Conclusions

Despite the encouraging progress witnessed over the last decade, a number of key unresolved issues represent barriers to the widespread use of oral appliances in the treatment of snoring and OSA. In particular, the inability to predict treatment outcome creates uneasiness at the prospect of an unsatisfactory outcome, involving a not insubstantial investment of time and money on the part of the patient. Hence further research aimed at identifying clinical factors that predict success and failure are critical. Another important issue is the need for an acclimatization phase before maximal efficacy is achieved. Research comparing different acclimatization protocols, including the potential clinical use of single-night titration protocols, may herald the development of a more efficient process. Such an approach would hopefully assist with the individualization of treatment "dosage," that is the degree of mandibular advancement required to control OSA in the individual patient. There is an ongoing need for long-term follow-up studies, with an emphasis on both efficacy and adherence. The development of objective adherence monitors, as is available for CPAP therapy, would be an important advance. Given the likely important, but largely unstudied, influence of appliance design on treatment outcome and side effects, the field requires comparative studies to help guide clinical recommendations regarding choice of appliance.

To date, there has been little or no consideration for the potential of combining therapies in order to achieve an adeqaute clinical outcome (67). For example, the combination of weight loss and an oral appliance would be expected to produce an additive benefit, and may be useful for converting oral appliance partial responders to complete responders. In a similar vein, experimental data suggest that the combination of electical stimulation and mandibular advancement produces a synergistic effect on airway caliber (68). Another more speculative example is the combination of a pharmacological compound with mandibular advancement. Such possibilities warrant exploration, with the aim of developing "tailored" management approaches for the diverse OSA phenotypes that are evident in clinical practice (69).

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Sleep Apnea

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