Editorial 1, Issue 13.2

Letter to a Colleague About Bite Changes

http://dx.doi.org/10.15331/jdsm.7428

Jean-François Masse, DMD, MSc, FACD, Diplomate, ABDSM
 
Editor-in-Chief Journal of Dental Sleep Medicine
Universite Laval, Quebec City, Quebec, Canada

Do you sometimes receive an email from a colleague where you can sense panic (or even frustration) after noticing a change in a patient’s occlusion following the use of an oral appliance? I keep the following response ready for such situations. Depending on how my colleague reaches out, sometimes I send this as an email and sometimes I pick up the phone and have a conversation. It could easily be much longer, but I prefer to remain concise and focus on what I consider the most important points.

Dear Colleague,
 
Thank you for taking the time to reach out and share your concerns regarding the dental changes you have observed in your patient. Your vigilance in identifying these changes is entirely appropriate. Occlusal changes associated with mandibular advancement devices are a known and well-described side effect of oral appliance therapy. I understand that you are considering asking the patient to discontinue the appliance, and your concern is entirely understandable. I am pleased to respond to your email and will try to remain concise, although the topic is somewhat more complex than it may initially appear.

Dental or mandibular changes can occasionally occur during treatment of snoring or obstructive sleep apnea with an oral appliance, a phenomenon that has been well documented in the scientific literature. In most patients these dental changes are gradual and modest, and they often stabilize over time. In many respects these changes resemble slow orthodontic-type tooth movement rather than structural damage to the dentition. Long-term studies, including the work of Doff et al., have demonstrated that although dental changes can occur with mandibular advancement devices, they are generally progressive, modest, and well tolerated by patients receiving treatment for obstructive sleep apnea.1-4

Your patient had been informed of this possibility and signed an informed consent form during the first appointment, which I also reviewed verbally with them and answered any questions.

The patient was also instructed to perform specific morning exercises intended to reduce the likelihood of such dental movements. In many cases we also use morning occlusal guides or repositioning exercises to help the mandible return to its habitual occlusion after appliance removal.

These potential dental changes are one of the reasons why patients treated with oral appliances are followed regularly so that occlusion and dental stability can be monitored over time.

An important question is whether discontinuing the appliance would benefit the patient’s occlusion. Clinically, we sometimes observe that teeth return toward their original position when the movement is recent—although this is not always the case.

However, asking a patient to stop treatment carries potential medical and legal implications, as this therapy is fundamentally a medical treatment prescribed for obstructive sleep apnea. Should discontinuation lead to negative health consequences, the decision to stop treatment could become problematic. If treatment were to be interrupted, it would therefore be essential to ensure that the patient is immediately transitioned to an alternative therapy with minimal delay.

In practice, CPAP therapy is the only treatment that can typically be initiated immediately. Other options such as surgical interventions or weight loss may be considered, but they usually require, at least initially, the continuation of oral appliance therapy.

It is also important to recognize that CPAP therapy is challenging for many patients. Adherence rates are relatively poor, and it has been estimated that between 46 % and 83 % of patients are non-adherent to CPAP therapy.5 On average, patients use CPAP for slightly more than three hours per night, and studies indicate that cardiovascular benefits are not observed when CPAP is used for less than four hours per night.6 While CPAP is highly efficacious when used, its effectiveness in real-world settings is often limited by adherence. This is one of the reasons why oral appliance therapy remains an important therapeutic option.

Consequently, there is a very real possibility that without the appliance, your patient may end up receiving no effective treatment for their sleep apnea.

In this context, we must ask whether it might be preferable to continue oral appliance therapy while recognizing that certain side effects may be acceptable given the benefits of treating sleep apnea. As in many areas of medicine, treatment decisions involve balancing potential side effects against the well-documented risks of leaving the underlying disease untreated. Occlusal changes associated with mandibular advancement devices must be weighed against the significant health risks associated with untreated obstructive sleep apnea.

Studies show that untreated sleep apnea is associated with increased mortality. For example, the Wisconsin Sleep Cohort Study demonstrated that individuals with severe sleep apnea had approximately three times the risk of death compared with those without the condition.7 Other work suggests that untreated sleep apnea may reduce life expectancy by seven to eight years.8

Sleep apnea also causes excessive daytime sleepiness, which increases the risk of motor vehicle accidents. Drivers with untreated sleep apnea have been shown to have a two- to seven-fold increased risk of motor vehicle accidents compared with the general population.9 Importantly, treatment with mandibular advancement devices has been shown to significantly reduce daytime sleepiness.10

Quality of life is also affected. Patients with untreated sleep apnea experience significantly poorer quality of life, particularly in moderate to severe disease.11 Both CPAP therapy and mandibular advancement devices have been shown to significantly improve quality-of-life measures.12

Finally, we should not overlook snoring. It is much more than a simple nuisance. Snoring has been associated with sleep disruption and increased cardiovascular risk, and studies have demonstrated that bed partners of habitual snorers frequently experience impaired sleep quality themselves.13 Oral appliance therapy is often very effective in reducing—and sometimes eliminating—snoring, providing benefits not only for the patient but also for their partner.

Thank you again for reaching out and for sharing your very legitimate concerns. Communication between colleagues is essential. I would be happy to reassess the patient and review the occlusal changes with you if needed so that we can determine together the most appropriate course of action moving forward.
 
Sincerely,
Jean-Francois Masse

CITATION

Masse, JF. Letter to a Colleague About Bite Changes. J Dent Sleep Med. 2026;13(2).

REFERENCES

  1. Doff MHJ, Hoekema A, Wijkstra PJ, van der Hoeven JH, Huddleston Slater JJR, de Bont LGM, Stegenga B. Long-term oral appliance therapy in obstructive sleep apnea: a controlled study on dental side effects. Clin Oral Investig. 2013;17:475-482.
  2. Almeida FR, Lowe AA, Sung JO, Tsuiki S, Otsuka R. Long-term dental changes in patients with obstructive sleep apnea treated with mandibular advancement splints. J Clin Sleep Med. 2006;2:173-178.
  3. Marklund M, Franklin KA, Sahlin C, Lundgren R. The effect of mandibular advancement device on apneas and dental side effects in obstructive sleep apnea. Am J Respir Crit Care Med. 2001;163:1457-1461.
  4. Pliska BT, Almeida FR, Lowe AA, et al. Dental and skeletal side effects of oral appliance therapy for obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2014;18:7-17.
  5. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy. Proc Am Thorac Soc. 2008;5:173-178.
  6. McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375:919-931.
  7. Young T, Finn L, Peppard PE, et al. Sleep-disordered breathing and mortality: the Wisconsin Sleep Cohort Study. Sleep. 2008;31:1071-1078.
  8. Marshall NS, Wong KKH, Liu PY, Cullen SRJ, Knuiman MW, Grunstein RR. Sleep apnea as an independent risk factor for all-cause mortality. Sleep. 2008;31:1079-1085.
  9. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. 2009;5:573-581.
  10. Gagnadoux F, Fleury B, Vielle B, et al. Titrated mandibular advancement versus CPAP for sleep apnea. Eur Respir J. 2009;34:914-920.
  11. Martínez-García MA, Capote F, Campos-Rodríguez F, et al. Effect of CPAP on quality of life in patients with obstructive sleep apnea. Sleep Med. 2015.
  12. Bratton DJ, Gaisl T, Wons AM, Kohler M. CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis. JAMA. 2015;314:2280-2293.
  13. Beninati W, Harris CD, Herold DL, Shepard JW. The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners. Mayo Clin Proc. 1999;74:955-958.

SUBMISSION AND CORRESPONDENCE INFORMATION

Submitted in final revised form March 9, 2026
 
Address correspondence to: Jean-François Masse, DDS, MSc, FACD, D.ABDSM, Professor, Universite Laval, 2780 Masson #200, Quebec City, QC, G1P 1J6, Canada; Tel: 418871-1447; Fax: 418-871-4983; Email: jean-francois.masse@fmd.ulaval.ca

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