Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015

Abstract

Introduction: Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clinical outcomes. The purpose of this new guideline is to replace the previous and update recommendations for the use of OAs in the treatment of obstructive sleep apnea (OSA) and snoring.

Methods: The American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) commissioned a seven-member task force. A systematic review of the literature was performed and a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the quality of evidence. The task force developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms. The AASM and AADSM Board of Directors approved the final guideline recommendations.

Recommendations: 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).

Conclusions: The AASM and AADSM expect these guidelines to have a positive impact on professional behavior, patient outcomes, and, possibly, health care costs. This guideline reflects the state of knowledge at the time of publication and will require updates if new evidence warrants significant changes to the current recommendations.

Keywords: mandibular advancement; obstructive sleep apnea; oral appliance; positive airway pressure; snoring.

© 2015 American Academy of Sleep Medicine.

Figures

Figure 1. Custom, Non-Titratable (C-NT) OAs for Mild to Moderate Adult OSA (AHI/RDI/REI).

Figure 2. Custom, Non-Titratable OAs for Moderate to Severe Adult OSA (AHI/RDI/REI).

Figure 3. Custom, Titratable (C-T) OAs for Mild to Moderate Adult OSA (AHI/RDI/REI).

Figure 4. Custom, Titratable OAs for Moderate to Severe Adult OSA (AHI/RDI/REI).

Figure 5. CPAP for Mild to Moderate Adult OSA (AHI/RDI/REI).

Figure 6. CPAP for Severe Adult OSA (AHI/RDI/REI).

Figure 7. OAs for Primary Snoring (Snoring Loudness).

Figure 8. Summary of Findings (Primary Snoring, Snoring Indices).

Figure 9. OAs for OSA (AHI/RDI/REI).

Figure 10. Custom OAs for OSA (AHI/RDI/REI).

Figure 11. Non-Custom OAs for OSA (AHI/RDI/REI).

Figure 12. Custom, Titratable OAs for OSA (AHI/RDI/REI).

Figure 13. Custom, Non-Titratable OAs for OSA (AHI/RDI/REI).

Figure 14. OAs vs. CPAP for OSA (AHI/RDI/REI).

Figure 15. OAs for OSA (Minimum Oxygen Saturation).

Figure 16. Custom OAs for OSA (Minimum Oxygen Saturation).

Figure 17. Non-Custom OAs for OSA (Minimum Oxygen Saturation).

Figure 18. Custom, Titratable OAs for OSA (Minimum Oxygen Saturation).

Figure 19. Custom, Non-Titratable OAs for OSA (Minimum Oxygen Saturation).

Figure 20. OAs vs. CPAP for OSA (Minimum Oxygen Saturation).

Figure 21. OAs for OSA (Arousal Index).

Figure 22. Custom, Titratable OAs for OSA (Arousal Index).

Figure 23. Custom, Non-Titratable OAs for OSA (Arousal Index).

Figure 24. OAs vs. CPAP for OSA (Arousal Index).

Figure 25. OAs for OSA (Oxygen Desaturation Index; ODI).

Figure 26. Custom, Titratable OAs for OSA (ODI).

Figure 27. Custom, Non-Titratable OA for OSA (ODI).

Figure 28. OAs vs. CPAP for OSA (ODI).

Figure 29. OAs for OSA (% Rapid Eye Movement; %REM).

Figure 30. Custom OAs (%REM).

Figure 31. Custom, Titratable OAs for OSA (%REM).

Figure 32. Custom, Non-Titratable OA for OSA (%REM).

Figure 33. OAs vs. CPAP for OSA (%REM).

Figure 34. OAs for OSA (Sleep Efficiency).

Figure 35. Custom OAs for OSA (Sleep Efficiency).

Figure 36. Non-Custom OAs for OSA (Sleep Efficiency).

Figure 37. Custom, Titratable OA for OSA (Sleep Efficiency).

Figure 38. Custom, Non-Titratable OA for OSA (Sleep Efficiency).

Figure 39. OAs vs. CPAP (Sleep Efficiency).

Figure 40. Summary of Findings: OA Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).

Figure 41. Summary of Findings: Custom OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).

Figure 42. Summary of Findings: Non-Custom OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).

Figure 43. Summary of Findings: Custom, Titratable OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).

Figure 44. Summary of Findings: Custom, Non-Titratable OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).

Figure 45. Summary of Findings: OAs vs. CPAP for OSA (All Physiologic Sleep Outcome Measures).

Figure 46. OAs for OSA (Epworth Sleepiness Scale; ESS).

Figure 47. Custom OAs for OSA (ESS).

Figure 48. Custom, Titratable OAs for OSA (ESS).

Figure 49. Custom, Non-Titratable OAs for OSA (ESS).

Figure 50. OAs vs. CPAP for OSA (ESS).

Figure 51. Summary of Findings: OAs Pre- vs. Post-Treatment for OSA (ESS).

Figure 52. Summary of Findings: Custom OAs for OSA (ESS).

Figure 53. Summary of Findings: Non-Custom OAs for OSA (ESS).

Figure 54. Summary of Findings: Custom, Titratable OAs for OSA (ESS).

Figure 55. Summary of Findings: Custom, Non-Titratable OAs for OSA (ESS).

Figure 56. Summary of Findings: OAs vs. CPAP for OSA (ESS).

Figure 57. OAs for OSA (Quality of Life, QOL; Short Form-36, SF-36).

Figure 58. Custom, Titratable OAs for OSA (QOL; SF-36).

Figure 59. Custom, Non-Titratable OAs for OSA (QOL; SF-36).

Figure 60. OAs vs. CPAP for OSA (QOL; SF-36).

Figure 61. Summary of Findings: OAs Pre- vs. Post-Treatment for OSA (Quality of Life; QOL).

Figure 62. Summary of Findings: Custom, Titratable OAs for OSA (QOL).

Figure 63. Summary of Findings: Custom, Non-Titratable OAs for OSA (QOL).

Figure 64. Summary of Findings: OAs vs. CPAP for OSA (QOL).

Figure 65. OAs for OSA (Systolic blood pressure).

Figure 66. OAs for OSA (Diastolic blood pressure).

Figure 67. Custom, Titratable OAs for OSA (Systolic blood pressure).

Figure 68. Custom, Titratable OAs for OSA (Diastolic blood pressure).

Figure 69. OAs vs. CPAP for OSA (Systolic blood pressure).

Figure 70. OAs vs. CPAP for OSA (Diastolic blood pressure).

Figure 71. Summary of Findings: OAs for OSA (Hypertension).

Figure 72. Summary of Findings: Custom, Titratable OAs for OSA (Hypertension).

Figure 73. Summary of Findings: Custom, Non-Titratable OAs for OSA (Hypertension).

Figure 74. Summary of Findings: OAs vs. CPAP for OSA (Hypertension).

Figure 75. OAs vs. CPAP for OSA (Adherence).

Figure 76. Summary of Findings: OAs vs. CPAP for OSA (Adherence).

Figure 77. OAs for OSA (Side Effects).

Figure 78. OAs vs. CPAP for OSA (Side Effects).

Figure 79. Summary of Findings: OAs for OSA (Side Effects).

Figure 80. Summary of Findings: OAs vs. CPAP for OSA (Side Effects).