New guidelines released by the American Academy of Sleep Medicine recommend the use of oral appliances in patients with obstructive sleep apnea (OSA) or those with snoring problems as an alternative treatment to continuous positive airway pressure (CPAP) treatment for those who are not candidates for CPAP or those who prefer them.
Increasing evidence shows that OSA and snoring (to a lesser degree) are treatable conditions associated with a wide range of adverse outcomes, most significantly hypertension, stroke, and congestive heart failure. The new recommendations focus on identifying candidates for oral appliance treatment and treatment objectives and are published in (2006;29:240-243).
The use of oral appliances for the treatment of OSA and snoring has become more popular since practice parameters were last published in 1995, the report says, and the clinical evidence about their use has increased significantly.
Most of these appliances are designed based on the understanding that advancing the mandible and holding it forward during sleep allows unobstructed breathing, according to an accompanying review (pages 244-262). Some devices incorporate a design that holds the tongue forward, the so-called boil-and-bite appliances, and can be fitted by the patients themselves.
The presence or absence of OSA must first be established before suggesting use of oral appliances. The severity of sleep-related breathing problems, which predicts the response to treatment, is determined by a combination of clinical signs, symptoms, and polysomnography findings.
Clinical signs and symptoms of sleep-disordered breathing include daytime sleepiness, obesity, poorly controlled hypertension, difficulty waking, and morning headache. Polysomnographic findings associated with severe sleep-disordered breathing include frequent hypopneas, severe oxygen desaturation, and poor sleep efficiency.
“Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion, and associated oral structures,” writes Clete Kushida, MD, of the Stanford University Center of Excellence for Sleep Disorders, and colleagues.
In addition, oral appliances can be used to treat primary snoring in patients who do not respond to or are not appropriate candidates for behavioral interventions such as weight loss and sleep position changes. The devices are also indicated for use in patients with OSA who do not respond to CPAP or to behavioral measures.
CPAP is routinely more effective than oral appliances in reducing respiratory disturbances in patients with sleep apnea, the report says, but may be equipotent with oral appliances in improving sleep. The devices are most likely to be successful when the sleep apnea is positional and when patients have a lower body mass index.
An appropriate follow-up with a dental specialist at 6 months and then annually is needed to monitor patient adherence, evaluate device fit, and check for symptoms of worsening sleep apnea.
“Oral appliances may aggravate temporomandibular joint disease and may cause dental misalignment and discomfort that are unique to each device,” the authors note.
Further studies are needed to identify objective adherence data for oral appliances, the design characteristics most beneficial in select patient groups, and accepted end points for OSA therapy, the report states.
The complete guidelines are available at www.aasmnet.org
Increasing evidence shows that obstructive sleep apnea and snoring can and should be treated.
Oral appliances are an appropriate alternative to continuous positive airway pressure.
They can also be used by primary snoring patients who do not respond to other treatments.
Adverse effects of device use include aggravated temporomandibular joint disease and dental misalignment.