Pacific Coast Society of Orthodontists Bulletin Fall 2017 - 7

Editorial

Oral Appliance Therapy
for Sleep Apnea

Dr. Jae Hyun Park
PCSO Bulletin Editor

Sleep disordered breathing (SDB) is a term used
to describe many conditions in which cessation
of breathing occurs during sleep. Although
awareness of these disorders has increased, more
than 82% of the population may have undiagnosed signs and symptoms of moderate to
severe SDB.1 The most common type, obstructive
sleep apnea (OSA), can lead to co-morbidity and
mortality if left untreated.2 Continuous positive
airway pressure (CPAP) is considered to be the
first-line treatment option for OSA, but the necessary equipment can be cumbersome, and compliance is an issue. Oral appliances (OAs) seem
to show better compliance and may be indicated
for CPAP-intolerant patients. A diagnosis of SDB
is made with a polysomnagram, which is considered to be the gold standard in diagnostic tools
for these disorders.
Orthodontists are in a unique position to identify
early signs of SDB, and many have incorporated
airway analysis into their diagnosis, utilizing
existing cephalometric or cone-beam computed
tomography (CBCT) data. Although the exact role
of orthodontics in definitive treatment for OSA is
yet to be determined, identifying high-risk findings during an orthodontic clinical exam is one
way to encourage interdisciplinary collaboration.1
When OAs are indicated, orthodontists and general dentists with advanced training in dental
sleep medicine can be instrumental in delivering
and monitoring these devices.
In 2015, the American Academy of Sleep Medicine
(AASM) and American Academy of Dental Sleep
Medicine (AADSM) commissioned a sevenmember task force to perform a systematic
review of the literature in an attempt to update
the 2006 clinical practice guidelines for treating
OSA with OAs.3 It is worth summarizing their
findings, since the dental profession plays such
an important role in treatment of OSA for
patients intolerant of CPAP therapy. Based on
the evidence, the six recommendations are:

Fall 2017  PCSO Bulletin

1. In adult patients requesting treatment for
snoring (without OSA), they recommend OAs
over no treatment. The diagnosis should be
made by a sleep physician in order to rule out
OSA. OAs may have advantages for patients
who are not compliant with conventional
measures (i.e., weight loss, positional therapy,
and avoiding alcohol).
2. In adult patients treated for OSA with OAs, a
custom, titratable appliance is preferred over
a non-custom appliance. A review of studies
comparing the improvement of the apnea
hypopnea index (AHI) and oxygen desaturation index (ODI) with various OAs found that
custom appliances were more effective than
non-custom appliances, with titratable
devices being preferred over non-titratable
devices.
3. In adult patients with OSA who are CPAPintolerant, they recommend OAs over no
treatment. If a patient is not able to tolerate
CPAP, evidence has shown that OAs can
improve daily function and quality of life.
Although CPAP is superior to OAs in improving
AHI and ODI, the benefits of using OA outweigh the risks of no treatment.
4. In patients using OAs, qualified dentists
should monitor for any dental-related side
effects and minimize their incidence. An experienced dentist should be able to select the
appropriate material for the OA based on the
patient's allergies and/or intraoral habits. OAs
need to be adjusted to adapt to any change
in occlusion, and to mitigate any unwanted
dental changes.
5. Sleep physicians should confirm treatment
efficacy with sleep testing and not solely subjective feedback. Follow-up sleep testing will
ensure that optimal treatment is rendered.
6. In patients using OAs, periodic office visits
should be scheduled with both the sleep
physician and the dentist. A combination of
follow-up testing with the physician and
subsequent adjustment of the appliance by
the dentist will increase compliance and treatment effects.

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Fall 2017