Oral appliances in the treatment of obstructive sleep apnea in adults
- Peter A Cistulli, MBBS, PhD, FRACP
Peter A Cistulli, MBBS, PhD, FRACP
- ResMed Chair in Sleep Medicine
- University of Sydney & Royal North Shore Hospital
Obstructive sleep apnea (OSA) is a disorder that is characterized by obstructive apneas and hypopneas due to repetitive collapse of the upper airway during sleep. The concept of using an oral appliance to relieve upper airway obstruction was first reported in the 1930s and applied to OSA more than 30 years ago. There has been increasing interest in oral appliances in recent years because of the high prevalence of OSA and recognition of the limitations of positive airway pressure therapy (eg, frequent non-adherence) and surgical therapy.
The management of patients with OSA using an oral appliance is reviewed here. Relevant definitions and the treatment of OSA using other modalities (eg, continuous positive airway pressure) are discussed in detail elsewhere. (See "Polysomnography in the evaluation of sleep-disordered breathing in adults" and "Management of obstructive sleep apnea in adults".)
A multidisciplinary approach is required to effectively manage a patient who has OSA with an oral appliance. This begins with a medical assessment and sleep study to confirm the diagnosis of OSA, determine whether treatment is indicated, and, if so, whether an oral appliance is appropriate therapy [1,2]. Dental evaluation by a qualified dentist or oral surgeon follows, which includes assessment of suitability for oral appliance therapy, device selection, and fitting.
Once oral appliance therapy is initiated, the effectiveness should generally be evaluated by objective testing, since subjective assessment alone is often unreliable. Long-term follow-up should be performed by both a medical and a dental clinician. This approach is described in this section and outlined in the figure (algorithm 1).
Diagnosis — The diagnosis of OSA should be confirmed and its severity determined prior to the initiation of therapy with an oral appliance [1,3]. Disease severity guides the selection of patients for treatment by identifying those who are at greatest risk for developing complications of OSA. It also provides a baseline from which to measure the effectiveness of therapy. The diagnostic approach to OSA in adults is described in detail separately and shown in the algorithm (algorithm 2). (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)
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- GENERAL APPROACH
- Patient selection
- - Advantages
- - Contraindications
- - Predictors of benefit
- Device selection
- - Mandibular advancement splints
- - Tongue retaining devices
- - Comparative efficacy
- Device titration
- Compared with positive airway pressure
- Compared with surgery
- ADVERSE EFFECTS
- SUMMARY AND RECOMMENDATIONS