February 2006

Oral appliances should be considered for patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to continuous positive airway pressure (CPAP) systems, who do not respond to CPAP, or who are not appropriate candidates for CPAP.

Review

WESTCHESTER, Ill., Feb. 1 - Oral appliances can be used as a first-line therapy in patients for treating mild-to-moderate obstructive sleep apnea, according to updated guidelines from the American Academy of Sleep Medicine. The updated guidelines, based on studies published since the original 1995 guidelines, appeared in the February 2006 issue of Sleep.

The previous guidelines recommended continuous positive airway pressure (CPAP) systems as first-line treatment for obstructive sleep apnea. But research suggests that in mild or moderate cases, usually defined as an apnea-hypopnea index from 10-30, oral appliances improve subjective and objective measures of sleepiness about as well, according to Clete A. Kushida, M.D., Ph.D., of Stanford, and colleagues.

CPAP systems are still superior in reducing measures of respiratory disturbances, and for this reason they should remain first-line therapy for patients with severe sleep apnea, the guidelines said. "Although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep-position change," according to the guidelines.

In various studies, the success rate of oral appliances hovered just above 50%, but in one study it reached as high as 81% for patients with mild obstructive sleep apnea, the guideline authors noted. Oral appliances, which resemble athletic mouth guards, may be associated with better compliance than CPAP systems, which many patients find uncomfortable because they require a mask delivering positive pressure to be worn while sleeping, the authors said. Oral appliances can also be used as a first-line treatment for primary snoring without features of obstructive sleep apnea, the guidelines noted.

Oral appliances should be fitted by a qualified dentist who has experience with the temporomandibular joint, dental occlusion, and associated oral structures, the guidelines said. To verify the efficacy of the device, patients should be followed with polysomnography or an attended cardiorespiratory sleep study. Patients should have regular follow-up office visits with their dentist to monitor adherence and make sure the device is functioning correctly. Patients should also have regular follow-up with a primary physician or sleep specialist to make sure that symptoms are not worsening, the guidelines said.

The guidelines were issued in conjunction with the Academy of Dental Sleep Medicine.

Primary source: Sleep Journal
Source reference: Kushida CA et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006; 29(2).