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Obstructive Sleep Apnea Options

by Mary Beth Nierengarten •

This review emphasizes the critical question facing otolaryngologists trying to decide whether or not to use an oral appliance: how to identify which patients will benefit the most from these devices.

Dr. Remmers said the prediction capability regarding which patients will respond to oral appliances is still lacking. Most physicians, he said, will only consider an oral appliance for patients who have a respiratory disturbance index of <20, are not obese, have failed CPAP and have an adequate dentition. “However, research on MADs has shown that many patients who fall outside of these criteria can be well treated with oral appliances,” he said.

To date, research on patient selection for MADs has involved looking at anatomical problems, such as structural narrowing of the pharynx, which may identify patients who may not be good candidates for an oral appliance. Other data suggest that the use of nasopharyngoscopy may help identify which patients will respond to MADs. One study found an association between a reduction in AHI in patients who showed improvement in upper airway patency with mandibular advancement during a drug-induced sleep nasopharyngoscopy (Eur J Orthod. 2005;27(6):607-614). In addition, evidence suggests that performing a nasopharyngoscopy when a patient is awake may be useful in predicting treatment response to MADs (Eur Respir J. 2010;35(4):836-42).

Other studies are looking at whether removing the obstruction in the airway of a patient by protruding the mandible during sleep may identify a patient as a good candidate for a MAD. According to Dr. Remmers, who is studying this approach, two published studies (Eur Respir J. 2006;27(5):1003-1009; Am J Respir Crit Care Med. 2004;170(4):366-370) and data from a recent unpublished study of 65 patients now show unequivocally that patients can be identified in a sleep study using a device in which the protrusion is progressively titrated, similar to CPAP titration, until the obstruction is removed. “The nice feature with this approach is that if you do eliminate the obstruction, you not only know that patient will respond to MADs but you know exactly how far the mandible needs to be protruded to achieve this,” he said. The research in this area is expected to be embodied in a new MAD titration product known as MATRx, due in early 2012.

Clinical Protocol for Treating OSA with Oral Appliances

  1. Medical assessment by physician or sleep specialist to ensure proper diagnosis, assessing the presence or absence of obstructive sleep apnea.
  2. Overnight polysomnogram or similar test evaluated by physician or sleep specialist sent to dentist.
  3. Complete oral examination that includes both medical and dental histories, along with dental radiographs, needed for assessment by dentist.
  4. Determination of type of oral appliance to use.
  5. Appliance is fitted and adjusted to patient after fabrication.
  6. Dentist needs to follow up with patient regardless of the type of appliance used.
  7. Patient should be referred back to attending physician for assessment of repeat sleep study to provide an objective measure of the efficacy of the oral appliance.
  8. If oral appliance is shown to be effective and is comfortable for the patient, dentist should schedule a follow-up appointment every six months for the first two years to monitor effectiveness, comfort and side effects such as occlusion.
  9. Regular follow-up appointments, at least once a year thereafter, to monitor outcomes and appliance wear and tear.

Source: Almeida FR, Lowe AA. Principles of oral appliance therapy for the management of snoring and sleep disordered breathing. Oral Maxillofac Surg Clin North Am. 2009;21(4):413-420.