Perspective chapter: Role of the Oral Healthcare Team in the Management of Obstructive Sleep Apnea

Abstract

Obstructive sleep apnea (OSA) represents a significant health issue with numerous social and health ramifications caused by disturbed sleep. Additionally, it is well-known that OSA has an influence on cardiovascular diseases. OSA has a multifactorial etiology, and therefore requires a multidisciplinary approach for both diagnosis and treatment. Traditionally, dentists have treated OSA at the request of physicians and do not routinely contribute to diagnosis and treatment; however, the awareness of OSA is increasing within the healthcare profession and the potential role of dental practitioners in its treatment is an emerging field. The dental profession is in a unique position to work with their medical colleagues in providing treatment which can dramatically improve quality of life.

Full text


Chapter
Perspective Chapter: Role of
the Oral Healthcare Team in the
Management of Obstructive Sleep
Apnea
MichaelGreaves, DwightMcLeod
and Ignacio ChristianMarquez
Abstract
Obstructive sleep apnea (OSA) represents a significant health issue with numerous
social and health ramifications caused by disturbed sleep. Additionally, it is well-known
that OSA has an influence on cardiovascular diseases. OSA has a multifactorial
etiology, and therefore requires a multidisciplinary approach for both diagnosis and
treatment. Traditionally, dentists have treated OSA at the request of physicians and do
not routinely contribute to diagnosis and treatment; however, the awareness of OSA is
increasing within the healthcare profession and the potential role of dental practitio-
ners in its treatment is an emerging field. The dental profession is in a unique position
to work with their medical colleagues in providing treatment which can dramatically
improve quality of life.
Keywords: obstructive sleep apnea, dentist, oral healthcare team, mandibular
advancement device, oral appliance therapy
. Introduction
Oral healthcare professionals can play an important role in the screening, evaluation
for clinical signs, and clinical management of obstructive sleep apnea (OSA). Dentists
and other oral healthcare professionals are trained to evaluate for the clinical signs of
obstructive sleep apnea, such as large tonsils, micro or retrognathia, bruxism, TMD,
etc. Working with a patient’s team of medical professionals, the oral healthcare team
can help provide treatment for mild to moderate OSA that includes the fabrication of
oral appliances, management of dental considerations, and follow-up care to maximize
treatment efficacy. In instances where patients cannot tolerate other treatment modali-
ties, oral appliance therapy can also help in managing patients with severe OSA. Due
to the high rates of patient adherence to oral appliance therapy and its efficacy, oral
appliance therapy is similar in effectiveness to CPAP therapy in the treatment of mild to
moderate OSA.

Obstructive Sleep Apnea – New Insights in the 21st Century

Figure 1.
Anatomy of the upper airway [4].
. Relevant anatomy
. Oropharynx
The pharynx is located in the midline of the neck and connects the oral cavity to
the gastrointestinal tract and the trachea. It is funnel-shaped with the upper portion
being larger and is at the base of the skull, while the lower end is narrower and located
at the level of the sixth cervical vertebra (C6). This is where the pharynx meets the
larynx and the esophagus. It is formed of muscles and mucous membranes, which
allows it to serve several functions related to both digestion and respiration, including
food swallowing, air conduction, and voice production [1–3].
The pharynx is divided into three parts from superior to inferior: the nasophar-
ynx, located behind the nasal conchae, the oropharynx, located posterior to the oral
cavity, and the laryngopharynx, which is inferior to the epiglottis. The nasopharynx is
part of the respiratory tract and conducts air from the nasal passages. Also, the lateral
surface of the posterior wall of the nasopharynx includes two openings, which are
called the auditory (or Eustachian/pharyngotympanic) tubes. These tubes are con-
nected to the middle ears posteriorly. Their main function is to equalize pressure and
to drain secretions of the middle ears. The oropharynx is a continuation of the oral
cavity and serves to pass the bolus of food to the laryngopharynx.

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Perspective Chapter: Role of the Oral Healthcare Team in the Management of Obstructive Sleep...
DOI: http://dx.doi.org/10.5772/intechopen.1003856
The muscles of the soft palate contract to close the nasal cavity as the bolus passes
from the oral cavity. This prevents the bolus from entering the nasal cavity. At the
same time, the epiglottis (which is cartilage located at the superior portion of the
larynx) is pushed anteriorly to close the opening to the airway and prevent food from
entering. Finally, the laryngopharynx receives the bolus and moves it into the esopha-
gus to continue digestion. Alternatively, air moves from either the nasal cavity to the
nasopharynx or from the oral cavity to the oropharynx and enters the laryngophar-
ynx to the trachea to continue its path on the respiratory tract (Figure ) [2, 5–7].
Figure 2.
Blockage of the airway in obstructive sleep apnea [16].

Obstructive Sleep Apnea – New Insights in the 21st Century

. Pathophysiology of obstructive sleep apnea
The pathophysiology of OSA contains many factors and differs between individu-
als. The major contributing components that impact the severity of the obstructive
sleep apnea include anatomic obstruction of the upper airway, low respiratory arousal
threshold, high loop gain (unstable respiratory control), and poor upper airway dila-
tor muscle responsiveness [8].
The most prominent feature of the treatment of OSA is a widening of the lateral
diameter of the airway, especially in the area behind the soft palate [9, 10], likely
through soft tissue connections between the lateral airway wall muscles and the man-
dible [11]. This lateral widening of the airway can be brought about by the advance-
ment of the mandible.
In dentistry, however, there are signs possibly related to OSA that can be observed:
a hard palate that is narrow or exhibits a high arch, relationship between the maxillary
and mandibular jaws, relative tongue size and other soft tissue characteristics (e.g.,
enlarged uvula and narrowing of the airway from the tonsillar area) [12–14].
Obstructive sleep apnea (OSA) is defined as repetitive and intermittent blockage of
the upper airway during sleep [15]. The pharyngeal walls collapse, leading to this con-
strictor or blockage of the airway. A complete closure of blockage leads to apnea and a
partial closure results in hypopnea. There can be significant consequences and changes
in the nervous and circulatory systems from continued apnea events. Snoring is caused
by a narrowing of the pharynx. The soft portions of the upper airway (the pharyngeal
walls, uvula, and soft palate) vibrate, leading to the snoring sound (Figure ).
. Common oral signs/symptoms
Dental professionals can identify many intraoral signs and symptoms associated
with OSA during routine appointments in the dental office. Examples of the intraoral
signs associated with OSA include redness of the soft palate and uvula area, narrow
palate, enlarged tongue and bilateral mandibular tori. Symptoms may include dry
mouth (xerostomia) and bruxism (grinding of the teeth). These signs and symptoms
are not necessarily indicative of OSA, however, identification by dental profession-
als may serve the dental professional in identifying the need for further evaluation
of OSA for the patient [17, 18]. There are several clinical indices, for example, the
Mallampati index, that can be used to determine the risk level of the patient for OSA
[19]. There are also several questionnaires/surveys, for example, the STOP-Bang,
that can also be evaluated by dental professionals to help screen their patients for
OSA [20–22]. OSA can negatively impact a patient’s oral and overall health, therefore
dental professionals serve as an important resource within health care for identifying
patients at risk for OSA and identifying non-adherent CPAP or OAT users.
A patient that exhibits a neck circumference greater than 40 centimeters, mac-
roglossia, Mallampati score of Class 3 or 4, and a deep palatal vault have been shown
to be predictive for a high risk for OSA [23]. When the dental professional identifies
a patient exhibiting one or more of these findings, the dental professional should
discuss the patient’s sleep history and screen the patient with a validated question-
naire and refer the patient for further evaluation/diagnosis if appropriate.
OSA should be seen as a condition that needs to have the signs/symptoms iden-
tified in dental appointments and should be included in a routine oral exam [24].
The inter-professional collaboration between dental and medical professionals to

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Perspective Chapter: Role of the Oral Healthcare Team in the Management of Obstructive Sleep...
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promote quality care for patients with potential OSA should also be brought to the
attention of dental/medical professionals in their education. This is in line with the
new oral health definition [20], which brings a holistic view of different domains
of overall health that impact oral health. Driving determinants, one domain of
oral health, are factors that affect oral health: genetic and biological factors, social
environment, physical environment, health behaviors, and access to care. This new
definition and framework are used “to explain the multidimensions of oral health
to our patients, other healthcare professionals, policy makers, and those others
we seek to collaborate with and inform” [20]. Thus, understanding associations
between oral health and OSA and interprofessional collaborations within health-
care is of importance. Increased training on OSA is required for oral health profes-
sionals. This additional knowledge is an important step that would improve patient
communication, education, and treatment in the dental field along with increasing
interprofessional collaboration between the oral health professionals and medical
professionals.
. Impact of OSA on oral health and outcomes of oral healthcare
OSA is a widely prevalent problem in the general population [25]. Untreated OSA
is associated with long-term health consequences including hypertension, heart
disease, diabetes, depression, metabolic disorders, and stroke. The high risk group
of OSA include patients with ischemic heart disease, heart failure, arrhythmias,
cerebrovascular diseases, and type II diabetes [26]. Untreated OSA has been shown
to be associated with cognitive dysfunction, impaired productivity in the workplace,
and an increased risk of motor vehicle accidents, which could result in increased risk
for injury or death. Impaired vigilance, daytime somnolence, performance deficits,
morning headaches, mood disturbances, neurobehavioral impairments, and general
malaise are reported in individuals with OSA [27]. These long-term health conse-
quences can drastically reduce the quality of life and wellbeing, leading to premature
death. Whether diagnosed or undiagnosed, OSA is a serious threat to the overall
health and longevity in those individuals who are burdened by this widely prevalent
sleep-related breathing disorder [28–32].
Obstructive sleep apnea is characterized by frequent episodes of airflow obstruc-
tion associated with a reduced caliber of the upper airway and is vulnerable to further
narrowing and collapse. Both acute and continued effects of apnea and hypopnea
include oxygen desaturation [33], reduction in intrathoracic pressure, excessive
daytime sleepiness, impaired cognitive function and central nervous system arousals
[27, 34]. Obesity is one of the major predisposing factors [35]. Three types of apneas
have been recognized, obstructive, central and mixed with Obstructive sleep apnea
being the most common [36]. Weight loss can lead to improvement in OSA. Treatments
for OSA are based upon a thorough medical and physical examination and a sleep
study or polysomnography. Medications are not effective in the management of sleep
apnea but could help with reducing the effects of pathogenic mechanisms [22, 36–38].
Table  highlights some of the potential risk factors/pathogenic mechanisms for OSA
as outlined by Jordan et al. Addressing individual pathogenic mechanisms may be
alternative treatments even though it is understood that Constant Positive Airway
Pressure (CPAP) is the acceptable treatment for Obstructive Sleep Apnea.
This table is a modification of Figure . Risk factors, pathogenic mechanism, and
possible treatments for obstructive sleep apnea as presented by Jordan et al. [37].

Obstructive Sleep Apnea – New Insights in the 21st Century

Phrase Question
Snore Do you snore loudly?
Tired Do you feel tired during the daytime often?
Observed Has anyone observed you
Pressure (Blood Pressure) Are you being treated or have you been
treated for high blood pressure?
Body Mass Index Is your BMI greater than 35?
Age Are you over 50 years of age?
Neck Circumference Is your neck circumference greater than 40
cm?
Gender Are you male?
Figure 3.
STOP-bang sleep apnea questionnaire [39].
. Oral-related conditions associated with OSA
Mouth breathing is a common finding in patients diagnosed with OSA or those
who show signs of OSA but are not diagnosed. Xerostomia is often associated with
mouth breathers and can predispose to caries and periodontal disease through
complete or partial reduction of protective salivary flow to portions of the dentition
during sleep or during the day. OSA and periodontal disease share some of the same
risk factors and it is not uncommon to see a greater periodontal disease prevalence in
patients with OSA [40]. Common risk factors may include obesity, gender, male more
than female, age, smoking and mouth breathing resulting in xerostomia, and alcohol-
ism. Additionally, increased adrenocorticosteroids stemming from stress and fatigue
of inadequate sleep can put a patient at risk for periodontal disease.
Risk factors Pathogenic mechanism Possible treatment
Nasal Congestion
Breathing
Small Upper Airway Lumen
Surface Forces
Surfactant
Genetic & Ethnic Origin
Craniofacial Structure
Obesity
Small Upper Airway Lumen
Small Upper Airway Lumen
Low Lung Volume
Respiratory Instability
Mandibular Advancement Device
Unknown
Oxygen or Drugs
Sex Small Upper Airway Lumen
Low Lung Volume
Respiratory Instability
Mandibular Advancement Device
Unknown
Oxygen or Drugs
Age Low Lung Volume
Respiratory Instability
Poor Airway Muscle Function
Low Arousal Threshold
Unknown
Oxygen or Drugs
Hypoglossal Nerve Stimulation
Sedatives
Tab le 1 .
Potential risk factors/pathogenic mechanism for obstructive sleep Apnea & Treatment.

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The association between xerostomia and OSA has been poorly investigated.
Nocturnal xerostomia or sleep-related xerostomia causes discomfort or dryness in
the mouth or throat making it difficult to swallow. In a clinical study investigating
xerostomia and hyposalivation in patients with OSA, the authors reported the clinical
implication that OSA patients showed a decreased pH value of oral fluid which may
put patients at risk for the development of dental caries. They further demonstrated
that dry mouth upon awakening is a common symptom with OSA and 22 (73.3%) of
the 30 patients evaluated had dry mouth and the prevalence of sleep-related xero-
stomia is correlated with OSA severity. In the majority of patients, dry mouth was
correlated with mouth breathing and not salivary hypofunction and only 20% of the
patients exhibited objective signs of hyposalivation [41].
The quantity and quality of saliva serve as a protective mechanism for the hard
and soft tissue of the periodontium while allowing optimal physiologic functions of
phonation, mastication and homeostasis. When the quantity and quality of saliva are
affected, the tendency for disease is increased because of loss of the beneficial ele-
ments in saliva and a likelihood for increase in bacterial plaque accumulation on soft
and hard tissue structures leading to inflammation of soft tissues and the potential for
the development of periodontal disease and dental caries. Duplancic and colleagues,
evaluating salivary parameters and periodontal inflammation in OSA patients,
showed that patients with hyposalivation and reduced salivation had higher con-
centrations of salivary electrolytes and lower salivary pH than subjects with normal
salivation and that patients with severe OSA tended to have a higher clinical attach-
ment levels and plaque volume. The authors noted that multiple interactions might
impact salivary flow and electrolyte composition and that complex interrelationships
might affect the integrity of oral health, especially considering OSA severity, inflam-
mation, concomitant diseases and medication [40].
. Temporomandibular joint disease
Individuals suffering from OSA complain of snoring, experienced apnoeas, waking
up with a choking sensation, excessive sleepiness [42], fatigue or exhaustion, morn-
ing headache [43], and even temporomandibular joint pain [44]. A recent systematic
review, linking an association between temporomandibular disorders (TMD) and
their association with sleep disorders in adults, concluded that there is inclusive
evidence between the relationship of TMD and sleep bruxism (SB) and insufficient
evidence regarding the relationship with obstructive sleep apnea (OSA). There is
consistent evidence that supports a link between TMD and sleep quality [45]. In a
review of over 706 reports on tooth wear and the mentioned dental sleep disorders,
the authors concluded that tooth wear is associated with the dental sleep disorders oro-
facial pain, dry mouth, GERD, and sleep bruxism. As these dental sleep disorders are
interlinked, it is difficult to determine the significant consequences of each individual
disorder and leads more to indirect associations [46].
. Screening for OSA in the dental office
In this era where interprofessional education and interprofessional collabora-
tion care are embedded in the curriculum and taught in most professional schools
to a certain degree, obstructive sleep apnea (OSA) is often a common topic that
brings professional teams together for the health benefit and wellbeing of the

Obstructive Sleep Apnea – New Insights in the 21st Century
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patient. Dental and dental hygiene students are learning more about how to incor-
porate assessment tooling to screen for OSA. There is evidence that the dental team
spends more time with their patients than their medical counterparts. According
to the ADA Health Policy Resources Center, in any given year 27 million Americans
visit a dentist but do not see a physician. Another 108 million visit a physician but
do not see a dentist, including more than 60 percent of children aged 1 through
4years. Increased interprofessional collaboration between dentists and medical
professionals will help to raise the awareness of providers and their patients to oral
and overall health [47].
Dentists and dental hygienists are exceptionally educated to counsel patients on
oral health and wellness topics. Dentists and dental hygienists’ in-depth knowledge
of the anatomy of the head and neck, in particular the oral cavity and oropha-
ryngeal area makes them well suited to assisting the medical team in identifying
high risk patients [48] and referring them for definitive diagnosis and treatment.
Berggren et al. reported that dental professionals, including dentists and hygien-
ists, in general dentistry experience with OSA varies widely which leads to oral and
overall health problems (such as OSA) not being recognized regularly. This lack
of experience can be attributed to lack of knowledge about OSA and of validated
indices/questionnaires that can be used to determine OSA risk or detect patients at
risk of OSA [49].
It is important to train oral health professionals about OSA as an oral health
determinant and which may promote interprofessional collaboration between dental
and medical professionals. Practicing dental hygienist and dentists can play even a
greater role in screening by the incorporation of screening questions as part of their
routine medical history, identifying potential risk factors (retrognathia, high arched
palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep,
supine sleep position, obesity, hypertension, morning headache or orofacial pain,
bruxism) and collaborating with the medical team in making referrals [50]. The
earlier undiagnosed cases are referred to the medical team from screening the dental
office, the sooner cases can be diagnosed and treated which may reduce the morbidity
and possible mortality of patients, especially those with severe OSA [51]. The dentist
and dental team should be proactive in screening patients for OSA and making timely
referrals for diagnosis and treatment.
The Ta ble  outlines some surgical considerations to manage snoring and OSA or
both. Surgical interventions are not always effective and predictable in the manage-
ment of OSA and/snoring, but there are notable advantages to surgery which may
widen airway spaces allowing better flow of oxygen and breathing [36, 60].
CPAP is the gold standard for treatment of OSA [61], and other treatment options
can be considered for treating mild to moderate OSA cases such as oral appliances
[51]. The dental team is suited to play a role in the treatment and management of
OSA when oral appliances are recommended by the sleep physician. Referrals can be
reciprocated back to the dental team from the medical team for those patients who are
diagnosed but cannot tolerate continuous positive airway pressure (CPAP) therapy
and could benefit from oral appliance, including tongue positioning and mandibular
advancing devices. OSA is the most common sleep disorder [25] and with increasing
awareness and diagnosis, healthcare providers can work with dentists [60], given
their knowledge of the structures and function of the oral cavity, to provide a cus-
tomized treatment plan that is cost effective, elicits compliance and improves sleep
quality, culminating in a better quality of life.

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Oral appliances, mainly the mandibular advancement devices which move the
mandible forward and open the airway during sleep are used to treat mild to moder-
ate OSA, can be beneficial for patients who do not tolerate CPAP, patients who are
at high risk for surgery and patients who decline surgery as a treatment option.
Treatment approach for oral appliances is simple, noninvasive, cost effective and
reversible. Observed oral changes associated with oral appliances in the management
of OSA include tooth mobility and repositioning, temporomandibular joint pain,
tenderness of teeth, sore oral soft tissues and muscle pain (Figure ).
Tonsillectomy [] Recommended for enlarged tonsils, reducing obstruction to breathing
Genioglossus Tongue
Advancement [52]
Creates a wider space at the posterior base of the tongue for improved
breathing
Uvulopalatopharyngoplasty
[53, 54]
Effective in snoring reduction but not a predictive therapy for OSA
Laser-assisted
Uvulopalatoplasty [55]
More applicable for snoring reduction and not a predictive therapy for OSA
Maxillomandibular
Advancement [56, 57]
A more aggressive treatment consideration when other treatment procedures
are not effective in controlling OSA
Radio frequency or
Somnoplasty [58]
A treatment consideration which shrinks internal tissue leaving external
tissues intact and requires multiple treatment sessions. Effective against
snoring and OSA
Hyoid Suspension [52, 56] Leads to a wider airway and is effective an effective treatment for OSA
Tracheostomy [52, 59] Old treatment method which is considered when OSA is severe, CPAP is ruled
out and cardio-pulmonary failure has developed
Bilateral Mandibular
Torectomy
Prevents posterior displacement of tongue
Tab le 2 .
Obstructive sleep apnea and its surgical management [36].
Figure 4.
Intraoral signs of obstructive sleep apnea [62].

Obstructive Sleep Apnea – New Insights in the 21st Century

Figure 5.
Enlargement of the Velopharynx with mandibular advancement [70].
. Oral appliance therapy
. Goals and mechanism of action of oral appliance therapy
Oral appliance therapy is an effective therapy for the treatment of obstructive
sleep apnea. The goal of therapeutic interventions for OSA varies in literature but has
a common factor in the decrease in the apnea-hypopnea index (AHI) [63]. The AHI
is defined as the average number of apneas/hypopneas that occur per hour of sleep
[64]. Mild OSA exhibits an AHI of 5–15, moderate OSA exhibits an AHI of 15–30,
and severe OSA is classified as an AHI>30 [64]. Generally, successful OSA treatment
is recognized as an AHI <5, a 50% reduction in AHI, to a combination of a decrease
in the AHI from baseline and final AHI [63]. Approximately two-thirds of patients
treated with OAT will achieve a decrease in AHI greater than 50%, with at least one-
third of these patients showing a complete response (AHI<5) [10].
Oral appliances help treat OSA in three ways: maintaining the mandible in a more
closed position, maintaining the mandible in a more anterior position (protrusion),
and anterior movement of the tongue [63, 65, 66].
Protrusion of the mandible is the primary mechanism of action in oral appliances
fabricated for the treatment of OSA [63]. The protrusion of the mandible leads to an
increase in the space of the airway, created by a widening of the airway laterally in the
velopharynx (posterior surface of the hard palate to the posterior wall of the phar-
ynx) [63]. The advancement of the mandible and the protrusion of the tongue lead to
an improvement, or decrease, in the collapsibility of the airway [66, 67], likely due to
the airway enlargement [63]. This reduction in collapsibility of the airway decreases
the number of episodes of complete or partial collapse of the airway, thereby improv-
ing the AHI of the patient [68]. Patients with mild OSA generally respond better to
oral appliance therapy, as their airways are less collapsible and they tend to show a
greater increase in the size of their pharynx with OAT [69]. It is not entirely clear
why the protrusion of the mandible and tongue leads to stretching of the soft tissue
connections between the mandible, tongue, lateral pharyngeal walls, and soft palate,
which leads to an overall enlargement of the velopharynx as shown in Figure  [70].

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Maintaining the mandible in a more closed position allows for a reduction in the
collapsibility of the airway [71]. Mouth breathing not only leads to an increase in
airway collapsibility, it compromises the adherence of patients to OAT as compared
to patients that breathe through their nose [72]. This leads to a decrease in overall
efficacy of the treatment as the patients are not only wearing the appliances less but
the appliances are less effective when they are worn.
. Classifications of oral appliances
Oral appliances fabricated for the treatment of OSA are classified into two cat-
egories: mandibular advancement splits (MAS) or mandibular advancement devices
(MAD) and tongue retaining devices (TRD) [63, 73]. MAS devices act by advancing
the mandible forward, therefore reducing the collapsibility of the airway and increas-
ing the size of the airway [73]. Tongue retaining devices work by suctioning the
tongue in an anterior position [63, 73]. Since TRD’s have limited evidence showing
their efficacy in the treatment of OSA [74], clinical guidelines relate to mandibular
advancement devices (Figures  and ) [63, 77].
Figure 6.
Titratable tongue retaining device [75].
Figure 7.
Mandibular advancement device [76].

Obstructive Sleep Apnea – New Insights in the 21st Century

There are a wide variety of MADs, ranging from custom-made to prefabricated
[78]. Prefabricated MADs are made from thermoplastic material and are generally a
lower cost alternative, as they are not custom fitted using bite registrations or plaster
casts [78]. Custom-made appliances are fabricated using casts and a bite registration
made by the oral healthcare team [78]. Evidence suggests that custom-made MADs
are more efficacious in reducing OSA severity than the prefabricated MADs [79]. Due
to the reduced efficacy of thermoplastic prefabricated MADs, these devices should
not be used as a screening tool for the success of treatment OSA using OAT [79].
MADs vary from “monobloc,” where the upper and lower devices are attached, to
“duobloc,” where the upper and lower devices are separated. The benefit of the newer
duobloc designs is that they allow for titration of the advancement of the mandible
and lead to less discomfort of the TMJ [78]. There are several types of duobloc designs
summarized below in Figure  that allow for titration in a variety of ways [78].
. Titration of oral appliances
The amount of protrusion of the mandible is a key factor in the efficacy of MAD
therapy [80]. However, more protrusion does not necessarily mean a better result
for the patient [80]. Since the optimal protrusion of the mandible depends on the
individual patient, the device must be titrated to determine the greatest efficacy
versus tolerability [80]. It has been suggested by literature that titration of the patient
in the range of 50–75% of the patient’s MMP is the most efficacious, with evidence
supporting no clinical difference between 50 and 75% MMP [81]. An increase in the
protrusion can lead to heavier forces applied to the oral/maxillofacial system and lead
to more side effects, including TMD and dental changes [81]. Therefore, a titration
target of 50% of MMP is most beneficial in the decrease in airway collapsibility,
increase in airway space, and limitation of potential side effects [81].
Evaluating the titration can be accomplished using a variety of methods. The patient
should return to the dentist within 30days to evaluate the calibration of the device The
device can be titrated using a standardized stepwise protocol, advancing the protru-
sion if subjective criteria (such as daytime sleepiness or perceived reduction in apneic
Figure 8.
Example schematics of mandibular advancement devices [78].

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events) do not show signs of improvement and a reduction of the protrusion if there are
side effects reported by the patient [82]. Evaluation of the device can also be completed
using an at home monitoring device, such as a high-resolution pulse oximeter or home
sleep apnea test (HSAT) [83]. The results of these objective tests can be sent to the
patient’s physician, who can then discuss the titration of the device with the oral health-
care team. The HSAT must be evaluated by the patient’s physician [82]. Once the dentist
has determined that the patient has achieved final calibration, the patient is referred
back to the treating physician for evaluation of the success of the OAT [83].
. Side effects/potential complications of oral appliance therapy
It is important that the dentist/oral healthcare team discuss fully with the patient
the potential for complications and the importance of routine follow-ups to evaluate
for both efficacy and possible side effects. During the initial stages of OAT, patients
may report soreness or tenderness of the TMJ, teeth, and gums, along with either
excessive salivation or dryness of the mouth [84]. These side effects are typically tran-
sient and can be related to the strain in the musculature of the due to protrusion or
an increase in vertical dimension while the patient is wearing the appliance [84]. The
first line treatment for soreness of the TMJ or muscles of mastication, joint sounds,
excess salivation, and dry mouth associated with the appliance is watchful waiting
[85]. During this time, the dentist will carefully observe and document the patient’s
symptoms and discuss follow-up, depending on the persistence of the side effect [85].
Fortunately, long-term discomfort or impact that is detrimental to the TMJ do not
seem to be long-term side effects [84]. Pain tends to decrease after 1–2years, likely
due to the adaptability of the temporomandibular complex [84].
A key part of the OAT would be the fabrication of a morning occlusal guide, also
known as an AM aligner [85]. These guides function by engaging the patient’s biting
force to help maintain the patient’s normal occlusal relationship in the morning fol-
lowing the use of the OAT at night [85]. These guides may also help in the stretching of
the muscles of mastication [85]. This morning occlusal guide is fabricated by the oral
healthcare team/dental laboratory and is made in the patient’s normal occlusion [85].
If the patient notices that he/she is unable to maintain the proper occlusion following
wear of the oral appliance, the patient should immediately follow up with his/her oral
healthcare provider to prevent permanent changes to the dentition or joint [85].
If the patient is experiencing soft-tissue irritation, gagging, or appliance breakage,
modification of the appliance is necessary [85]. Passive jaw stretching exercises and
palliative care with the use of intermittent application of ice, a soft diet, and use of
anti-inflammatory medication are the first line therapy for tenderness in the muscles
of mastication or persistent TMJ pain throughout the day [85]. Changes to the denti-
tion, decreased overbite/overjet, and tooth mobility all require thorough evaluation
by the dentist. In these cases, decreasing the titration of the appliance, changing the
design of the appliance, or ceasing oral appliance therapy may be required [85]. To
help avoid these changes, it is important for the patient to routinely use the morning
occlusal guide.
Skeletal changes caused by the downward rotation of the mandible and an increase
in the lower facial height are common with mandibular advancement OAT [84]. There
is also a tendency for the development of a bilateral crossbite in the posterior dentition
after long-term oral appliance therapy use [84]. Using a stepwise approach to the titra-
tion and calibration of the oral appliance helps lower the risk of mandibular advance-
ment beyond the optimal position and therefore lessens the side effects experienced by

Obstructive Sleep Apnea – New Insights in the 21st Century

the patient [84]. Due to the potential side effects and changes, it is important that the
patient seek routine follow-up with the oral healthcare provider to prevent long-term
changes that are detrimental to the patient’s health or function [85]. In some cases, it is
prudent to cease OAT and consult with the patient’s physician (Table ) [85].
. Benefits of oral appliance therapy
Although there are potential complications with OAT, there are also numerous
benefits that make OAT an appropriate first line therapy for patients with mild to
moderate OSA or who are not able to tolerate PAP therapy in severe OSA. OAT and
PAP have equivalent health outcomes [63]. This is due to the fact that PAP therapy is
highly efficacious but has moderate usage/compliance, while OAT therapy is moder-
ately efficacious with higher usage [63, 86]. Although PAP has a higher efficacy, it has
a lower rate of compliance when compared to OAT and therefore has a similar effec-
tiveness [86]. Furthermore, studies show patient preference toward OAT over PAP
[86]. OAT has shown to be either equal or superior to PAP therapy when evaluating
• Transient morning jaw pain
• Persistent temporomandibular joint pain
• Tenderness in muscles of mastication
• Joint sounds
• Intraoral tissue-related side effects
• Soft tissue and tongue irritation
• Gingival irritation
• Excessive salivation/drooling
• Dry mouth
• Occlusal changes
• Altered occlusal contacts/bite changes
• Incisor changes
• Decreased overjet and overbite
• Alterations in position of mandibular canines and molars
• Interproximal gaps
• Damage to teeth or restorations
• Tooth mobility
• Tooth fractures or damage to dental restorations
• Appliance issues
• Appliance breakage
• Allergies to appliance material
• Gagging
• Anxiety
Table 3.
Oral appliance therapy related side effects [85].


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DOI: http://dx.doi.org/10.5772/intechopen.1003856
quality of life and subjective sleepiness scores [86]. Along with better patient compli-
ance, OAT also shows an improvement over PAP in social factors such as perceptions
of the partner, which would lead to further success of the OAT through better adher-
ence [87]. Although PAP has been shown to be a highly efficacious treatment for OSA,
OAT should also be considered for patients due to the improvements over PAP in
adherence to OAT.
. Combination therapy
Oral appliance therapy can be used in conjunction with other treatment modali-
ties to improve adherence and patient outcomes. Using oral appliance therapy in
conjunction with PAP can reduce the PAP pressure requirement [63, 88]. When used
in combination, PAP and OAT together have been shown to decrease both AHI and
oxygen desaturation of the patient [88]. Furthermore, patients undergoing combi-
nation PAP and OAT had lowered therapeutic pressures, which helps with patient
compliance in patients who are PAP intolerant [88]. OAT has also been shown to be
beneficial and an increase in efficacy when used in combination with uvulopalato-
pharyngoplasty (UPPP) vs. UPPP alone [89]. Along with the benefits of combining
OAT with other treatments, combination therapy can allow for patients to use
the treatments interchangeably depending on the patient’s preference [63]. For
example, when a patient is traveling, the patient can use the oral appliance as a short
term treatment [90]. Oral appliance therapy can be used to help improve outcomes
when paired with other therapies or can provide a short term therapy for patients
when compliance is difficult.
. Professional organizations
With the increase in the use of oral appliance therapy, there has been development
in the number and specificity of organizations focused on the treatment of obstruc-
tive sleep apnea with oral appliance therapies. In the United States, the American
Academy of Dental Sleep Medicine (AADSM) was founded in 1991 as the Sleep
Disorders Dental Society and is the only non-profit national professional society
dedicated solely to the practice of dental sleep medicine [91]. In 2004, the American
Board of Dental Sleep Medicine was established. To support the training of qualified
dentists, the AADSM has Mastery Programs that certify a dentist as a “Qualified
Dentist” to practice dental sleep medicine. The AADSM has worked with the
American Academy of Sleep Medicine (AASM) to establish guidelines for interdis-
ciplinary treatment of OSA between physicians and dentists [92]. Furthermore, the
American Dental Association has released an evidence brief [93] for the use of oral
appliances for sleep-related breathing disorders and a policy statement in 2019 outlin-
ing the Role of Dentistry in Sleep Related Breathing Disorders [94]. In this policy
statement, dentists are encouraged to screen for SRBDs and establishes that OAT is
an appropriate treatment for patients with mild and moderate OSA or for severe OSA
when CPAP is not tolerated by the patient [94]. In Europe, the European Academy
of Dental Sleep Medicine promotes best practices to support the dental treatment of
sleep related breathing disorders [95]. The growth of dental sleep medicine has been
supported by the development of numerous organizations to help promote and guide
the interdisciplinary treatment of OSA between dentists and physicians.

Obstructive Sleep Apnea – New Insights in the 21st Century

Author details
MichaelGreaves*, DwightMcLeod and Ignacio ChristianMarquez
Missouri School of Dentistry and Oral Health, A.T. Still University,
St.Louis,Missouri, UnitedStates
*Address all correspondence to: michaelgreaves@atsu.edu
. Conclusion
OSA is a common sleep-related breathing disorder which predisposes to life-
threatening disease and can affect the quality and well-being of life. Early screening
is an effective approach which could lead to referral, diagnosis and treatment. The
dental team can play a vital role in this process by incorporating an in-office screening
program and making referrals to the medical team. Reciprocating referrals from the
medical team for fabrication of oral appliances is another way the dental team can help
to improve the quality of life and well-being of patients who are diagnosed with OSA.
Acknowledgements
The authors acknowledge Ms. Maud Mundava for her assistance in conducting the
literature search and compiling the references. The authors acknowledge Ms. Alyssa
Timmer for her assistance in formatting the chapter. The authors would also like to
acknowledge Ms. Danielle Williams for her assistance in obtaining permissions for the
images and figures in this chapter. The authors would like to thank Dr. Hanan Omar
for help in obtaining funding for this chapter and the ATSU Division of Research,
Grants and Scholarly Innovations for their financial support in publishing this
chapter.
Conflict of interest
The authors have no conflicts of interest to disclose.
© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of
the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.

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DOI: http://dx.doi.org/10.5772/intechopen.1003856

References
[1] Sakamoto Y. Gross anatomical
observations of attachments of the
middle pharyngeal constrictor. Clinical
Anatomy. 2014;(4):603-609
[2] Heyd C, Yellon R. Anatomy, Head and
Neck, Pharynx Muscles. Treasure Island
(FL): StatPearls Publishing; 2022
[3] Ball M, Hossain M, Padalia D.
Anatomy, Airway. Treasure Island (FL):
StatPearls Publishing; 2022
[4] Blausen.com Staff. Medical gallery
of Blausen medical 2014. WikiJournal
of Medicine. 2014;(2). DOI:10.15347/
wjm/2014.010. ISSN 2002-4436
[5] Kagaya H, Yokoyama M, Saitoh E,
et al. Isolated pharyngeal swallow exists
during normal human feeding. The
Tohoku Journal of Experimental
Medicine. 2015;(1):39-43
[6] Shaw SM, Martino R. The
normal swallow: Muscular and
neurophysiological conrol.
Otolaryngologic Clinics of North
America. 2013;(6):937-956
[7] Casale J, Shumway KR, Hatcher JD.
Physiology, Eustachian Tube Function.
Treasure Island (FL): StatPearls
Publishing; 2023
[8] Eckert DJ, Atul M. Pathophysiology
of adult obstructive sleep apnea.
Proceedings of the American Thoracic
Society. 2008;(2):144-153
[9] Chan AS, Lee RW, Srinivasan VK,
et al. Nasopharyngoscopic evaluation of
oral appliance therapy for obstructive
sleep Apnoea. The European Respiratory
Journal. 2010;:836-842
[10] Chan AS, Sutherland K, Schwab RJ,
Zeng B, Petocz P, Lee RW, et al. The
effect of mandibular advancement on
upper airway structure in obstructive
sleep apnoea. Thorax. 2010;(8):726-
732. DOI:10.1136/thx.2009.131094
[11] Brown EC,Cheng S,McKenzie DK,
Butler JE, Gandevia SC, Bilston LE.
Tongue and lateral upper airway
movement with mandibular
advancement. Sleep [Internet].
2013;(3):397-404. DOI:10.5665/
sleep.2458
[12] Adult Obstructive Sleep Apnea Task
Force of the American Academy of Sleep
Medicine. Clinical guidelines for the
evaluation, management, and long-time
care of obstructive sleep apnea in adults.
Journal of Clinical Sleep Medicine.
2009;:263-276
[13] Patil PS, Schneider H, Schwartz AR,
et al. Adult obstructive sleep apnea
pathophysiology and diagnosis. Chest.
2007;:325-337
[14] Pahkala R, Puustinen R,
Tuomilehto H, et al. Risk factors for
sleep-disordered breathing: The role of
craniofacial structure. Acta Odontologica
Scandinavica. 2011;:137-143
[15] Rodríguez-Lozano FJ, Sáez-Yuguero
Mdel R, Linares Tovar E, et al. Sleep
apnea and mandibular advancement
device. Revision of the literature.
Medicina Oral, Patología Oral y Cirugía
Bucal. 2008;(9):E549-E554
[16] Mayo Foundation for Medical
Education and Research. Obstructive
Sleep Apnea [Internet]. Mayo
Foundation for Medical Education
and Research; Available from: https://
www.mayoclinic.org/diseases-
conditions/obstructive-sleep-apnea/
symptoms-causes/syc-20352090

Obstructive Sleep Apnea – New Insights in the 21st Century

[17] Ruangsri S, Jorns TP, Puasiri S,
et al. Which oropharyngeal factors are
significant risk factors for obstructive
sleep apnea? An age-matched study and
dentist perspectives. Nature and Science
of Sleep. 2016;:215-219 [Online]
[18] Vuorjoki-Ranta TR, Lobbezoo F,
Vehkalahti M, et al. Treatment of
obstructive sleep apnoea patients in
community dental care: Knowledge
and attitudes among general dental
practitioners and specialist dentists.
Journal of Oral Rehabilitation.
2016;(12):937-942
[19] Chung F, Subramanyam R, Liao P,
et al. High STOP-bang score indicates
a high probability of obstructive sleep
apnoea. British Journal of Anaesthesia.
2012;(5):768-775
[20] Chung F, Yegneswaran B,
Liao P, et al. STOP questionnaire: A
tool to screen patients for obstructive
sleep apnea. Anesthesiology: The
Journal of the American Society of
Anesthesiologists. 2008;(5):812-821
[21] Mallampati S, Gatt S, Gugino L,
et al. A clinical sign to predict difficult
tracheal intubation: A prospective study.
Canadian Anaesthetists' Society Journal.
1985;(4):429-434
[22] Jauhar S, Orchardson R,
Jauhar I, et al. The role of the dentist
in sleep disorders. Dental Update.
2010;(10):674-679
[23] Glick M, Williams DM, Kleinman DV,
et al. A new definition for oral health
developed by the FDI world dental
federation opens the door to a universal
definition of oral health. The Journal
of the American Dental Association.
2016;(12):915-917
[24] Kale SS, Kakodkar P, Shetiya SH.
Assessment of oral findings of dental
patients who screen high and no risk for
obstructive sleep apnea (OSA) reporting
to a dental college—a cross sectional
study. Sleep Science. 2018;(2):112-117
[25] Franklin KA, Lindberg E.
Obstructive sleep apnea is a common
disorder in the population-a review on
the epidemiology of sleep apnea. Journal
of Thoracic Disease. 2015;(8):1311
[26] Garvey JF, Pengo MF,Drakatos P,
Kent BD. Epidemiological aspects of
obstructive sleep apnea. Journal of
Thoracic Disease. 2015;(5):920-929
[27] Morsy NE, Farrag NS, Zaki NFW,
Badawy AY, Abdelhafez SA, El-Gilany
A-H, et al. Obstructive sleep apnea:
Personal, societal, public health,
and legal implications. Reviews on
Environmental Health (Berlin/Boston).
2019;(2):153-169
[28] Stepnowsky C, Sarmiento KF,
Bujanover S, Villa KF, Li VW, Flores NM.
Comorbidities, health-related quality
of life, and work productivity among
people with obstructive sleep apnea
with excessive sleepiness: Findings
from the 2016 US National Health and
wellness survey. Journal of Clinical Sleep
Medicine. 2019;(2):235-243
[29] Iacono Isidoro S, Salvaggio A, Lo
Bue A, Romano S, Marrone O, Insalaco G.
Quality of life in patients at first time
visit for sleep disorders of breathing at a
sleep centre. Health and Quality of Life
Outcomes. 2013;:207
[30] D'Ambrosio C, Bowman T,
Mohsenin V. Quality of life in patients
with obstructive sleep apnea: Effect
of nasal continuous positive airway
pressure—A prospective study. Chest.
1999;(1):123-129
[31] Lacasse Y, Godbout C, Sériès F.
Health-related quality of life in

Perspective Chapter: Role of the Oral Healthcare Team in the Management of Obstructive Sleep...
DOI: http://dx.doi.org/10.5772/intechopen.1003856

obstructive sleep apnoea. The European
Respiratory Journal. 2002;(3):499-503
[32] Diamanti C, Manali E,
Ginieri-Coccossis M, et al. Depression,
physical activity, energy consumption,
and quality of life in OSA patients before
and after CPAP treatment. Sleep &
Breathing. 2013;(4):1159-1168
[33] Punjabi NM. The epidemiology
of adult obstructive sleep apnea.
Proceedings of the American Thoracic
Society. 2008;(2):136-143
[34] Young T, Peppard PE, Gottlieb DJ.
Epidemiology of obstructive sleep
apnea: A population health perspective.
American Journal of Respiratory
and Critical Care Medicine.
2002;(9):1217-1239
[35] Mokdad AH, Serdula MK, Dietz WH,
Bowman BA, Marks JS, Koplan JP.
The spread of the obesity epidemic in
the United States, 1991-1998. JAMA.
1999;:1519-1522
[36] Sunitha C, Kumar SA. Obstructive
sleep apnea and its management.
Indian Journal of Dental Research.
2010;(1):119-124
[37] Jordan AS, McSharry DG,
Malhotra A. Adult obstructive
sleep apnoea. Lancet.
2014;(9918):736-747
[38] Hudgel DW, Thanakitcharu S.
Pharmacologic treatment of sleep-
disordered breathing. American
Journal of Respiratory and Critical Care
Medicine. 1998;:691-699
[39] Chung F, Yegneswaran B,
Liao P, Chung SA, Vairavanathan S,
Islam S, et al. STOP questionnaire.
Anesthesiology [Internet].
2008;(5):812-821. DOI:10.1097/
aln.0b013e31816d83e4
[40] Tranfić Duplančić M,Pecotić R,
Lušić Kalcina L, Pavlinac
Dodig I, Valić M, Roguljić M, et al.
Salivary parameters and periodontal
inflammation in obstructive sleep
apnoea patients. Scientific Reports.
2022;(1):19387
[41] Makeeva IM,Budina TV,
Turkina AY, Poluektov MG,
Kondratiev SA, Arakelyan MG, et al.
Xerostomia and hyposalivation
in patients with obstructive sleep
apnoea. Clinical Otolaryngology.
2021;(4):782-787
[42] Malhotra A, White DP. Obstructive
sleep apnoea. Lancet. 2002;:237-245
[43] Chervin RD. Sleepiness, fatigue,
tiredness, and lack of energy in
obstructive sleep apnea. Chest.
2000;:372-379
[44] Sanders AE, Essick GK, Fillingim R,
et al. Sleep apnea symptoms and risk for
temporomandibular disorder: OPPERA
cohort. Journal of Dental Research.
2013;:70S-77S
[45] Al-Jewair T, Shibeika D, Ohrbach R.
Temporomandibular disorders and their
association with sleep disorders in adults:
A systematic review. Journal of Oral &
Facial Pain and Headache. 2021;(1):41-
53. DOI:10.11607/ofph.2780
[46] Wetselaar P, Manfredini D, Ahlberg J,
Johansson A, Aarab G, Papagianni CE,
et al. Associations between tooth wear
and dental sleep disorders: A narrative
overview. Journal of Oral Rehabilitation.
2019;(8):765-775
[47] Marko Vujicic PD, Hilton
Israelson DDS, James Antoon DMD,
Roger Kiesling DDS, DDS TP, DDS MZ.
A profession in transition. The Journal
of the American Dental Association
(JADA). 2014;(2):118-121

Obstructive Sleep Apnea – New Insights in the 21st Century

[48] Demko BG. Screening for obstructive
sleep apnea in the dental office setting.
Journal of the Massachusetts Dental
Society. 2008;(1):18-20
[49] Berggren K, Broström A,
Firestone A, Wright B, Josefsson E,
Lindmark U. Oral health problems linked
to obstructive sleep apnea are not
always recognized within dental care-as
described by dental professionals.
Cllinical and Experimental Dental
Research. 2022;(1):84-95
[50] Lyons-Coleman M, Bates C, Barber S.
Obstructive sleep apnoea and the role of
the dental team. British Dental Journal.
2020;(9):681-685. DOI:10.1038/
s41415-020-1523-9
[51] Parmenter D, Millar BJ. How can
general dental practitioners help in the
management of sleep apnoea? British
Dental Journal. 2023;(7):505-509.
DOI:10.1038/s41415-023-5684-1
[52] Mehra P, Wolford LM. Surgical
management of obstructive sleep
apnea. Proc (Bayl Univ Med Cent).
2000;:338-342
[53] Ikematsu T. Study of snoring,
4th report: Therapy. Journal
of Otolaryngology of Japan.
1964;:434-435
[54] Fujita S, Conway W, Zorick F,
Roth T. Surgical correction of anatomic
abnormalities in obstructive sleep apnea
syndrome: Uvulopalatopharyngoplasty.
Otolaryngology–Head and Neck Surgery.
1981;:923-934
[55] Ferguson KA, Heighway K, Ruby RR.
A randomized trial of laser-assisted
uvulopalatoplasty in the treatment of
mild obstructive sleep apnea. American
Journal of Respiratory and Critical Care
Medicine. 2003;:15-191
[56] Rw R, Powell NB, Guilleminault C.
Obstructive sleep apnea syndrome: A
surgical protocol for dynamic airway
reconstruction. Journal of Oral and
Maxillofacial Surgery. 1993;:742-747
[57] Reiche-Fischel O, Wolford LM.
Posterior airway space changes after
double jaw surgery with counter-
clockwise rotation. Journal of Oral and
Maxillofacial Surgery. 1996;:96-99
[58] Cartwright R, Venkatesan TK,
Caldarelli D, Diaz F. Treatments for
snoring: A comparison of somnoplasty
and an oral appliance. Laryngoscope.
1999;:1680-1683
[59] Tiner BD. Surgical management
of obstructive sleep apnea. Journal
of Oral and Maxillofacial Surgery.
1996;:1109-1114
[60] Tanna N, Smith BD, Zapanta P, et al.
Surgical management of obstructive
sleep apnea. Plastic and Reconstructive
Surgery. 2016;:1263-1272
[61] Motamedi KK, McClary AC,
Amedee RG. Obstructive sleep apnea: A
growing problem. The Ochsner Journal.
2009;:149-153
[62] Simmons M. What your Dentist
Looks for In Diagnosing Sleep Apnea
[Internet]. Dear Doctor, Inc.; 2010.
Available from: https://www.deardoctor.
com/articles/sleep-disorders-and-
dentistry/page2.php
[63] Sutherland K, Cistulli PA. Oral
appliance therapy for obstructive sleep
apnoea: State of the art. Journal of
Clinical Medicine. 2019;(12):2121.
DOI:10.3390/jcm8122121
[64] American Academy of Sleep
Medicine. Obstructive Sleep Apnea.
Illinois: American Academy of Sleep
Medicine; 2008
[65] Isono S, Tanaka A, Tagaito Y,
Ishikawa T, Nishino T. Influences of head

Perspective Chapter: Role of the Oral Healthcare Team in the Management of Obstructive Sleep...
DOI: http://dx.doi.org/10.5772/intechopen.1003856

positions and bite opening on collapsibility
of the passive pharynx. Journal of Applied
Physiology. 2004;(1):339-346, Policy
Statement 2019
[66] Ng AT, Gotsopoulos H, Qian J,
Cistulli PA. Effect of oral appliance
therapy on upper airway collapsibility
in obstructive sleep apnea. American
Journal of Respiratory and Critical
Care Medicine. 2003;(2):238-241.
DOI:10.1164/rccm.200211-1275OC.
Epub 2003 Apr 30
[67] Issa FG, Sullivan CE. Upper airway
closing pressures in obstructive sleep
apnea. Journal of Applied Physiology:
Respiratory, Environmental and
Exercise Physiology. 1984;(2):520-527.
DOI:10.1152/jappl.1984.57.2.520
[68] Goyal M, Johnson J. Obstructive
sleep apnea diagnosis and management.
Missouri Medicine. 2017;(2):120-124
[69] Marklund M. Update on oral
appliance therapy for OSA. Current Sleep
Medicine Reports. 2017;(3):143-151.
DOI:10.1007/s40675-017-0080-5. Epub
2017 Jul 10
[70] Sutherland K, Takaya H,
Qian J, Petocz P, Ng AT, Cistulli PA.
Oral appliance treatment response
and polysomnographic phenotypes
of obstructive sleep apnea. Journal of
Clinical Sleep Medicine. 2015;(8):861-
868. DOI:10.5664/jcsm.4934
[71] Labarca G, Sands SA, Cohn V,
Demko G, Vena D, Messineo L, et al.
Mouth closing to improve the
efficacy of mandibular advancement
devices in sleep apnea. Annals of
the American Thoracic Society.
2022;(7):1185-1192. DOI:10.1513/
AnnalsATS.202109-1050OC
[72] Bachour A, Maasilta P. Mouth
breathing compromises adherence to
nasal continuous positive airway pressure
therapy. Chest. 2004;:1248-1254
[73] Medical Advisory Secretariat. Oral
appliances for obstructive sleep apnea:
An evidence-based analysis. Ontario
Health Technology Assessment Series.
2009;(5):1-51. Epub 2009 Sep 1
[74] Chang ET, Fernandez-Salvador C,
Giambo J, Nesbitt B, Liu SY,
Capasso R, et al. Tongue retaining
devices for obstructive sleep apnea: A
systematic review and meta-analysis.
American Journal of Otolaryngology.
2017;(3):272-278. DOI:10.1016/j.
amjoto.2017.01.006. Epub 2017 Jan 18
[75] Alshhrani WM, Hamoda MM,
Okuno K, et al. The efficacy of a titrated
tongue-stabilizing device on obstructive
sleep apnea: A quasi-experimental study.
Journal of Clinical Sleep Medicine.
2021;(8):1607-1618
[76] Mandibular repositioning device
[Internet]. Healthwise, Incorporated.
2022. Available from: https://www.cigna.
com/knowledge-center/hw/mandibular-
repositioning-device-zm6313 [Accessed:
September 1, 2023]
[77] Ramar K, Dort LC, Katz SG,
Lettieri CJ, Harrod CG, Thomas SM,
et al. Clinical practice guideline for the
treatment of obstructive sleep apnea and
snoring with oral appliance therapy: An
update for 2015 an American Academy of
sleep medicine and American Academy
of dental sleep medicine clinical practice
guideline. Journal of Clinical Sleep
Medicine. 2015;(7):773-827
[78] Dieltjens M, Vanderveken O. Oral
appliances in obstructive sleep apnea.
Healthcare (Basel). 2019;(4):141.
DOI:10.3390/healthcare7040141
[79] Vanderveken OM, Devolder A,
Marklund M, Boudewyns AN, Braem MJ,

Obstructive Sleep Apnea – New Insights in the 21st Century

Okkerse W, et al. Comparison of a
custom-made and a thermoplastic oral
appliance for the treatment of mild
sleep apnea. American Journal of
Respiratory and Critical Care Medicine.
2008;(2):197-202. DOI:10.1164/
rccm.200701-114OC. Epub 2007 Aug 2
[80] Kato J, Isono S, Tanaka A,
Watanabe T, Araki D, Tanzawa H, et al.
Dose-dependent effects of mandibular
advancement on pharyngeal mechanics
and nocturnal oxygenation in patients
with sleep-disordered breathing. Chest.
2000;(4):1065-1072. DOI:10.1378/
chest.117.4.1065
[81] Ma Y, Yu M, Gao X. The effect
of gradually increased mandibular
advancement on the efficacy of an oral
appliance in the treatment of obstructive
sleep apnea. Journal of Clinical Sleep
Medicine. 2020;(8):1369-1376
[82] de Ruiter MHT, Aarab G, de Vries N,
Lobbezoo F, de Lange J. A stepwise
titration protocol for oral appliance
therapy in positional obstructive sleep
apnea patients: Proof of concept. Sleep
& Breathing. 2020;(3):1229-1236.
DOI:10.1007/s11325-020-02045-w. Epub
2020 Mar 11
[83] Levine M, Bennett K, Cantwell M,
Postol K, Schwartz D. Dental sleep
medicine standards for screening,
treating, and managing adults with sleep-
related breathing disorders. Journal of
Dental Sleep Medicine. 2018;(3):61-68
[84] Martins OFM, Chaves Junior CM,
Rossi RRP, Cunali PA, Dal-Fabbro C,
Bittencourt L. Side effects of mandibular
advancement splints for the treatment of
snoring and obstructive sleep apnea: A
systematic review. Dental Press Journal
of Orthodontics. 2018;(4):45-54.
DOI:10.1590/2177-6709.23.4.045-054.oar
[85] Sheats RD, Schell TG, Blanton AO,
et al. Management of side effects of oral
appliance therapy for sleep-disordered
breathing. Journal of Dental Sleep
Medicine. 2017;(4):111-125
[86] Phillips CL, Grunstein RR,
Darendeliler MA, Mihailidou AS,
Srinivasan VK, Yee BJ, et al. Health
outcomes of continuous positive
airway pressure versus oral appliance
treatment for obstructive sleep apnea: A
randomized controlled trial. American
Journal of Respiratory and Critical
Care Medicine. 2013;(8):879-887.
DOI:10.1164/rccm.201212-2223OC
[87] Gjerde K, Lehmann S, Bjorvatn B,
Berge M, Thuen F, Berge T, et al. Partner
perceptions are associated with objective
sensor-measured adherence to oral
appliance therapy in obstructive sleep
apnea. Journal of Sleep Research.
2022;:e13462
[88] Liu HW, Chen YJ, Lai YC, Huang CY,
Huang YL, Lin MT, et al. Combining
MAD and CPAP as an effective strategy
for treating patients with severe sleep
apnea intolerant to high-pressure PAP
and unresponsive to MAD. PLoS One.
2017;(10):e0187032. DOI:10.1371/
journal.pone.0187032. Erratum in: PLoS
One. 2018;13(4):e0196319
[89] Yang D, Zhou HF, Xie Y. Efficacy of
uvulopalatopharyngoplasty combined
with oral appliance in treatment of
obstructive sleep apnea-hypopnea
syndrome. Irish Journal of Medical
Science. 2015;(2):329-334.
DOI:10.1007/s11845-014-1112-5. Epub
2014 Apr 16
[90] Almeida FR, Mulgrew A,
Ayas N, Tsuda H, Lowe AA, Fox N,
et al. Mandibular advancement splint
as short-term alternative treatment
in patients with obstructive sleep
apnea already effectively treated with
continuous positive airway pressure.
Journal of Clinical Sleep Medicine.

Perspective Chapter: Role of the Oral Healthcare Team in the Management of Obstructive Sleep...
DOI: http://dx.doi.org/10.5772/intechopen.1003856

2013;(4):319-324. DOI:10.5664/
jcsm.2576
[91] About - American academy of dental
sleep medicine [Internet]. Aadsm.org.
Available from: https://www.aadsm.org/
about.php [Accessed: September 1, 2023]
[92] American Academy of Sleep
Medicine – Association for Sleep
Clinicians and Researchers [Internet].
AASM and AADSM Issue New Joint
Clinical Practice Guideline for Oral
Appliance Therapy. American Academy
of Sleep Medicine – Association for
Sleep Clinicians and Researchers;
2017. Available from: https://aasm.org/
aasm-and-aadsm-issue-new-joint-
clinical-practice-guideline-for-oral-
appliance-therapy/ [Accessed: July 6,
2019]
[93] American Dental Association.
Evidence Brief: Oral Appliances for
Sleep-Related Breathing Disorders
[Internet]. American Dental Association.
Available from: https://www.ada.
org/-/media/project/ada-organization/
ada/ada-org/files/resources/research/
ada_sci_oralappl_srbd_brief_final_15.
pdf; [Accessed: September 1, 2023]
[94] American Dental Association. Policy
Statement on the Role of Dentistry
in the Treatment of Sleep Related
Breathing Disorders [Internet]. Darien,
IL: American Dental Association;
2017. Available from: https://www.ada.
org/-/media/project/ada-organization/
ada/ada-org/files/resources/research/
oral-health-topics/ada_2019_policy_
role_of_dentistry_sleep_related_
breathing_disorders.pdf; [Accessed:
September 1, 2023]
[95] About [Internet]. EADSM. European
Academy of Dental Sleep Medicine’. Bad
Reichenhall, Germany; 2014. Available
from: https://eadsm.academy/about/
[Accessed: September 2, 2023]