Oral Appliances for Obstructive Sleep Apnea Syndrome (OSAS) Therapy

Abstract

Multiple treatment modalities are currently available for the management of obstructive sleep apnea syndrome (OSAS) including continuous positive airway pressure (CPAP), surgical interventions, weight loss and other lifestyle modifications, positional therapy, oral appliances (OAs), and any combination of the aforementioned modalities. The treatment approach to OSAS should be individualized to each patient based on a careful risk-benefit analysis that takes into account their age, severity of symptoms, presence of associated co-morbidities or safety critical occupation, etiology of upper airway obstruction, overnight sleep monitoring findings, the local expertise in terms of specialized treatments, and the ability to provide long-term follow-up. One of the main goals of treatment for OSAS is symptom improvement, so the need to establish effective treatment is more important in patients with marked daytime symptoms. Some treatments, such as CPAP, can be established in a more timely fashion compared to others, such as OA and corrective upper airway surgery. This is an important factor when the patient has a comorbidity/condition or a safety critical occupation. Relevant comorbidities and conditions are ischemic heart disease, cerebrovascular disease, congestive heart failure, refractory systemic hypertension, obstructive/restrictive lung disease, pulmonary hypertension, hypercapnic respiratory failure, and pregnancy. Safety critical occupations include patients working with machinery, or employed in hazardous occupations and include truck, taxi and bus drivers; railway engineers, airline pilots, air traffic controllers, aircraft mechanics, ship captains, and pilots. Car drivers who admit to have fallen asleep while driving within the last 2 years also require expedited treatment. The indications for the treatment of asymptomatic patients with OSAS are less clear. Treatment may be considered in asymptomatic patients with significant comorbid illness, who work in a safety critical occupation, or who have an apnea-hypopnea index (AHI) >30 events/hour. Certain physical factors limit the use of some treatments. Severe nasal obstruction may preclude nasal CPAP and may need to be addressed before these treatments are considered. Mandibular advancement devices, the most common type of OA used, require adequate dentition for their effective use, while tongue retaining devices can effectively treat edentulous patients. Severe temporo-mandibular joint dysfunction may postpone or prevent the use of a mandibular advancement device. The presence of large tonsils should prompt referral to an otolaryngologist for consideration of tonsillectomy. Corrective upper airway surgery may not be a suitable option for patients who use their voice professionally. Long-term follow-up by either a primary care provider or sleep-disorders specialist should be arranged in a similar fashion to other chronic diseases such as diabetes or hypertension. Patient education about the nature, complications, and treatment of OSAS by a trained healthcare professional (respiratory therapist/nurse/polysomnographic technologist) is an important component of all treatment strategies.