The American Academy of Dental Sleep Medicine (AADSM) is committed to endorsing evidence-based, clinically proven therapies and ensuring any emerging therapies are supported by adequate science prior to recommendation. Consequently, the AADSM recently launched an important review of the available literature regarding some of these emerging treatments to provide guidance to the dental sleep medicine field.
Continuous positive airway pressure (CPAP) therapy is often the first-line treatment for OSA in adults. Oral appliance therapy (OAT) is also an appropriate first-line treatment for adults who cannot tolerate or prefer not to use CPAP. Our clinical consensus panel recently published a detailed evaluation of emerging dental therapies for OSA and snoring in a special article in the Journal of Dental Sleep Medicine.2
While their paper covers both pediatric and adult populations, this article summarizes the panel’s findings for adult patients with OSA.
Myofunctional Orthodontics for Malocclusion
The treatment: Myofunctional orthodontics for malocclusion relies on removable or fixed devices designed to correct poor muscular habits that cause jaw misalignment.
The claim: Myofunctional orthodontics improves oral posture, tongue function, and muscle coordination, thereby reducing snoring by improving breathing patterns and oral habits that can lead to airway dysfunction.
The findings: When considering potential harms, alongside the lack of evidence, the panel determined that there is not enough evidence to support the use of myofunctional orthodontics for adults with OSA.
The consensus panel evaluated peer-reviewed literature indexed in PubMed for this project. Only one paper was available that reported on the use of myofunctional orthodontics for OSA in adults.3 While the study claimed a statistically significant reduction in OSA severity, some patients actually experienced an increase in apnea hypopnea index (AHI) with this treatment.
The methodology and statistical approach in this paper did not provide clarity as to how the impact of the proprietary device being studied was separate from other potential variables, such as the other components of the therapy or night-to-night sleep test variability. The clinical consensus panel noted that bone growth may not be feasible in adult populations and that moving teeth into areas without bone can be associated with significant adverse effects for the patient.
Expansion for Maxillary Constriction
The treatment: Rapid maxillary expansion (RME) is an orthodontic treatment that widens the maxilla by placing an expansion screw in the palate that is secured to the teeth.
The claim: By increasing the space in the mouth for soft tissue, nasal resistance is reduced, which leads to lowering the risk for pharyngeal collapse.
The findings: The panel concluded that, for adults, the use of expansion to manage OSA is only supported in the literature for patients with an orthodontic transverse discrepancy—a skeletal deficiency in the upper jaw that can be a major component of malocclusion. Even in those cases, the panel cautions that current evidence is not available to confirm the long-term persistence of any benefits achieved with this treatment. Expansion in adult patients is not currently supported in the literature in the absence of a transverse discrepancy or for use in preventing or curing OSA.
Expansion is difficult to accomplish in adults without surgical assistance because the midpalatal suture and adjacent sutures are resistant to movement after adolescence. Using nonsurgical arch expansion in adults increases the risk of tooth tipping in unstable teeth, increased root resorption, and cortical bone damage. Although the studies reviewed do suggest that a reduction in AHI and improvement in subjective measures could result from maxillary expansion in adults, the panel noted that available evidence shows residual disease after expansion and that future longitudinal studies are required to determine the durability of the benefits of this procedure. Additionally, all the research participants presented with some form of orthodontic transverse discrepancy, making it unrealistic to generalize the findings to the entire adult population.
Myofunctional Therapy for Tongue Motor Immaturity
The treatment: Myofunctional therapy (MFT) uses breathing exercises and orthopedic devices to improve mouth and throat functions. The treatment is focused on improving speech and swallowing to enhance orofacial growth.
The claim: These endurance exercises improve the tone, tension, and mobility of the muscles in the tongue and surrounding soft tissues, which reduce airway collapse during sleep.
The findings: The panel found that the current literature does not support the use of myofunctional therapy in adults as a standalone treatment for OSA; however, it may be an adjunct management therapy to consider for use in some circumstances.
A number of studies have been published in recent years on the use of MFT in adults with OSA. The panel noted the lack of a standardized approach to MFT in these studies and, therefore, found it difficult to support a recommendation for adoption of the therapy. However, the panel agreed that the risk of harm from MFT is relatively low, so treating practitioners may use their clinical judgement to determine whether the provision of MFT by an appropriately trained individual may be suitable in some cases.
Lingual and Buccal Releases for Tethered Tissues
The treatment: Lingual and buccal releases involve the surgical alteration of tethered oral tissues, including the frenulum.
The claim: Altering tethered oral tissues allows the tongue to move more freely to the top of the mouth during sleep, reducing the likelihood of tongue collapse.
The findings: The panel found no current literature to support the use of lingual or buccal tethered tissue release in adults as an effective treatment for OSA.
In addition to the lack of literature, the panel noted that these procedures are associated with a number of significant risks. For example, lingual and buccal releases can lead to infection, scarring, pain, and altered sensory or motor function. As there is no proven benefit of these procedures to address OSA, it is not advised to undertake such risks.
Laser Treatment for Elongated or Edematous Soft Palate and Adjacent Tissue
The treatment: Laser treatments are used to remove excess upper airway tissue prone to collapse. Lasers are applied to various soft tissues in the upper airway, including the soft palate, uvula, and surrounding tissues.
The claim: Laser procedures tighten the soft palate tissue, which opens airways and reduces or eliminates snoring.
The findings: The panel did not find sufficient evidence to recommend ablative or non-ablative laser therapy (NALT) for adults with OSA.
The panel also noted that ablative laser therapy is no longer recommended by the American Academy of Sleep Medicine as a treatment for OSA in adults due to unclear benefits and an elevated risk for adverse effects. The consensus panel’s review confirmed that the evidence is insufficient to recommend ablative laser therapy at this time.
The panelists noted several weaknesses in the current literature studying NALT for adult OSA treatment. In general, the studies lacked valid scientific methodology, including lack of control groups, confounding results from studies on ablative and non-ablative laser therapy, and did not confirm whether patients in the study had a diagnosis of OSA. Due to these variations, the panel concluded that currently there is insufficient evidence to support the use of NALT for adult OSA.
Conclusion
It is highly likely that another product or therapy promising to “cure OSA” will pop up before this article is even published. After all, OSA is a problem nearly 54 million Americans have. However, conducting further research on any potential OSA therapy is essential. Clinical studies, peer-reviewed findings, and years of proven effectiveness are essential, and so far, OAT is the only dental treatment proven to be as effective as CPAP to manage OSA in adults.
References
1. Heim S, Keil A. Too much information, too little time: How the brain separates important from unimportant things in our fast-paced media world. Front Young Minds. 2017;5:23.
2. Sheats R, Masse J, Levine M, et al. Novel therapies for preventing, managing and treating obstructive sleep apnea and snoring in pediatric and adult patients. J Dent Sleep Med. 2024;11(2).
3. Katz D, DeMaria S, Heckman S, Lin F, Kushida C. Use of the Complete Airway Repositioning and Expansion (CARE) approach in 220 patients with obstructive sleep apnea (OSA): A retrospective cohort study. Sleep Med. 2022;99:18-22.
