Updated Practice Guidelines on Oral Appliance Therapy for OSA

Introduction

Snoring and obstructive sleep apnea (OSA) are highly prevalent conditions that occur due to repeated narrowing or complete closure of the upper airway during sleep. Snoring is a nuisance for the bed partner and may also have negative implications such as increased risk for cardiovascular disease. OSA when untreated is associated with multiple adverse health outcomes including systemic hypertension, coronary artery disease, stroke, atrial fibrillation, increased motor vehicle accidents, congestive heart failure, daytime sleepiness, and decreased quality of life. Continuous positive airway pressure (CPAP) continues to remain the mainstay of treatment for OSA. However, due to problems related to low adherence to CPAP, in recent years, other treatment options such as oral appliance (OA) are commonly considered and used to treat OSA.

The American Academy of Sleep Medicine (AASM) publishes practice parameters based on the available evidence periodically. Since the last practice parameter paper was in 2005, there has been an increase in scientific literature on OA in the treatment of OSA with improved clinical outcomes. Therefore the AASM commissioned a task force of seven members along with the American Academy of Dental Sleep Medicine (AADSM) to update the practice parameter guidelines based on this recent literature.

Results

Using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process to assess evidence quality, the task force came up with the following recommendations:

  1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD)
  2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE)
  3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD)
  4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE)
  5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE)
  6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE)

Conclusions

This guideline paper reflects the current state of knowledge and may have an impact on practice pattern of sleep physicians to treat OSA and snoring, thereby positively affecting patient outcomes and healthcare costs with the use of OA.

Reference

  1. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med 2015;11(7):773-827.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Hypertension, Sleep Apnea

Keywords: Accidents, Atrial Fibrillation, Continuous Positive Airway Pressure, Coronary Artery Disease, Coronary Disease, Dentists, Follow-Up Studies, Health Care Costs, Heart Failure, Hypertension, Incidence, Office Visits, Polysomnography, Quality of Life, Sleep Apnea, Obstructive, Snoring, Stroke, Treatment Outcome


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