Obstructive Sleep Apnea Options

Treatment for patients with obstructive sleep apnea (OSA) remains challenging given the low compliance rate for continuous positive airway pressure (CPAP) therapy. Oral appliances are increasingly as a primary treatment for patients with mild to moderate sleep apnea or for patients who are unable or unwilling to tolerate the CPAP mask and machine. These uses are in accordance with the American Academy of Sleep Medicine’s (AASM) 2006 practice parameters for oral appliance use (Sleep. 2006;29(2):240-243). Data show improvements in sleepiness and quality of life with these appliances, although CPAP remains superior in reducing polysomnographic indices of OSA such as reductions in apnea-hypopnea index (AHI) and oxygen saturation (Intern Med J. 2010;40(2):102-106). Some evidence suggests, however, that oral appliances may confer comparable AHI and oxygen saturation to CPAP because of their compliance rates. The growing emergence of oral appliances as an alternative to CPAP has highlighted a multidisciplinary approach to treatment for sleep apnea.

“The basic issue for me is that sleep apnea is a medical disease, and although a dentist needs to be involved when using an oral appliance to maintain dental health, a physician needs to be involved in treating the airway and medical disease,” said B. Tucker Woodson, MD, professor of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee, Wisc. “The otolaryngologist is ideally positioned because we understand the airway and we understand dental disease.”

John Remmers, MD, a pulmonologist and professor of internal medicine and physiology and biophysics at the University of Calgary in Alberta, Canada and one of the inventors of CPAP, said otolaryngologists may be the physicians most prone to recommending oral appliances.

“Most of us sleep physicians are pulmonologists and we are comfortable with pressures and air flows, so CPAP is very intuitive to us,” he said. “Surgeons are different and are more anatomically oriented, so it is understandable that they may be more open to oral appliances.”

Oral Appliances

According to Alan A. Lowe, DMD, PhD, there are two kinds of oral appliances: those that move the jaw forward and tongue-stabilizing devices that hold the tongue forward. The goal of both types of devices is to expand the upper airway to improve airflow, thereby preventing the collapse of the pharynx during sleep, said Dr. Lowe, chair of orthodontics at the University of British Columbia in Vancouver, BC.

Appliances that move the jaw forward are known as mandibular advancement devices (MADs). To date, most of the research on mandibular advancement has focused on these devices. MADs prevent the collapse of the upper airway by mechanically protruding the mandible (Intern Med J. 2010;40(2):102-106). A key issue still to be resolved, however, is the best way of titrating mandibular advancement to achieve optimal efficacy and comfort for each patient. The need for proper titration is highlighted by data that show high response rates, improvements in sleepiness and cognitive tests, and increases in health-related quality of life in patients fitted to MADs that are properly titrated (Curr Opin Pulm Med. 2009;15(6):591-596).