Clinical Practice Issues Indications and Contraindications

According to the updated AASM practice parameters published in 2006, oral appliances are indicated in patients with mild-to-moderate OSA who prefer this form of treatment over CPAP, or who do not respond to or are unable to tolerate CPAP (20). The AASM also recommends that patients with severe OSA be considered for CPAP in preference to oral appliances whenever possible, given its greater efficacy. A major clinical limitation of oral appliance therapy, stemming from the need for titration during an acclimatization period, is in circumstances where there is an imperative to commence treatment quickly. This includes situations involving severe symptomatic OSA (e.g., concern about driving risk), with or without coexistent medical comorbidities such as ischaemic heart disease.

Not all patients are suitable candidates for the use of oral appliances. This treatment modality has no known role in treating central sleep apnea or hypoventilation states. Some case reports have shown OSA being worsened by oral appliance therapy (59,60), and this together with the known potential for a placebo reponse (12,13), highlights the need for objective assessment of treatment response. Caution is warranted in patients with TMJ problems, and it may be advisable to seek expert dental/specialist assessment prior to initiation of treatment. Insufficient number of teeth to permit adequate retention of the appliance may preclude treatment. It is commonly accepted that 10 teeth on each dental arch would represent the minimum number required (61). Less teeth will increase the partition of the pressure on each tooth and will cause more dental side effects. Similarly, the presence of periodontal disease may promote excessive tooth movement with an oral appliance. These cases may benefit from using TRD, although there is no strong evidence for this approach. In partial denture patients, the denture may become loose after the use of splints due to dental movements. All these factors tend to limit the scope of this form of therapy, and one European study has suggested that up to one-third of patients are excluded on the basis of such factors (62).

Sleep Apnea

Sleep Apnea

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