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Obstructive sleep apnea (OSA) represents a significant health issue with numerous social and health ramifications caused by disturbed sleep. Additionally, it is well-known that OSA has an influence on cardiovascular diseases. OSA has a multifactorial etiology, and therefore requires a multidisciplinary approach for both diagnosis and treatment. Traditionally, dentists have treated OSA at the request of physicians and do not routinely contribute to diagnosis and treatment; however, the awareness of OSA is increasing within the healthcare profession and the potential role of dental practitioners in its treatment is an emerging field. The dental profession is in a unique position to work with their medical colleagues in providing treatment which can dramatically improve quality of life.
Missouri School of Dentistry and Oral Health, A.T. Still University, St. Louis, Missouri, United States
Dwight McLeod
Missouri School of Dentistry and Oral Health, A.T. Still University, St. Louis, Missouri, United States
Ignacio Christian Marquez
Missouri School of Dentistry and Oral Health, A.T. Still University, St. Louis, Missouri, United States
*Address all correspondence to: michaelgreaves@atsu.edu
1. Introduction
Oral healthcare professionals can play an important role in the screening, evaluation for clinical signs, and clinical management of obstructive sleep apnea (OSA). Dentists and other oral healthcare professionals are trained to evaluate for the clinical signs of obstructive sleep apnea, such as large tonsils, micro or retrognathia, bruxism, TMD, etc. Working with a patient’s team of medical professionals, the oral healthcare team can help provide treatment for mild to moderate OSA that includes the fabrication of oral appliances, management of dental considerations, and follow-up care to maximize treatment efficacy. In instances where patients cannot tolerate other treatment modalities, oral appliance therapy can also help in managing patients with severe OSA. Due to the high rates of patient adherence to oral appliance therapy and its efficacy, oral appliance therapy is similar in effectiveness to CPAP therapy in the treatment of mild to moderate OSA.
The pharynx is located in the midline of the neck and connects the oral cavity to the gastrointestinal tract and the trachea. It is funnel-shaped with the upper portion being larger and is at the base of the skull, while the lower end is narrower and located at the level of the sixth cervical vertebra (C6). This is where the pharynx meets the larynx and the esophagus. It is formed of muscles and mucous membranes, which allows it to serve several functions related to both digestion and respiration, including food swallowing, air conduction, and voice production [1, 2, 3].
The pharynx is divided into three parts from superior to inferior: the nasopharynx, located behind the nasal conchae, the oropharynx, located posterior to the oral cavity, and the laryngopharynx, which is inferior to the epiglottis. The nasopharynx is part of the respiratory tract and conducts air from the nasal passages. Also, the lateral surface of the posterior wall of the nasopharynx includes two openings, which are called the auditory (or Eustachian/pharyngotympanic) tubes. These tubes are connected to the middle ears posteriorly. Their main function is to equalize pressure and to drain secretions of the middle ears. The oropharynx is a continuation of the oral cavity and serves to pass the bolus of food to the laryngopharynx.
The muscles of the soft palate contract to close the nasal cavity as the bolus passes from the oral cavity. This prevents the bolus from entering the nasal cavity. At the same time, the epiglottis (which is cartilage located at the superior portion of the larynx) is pushed anteriorly to close the opening to the airway and prevent food from entering. Finally, the laryngopharynx receives the bolus and moves it into the esophagus to continue digestion. Alternatively, air moves from either the nasal cavity to the nasopharynx or from the oral cavity to the oropharynx and enters the laryngopharynx to the trachea to continue its path on the respiratory tract (Figure 1) [2, 5, 6, 7].
Figure 1.
Anatomy of the upper airway [4].
2.2 Pathophysiology of obstructive sleep apnea
The pathophysiology of OSA contains many factors and differs between individuals. The major contributing components that impact the severity of the obstructive sleep apnea include anatomic obstruction of the upper airway, low respiratory arousal threshold, high loop gain (unstable respiratory control), and poor upper airway dilator muscle responsiveness [8].
The most prominent feature of the treatment of OSA is a widening of the lateral diameter of the airway, especially in the area behind the soft palate [9, 10], likely through soft tissue connections between the lateral airway wall muscles and the mandible [11]. This lateral widening of the airway can be brought about by the advancement of the mandible.
In dentistry, however, there are signs possibly related to OSA that can be observed: a hard palate that is narrow or exhibits a high arch, relationship between the maxillary and mandibular jaws, relative tongue size and other soft tissue characteristics (e.g., enlarged uvula and narrowing of the airway from the tonsillar area) [12, 13, 14].
Obstructive sleep apnea (OSA) is defined as repetitive and intermittent blockage of the upper airway during sleep [15]. The pharyngeal walls collapse, leading to this constrictor or blockage of the airway. A complete closure of blockage leads to apnea and a partial closure results in hypopnea. There can be significant consequences and changes in the nervous and circulatory systems from continued apnea events. Snoring is caused by a narrowing of the pharynx. The soft portions of the upper airway (the pharyngeal walls, uvula, and soft palate) vibrate, leading to the snoring sound (Figure 2).
Figure 2.
Blockage of the airway in obstructive sleep apnea [16].
Dental professionals can identify many intraoral signs and symptoms associated with OSA during routine appointments in the dental office. Examples of the intraoral signs associated with OSA include redness of the soft palate and uvula area, narrow palate, enlarged tongue and bilateral mandibular tori. Symptoms may include dry mouth (xerostomia) and bruxism (grinding of the teeth). These signs and symptoms are not necessarily indicative of OSA, however, identification by dental professionals may serve the dental professional in identifying the need for further evaluation of OSA for the patient [17, 18]. There are several clinical indices, for example, the Mallampati index, that can be used to determine the risk level of the patient for OSA [19]. There are also several questionnaires/surveys, for example, the STOP-Bang, that can also be evaluated by dental professionals to help screen their patients for OSA [20, 21, 22]. OSA can negatively impact a patient’s oral and overall health, therefore dental professionals serve as an important resource within health care for identifying patients at risk for OSA and identifying non-adherent CPAP or OAT users.
A patient that exhibits a neck circumference greater than 40 centimeters, macroglossia, Mallampati score of Class 3 or 4, and a deep palatal vault have been shown to be predictive for a high risk for OSA [23]. When the dental professional identifies a patient exhibiting one or more of these findings, the dental professional should discuss the patient’s sleep history and screen the patient with a validated questionnaire and refer the patient for further evaluation/diagnosis if appropriate.
OSA should be seen as a condition that needs to have the signs/symptoms identified in dental appointments and should be included in a routine oral exam [24]. The inter-professional collaboration between dental and medical professionals to promote quality care for patients with potential OSA should also be brought to the attention of dental/medical professionals in their education. This is in line with the new oral health definition [20], which brings a holistic view of different domains of overall health that impact oral health. Driving determinants, one domain of oral health, are factors that affect oral health: genetic and biological factors, social environment, physical environment, health behaviors, and access to care. This new definition and framework are used “to explain the multidimensions of oral health to our patients, other healthcare professionals, policy makers, and those others we seek to collaborate with and inform” [20]. Thus, understanding associations between oral health and OSA and interprofessional collaborations within healthcare is of importance. Increased training on OSA is required for oral health professionals. This additional knowledge is an important step that would improve patient communication, education, and treatment in the dental field along with increasing interprofessional collaboration between the oral health professionals and medical professionals.
4. Impact of OSA on oral health and outcomes of oral healthcare
OSA is a widely prevalent problem in the general population [25]. Untreated OSA is associated with long-term health consequences including hypertension, heart disease, diabetes, depression, metabolic disorders, and stroke. The high risk group of OSA include patients with ischemic heart disease, heart failure, arrhythmias, cerebrovascular diseases, and type II diabetes [26]. Untreated OSA has been shown to be associated with cognitive dysfunction, impaired productivity in the workplace, and an increased risk of motor vehicle accidents, which could result in increased risk for injury or death. Impaired vigilance, daytime somnolence, performance deficits, morning headaches, mood disturbances, neurobehavioral impairments, and general malaise are reported in individuals with OSA [27]. These long-term health consequences can drastically reduce the quality of life and wellbeing, leading to premature death. Whether diagnosed or undiagnosed, OSA is a serious threat to the overall health and longevity in those individuals who are burdened by this widely prevalent sleep-related breathing disorder [28, 29, 30, 31, 32].
Obstructive sleep apnea is characterized by frequent episodes of airflow obstruction associated with a reduced caliber of the upper airway and is vulnerable to further narrowing and collapse. Both acute and continued effects of apnea and hypopnea include oxygen desaturation [33], reduction in intrathoracic pressure, excessive daytime sleepiness, impaired cognitive function and central nervous system arousals [27, 34]. Obesity is one of the major predisposing factors [35]. Three types of apneas have been recognized, obstructive, central and mixed with Obstructive sleep apnea being the most common [36]. Weight loss can lead to improvement in OSA. Treatments for OSA are based upon a thorough medical and physical examination and a sleep study or polysomnography. Medications are not effective in the management of sleep apnea but could help with reducing the effects of pathogenic mechanisms [22, 36, 37, 38]. Table 1 highlights some of the potential risk factors/pathogenic mechanisms for OSA as outlined by Jordan et al. Addressing individual pathogenic mechanisms may be alternative treatments even though it is understood that Constant Positive Airway Pressure (CPAP) is the acceptable treatment for Obstructive Sleep Apnea.
Unknown Oxygen or Drugs Hypoglossal Nerve Stimulation Sedatives
Table 1.
Potential risk factors/pathogenic mechanism for obstructive sleep Apnea & Treatment.
This table is a modification of Figure 3. Risk factors, pathogenic mechanism, and possible treatments for obstructive sleep apnea as presented by Jordan et al. [37].
Mouth breathing is a common finding in patients diagnosed with OSA or those who show signs of OSA but are not diagnosed. Xerostomia is often associated with mouth breathers and can predispose to caries and periodontal disease through complete or partial reduction of protective salivary flow to portions of the dentition during sleep or during the day. OSA and periodontal disease share some of the same risk factors and it is not uncommon to see a greater periodontal disease prevalence in patients with OSA [40]. Common risk factors may include obesity, gender, male more than female, age, smoking and mouth breathing resulting in xerostomia, and alcoholism. Additionally, increased adrenocorticosteroids stemming from stress and fatigue of inadequate sleep can put a patient at risk for periodontal disease.
The association between xerostomia and OSA has been poorly investigated. Nocturnal xerostomia or sleep-related xerostomia causes discomfort or dryness in the mouth or throat making it difficult to swallow. In a clinical study investigating xerostomia and hyposalivation in patients with OSA, the authors reported the clinical implication that OSA patients showed a decreased pH value of oral fluid which may put patients at risk for the development of dental caries. They further demonstrated that dry mouth upon awakening is a common symptom with OSA and 22 (73.3%) of the 30 patients evaluated had dry mouth and the prevalence of sleep-related xerostomia is correlated with OSA severity. In the majority of patients, dry mouth was correlated with mouth breathing and not salivary hypofunction and only 20% of the patients exhibited objective signs of hyposalivation [41].
The quantity and quality of saliva serve as a protective mechanism for the hard and soft tissue of the periodontium while allowing optimal physiologic functions of phonation, mastication and homeostasis. When the quantity and quality of saliva are affected, the tendency for disease is increased because of loss of the beneficial elements in saliva and a likelihood for increase in bacterial plaque accumulation on soft and hard tissue structures leading to inflammation of soft tissues and the potential for the development of periodontal disease and dental caries. Duplancic and colleagues, evaluating salivary parameters and periodontal inflammation in OSA patients, showed that patients with hyposalivation and reduced salivation had higher concentrations of salivary electrolytes and lower salivary pH than subjects with normal salivation and that patients with severe OSA tended to have a higher clinical attachment levels and plaque volume. The authors noted that multiple interactions might impact salivary flow and electrolyte composition and that complex interrelationships might affect the integrity of oral health, especially considering OSA severity, inflammation, concomitant diseases and medication [40].
5.1 Temporomandibular joint disease
Individuals suffering from OSA complain of snoring, experienced apnoeas, waking up with a choking sensation, excessive sleepiness [42], fatigue or exhaustion, morning headache [43], and even temporomandibular joint pain [44]. A recent systematic review, linking an association between temporomandibular disorders (TMD) and their association with sleep disorders in adults, concluded that there is inclusive evidence between the relationship of TMD and sleep bruxism (SB) and insufficient evidence regarding the relationship with obstructive sleep apnea (OSA). There is consistent evidence that supports a link between TMD and sleep quality [45]. In a review of over 706 reports on tooth wear and the mentioned dental sleep disorders, the authors concluded that tooth wear is associated with the dental sleep disorders oro-facial pain, dry mouth, GERD, and sleep bruxism. As these dental sleep disorders are interlinked, it is difficult to determine the significant consequences of each individual disorder and leads more to indirect associations [46].
In this era where interprofessional education and interprofessional collaboration care are embedded in the curriculum and taught in most professional schools to a certain degree, obstructive sleep apnea (OSA) is often a common topic that brings professional teams together for the health benefit and wellbeing of the patient. Dental and dental hygiene students are learning more about how to incorporate assessment tooling to screen for OSA. There is evidence that the dental team spends more time with their patients than their medical counterparts. According to the ADA Health Policy Resources Center, in any given year 27 million Americans visit a dentist but do not see a physician. Another 108 million visit a physician but do not see a dentist, including more than 60 percent of children aged 1 through 4 years. Increased interprofessional collaboration between dentists and medical professionals will help to raise the awareness of providers and their patients to oral and overall health [47].
Dentists and dental hygienists are exceptionally educated to counsel patients on oral health and wellness topics. Dentists and dental hygienists’ in-depth knowledge of the anatomy of the head and neck, in particular the oral cavity and oropharyngeal area makes them well suited to assisting the medical team in identifying high risk patients [48] and referring them for definitive diagnosis and treatment. Berggren et al. reported that dental professionals, including dentists and hygienists, in general dentistry experience with OSA varies widely which leads to oral and overall health problems (such as OSA) not being recognized regularly. This lack of experience can be attributed to lack of knowledge about OSA and of validated indices/questionnaires that can be used to determine OSA risk or detect patients at risk of OSA [49].
It is important to train oral health professionals about OSA as an oral health determinant and which may promote interprofessional collaboration between dental and medical professionals. Practicing dental hygienist and dentists can play even a greater role in screening by the incorporation of screening questions as part of their routine medical history, identifying potential risk factors (retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism) and collaborating with the medical team in making referrals [50]. The earlier undiagnosed cases are referred to the medical team from screening the dental office, the sooner cases can be diagnosed and treated which may reduce the morbidity and possible mortality of patients, especially those with severe OSA [51]. The dentist and dental team should be proactive in screening patients for OSA and making timely referrals for diagnosis and treatment.
The Table 2 outlines some surgical considerations to manage snoring and OSA or both. Surgical interventions are not always effective and predictable in the management of OSA and/snoring, but there are notable advantages to surgery which may widen airway spaces allowing better flow of oxygen and breathing [36, 60].
A treatment consideration which shrinks internal tissue leaving external tissues intact and requires multiple treatment sessions. Effective against snoring and OSA
Old treatment method which is considered when OSA is severe, CPAP is ruled out and cardio-pulmonary failure has developed
Bilateral Mandibular Torectomy
Prevents posterior displacement of tongue
Table 2.
Obstructive sleep apnea and its surgical management [36].
CPAP is the gold standard for treatment of OSA [61], and other treatment options can be considered for treating mild to moderate OSA cases such as oral appliances [51]. The dental team is suited to play a role in the treatment and management of OSA when oral appliances are recommended by the sleep physician. Referrals can be reciprocated back to the dental team from the medical team for those patients who are diagnosed but cannot tolerate continuous positive airway pressure (CPAP) therapy and could benefit from oral appliance, including tongue positioning and mandibular advancing devices. OSA is the most common sleep disorder [25] and with increasing awareness and diagnosis, healthcare providers can work with dentists [60], given their knowledge of the structures and function of the oral cavity, to provide a customized treatment plan that is cost effective, elicits compliance and improves sleep quality, culminating in a better quality of life.
Oral appliances, mainly the mandibular advancement devices which move the mandible forward and open the airway during sleep are used to treat mild to moderate OSA, can be beneficial for patients who do not tolerate CPAP, patients who are at high risk for surgery and patients who decline surgery as a treatment option. Treatment approach for oral appliances is simple, noninvasive, cost effective and reversible. Observed oral changes associated with oral appliances in the management of OSA include tooth mobility and repositioning, temporomandibular joint pain, tenderness of teeth, sore oral soft tissues and muscle pain (Figure 4).
7.1 Goals and mechanism of action of oral appliance therapy
Oral appliance therapy is an effective therapy for the treatment of obstructive sleep apnea. The goal of therapeutic interventions for OSA varies in literature but has a common factor in the decrease in the apnea-hypopnea index (AHI) [63]. The AHI is defined as the average number of apneas/hypopneas that occur per hour of sleep [64]. Mild OSA exhibits an AHI of 5–15, moderate OSA exhibits an AHI of 15–30, and severe OSA is classified as an AHI > 30 [64]. Generally, successful OSA treatment is recognized as an AHI <5, a 50% reduction in AHI, to a combination of a decrease in the AHI from baseline and final AHI [63]. Approximately two-thirds of patients treated with OAT will achieve a decrease in AHI greater than 50%, with at least one-third of these patients showing a complete response (AHI < 5) [10].
Oral appliances help treat OSA in three ways: maintaining the mandible in a more closed position, maintaining the mandible in a more anterior position (protrusion), and anterior movement of the tongue [63, 65, 66].
Protrusion of the mandible is the primary mechanism of action in oral appliances fabricated for the treatment of OSA [63]. The protrusion of the mandible leads to an increase in the space of the airway, created by a widening of the airway laterally in the velopharynx (posterior surface of the hard palate to the posterior wall of the pharynx) [63]. The advancement of the mandible and the protrusion of the tongue lead to an improvement, or decrease, in the collapsibility of the airway [66, 67], likely due to the airway enlargement [63]. This reduction in collapsibility of the airway decreases the number of episodes of complete or partial collapse of the airway, thereby improving the AHI of the patient [68]. Patients with mild OSA generally respond better to oral appliance therapy, as their airways are less collapsible and they tend to show a greater increase in the size of their pharynx with OAT [69]. It is not entirely clear why the protrusion of the mandible and tongue leads to stretching of the soft tissue connections between the mandible, tongue, lateral pharyngeal walls, and soft palate, which leads to an overall enlargement of the velopharynx as shown in Figure 5 [70].
Figure 5.
Enlargement of the Velopharynx with mandibular advancement [70].
Maintaining the mandible in a more closed position allows for a reduction in the collapsibility of the airway [71]. Mouth breathing not only leads to an increase in airway collapsibility, it compromises the adherence of patients to OAT as compared to patients that breathe through their nose [72]. This leads to a decrease in overall efficacy of the treatment as the patients are not only wearing the appliances less but the appliances are less effective when they are worn.
7.2 Classifications of oral appliances
Oral appliances fabricated for the treatment of OSA are classified into two categories: mandibular advancement splits (MAS) or mandibular advancement devices (MAD) and tongue retaining devices (TRD) [63, 73]. MAS devices act by advancing the mandible forward, therefore reducing the collapsibility of the airway and increasing the size of the airway [73]. Tongue retaining devices work by suctioning the tongue in an anterior position [63, 73]. Since TRD’s have limited evidence showing their efficacy in the treatment of OSA [74], clinical guidelines relate to mandibular advancement devices (Figures 6 and 7) [63, 77].
Figure 6.
Titratable tongue retaining device [75].
Figure 7.
Mandibular advancement device [76].
There are a wide variety of MADs, ranging from custom-made to prefabricated [78]. Prefabricated MADs are made from thermoplastic material and are generally a lower cost alternative, as they are not custom fitted using bite registrations or plaster casts [78]. Custom-made appliances are fabricated using casts and a bite registration made by the oral healthcare team [78]. Evidence suggests that custom-made MADs are more efficacious in reducing OSA severity than the prefabricated MADs [79]. Due to the reduced efficacy of thermoplastic prefabricated MADs, these devices should not be used as a screening tool for the success of treatment OSA using OAT [79]. MADs vary from “monobloc,” where the upper and lower devices are attached, to “duobloc,” where the upper and lower devices are separated. The benefit of the newer duobloc designs is that they allow for titration of the advancement of the mandible and lead to less discomfort of the TMJ [78]. There are several types of duobloc designs summarized below in Figure 8 that allow for titration in a variety of ways [78].
Figure 8.
Example schematics of mandibular advancement devices [78].
7.3 Titration of oral appliances
The amount of protrusion of the mandible is a key factor in the efficacy of MAD therapy [80]. However, more protrusion does not necessarily mean a better result for the patient [80]. Since the optimal protrusion of the mandible depends on the individual patient, the device must be titrated to determine the greatest efficacy versus tolerability [80]. It has been suggested by literature that titration of the patient in the range of 50–75% of the patient’s MMP is the most efficacious, with evidence supporting no clinical difference between 50 and 75% MMP [81]. An increase in the protrusion can lead to heavier forces applied to the oral/maxillofacial system and lead to more side effects, including TMD and dental changes [81]. Therefore, a titration target of 50% of MMP is most beneficial in the decrease in airway collapsibility, increase in airway space, and limitation of potential side effects [81].
Evaluating the titration can be accomplished using a variety of methods. The patient should return to the dentist within 30 days to evaluate the calibration of the device The device can be titrated using a standardized stepwise protocol, advancing the protrusion if subjective criteria (such as daytime sleepiness or perceived reduction in apneic events) do not show signs of improvement and a reduction of the protrusion if there are side effects reported by the patient [82]. Evaluation of the device can also be completed using an at home monitoring device, such as a high-resolution pulse oximeter or home sleep apnea test (HSAT) [83]. The results of these objective tests can be sent to the patient’s physician, who can then discuss the titration of the device with the oral healthcare team. The HSAT must be evaluated by the patient’s physician [82]. Once the dentist has determined that the patient has achieved final calibration, the patient is referred back to the treating physician for evaluation of the success of the OAT [83].
7.4 Side effects/potential complications of oral appliance therapy
It is important that the dentist/oral healthcare team discuss fully with the patient the potential for complications and the importance of routine follow-ups to evaluate for both efficacy and possible side effects. During the initial stages of OAT, patients may report soreness or tenderness of the TMJ, teeth, and gums, along with either excessive salivation or dryness of the mouth [84]. These side effects are typically transient and can be related to the strain in the musculature of the due to protrusion or an increase in vertical dimension while the patient is wearing the appliance [84]. The first line treatment for soreness of the TMJ or muscles of mastication, joint sounds, excess salivation, and dry mouth associated with the appliance is watchful waiting [85]. During this time, the dentist will carefully observe and document the patient’s symptoms and discuss follow-up, depending on the persistence of the side effect [85]. Fortunately, long-term discomfort or impact that is detrimental to the TMJ do not seem to be long-term side effects [84]. Pain tends to decrease after 1–2 years, likely due to the adaptability of the temporomandibular complex [84].
A key part of the OAT would be the fabrication of a morning occlusal guide, also known as an AM aligner [85]. These guides function by engaging the patient’s biting force to help maintain the patient’s normal occlusal relationship in the morning following the use of the OAT at night [85]. These guides may also help in the stretching of the muscles of mastication [85]. This morning occlusal guide is fabricated by the oral healthcare team/dental laboratory and is made in the patient’s normal occlusion [85]. If the patient notices that he/she is unable to maintain the proper occlusion following wear of the oral appliance, the patient should immediately follow up with his/her oral healthcare provider to prevent permanent changes to the dentition or joint [85].
If the patient is experiencing soft-tissue irritation, gagging, or appliance breakage, modification of the appliance is necessary [85]. Passive jaw stretching exercises and palliative care with the use of intermittent application of ice, a soft diet, and use of anti-inflammatory medication are the first line therapy for tenderness in the muscles of mastication or persistent TMJ pain throughout the day [85]. Changes to the dentition, decreased overbite/overjet, and tooth mobility all require thorough evaluation by the dentist. In these cases, decreasing the titration of the appliance, changing the design of the appliance, or ceasing oral appliance therapy may be required [85]. To help avoid these changes, it is important for the patient to routinely use the morning occlusal guide.
Skeletal changes caused by the downward rotation of the mandible and an increase in the lower facial height are common with mandibular advancement OAT [84]. There is also a tendency for the development of a bilateral crossbite in the posterior dentition after long-term oral appliance therapy use [84]. Using a stepwise approach to the titration and calibration of the oral appliance helps lower the risk of mandibular advancement beyond the optimal position and therefore lessens the side effects experienced by the patient [84]. Due to the potential side effects and changes, it is important that the patient seek routine follow-up with the oral healthcare provider to prevent long-term changes that are detrimental to the patient’s health or function [85]. In some cases, it is prudent to cease OAT and consult with the patient’s physician (Table 3) [85].
Transient morning jaw pain
Persistent temporomandibular joint pain
Tenderness in muscles of mastication
Joint sounds
Intraoral tissue-related side effects
Soft tissue and tongue irritation
Gingival irritation
Excessive salivation/drooling
Dry mouth
Occlusal changes
Altered occlusal contacts/bite changes
Incisor changes
Decreased overjet and overbite
Alterations in position of mandibular canines and molars
Although there are potential complications with OAT, there are also numerous benefits that make OAT an appropriate first line therapy for patients with mild to moderate OSA or who are not able to tolerate PAP therapy in severe OSA. OAT and PAP have equivalent health outcomes [63]. This is due to the fact that PAP therapy is highly efficacious but has moderate usage/compliance, while OAT therapy is moderately efficacious with higher usage [63, 86]. Although PAP has a higher efficacy, it has a lower rate of compliance when compared to OAT and therefore has a similar effectiveness [86]. Furthermore, studies show patient preference toward OAT over PAP [86]. OAT has shown to be either equal or superior to PAP therapy when evaluating quality of life and subjective sleepiness scores [86]. Along with better patient compliance, OAT also shows an improvement over PAP in social factors such as perceptions of the partner, which would lead to further success of the OAT through better adherence [87]. Although PAP has been shown to be a highly efficacious treatment for OSA, OAT should also be considered for patients due to the improvements over PAP in adherence to OAT.
7.6 Combination therapy
Oral appliance therapy can be used in conjunction with other treatment modalities to improve adherence and patient outcomes. Using oral appliance therapy in conjunction with PAP can reduce the PAP pressure requirement [63, 88]. When used in combination, PAP and OAT together have been shown to decrease both AHI and oxygen desaturation of the patient [88]. Furthermore, patients undergoing combination PAP and OAT had lowered therapeutic pressures, which helps with patient compliance in patients who are PAP intolerant [88]. OAT has also been shown to be beneficial and an increase in efficacy when used in combination with uvulopalatopharyngoplasty (UPPP) vs. UPPP alone [89]. Along with the benefits of combining OAT with other treatments, combination therapy can allow for patients to use the treatments interchangeably depending on the patient’s preference [63]. For example, when a patient is traveling, the patient can use the oral appliance as a short term treatment [90]. Oral appliance therapy can be used to help improve outcomes when paired with other therapies or can provide a short term therapy for patients when compliance is difficult.
With the increase in the use of oral appliance therapy, there has been development in the number and specificity of organizations focused on the treatment of obstructive sleep apnea with oral appliance therapies. In the United States, the American Academy of Dental Sleep Medicine (AADSM) was founded in 1991 as the Sleep Disorders Dental Society and is the only non-profit national professional society dedicated solely to the practice of dental sleep medicine [91]. In 2004, the American Board of Dental Sleep Medicine was established. To support the training of qualified dentists, the AADSM has Mastery Programs that certify a dentist as a “Qualified Dentist” to practice dental sleep medicine. The AADSM has worked with the American Academy of Sleep Medicine (AASM) to establish guidelines for interdisciplinary treatment of OSA between physicians and dentists [92]. Furthermore, the American Dental Association has released an evidence brief [93] for the use of oral appliances for sleep-related breathing disorders and a policy statement in 2019 outlining the Role of Dentistry in Sleep Related Breathing Disorders [94]. In this policy statement, dentists are encouraged to screen for SRBDs and establishes that OAT is an appropriate treatment for patients with mild and moderate OSA or for severe OSA when CPAP is not tolerated by the patient [94]. In Europe, the European Academy of Dental Sleep Medicine promotes best practices to support the dental treatment of sleep related breathing disorders [95]. The growth of dental sleep medicine has been supported by the development of numerous organizations to help promote and guide the interdisciplinary treatment of OSA between dentists and physicians.
OSA is a common sleep-related breathing disorder which predisposes to life-threatening disease and can affect the quality and well-being of life. Early screening is an effective approach which could lead to referral, diagnosis and treatment. The dental team can play a vital role in this process by incorporating an in-office screening program and making referrals to the medical team. Reciprocating referrals from the medical team for fabrication of oral appliances is another way the dental team can help to improve the quality of life and well-being of patients who are diagnosed with OSA.
The authors acknowledge Ms. Maud Mundava for her assistance in conducting the literature search and compiling the references. The authors acknowledge Ms. Alyssa Timmer for her assistance in formatting the chapter. The authors would also like to acknowledge Ms. Danielle Williams for her assistance in obtaining permissions for the images and figures in this chapter. The authors would like to thank Dr. Hanan Omar for help in obtaining funding for this chapter and the ATSU Division of Research, Grants and Scholarly Innovations for their financial support in publishing this chapter.
Conflict of interest
The authors have no conflicts of interest to disclose.
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Written By
Michael Greaves, Dwight McLeod and Ignacio Christian Marquez
Submitted: 24 October 2023Reviewed: 01 November 2023Published: 06 February 2024
Open access peer-reviewed chapter
