Guidelines for treatment of sleep apnea with oral appliance therapy

In the first official joint guideline from the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), oral appliance therapy is recommended for the treatment of adult patients with obstructive sleep apnea (OSA) who are intolerant of continuous positive airway pressure (CPAP) therapy or prefer alternate therapy.

This AASM and AADSM guideline supports increased teamwork between physicians and dentists to achieve optimal treatment of patients with OSA. While their recommendations were published in 2015, it is important that we make sure we are familiar with them. Their recommendations are vital to our care for our patients with sleep apnea.

The AASM and AADSM have six recommendations for dentists to follow.

  1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD)
  2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE)
  3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD)
  4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE)
  5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE)
  6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE)

For more information on their recommendations, such as the summary for each, download the document. I hope this helps moving forward for a better understanding of what the AASM and AADSM recommend for treatment of sleep apnea with oral appliance therapy.  

Treating sleep apnea may improve stroke outcomes

If treatment of sleep apnea occurs immediately after a stroke or mini-stroke, new research shows that it may improve patients’ neurological symptoms and daily functioning. More than 20 million adults in the U.S. have obstructive sleep apnea, which has been linked with increased risk for heart attack, hypertension, sudden death, stroke and faster progression of cardiovascular disease.

In a recent study, researchers found that stroke patients who were diagnosed with sleep apnea saw greater improvements in both neurological symptoms and daily ability to function when they used treatment for OSA. This was in comparison to patients with sleep apnea who only received typical medical care.

Sleep apnea and stroke

The study looked at 252 adults that were hospitalized for an ischemic stroke or a mini-stroke, which is known as a transient ischemic attack (TIA). Every participant was screened for sleep apnea. Researchers found that three-quarters of patients had sleep apnea and about two-thirds of those patients with sleep apnea were assigned to one of two interventions that included receiving CPAP therapy, training and encouragement. The other one-third with sleep apnea served as a control group and received usual medical care, plus recommendation at the end of the study to seek CPAP treatment.

Patients’ neurological symptoms and their ability to function in normal activities, such as walking and self care, were assessed at the beginning of the study and six months to one year later. At follow-up, all patients experienced improvement in both neurological symptoms and functional status. However, 59 percent of the patients who used CPAP had neurological symptoms scores at or close to normal. This was in contrast to 38 percent who had just received typical medical care.

If you treat sleep apnea early, the better your stroke outcome will be. Contact Dr. Mayoor Patel to discuss this further. What are some ways to help your patients now and in the future? My guess is that we will need to continue to build upon our relationships with physicians in our communities.

Does treating sleep apnea improve diabetes management?

Managing diabetes requires a “day-in, day-out” effort to control the factors that affect blood sugar levels. And what might make it even more difficult to manage symptoms is if you suffer from obstructive sleep apnea. A study conducted by a team of scientists, including two professors at the West Virginia University School of Medicine, is working as part of a multi-center project sponsored by the National Institutes of Health.

The team of researchers looked to assess what impact treating obstructive sleep apnea has on diabetes self-management. Let’s take a look at what impact treating OSA has on diabetes self-management for our patients.

What is the connection?

OSA is a common disease that is linked to a range of problems in patients with diabetes and those who do not suffer from this condition. From poor work performance to heart failure, sleep apnea is the reason behind many health conditions. It can even make patients with diabetes less sensitive to their insulin.

In a recent study, researchers split patients in half. One half used a CPAP machine to treat their sleep apnea, while the other half used a mock CPAP machine that looks and feels like a regular machine, but does not impart any of its benefits. Throughout the study patients also underwent periodic blood sugar checks.

While the study has not concluded yet, researchers are hopeful that treatment of sleep apnea will help improve diabetes self-management in their patients. If the study does show that using CPAP machines improves blood sugar control in patients with diabetes and sleep apnea, there will be no reason why we should not screen more of our patients with diabetes for OSA.

If a patient has been diagnosed with sleep apnea, physicians can persuade them to use CPAP machines regularly. This can work with oral appliances too. Patients with diabetes struggle so much with their sugar levels. This study can provide some relief knowing there is another option to help improve their health.

I know this study doesn’t focus on oral appliances. But should look to oral appliance therapy as a safe alternative to CPAP for our patients.

Pay attention to dental side effects during long-term oral appliance therapy

We understand how successful treatment of obstructive sleep apnea (OSA) can be. However, we need to pay attention to the potential side effects from long-term oral appliance use. If we are aware of these side effects, we can help educate our patients and prevent them from occurring and interrupting care.

What do we do as dentists to help?

I have read several studies that looked at the predictors of dental changes associated with long-term treatment with oral appliances in patients with OSA. From these studies I have found that yes, long-term use can lead to dental complications if we do not educate our patients.

Before you fit your patient for an oral appliance, ask them if they are willing to take at least two-minutes out of their morning to perform exercises. That’s all it takes. Just two minutes (maybe even less) a day to prevent further complications. And, of course, if they do notice any shifts in their teeth, it is important for them to keep you up-to-date. You can provide an adjustment to their treatment or offer other solutions to improve this change.

When you are fitting your patients for their oral appliance, let them know that it is important to perform daily exercises after removal of the device. By performing jaw exercises, it can help prevent the patient’s mouth from becoming stiff or sore. It can also help to prevent lock-jaw and other complications.

It is our duty as dentists to take care of our patients and that means proper education for daily exercises after removing the oral appliance each morning.

What are you doing to help your patients through the oral appliance process? Are you having them perform exercises? If so, what kind? I am interested in learning what everyone is doing to help their patients each step of this journey.