Practical considerations for effective oral appliance use in the treatment of obstructive sleep apnea: a clinical review

Oral appliance (OA) therapy is a promising alternative to continuous positive airway pressure (CPAP) for patients with obstructive sleep apnea (OSA). By holding the mandible in a forward position, an OA keeps the airway open and prevents collapse. The recently revised practice parameters of the American Academy of Sleep Medicine extend the indications for OA therapy, recommending that “sleep physicians consider prescription of an OA for adult patients with OSA who are intolerant of CPAP therapy or prefer alternative therapy.” This manuscript reviews the practical considerations for effective OA therapy with a discussion of three factors: patient eligibility for OA therapy, device features, and requirements for OA providers. Identification of patients who are eligible for OA therapy is a key factor because the overall success rate of OA therapy is lower than that of CPAP. Conventional predictive variables have low sensitivity and specificity; however, new tools such as drug-induced sleep endoscopy and single-night polysomnographic OA titration have been developed. Other factors to consider when determining the indications for OA include the patient’s oral health, evidence of inadequate treatment for older populations, and the risk of long-term dentofacial side effects. For the second factor, customization of OA features is a key component of treatment success, and no single OA design most effectively improves every situation. Although adjustment of the mandibular position is much more important than device selection, the adjustment procedure has not been standardized. Additionally, a pitfall that tends to be forgotten is the relationship between application of the mandibular position and device selection. Promising new technology has become commercially available in the clinical setting to provide objective adherence monitoring. Finally, the third factor is the availability of enough qualified dentists because sleep medicine is a relatively new and highly multidisciplinary field. Because OSA treatments such as CPAP and OA therapy are generally considered for continuous use, treatments should be carefully planned with attention to multiple aspects. Additionally, because OA therapy requires the cooperation of professionals with different areas of expertise, such as dentists and physicians with various specialties, everyone involved in OA therapy must understand it well.