ITSMN Articles

Updated Guidelines Address Use of Oral Appliances for Sleep Apnea CME

Author: News: Laurie Barclay, MD - CME Author: Charles Vega, MD, FAAFP | Posted: 2007-08-06

Feb. 2, 2006 — An expert task force from The American Academy of Sleep Medicine (AASM) updated their 1995 guidelines on the use of oral appliances (OAs) for the treatment of obstructive sleep apnea (OSA). The new practice parameter, which is based on an accompanying review of extensive evidence in the scientific literature, is published in the February 1 issue of Sleep.

"OSA is a serious, life-threatening condition — but for many patients, alleviating its effects can be as easy as utilizing an oral appliance at night," Kent Moore, MD, DDS, president of the Academy of Dental Sleep Medicine, said in a news release. "Oral appliances, which resemble sports mouth guards, may control mild to moderate OSA with minimal discomfort or disruption."

OSA, which is caused by repetitive dynamic obstruction of the oropharyngeal airway, has a prevalence of about 18 million in the United States. Symptoms include snoring, airway blockage, and sleep disruption, and more severe complications include excessive daytime sleepiness, increased risk for hypertension, and higher rates of stroke, coronary artery disease, congestive heart failure, atrial fibrillation, myocardial infarction, and death. OSA may also contribute to work-related injuries, motor vehicle crashes, and impaired quality of life.

A new recommendation of the guidelines is that OAs are indicated in patients with mild to moderate OSA who prefer their use to continuous positive airway pressure (CPAP) treatment or who are inappropriate candidates for or who are refractory to CPAP treatment.

"Oral appliances may help people who have tried other OSA treatments and been unsuccessful or who have not complied with their treatment," says AASM president Lawrence Epstein, MD.

For patients with severe OSA, CPAP is indicated whenever possible before considering OAs, until there is higher quality evidence to suggest efficacy.

"Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures," write Clete A. Kushida, MD, PhD, from the Stanford University Center of Excellence for Sleep Disorders in California, and colleagues. "Follow-up polysomnography or an attended cardiorespiratory (Type 3) sleep study is needed to verify efficacy, and may be needed when symptoms of OSA worsen or recur."

The guidelines also recommend that patients with OSA who are treated with OAs have regular follow-up with the dental specialist to monitor compliance, evaluate device deterioration or maladjustment, and determine oral health and integrity of the occlusion. Regular follow-up is also required to determine if OSA is worsening.

Specific recommendations included in the guidelines are intended for adolescents and adults, because the literature regarding use of OAs in treatment of children is not well developed. The authors’ further note that the guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care and that the ultimate judgment rests on the clinician.

OSA must be diagnosed, and the severity of sleep-related respiratory problems must be established before beginning treatment with OAs, using detailed diagnostic criteria, including clinical signs, symptoms and polysomnographic findings.

Cephalometric evaluation is not always required, but should be performed when necessary.

For patients with primary snoring without OSA, the treatment goal objective is to reduce snoring to a subjectively acceptable level. For patients with OSA, treatment goals include resolution of the clinical signs and symptoms of OSA and normalization of the apnea-hypopnea index and oxyhemoglobin saturation.

OAs are appropriate in patients with primary snoring in whom behavioral measures, such as weight loss or sleep-position change, are inappropriate or ineffective. In patients with mild to moderate OSA, OAs are not as efficacious as CPAP. However, they are indicated in patients with mild to moderate OSA who prefer OA to CPAP, who do not respond to CPAP, who are not appropriate candidates for CPAP, or who fail treatment with CPAP or behavioral measures.

Predictors of success with OAs are positional OSA and lower body mass index. However, the inability to predict success reliably mandates follow-up testing to ensure treatment effectiveness.

For patients with severe OSA, an initial trial of nasal CPAP is warranted because of greater efficacy. Upper airway surgery, including tonsillectomy and adenoidectomy, craniofacial operations and tracheostomy, may also be indicated before use of OAs in selected patients.

Follow-up sleep testing is not needed for patients with primary snoring, but it should be performed in patients with OSA after final adjustments of the OA. The latter group should also have dental specialist follow-up every 6 months for the first year and at least annually thereafter. Repeat sleep study is indicated if signs or symptoms of OSA worsen or reoccur.

Future research priorities are definition of patient characteristics associated with OA acceptance, success, and adherence; determination of accepted endpoints for OA therapy for OSA; and cost-benefit analysis.

"Economic assessment, focusing on both short and long-range costs (inclusive of needed follow-up and indirect costs of OA therapy) is needed so that OA therapy can be compared with alternate therapies through cost and effectiveness analyses," the authors conclude. "Research is needed to clarify design characteristics most beneficial in given patient groups, so that device selection is driven by data that are more precise."

The authors have disclosed no relevant financial relationships.

Sleep. 2006;29:240-243

Clinical Context

OSA has been associated with multiple negative health consequences, including higher risks for hypertension, coronary heart disease, stroke, congestive heart failure, atrial fibrillation, and mortality. While snoring might also increase the risk for cardiovascular and cerebrovascular disease, previous research has failed to consistently separate patients with snoring from those with mild OSA.

OAs are commonly used in the management of OSA and snoring. The current practice parameters from the AASM address when to use these devices as well as recommendations for follow-up of their efficacy and tolerability.

Study Highlights

The Standards of Practice Committee of the AASM reviewed relevant literature through July 2004 in developing the current recommendations. Most evidence was derived from peer-reviewed literature, with a preference for randomized, well-designed trials.
The authors stress that the current practice parameters represent guidelines that should not supplant clinical judgment for individual patients.
The presence or absence of OSA should be determined with a review of symptoms, signs, and polysomnographic findings prior to initiation of treatment with OA. The most practical relevance of this recommendation is that patients found to have severe OSA should not be treated with OA, as this modality is judged to be less effective than nasal CPAP in severe OSA.
OA should be fitted by qualified dental personnel with experience in the care of patients receiving such devices.
Cephalometric evaluation is not always necessary prior to use of OA.
For patients with primary snoring but no evidence of OSA, the treatment goal is to reduce snoring to a subjectively acceptable level. However, treatment goals for OSA include symptomatic relief along with normalization of the apnea-hypopnea index and oxyhemoglobin saturation.
OA can be used for patients with primary snoring when weight loss and change in sleep position fail to improve symptoms.
While OA are generally not as effective as CPAP among patients with OSA, they are indicated for patients with mild to moderate OSA who prefer OA to CPAP, who do not respond to CPAP or behavioral measures, and who are not appropriate candidates for CPAP. OA may be particularly successful in cases in which OSA is positional, and the patient's body mass index is lower.
Patients with severe OSA should be treated with CPAP or, when appropriate, upper airway surgery.
Following final device adjustments, patients using OA should undergo either polysomnography or an attended cardiorespiratory sleep study to assess the efficacy of the device.
If the device is effective, patients treated with OA should complete follow-up with their dental specialist every 6 months for 1 year, and then at least annually. These visits should focus on patient adherence and symptoms, oral health, and the integrity of occlusion, and any device deterioration. In general, adherence to OA declines over time, and intolerance to the device along with temporomandibular joint problems contribute to nonadherence.
The referring clinician should also evaluate the patient treated with OA regularly for symptoms or signs of worsening OSA.
Future research should focus on appropriate endpoints of OA therapy for OSA, means to evaluate adherence to OA, the economic impact of treatment with OA, and clarification of subgroups of patients most likely to benefit from OA.

Pearls for Practice

OSA is associated with higher risks for hypertension, coronary heart disease, stroke, congestive heart failure, atrial fibrillation, and mortality. Snoring may also be associated with increased cardiovascular and cerebrovascular risk, but it has been difficult to separate snoring from mild OSA.
Patients with OSA who are candidates for OA include those with mild to moderate OSA who prefer OA to CPAP, who do not respond to CPAP or behavioral measures, and who are not appropriate candidates for CPAP.