Alternative interventions for obstructive sleep apnea

September 3, 2019|Cleveland Clinic Journal of Medicine
Tina Waters, MD
Author and Disclosure Information

Tina Waters, MD
Sleep Disorders Center, Neurological Institute, Cleveland Clinic

Correspondence: Tina Waters, MD, Medical Principal, Cigna; tina.waters@cigna.com

Dr. Waters reported no financial interests or relationships that pose a potential conflict of interest with this article.

This article is based on Dr. Waters’ “Alternative Interventions for Obstructive Sleep Apnea” webcast released May 23, 2019, part of the “Obstructive Sleep Apnea: A Cleveland Clinic State-of-the-Art Review” online series (available at www.clevelandclinicmeded.com/online/sleep-apnea). The article was drafted by Cleveland Clinic Journal of Medicine staff and was then reviewed, revised, and approved by Dr. Waters.

Release date: September 1, 2019
Expiration date: August 31, 2022
Estimated time of completion: 0.75 hour

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ABSTRACT

Positive airway pressure (PAP) therapy is the gold standard treatment for patients with obstructive sleep apnea (OSA) and has been shown to positively impact quality of life and cardiovascular outcomes. However, not all patients with OSA can use or tolerate PAP therapy. Alternative interventions to PAP include lifestyle measures, surgical interventions, hypoglossal nerve stimulation, oral appliance therapy, and expiratory PAP devices for OSA. While these alternative interventions may benefit patients and have demonstrated improvements in OSA and quality-of-life measures, the cardiovascular impact of these interventions is uncertain as data are limited.

KEY POINTS

  • Alternative interventions for OSA are available for patients who cannot use PAP therapy.
  • Lifestyle interventions that may benefit patients with OSA are weight loss, exercise, change in sleep position, alcohol avoidance, and a review of concomitant medications.
  • Surgical interventions for OSA target the airway obstruction and include uvulopalatopharyngoplasty, maxillomandibular advancement, and bariatric surgery. Drug-induced sleep endoscopy is increasingly used to locate airway obstruction in patients with OSA.
  • Alternative device therapies for OSA are the implanted hypoglossal nerve stimulation system, oral appliances, and nasal expiratory PAP therapy valves.

ORAL APPLIANCE THERAPY

OAT devices help protrude the mandible forward and stabilize it to maintain a more patent airway during sleep. Oral appliances can be custom-made or prefabricated. Oral appliances can be titratable or nontitratable: titration provides a mechanism to adjust mandibular protrusion analogous to PAP titration, whereas the absence of titration holds the mandible in a single position. The most effective oral appliances are custom-made and titratable.

Types of OAT devices

Custom oral appliances. Custom oral appliances are fabricated using digital or physical impressions of the patient’s oral structures. Custom oral appliances are made of biocompatible materials and engage both the maxillary and mandibular arches.

Custom oral appliances are made by a qualified dentist who takes maxillary and mandibular impressions with a bite registration using the George Gauge with 40% to 50% of maximum protrusion. The appliance is fabricated in a laboratory and then fitted to the patient, who is instructed to titrate the device 0.5 mm to 1 mm per week and follow-up with the dentist at 2-week intervals. Once the patient has titrated the device to the point of comfort or improved sleep quality or snoring, polysomnography should be done with the device in place and titrated to improve the AHI as much as possible. Follow-up is recommended at 6 months and annually thereafter.

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Prefabricated oral appliances. Prefabricated oral appliances are of the boil-and-bite type, only partially modified to the patient’s oral structures.

Tongue-retaining devices. Another type of oral appliance is a tongue-retaining device, which is designed to hold the tongue forward and can be custom-made or prefabricated.

Patient considerations for OAT

OAT is not appropriate for all patients with OSA, and the indications and contraindications for use of OAT are presented in Table 3. If OAT is indicated, several considerations may influence the type of device that is most appropriate for the patient (Table 4).

Practice recommendations

The American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine established clinical practice guidelines and recommendations for OAT in patients with OSA:

  • Prescribed OAT should be done by a qualified dentist, and a custom, titratable appliance is preferred
  • OAT is preferred over no therapy for adults with OSA who are intolerant to PAP or prefer alternative therapies
  • A qualified dentist should provide oversight for dental-related side effects or occlusal changes
  • Follow-up sleep testing should be conducted to confirm efficacy or titrate treatment
  • Periodic office visits with the sleep physician and qualified dentist are recommended.26

The quality of evidence for these recommendations is low, with the exception of use of OAT rather than no therapy, which is considered of moderate quality.

Effects of OAT

Anatomic and physiologic effects. With OAT in place in the mouth, the airway caliber in the lateral dimension are increased, and the airway size at the retropalatal level is increased.27–30 With respect to the tongue, increased genioglossus muscle activity has been reported with OAT.

Side effects. Side effects of OAT include excess salivation, dry mouth, tooth tenderness, soft-tissue changes, jaw discomfort, tooth movement, and occlusal changes such as difficulty chewing in the morning. Feelings of suffocation, vivid dreams, and anxiety have also been reported with OAT.31–33

Efficacy and outcomes

Review of the data on the efficacy of OAT did not illuminate factors that predict treatment success.26 Data indicate that in patients with mild OSA using OAT or PAP therapy, there was no significant difference in the percentage achieving their target AHI; however, patients with moderate to severe OSA had a statistically significant greater odds of achieving their target AHI using PAP therapy compared with OAT. Therefore, OAT should be reserved for patients with severe OSA who cannot use or are intolerant to PAP.

Moderate-grade quality of evidence was reviewed for the established OAT practice recommendations for OSA outcomes before and after use of custom, titratable OAT devices.26 Use of a custom OAT device reduced the mean AHI, increased mean oxygen saturation, decreased the mean oxygen desaturation, decreased the arousal index, decreased the ESS, and increased quality of life compared with values prior to use of OAT.

With respect to adherence and discontinuation, patients using OAT had higher mean adherence and lower discontinuation because of side effects compared with patients using continuous PAP.26