibular crowding (1.3 ± 1.8 mm). Interestingly, signifi cant increases in mandibular intercanine (0.7 ± 1.5 mm) and intermolar widths (1.1 ± 1.4 mm) were found. Half of the patients developed a posterior openbite, defi ned as a loss of occlusal contact on at least 2 posterior teeth. Moreover, 62% (48/77) of the group also developed an anterior crossbite of at least one tooth with an average of 4 teeth being observed. This study builds on previous work by these authors and others.1,2 The magnitude of overbite (2.3 mm) and overjet (1.9 mm) changes described in this study associated with over a decade of MAS use is greater than previous long term (> 5 years) studies. Think Before Sinking Your Teeth into Oral Appliance Therapy Commentary on Pliska et al. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med 2014;10:1285-1291.