Comparison of a noncustom vs custom mandibular advancement device to treat obstructive sleep apnea

Journal of Clinical Sleep MedicineVolume 19, Issue 1 INTRODUCTION The recent article by Bosschieter et al1 compared a custom fabricated appliance to a noncustom, temporary appliance and found that, over a 12-week period, the 2 devices were statistically similar in efficacy. While this article provides evidence of noncustom appliances as an interim treatment, dentists must still provide a custom appliance in a timely manner and adhere to the American Academy of Sleep Medicine (AASM) clinical practice guideline that suggests custom, titratable appliances be used over noncustom appliances.2 During the study, the fitting and treatment of both the custom and noncustom appliances were overseen by a dentist. In practice, a qualified dentist selects an appropriate custom appliance based on craniofacial structures; dental, temporomandibular joint, and periodontal status; and patient cognitive ability, manual dexterity, visual acuity, and nasal patency.3 Many patients may be unaware of their own contraindications to treatment and studies report side effects with noncustom appliances. In a direct-to-consumer world, we have concerns that irreversible insult to the temporomandibular joint and surrounding oral structures may occur4 and caution both providers and their patients from conflating a noncustom, temporary device with an over-the-counter oral appliance. Also, although the article did not show any significant differences in reported side effects, this may be attributable to the very small sample size. It is noted that both appliances were initially protruded to 50% and then titrated to maximum comfortable protrusion.1 In the short and long term, this approach could lead to an increased occurrence of side effects.5 This study suggests promise for the use of noncustom fabricated appliances as a trial device, but more long-term research on side effects and patient compliance must be conducted, especially given the conflicting research in this area.6–9 In practice, when noncustom appliances are used, they should be utilized in the short term only and not as a replacement for custom-fabricated, long-term oral appliances. A qualified dentist should always supervise oral appliance therapy, as they are trained to minimize side effects as well as manage side effects that may arise. If a noncustom fabricated appliance is provided, the qualified dentist should refer to Food and Drug Administration and manufacturer guidelines on how long such appliances can last and subsequently provide the patient with a long-term, custom-fabricated appliance.