The impact of oral appliance therapy and mandibular advancement devices on jaw function symptoms in sleep apnea: a narrative review
Keita Takizawa1
, Kana Ozasa1, Shuangshuang Wu2, Zhimin Yan2, Andrew Young3, Noboru Noma1
Contributions: (I) Conception and design: All authors; (II) Administrative support: N Noma; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background and Objective: Temporomandibular disorders (TMDs) are a common concern for patients using oral appliances (OAs) and mandibular advancement devices (MADs) for the treatment of obstructive sleep apnea (OSA). This narrative review aims to provide a comprehensive understanding of how OAs and MADs affect TMD, by highlighting the existing knowledge gap, exploring their impact on dental structures, and examining their role in TMD management and patient adherence to treatment.
Methods: Fifteen comparative studies on the effects of OA or MAD on the prevalence of TMD signs and symptoms in OSA patients were selected from PubMed, screened by N.N. and K.T., with disagreements resolved by a consensus team.
Key Content and Findings: This review highlights both the positive outcomes and the challenges associated with OA and MAD therapy for OSA patients. While some studies showed reduced TMD symptoms, others report TMD pain and occlusal changes. Proper management strategies, including jaw exercises and dental titration, are important for mitigating these side effects. Long-term use of MADs often involves transient TMD issues resolving within 6 months to a year, emphasizing the importance of careful patient evaluation and follow-up to ensure treatment success and minimize TMD-related complications.
Conclusions: Proper management and follow-up are crucial for mitigating TMD symptoms in OSA patients using OA and MAD therapies.
Keywords: Oral appliances (OAs); mandibular advancement devices (MADs); temporomandibular disorders (TMDs); obstructive sleep apnea (OSA)
Received: 20 July 2024; Accepted: 13 September 2024; Published online: 24 October 2024.
doi: 10.21037/joma-24-16
Introduction
Background
Oral appliance (OA) therapy is one of many treatment modalities for obstructive sleep apnea (OSA). An OA functions by positioning the mandible forward to enlarge the upper airway and prevent airway obstruction during sleep (1-3). However, OA therapy may result in short-term side effects such as occlusal discomfort, and for some patients, it can lead to temporomandibular disorders (TMDs) involving pain in the temporomandibular joint (TMJ) and masticatory muscles due to the unnatural anterior positioning of the mandible (4-7). Pain in the TMJ and masticatory muscles associated with OA use can reduce treatment compliance and potentially lead to treatment failure. In fact, common reasons for discontinuation of OA therapy include perceived lack of improvement and side effects (8-10). Therefore, long-term use and successful treatment outcomes of OA therapy requires prevention of TMD and maintaining oral comfort with the OA.
Conversely, the use of mandibular advancement devices (MADs), which also position the mandible forward, has been debated, with some suggesting they are contraindicated for patients suffering from musculoskeletal disorders of the masticatory system, known as TMD (11,12). TMD encompasses a range of clinical conditions involving the masticatory muscles, the TMJ, or both (13). TMD prevalence has been reported to reach up to 30% (14-17), often starting in early adulthood and intermittently continuing into middle age (18).
Rationale and knowledge gap
OA therapy positions the mandible forward to treat OSA. The impact of OA therapy on TMD remains a knowledge gap in current literature, particularly regarding their specific effects on TMD prevalence in OSA patients.
Objective
Given that the management of OSA is often a long-term commitment, it is crucial to understand the impact of OAs and MADs on dental structures and TMDs. This narrative review aims to evaluate the effects of OAs and MADs on the prevalence of TMD signs and symptoms in OSA patients. Furthermore, it seeks to address the existing knowledge gap regarding the long-term impact of these devices on TMD, focusing specifically on how different aspects of device design and usage contribute to TMD outcomes. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-16/rc).
Methods
Source material was obtained through a PubMed literature search using the terms “OSA AND oral appliance AND (temporomandibular disorders OR painful TMD)” (Table 1). Our inclusion criteria were any type of studies with comparison groups on the topic of OA of MAD and jaw function in sleep apnea, totaling fifteen studies, including original studies published in English. Our exclusion criteria case reports, protocols, short communications, review articles and meta-analyses. N.N. and K.T. screened full-text article independently and all disagreements were resolved through consensus with K.O., S.W., Z.Y. and A.Y. (Table 2).
Table 1
| Items | Specification |
|---|---|
| Date of search | July/12/2024 |
| Databases and other sources searched | PubMed |
| Search terms used | “OSA AND oral appliance AND (temporomandibular disorders OR painful TMD)” |
| Timeframe | July/01/2014–July/01/2024 |
| Inclusion and exclusion criteria | Inclusion criteria: studies of any type of studies with comparison groups on the topic of OA, MAD and jaw function in sleep apnea |
| Exclusion criteria: case reports, protocols, short communications, review articles, meta-analyses | |
| Selection process | Selection performed by N.N. |
OSA, obstructive sleep apnea; TMD, temporomandibular disorder; OA, oral appliance; MAD, mandibular advancement device.
Table 2
| Author, year | Study design | Sample size | Type of appliance | Advancement | Assessment method | Follow-up | Authors main conclusions |
|---|---|---|---|---|---|---|---|
| Banhiran et al. 2014, (19) | Prospective, nonrandomized, before-after study | 64 adult patients (40 men and 24 women) | MAD (attached lower midline, prefabricated trays with thermoplastic interior surface, allows laterotrusion) | Not stated | • Epworth Sleepiness Scale | 4 to 6 months | A properly fitted AT-MAD is an effective short-term OSA treatment with improved QOL and tolerable adverse effects like TMJ discomfort, dry mouth, and excessive salivation |
| • Questionnaire | |||||||
| Alessandri-Bonetti et al. 2016, (20) | Prospective controlled cohort study | 27 OSA patients (24 males and 3 females; 54.8±11.8 years. 27 age- and sex-matched controls | MAD (attached bilateral traction, laboratory-fabricated, allows opening and laterotrusion) | Not stated | • Pressure Pain Threshold of Masticatory Muscles | 15 days (T1), and after 6 months | The use of a MAD initially reduces PPT in masticatory muscles, but adaptation occurs within 6 months |
| • Questionnaire | |||||||
| Ishiyama et al. 2017, (21) | Randomized, double-blind, placebo-controlled trial | 25 patients (21 men, 4 women) | MAD (unattached bilateral interlocking, laboratory-fabricated, allows opening and laterotrusion) | 50–70% | RDC/TMD | 2 weeks, 1 month, 3 months | Performing jaw-opening exercises before initiating oral appliance therapy was found to decrease the risk of TMD pain associated with OA use |
| Nikolopoulou et al. 2020, (22) | Randomized, placebo-controlled trial | 64 mild to severe OSA patients (52.0±9.6 years) | Nasal CPAP and MAD (laboratory-fabricated, does not allow opening or laterotrusion) | 25–70% | Questionnaire | 6 months | After 6 months, OSA patients showed low TMD pain frequency and no difference in mandibular function impairment, regardless of treatment with MAD or nCPAP |
| Tegelberg et al. 2023, (23) | Randomized controlled trial | 192 patients | Two types of MAD (unattached bilateral interlocking, laboratory-fabricated, allows opening and laterotrusion) and (laboratory-fabricated, does not allow opening or laterotrusion) | 75% | Questionnaire | 1 year | The low risk of pain and functional issues in the masticatory system suggests that oral appliance therapy is safe and recommended |
| Pahkala 2024, (24) | Prospective controlled cohort study | 28 males | MAD (unattached bilateral interlocking, laboratory-fabricated, allows opening and laterotrusion) | 70% | • Questionnaire | 1 week, 3 months, 6 months, 12 months | Oral appliance use showed time-dependent mild changes in overjet, overbite, and TMD signs over 1 year |
| • Occlusal indicate | |||||||
| • TMD findings |
The values of age are presented as mean ± standard deviation. OSA, obstructive sleep apnea; MAD, mandibular advancement device; CPAP, continuous positive airway pressure; RDC/TMD, research diagnostic criteria for temporomandibular disorder; AT-MAD, adjustable thermoplastic mandibular advancement device; QOL, quality of life; TMJ, temporomandibular joint; PPT, pressure pain threshold; OA, oral appliance; nCPAP, nCPAP, nasal continuous positive airway pressure.
Results
The literature search retrieved 15 candidate articles (Figure 1), which underwent screening. Based on the abstracts, 5 articles did not meet the inclusion criteria and were excluded from the review. Full texts of remaining 10 articles were retrieved, and after fill-text review, 4 more articles were excluded. Additionally, 6 articles [Banhiran et al. 2014 (19), Alessandri-Bonetti et al. 2016 (20), Ishiyama et al. 2017 (21), Nikolopoulou et al. 2020 (22), Tegelberg et al. 2023 (23), and Pahkala 2024 (24)] were identified through the references of the included studies; upon full-text review, they met the inclusion criteria and were included in this review.
Discussion
OA are effective in ameliorating the respiratory events of OSA, but they often come with side effects such as changes in occlusal (tooth) contacts, changes in mandibular positioning, and signs and symptoms of TMD, and can have both positive and negative effects on TMD symptoms (25). The aim of this narrative review was to examine the impact of MAD or OA on the TMJ, masticatory muscles, and occlusion in OSA patients. Additionally, this review discusses literature-based considerations for addressing these side effects. All MADs included in this review covered all teeth of both arches, fit passively without causing orthodontic movement of teeth, and allowed adjustment in the amount of mandibular protrusion.
In some studies, TMD was observed to be significantly reduced during OA treatment, while in other studies, TMD developed or increased. These opposite effects highlight the need to carefully consider factors such as the type of MAD device, TMD evaluation techniques, and follow-up periods. These findings provide insights for clinical decision-making and further research on the relationship between MAD treatment and TMD occurrence.
Three studies included in this review report on the occurrence of TMJ pain, TMD symptoms, jaw functional abnormalities, and occlusal changes with OA therapy (21-24). In a study by Ishiyama et al., to prevent early onset of painful TMD during OA therapy, 13 of the 25 patients were instructed to perform jaw opening exercises for 1 month, and 12 performed a placebo exercise (21). One case in the exercise group, and four cases in the placebo group experienced TMD, which resolved by the 3-month evaluation. Average pain levels were also significantly lower in the exercise group compared to the placebo group. This study suggested the importance of focused exercises for managing TMD related to OA.
Tegelberg et al. reported that treatment of OSA with OA did not significantly affect TMJ function or related symptoms over a 1-year period (23). They observed improvements in morning headaches, but increased difficulty in jaw function upon awakening. There were no significant changes in jaw mobility, dental occlusion, or pain in TMJ and masticatory muscles. Their findings indicate a low risk of pain and functional impairment in the TMJ with OA use.
Pahkala evaluated three occlusal indicators (overjet, overbite, molar occlusion) and clinical TMD signs (TMJ pain, muscle pain, clicking, jaw deviation on opening) at baseline and at 3-, 6-, and 12-month follow-ups after OA placement (24). Clicking was found to be a persistent TM disorder and was significantly more frequent in females than males. Regarding occlusal indicators, they reported reductions of 0.36 mm in overjet and 0.25 mm in overbite over one year, with occlusal changes observed in only four men and four women after OA treatment.
On the other hand, three studies reported occurrences of TMD pain, TMD symptoms, and mandibular functional impairment after MAD use (19,20,22). Banhiran et al. reported mild to moderate symptoms of TMJ discomfort and occlusal changes, with only 3 out of 64 patients experiencing severe TMJ discomfort or toothache intolerable enough to discontinue device use (19). Other side effects included halitosis, gingival pain, toothache, dry mouth, and excessive salivation, as well as issues with poor device fit (19).
Alessandri-Bonetti et al. investigated changes in pressure pain thresholds (PPTs) of masticatory and neck muscles at 15 days and 6 months after MAD therapy initiation, finding a significant decrease in PPTs at 15 days, which returned to baseline levels after 6 months of treatment (20). These results can be attributed to the immediate stretching induced by MAD, causing elongation of muscle fibers, from which the muscles physiologically recover by increasing their activity.
Nikolopoulou et al. compared MAD and nasal continuous positive airway pressure (CPAP) therapies, evaluating clinical signs of TMD pain and mandibular function impairment through functional tests at baseline and after 6 months of treatment (22). They found no significant differences in clinical signs of TMD pain mandibular function impairment among MAD, nasal CPAP, and placebo groups over the 6-month period.
These studies on MAD indicate that while TMD symptoms may arise in the short term, they commonly resolve over the long term (19,20,22). Doff et al. conducted a study comparing 51 MAD patients with 52 CPAP patients over a 2-year follow-up period, focusing on the occurrence of TMD and the risk of pain and functional impairment (26). They found that MAD therapy initially led to increased TMD pain during the first 2 months, but this side effect was transient, with no significant difference in TMD pain between the MAD and CPAP groups after 1 year. They concluded that the transient nature of TMD pain should not preclude MAD treatment. Additionally, Knappe et al. reported a low prevalence rate of jaw-muscle tenderness (7.1%) and no significant changes in orofacial function associated with MAD therapy after 6 months (27).
Sheats et al. presented the side effects associated with the use of MAD and their corresponding management strategies (7) (Tables 3,4).
Table 3
| Temporomandibular joint-related side effects | Managing side effects |
|---|---|
| Transient morning jaw pain | (I) Observation: regular follow-ups to monitor the patient’s condition and side effects |
| (II) Stretching exercises instruction: provide guidance on jaw and facial muscle stretching exercises to alleviate discomfort | |
| (III) MAD adjustment: adjust the mandibular advancement device by reducing the degree of mandibular protrusion to improve comfort and reduce adverse effects | |
| Persistent temporomandibular joint pain | (I) Symptomatic treatment (resting the temporomandibular joint, applying ice, pharmacotherapy with anti-inflammatories or pain relievers, consuming soft foods) |
| (II) Instruction on stretching exercises | |
| (III) Adjusting the MAD (checking and adjusting the horizontal position between upper and lower jaws, reducing mandibular advancement) | |
| (IV) Evaluation and management of temporomandibular joint disorders | |
| Tenderness in muscles of mastication | (I) Symptomatic treatment (massaging the affected area, applying warmth, icing with a cold pack if inflammation is present) |
| (II) Instruction on stretching exercises | |
| (III) Adjusting the MAD (checking and adjusting the horizontal position between upper and lower jaws, reducing mandibular advancement, adjusting occlusion, reducing thickness in the vertical dimension) | |
| (IV) Morning bite registration | |
| Joint sounds | Observation: regular follow-ups to monitor the patient’s condition and side effects |
MAD, mandibular advancement device.
Table 4
| Occlusal changes | Managing side effects |
|---|---|
| Altered occlusal contacts/bite changes | (I) Observation: regular follow-ups to monitor the patient’s condition and side effects |
| (II) Stretching exercises instruction: provide guidance on jaw and facial muscle stretching exercises to alleviate discomfort | |
| (III) Morning bite registration | |
| Incisor changes | (I) Observation: regular follow-ups to monitor the patient’s condition and side effects |
| (II) Morning bite registration | |
| (III) Adjustment of MAD (inner surface adjustment) | |
| Decreased overjet and overbite | (I) Observation: regular follow-ups to monitor the patient’s condition and side effects |
| (II) Stretching exercises instruction: provide guidance on jaw and facial muscle stretching exercises | |
| (III) Morning bite registration | |
| Alterations in position of mandibular canines and molars | (I) Observation: regular follow-ups to monitor the patient’s condition and side effects |
| (II) Morning bite registration | |
| Interproximal gaps | (I) Observation: regular follow-ups to monitor the patient’s condition and side effects |
| (II) Morning bite registration | |
| (III) Adjustment of MAD (adjusting areas affecting interdental spacing) | |
| (IV) Use of daytime retainer |
MAD, mandibular advancement device.
The following decision tree (Figure 1) is proposed to summarize the decision-making process for MAD use related to TMD or side effect, based on the “Decision tree for MAD therapy in relation to TMD” proposed by Alessandri-Bonetti (20). When a sleep specialist indicates MAD treatment, the patient should to be evaluated by a dentist who specializes in sleep disorders and orofacial pain. The patient should undergo dental and TMD examinations during the first evaluation and at every follow-up appointment. Generally, the diagnostic criteria for TMD (DC/TMD) are used for TMD evaluation (28).
If transient pain is present in the TMJ, it can be managed by increasing the frequency of stretching exercises and performing dental titration if necessary. For persistent pain, palliative treatments such as applying cold to the affected area, performing stretching exercises, and dental titration could be used. A more thorough examination may be needed to determine additional treatments. As previously mentioned, TMJ pain in the early stages of MAD use tends to abate over time, with most patients experiencing symptom resolution within 6 months to a year of beginning MAD use.
Secondly, if there is pain in the masticatory muscles, in addition to palliative treatments, stretching exercises, and dental titration, adjustments to the occlusion and reducing the vertical dimension of the MAD may be necessary. These interventions should be carried out promptly, and if symptoms do not improve, it may be necessary to change the type of MAD or discontinue its use and consider alternative treatments such as OA therapy or nasal CPAP.
This review has several limitations that affect the reliability and generalizability of its findings. Variations in measurement methods across studies, small sample sizes, short follow-up periods, demographic biases, insufficient consideration of confounding factors, lack of standardization, and limited patient demographics collectively impact the review’s conclusions. Furthermore, a notable limitation is the generalization of MADs without detailed consideration of the specific characteristics of these appliances. MADs encompass a wide range of designs with significant variations that could influence their impact on TMD. For instance, some devices offer posterior support while others do not, some allow for mouth opening whereas others restrict it, and some permit excursive movements while others do not. These design differences can affect the development or exacerbation of TMD. Additionally, factors such as the number of remaining teeth, presence of mobile teeth, sleep bruxism, bony protrusions, and available intraoral space should be considered when selecting OAs. Optimal device selection, taking these factors into account, is crucial for effective treatment and minimizing the risk of TMD. Future research should focus on investigating the effects of specific MAD designs on TMD outcomes to better understand the potential risks and benefits associated with each type.
Conclusions
This narrative review focuses on the complexity of managing OSA with OA and MAD, particularly concerning their impact on TMD. While OA and MAD are effective in treating OSA, they can potentially induce TMD symptoms, such as pain in the TMJ, masticatory muscles, and occlusal changes. These side effects can reduce treatment adherence and effectiveness. This review emphasizes the need for careful patient selection, thorough TMD evaluation, and consistent follow-up to monitor and manage these issues. Effective strategies include jaw stretching exercises, adjustments to the MAD device, and palliative care. To reduce risks, it is recommended to perform stretching exercises for a total of one minute every morning after removing the MAD device. Additionally, adjusting the MAD device through continuous and gradual changes in vertical positioning and internal adjustments can help alleviate symptoms. Long-term studies suggest that initial TMD symptoms often resolve within 6 months to a year, indicating that with proper management, OA and MAD can be effective long-term treatments for OSA without causing persistent TMD.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the Guest Editors (Mythili Kalladka and Ming Xia) for the series “Current status and latest research progress in the pain management of temporomandibular disorders (TMDs)” published in Journal of Oral and Maxillofacial Anesthesia. The article has undergone external peer review.
Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-16/rc
Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-16/prf
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-16/coif). The series “Current status and latest research progress in the pain management of temporomandibular disorders (TMDs)” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep 1999;22:667-89. [Crossref] [PubMed]
- Dieltjens M, Vanderveken O. Oral Appliances in Obstructive Sleep Apnea. Healthcare (Basel) 2019;7:141. [Crossref] [PubMed]
- Doff MH, Finnema KJ, Hoekema A, et al. Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on dental side effects. Clin Oral Investig 2013;17:475-82. [Crossref] [PubMed]
- Araie T, Okuno K, Ono Minagi H, et al. Dental and skeletal changes associated with long-term oral appliance use for obstructive sleep apnea: A systematic review and meta-analysis. Sleep Med Rev 2018;41:161-72. [Crossref] [PubMed]
- Tsolakis IA, Palomo JM, Matthaios S, et al. Dental and Skeletal Side Effects of Oral Appliances Used for the Treatment of Obstructive Sleep Apnea and Snoring in Adult Patients-A Systematic Review and Meta-Analysis. J Pers Med 2022;12:483. [Crossref] [PubMed]
- Fransson AMC, Benavente-Lundahl C, Isacsson G. A prospective 10-year cephalometric follow-up study of patients with obstructive sleep apnea and snoring who used a mandibular protruding device. Am J Orthod Dentofacial Orthop 2020;157:91-7. [Crossref] [PubMed]
- Sheats RD. Management of side effects of oral appliance therapy for sleep-disordered breathing: summary of American Academy of Dental Sleep Medicine recommendations. J Clin Sleep Med 2020;16:835. [Crossref] [PubMed]
- Isacsson G, Nohlert E, Fransson AMC, et al. Use of bibloc and monobloc oral appliances in obstructive sleep apnoea: a multicentre, randomized, blinded, parallel-group equivalence trial. Eur J Orthod 2019;41:80-8. [Crossref] [PubMed]
- Tegelberg A, Wilhelmsson B, Walker-Engström ML, et al. Effects and adverse events of a dental appliance for treatment of obstructive sleep apnoea. Swed Dent J 1999;23:117-26. [PubMed]
- Walker-Engström ML, Ringqvist I, Vestling O, et al. A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea. Sleep Breath 2003;7:119-30. [Crossref] [PubMed]
- Sharma SK, Katoch VM, Mohan A, et al. Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 (first edition). Lung India 2015;32:422-34.
- Ngiam J, Balasubramaniam R, Darendeliler MA, et al. Clinical guidelines for oral appliance therapy in the treatment of snoring and obstructive sleep apnoea. Aust Dent J 2013;58:408-19. [Crossref] [PubMed]
- De Leeuw R, Klasser GD. Orofacial pain: guidelines for assessment, diagnosis, and management. 5th ed. Chicago: Quintessence Pub. Co.; 2013.
- Macfarlane TV, Blinkhorn AS, Davies RM, et al. Oro-facial pain in the community: prevalence and associated impact. Community Dent Oral Epidemiol 2002;30:52-60. [Crossref] [PubMed]
- Pow EH, Leung KC, McMillan AS. Prevalence of symptoms associated with temporomandibular disorders in Hong Kong Chinese. J Orofac Pain 2001;15:228-34. [PubMed]
- De Kanter RJ, Truin GJ, Burgersdijk RC, et al. Prevalence in the Dutch adult population and a meta-analysis of signs and symptoms of temporomandibular disorder. J Dent Res 1993;72:1509-18. [Crossref] [PubMed]
- Bush FM, Harkins SW, Harrington WG, et al. Analysis of gender effects on pain perception and symptom presentation in temporomandibular pain. Pain 1993;53:73-80. [Crossref] [PubMed]
- Bueno CH, Pereira DD, Pattussi MP, et al. Gender differences in temporomandibular disorders in adult populational studies: A systematic review and meta-analysis. J Oral Rehabil 2018;45:720-9. [Crossref] [PubMed]
- Banhiran W, Kittiphumwong P, Assanasen P, et al. Adjustable thermoplastic mandibular advancement device for obstructive sleep apnea: outcomes and practicability. Laryngoscope 2014;124:2427-32. [Crossref] [PubMed]
- Alessandri-Bonetti G, Bortolotti F, Bartolucci ML, et al. The Effects of Mandibular Advancement Device on Pressure Pain Threshold of Masticatory Muscles: A Prospective Controlled Cohort Study. J Oral Facial Pain Headache 2016;30:234-40. [Crossref] [PubMed]
- Ishiyama H, Inukai S, Nishiyama A, et al. Effect of jaw-opening exercise on prevention of temporomandibular disorders pain associated with oral appliance therapy in obstructive sleep apnea patients: A randomized, double-blind, placebo-controlled trial. J Prosthodont Res 2017;61:259-67. [Crossref] [PubMed]
- Nikolopoulou M, Aarab G, Ahlberg J, et al. Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: A randomized, placebo-controlled trial on temporomandibular side-effects. Clin Exp Dent Res 2020;6:400-6. [Crossref] [PubMed]
- Tegelberg Å, Nohlert E, List T, et al. Oral appliance influence on jaw function in obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2023;164:682-9. [Crossref] [PubMed]
- Pahkala R. Objectively measured adherence may affect side effects of mandibular advancement therapy in subjects with obstructive sleep apnea. Sleep Breath 2024;28:813-21. [Crossref] [PubMed]
- Lavalle S, Masiello E, Iannella G, et al. Unraveling the Complexities of Oxidative Stress and Inflammation Biomarkers in Obstructive Sleep Apnea Syndrome: A Comprehensive Review. Life (Basel) 2024;14:425. [Crossref] [PubMed]
- Doff MH, Finnema KJ, Hoekema A, et al. Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on dental side effects. Clin Oral Investig 2013;17:475-82. [Crossref] [PubMed]
- Knappe SW, Bakke M, Svanholt P, et al. Long-term side effects on the temporomandibular joints and oro-facial function in patients with obstructive sleep apnoea treated with a mandibular advancement device. J Oral Rehabil 2017;44:354-62. [Crossref] [PubMed]
- Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache 2014;28:6-27. [Crossref] [PubMed]
Cite this article as: Takizawa K, Ozasa K, Wu S, Yan Z, Young A, Noma N. The impact of oral appliance therapy and mandibular advancement devices on jaw function symptoms in sleep apnea: a narrative review. J Oral Maxillofac Anesth 2024;3:26.
