Physicians and sleep specialists serve as the primary health care providers in the diagnosis and management of OSA and other sleep-related breathing disorders. In the event oral appliances are the prescribed therapy, managing physicians may work with each patient’s dentist to ensure that a comprehensive oral clinical examination has been obtained when necessary, including assessment of intraoral and extraoral findings.
Behavioral Modification: As an initial treatment option, patients with mild-to-moderate OSA may begin with behavioral interventions or changes in lifestyle (diet, weight loss, exercise), particularly obese or overweight individuals with OSA or strongly suspected of having the condition.104 Reducing alcohol consumption, especially before bedtime, may also provide therapeutic and preventive value.45 Supplementary education can also be offered to advise patients of the negative impact on OSA therapy that may result from use of alcohol or recreational drugs.105
Positional Sleep: Patients may also be advised that sleeping in a supine position (horizontal position with face and torso facing up) has been found to increase episodes of airway obstruction and aggravate OSA-related symptoms.106, 107 This condition is known as position-dependent obstructive sleep apnea, and researchers estimate that up to half of all OSA-related cases in adults could be classified as supine-related OSA.107
For some adults, sleeping on one’s side (positional therapy) may assist in improving AHI levels and sleepiness measures (per the Epworth Sleepiness Scale).108 For individuals with mild to moderate OSA, mild head-of-bed elevation may also assist in reducing OSA severity.109 A patient’s primary care physician or sleep specialist may advise whether positional therapy might assist in providing therapeutic benefit and improved breathing stability.
PAP Therapy: Positive airway pressure is recommended as a primary therapy for managing adult OSA.110,111 PAP devices use air pressure from a mechanical device to counteract airway narrowing through the delivery of compressed air to the oropharynx. Air pressure is delivered through an air-tight attachment (e.g., a mask covering the sleeper’s nose), which splints the airway with increased air pressure to maintain patency during sleep.112 PAP devices are available in a wide range of machine sizes and mask types. Based on the available evidence, PAP can provide patients with improved sleep patterns and quality of life when used consistently and properly.112
Although PAP devices are commonly prescribed for the treatment of adult OSA, there are significant issues with patient compliance and adverse events (e.g., mask discomfort, mouth dryness, nasal congestion).113 PAP therapy has a persistently low rate of adherence, ranging from 17% to 60% (with adherence defined as greater than four hours of PAP use on 70% of nights).114-116 The use of PAP also may not fully resolve an individual’s OSA or sufficiently reduce its severity.112 To improve patient comfort and adherence to PAP therapy, an American Academy of Sleep Medicine (AASM) guideline111 recommends the use of heated humidification with PAP devices, which can assist in reducing oral dryness and other PAP-related side effects. In adults with OSA, the AASM guideline111 also recommends that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy, which have shown clinically significant improvements in patient compliance with PAP therapy over time.117, 118
As an alternative course of treatment, physicians may refer OSA patients who formerly used PAP to their dentist for assessment for oral appliance therapy, a common treatment modality for individuals with mild to moderate OSA.
Oral Appliances: Individuals with OSA can also consult with their physician and dentist to determine if an oral appliance would serve as an effective therapeutic option for treating the condition. Oral appliances may be custom-fitted by a dentist for placement in the mouth during sleep to help stabilize the mandible and prevent oropharyngeal tissue and the base of the tongue from recurrent collapse and blockage of the upper airway.119
Numerous oral appliances are available today, and they generally move the mandible, tongue and soft palate forward to increase pharyngeal airway space and reduce the risk of airway collapse.120, 121 Many terms are used to describe oral appliance therapies for obstructive sleep apnea, including mandibular advancement devices (also called mandibular advancement splints), upper airway devices and tongue-retaining devices.
Oral appliances provide therapeutic benefit by repositioning and stabilizing the mandible, tongue, hyoid bone and soft palate in a forward position.122, 123 Current guidelines from the field of sleep medicine recommend that when physicians prescribe oral appliance therapy for adults with OSA, the dentist should use a custom, titratable oral appliance rather than a non-custom appliance, and should also evaluate for dental adverse effects of oral appliance use over time.120 One recent systematic review concluded that custom-fabricated mandibular advancement devices performed more favorably than thermoplastic devices in terms of treatment outcomes (e.g., improved AHI and subjective sleepiness scores), primarily due to improved patient preference and better compliance.124
Oral appliances have been viewed as a simpler therapeutic option for patients with OSA,125 particularly for patients with mild to moderate OSA or patients with severe OSA who have difficulty tolerating PAP therapy. Patients with OSA should be advised to use their oral appliances nightly (or during each sleep session) to help achieve optimal control of OSA symptoms.
Patients using oral appliance therapy for OSA may benefit from having an initial evaluation of the temporomandibular joint (TMJ) region to help reduce risks of adverse effects associated with long-term use of oral appliances (e.g., symptoms of TMJ disorders, changes in dental occlusion).126 Oral appliance therapy has been associated with progressive dental changes over time (e.g., reductions in overbite, overjet or mandibular crowding),127 as well as TMJ issues (e.g., transient morning jaw pain), hypersalivation or irritation of oral soft tissues.126, 128 Oral appliances can be modified to help ensure optimal fit and help the patient avoid mouth breathing, which can cause dry mouth symptoms.
Based on the available evidence, oral appliances—specifically custom-made, titratable oral appliances--have been found to improve OSA in adult patients compared to no therapy or placebo devices.125 It is appropriate for dentists to work closely with patients with OSA to determine their individual treatment needs and preferences (e.g., oral appliance recommendations may vary for heavy bruxing patients). Additional information on oral appliance therapy for OSA is presented in a 2016 Evidence Brief: Oral Appliances for Sleep-Related Breathing Disorders, which was developed by an expert panel organized by the ADA.
Surgical Options: Surgery may be recommended for patients who do not improve or respond to non-surgical therapies for OSA. Surgical procedures are used to adjust structures (bone or soft tissues) to reduce obstruction in the upper airways, or for implantation of neurostimulator devices.
One surgical procedure for OSA is uvulopalatopharyngoplasty, which removes or shortens the uvula, excessive tissue in the throat as well as the tonsils. Maxillary-mandibular advancement surgery is another option for expanding an individual’s upper and lower pharyngeal airway to reduce airway obstruction. Tracheostomy is another surgical intervention for OSA, but it is typically reserved for use as a potential interim treatment in select circumstances (e.g., individuals with severe OSA, or cases when other clinical options have failed or do not exist).129 Individuals with moderate-to-severe OSA who are unable to tolerate PAP therapy may be considered for hypoglossal nerve stimulation, which uses an implantable neurostimulator device to move the patient’s tongue forward during sleep for improved airway patency.130, 131