13 Dec AASM & ADSM rule on new oral appliance therapy clinical guidelines
The American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine have recently reviewed their guidelines for the use of oral appliances (OAs) in the treatment of obstructive sleep apnoea (OSA) and snoring, providing new criteria for the implementation and management of the devices1.
Oral appliances such as Mandibular Advancement Splints are, in essence, a “mouth guard” fitted to both the top teeth and bottom teeth and then joined together in such a way that the bottom teeth end up in front of the top teeth. Pushing this bottom jaw forward in most people opens up the airway and supports it making it less likely to collapse and therefore leads to a reduction in either the number or severity of the apnoea events2. Currently these oral appliances are generally used as second line treatment option for those patients with OSA who find CPAP intolerable.
The previous review paper for oral appliances was released in 2006 and since then the amount of available scientific literature regarding the topic has considerably grown. Because of this, the AASM and ADSM have updated these recommendations by commissioning a task force to conduct a systematic review of the literature. These Recommendations are:
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)”1
- OAs reduce the frequency and intensity of snoring and can lead to improved sleep quality for both the patient and partner. OAs should only be recommended for patients who snore who fail conservative measures (i.e. weight loss, positional therapy and alcohol avoidance) as insufficient evidence exists to conclude that treatment of primary snoring improves other health-related outcomes. Diagnosis of primary snoring should still be rendered by a sleep physician and not a dentist, due to the possible presence of OSA, which could be missed by a dentist.
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)”1
- Review of the evidence has shown that custom, adjustable OAs reduce the AHI, arousal index, and oxygen desaturation index, and increase oxygen saturation to a greater extent than do non-custom OAs.
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)”1
- Studies have shown that patient usage rates for OAs are greater than those observed using CPAP. However the subjective reporting of adherence rate is prone to bias, and needs to be interpreted with caution as patients may overestimate their OA use. Continuous positive airway pressure (CPAP) was also found to be superior to OAs in reducing the AHI, arousal index, and oxygen desaturation index and improving oxygen saturation, and therefore, should still generally be the first-line option for treating OSA.
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)”1
- Treatment-related side effects may occur during OA therapy, with most of these effects being dental related. These side effects could reduce the effectiveness or compliance of OSA therapy and as such a qualified dentist should be seen. This dentist will be able to screen for many problems and choose and/or build the OA with features to minimize the side effects of the therapy.
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)”1
- Most studies report significant improvement in OA efficacy when changes were made to the appliances based on data obtained either during the sleep studies and current information suggests that subjective feedback is not sufficient to determine the optimal setting of the OA in the management of OSA. Without objective data the patient may, unnecessarily, remain sub-optimally treated. Follow-up sleep testing by sleep physicians should also be considered for OA-treated patients who develop recurrent symptoms, show substantial weight changes, or receive diagnoses of comorbidities/conditions relevant to OSA.1
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)”1
- Current evidence suggests that patients may benefit from periodic follow-up visits with a physician and with a qualified dentist. Absence of periodic follow-up visits may result in suboptimal improvement in OSA or side effects that increase risk for discontinuation of therapy.1
These new guidelines are likely to generate a positive impact on professional behaviour and patient outcomes. AASM will keep sleep professionals updated if, in light of new information, significant changes are made to these recommendations.