GUIDELINES

Treatment of Snoring and Obstructive Sleep Apnea

October 2003

Preamble

Snoring and Obstructive Sleep Apnea (OSA) are medical disorders. Therefore, the dentist's role is adjunctive, and oral appliance therapy is to be provided only after the written request or prescription from the attending physician, preferably a physician with advanced training in sleep disorder medicine. (See Appendix I) Because of the obvious life-threatening implications of sleep disorders, it is imperative that treatment to stop snoring commence only after the potential presence of other associated medical conditions, including sleep apnea, is ascertained.

In excess of 80 oral appliances are currently available for the treatment of snoring. OSA and dental practitioners should have training in and experience with a variety of appliances so as to provide their patients with a high level of comprehensive therapeutic care. The term "oral appliance" is used as a generic term for devices inserted into the mouth in order to modify the position of the mandible, the tongue, and other structures in the upper airway for the purpose of relieving snoring or sleep apnea. Combination therapy with other treatments such as weight loss, surgery and nasal Continuous Positive Airway Pressure (CPAP) may be indicated for some patients and must be coordinated with the attending physician. Insurance reimbursement for oral appliance therapy may be available under extended health benefit (not dental) coverage.

Treatment Protocol

The following therapy sequence is suggested for the management of oral appliances in patients who are being treated for snoring or OSA.

  1. In agreement with British Columbia Medical Association protocols, a medical assessment (often an overnight polysomnogram) is interpreted by an accredited physician with advanced training in sleep disorder medicine if an oximetery test, as completed by the family physician, suggests a sleep disorder.
  2. Written referral or prescription and diagnostic report sent to dentist or dental specialist.
  3. Dental examination
    1. medical-dental histories
    2. soft tissue-intraoral assessment
    3. periodontal evaluation
    4. temporomandibular joint examination
    5. occlusal examination
    6. intraoral habit assessment
    7. examination of teeth and restorations
    8. initial dental radiographs if diagnostic films have not been taken in the preceding 12 months
      1. panoramic or full mouth survey as indicated
      2. cephalometric radiograph as indicated
    9. diagnostic models as appropriate for the specific dental appliance
  4. Appliance design, fabrication fitting and placement as indicated
  5. Appliance evaluation during 6 to 12 months of regular use a) required adjustments to appliance b) subjective symptom evaluation c) cephalometric radiograph (optional)
  6. Referral of patient to attending physician for repeat of oximetry/overnight sleep study when there is a significant reduction in snoring and/or symptoms
  7. Possible modification, redesign or remake of appliance as required
  8. Repeated adjustment and evaluation process
  9. Referral to physician for ongoing evaluation
  10. Recall appointments and maintenance as requested by patient or physician. Generally, patients should be monitored monthly for the first 12 months and at least annually thereafter, as long as the oral appliance is being worn.
  11. A patient diagnosed with OSA should be monitored by both the dentist involved and by a physician accredited in sleep disorder medicine.

APPENDIX I

An American Sleep Disorders Association Report Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: Schmidt-Nowara, W., Lowe, A., Wigand, L., Cartwright, R., Perez-Guerra, F., and Mean, S. Sleep, Vol. 18, No. 6, March 1995

(All information & references below are excerpts from An American Sleep Disorders Association Report.)

Diagnosis

The presence or absence of OSA must be determined before initiating treatment with oral appliances to identify those patients at risk of complications of sleep apnea and to provide a baseline to establish the effectiveness of subsequent treatment. Detailed diagnostic criteria for OSA are available and include clinical signs, symptoms and the findings identified by polysomnography (2). The severity of sleep-related respiratory problems must be established in order to make an appropriate treatment decision.

Treatment Objectives

  1. For patients with primary snoring without features of OSA or upper-airway resistance syndrome, the treatment objective is to reduce the snoring to a subjectively acceptable level [3.0, 5.0].
  2. For patients with OSA, the desired outcome of treatment includes the resolution of the clinical signs and symptoms of OSA and the normalization of the apnea-hypopnea index and oxyhemoglobin saturation.

Indications

  1. Oral appliances are indicated for use in patients with primary snoring or mild OSA who do not respond to or are not appropriate candidates for treatment with behavioural measures such as weight loss or sleep-position change [6.2]. Oral appliances may also be useful during the period of weight loss or adaptation to sleep-position changes.
  2. Patients with moderate to severe OSA should have an initial trial of nasal CPAP because greater effectiveness has been shown with this intervention than with the use of oral appliances [9.0]. Upper-airway surgery (including tonsillectomy and adenoidectomy) may also be indicated for patients for whom these operations are predicted to be highly effective in treating sleep apnea.
  3. Oral appliances are indicated for patients with moderate to severe OSA who are intolerant of or refuse treatment with CPAP. Oral appliances are also indicated for patients who refuse or are not candidates for tonsillectomy and adenoidectomy, cranofacial operations or tracheostomy [9.0]. The choice of treatment options, which include medical management and uvulopalatopharyngoplasty, should then be based upon the severity of the OSA, the patient's medical condition, the degree of urgency in treating the apnea and the patient's preference.

Follow-up

  1. Follow-up polysomnography is not indicated for patients with either primary snoring or mild OSA unless symptoms worsen or do not resolve.
  2. To ensure satisfactory therapeutic benefit, patients with moderate to severe OSA should undergo polysomnography or another objective measure of respiration during sleep, with the oral appliance in place after final adjustments of fit have been performed [6.3, 9.0].
  3. Patients with moderate to severe OSA who are treated with oral appliances should return for follow-up visits with both the referring clinician and the dentist. These visits should occur at regular intervals to monitor patient compliance, evaluate device deterioration or maladjustment, evaluate the health of the oral structures and integrity of the occlusion, and assess the patient for signs and symptoms of worsening of OSA [8.0]. Oral appliances may cause a worsening of OSA in some patients and appropriate follow-up care is therefore essential [6.3]. Intolerance and improper use of the device are potential problems for patients using oral appliances, which require patient effort to use properly. In addition, oral appliances can be rendered ineffective by patient alteration of the device. An objective re-evaluation of respiration during sleep is indicated if signs or symptoms of OSA reoccur.
  4. Oral appliances may aggravate temporomandibular joint disease and may cause dental misalignment and discomforts that are unique to each device [7.0]. Follow-up care by a dentist is necessary to assess the development of any of these complications.
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