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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
Oral Appliance Therapy
203
13
the signs of the disease in order for the patients to seek
medical care [239, 241, 243–245]. One guideline highlights
that there might be differences in signs and symptoms of
OSA in a geriatric population who still will be at great
risk of complications of untreated OSA [242]. In the recognition of OSA, there are some validated methods such
as the Berlin Questionnaire and STOP-Bang, but also a
validated app for the mobile phone: the NoSAS [246].
The guidelines generally recommend OA therapy for
patients with snoring, mild to moderate OSA, or CPAPintolerance. The need to treat patients within the mildest spectrum of sleep-disordered breathing has, however,
been questioned, because of reports that mild OSAS is
not signicantly associated with comorbidities [90, 247].
New methods do diagnose this disease will probably
change these indications [5]. Dentists who are educated
in dental sleep medicine can provide treatment with OA
therapy for referred patients. The treatment must be proceeded by a thorough odontological investigation regarding dental and periodontal health. Assessment of the
temporomandibular joint, and movement capacity of the
lower jaw as well as diagnosis of dental occlusion must be
performed. Custom-made, titratable oral appliances are
recommended, preferably those that have been evaluated
in studies. It is emphasized that the treatment should be
regularly followed-up and yearly controls of subjective
effects, side effects, and device quality are recommended.
This regime will probably be facilitated by the novel EC
recommendations regarding requirements for drivers with
OSA [248]. One guideline [2] highlights the need for a strict
terminology and advises to use the term “OA” instead of
the many local terms. In addition, well- dened protocols
for titration and follow-up should be developed. More
research concerning longer term health outcomes during
OA
treatment, avoidance of side effects, and device com-
M
parison is needed [2].
13.17 Summary ofOA
M
of bite changes are common and progressively increase.
The treatment effect may deteriorate when patients age
and sleep-disordered breathing become more severe and
change in character. Most likely, OAM treatment will
therefore take place during periods of the patients’ lives.
When OAM treatment is initiated earlier in life, it is likely
that PAP treatment will be needed after some time. It is
important to carefully follow-up OAM treatment regularly
in terms of efcacy, side effects, and the need for other or
combined treatment options.
13.18 Devices That Hold theTongue
Forward—OA
13.18.1 Eects
T
OAT is designed to produce suction of the tongue into
an anterior bulb and do not require teeth [249–252]. OA
T
produces a similar apnea reduction as OAM in patients
who tolerate both devices [250]. The adherence is generally poor with OAT, since only around one third of the
patients continued after 3 weeks [250]. Only one fth
could be followed up with a renewed sleep apnea recording after some months in another study [252], while half
of the patients continued for 5 years in further another
study [249]. OAM are preferred compared with OAT by
over 90% of patients who had tried both treatments [250].
13.18.2 Side Eects
The short-term side effects from OAT resemble those
from OAM including excessive salivation and a dry
mouth [249, 250, 252]. In addition, patients who are
treated with OAT often complain about tongue soreness
and problems to keep the appliance in place [250, 252].
Bite alterations with anterior or posterior open bites and
a reduced overjet have been reported from OATT [253].
OAM is the most effective non-CPAP therapy for patients
who snore or those with mild to moderate sleep apnea and
PAP-intolerant patients. More precise predictors based
on the etiology of the disease in the individual patient
are under development. This will provide better tools to
avoid ineffective OA
treatments. In patients with mild
M
disease who suffer from daytime sleepiness, a test period
with PAP treatment is of help to nd if they respond
with a symptomatic relief to OSA treatment before OAM
therapy is started. The efcacy of OAM must be tested in
order to verify the objective outcome of the treatment,
since symptoms are poorly correlated with sleep-disordered breathing. In the longer term, side effects in terms
13.18.3 Summary ofOA
T
Tongue-retaining devices may reduce obstructive sleep
apneas, but poor tolerance and side effects make this
treatment less useful in patients with snoring or obstructive sleep apnea.
Conict of Interest The author certies that she has no
afliations with or involvement in any organization or
entity with any nancial interest, except for a consultancy fee from ResMed, or non-nancial interest in the
subject matter or materials discussed in this manuscript.
204
M. Marklund
13
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213
Other Therapies andEmerging
Options forManagement
ofOSA
AbbeyDunn andNeerajKaplish
Contents
14.1 Introduction – 214
14.2 Positional Therapy – 214
14.2.1 Weight Loss – 215
14.2.2 Nasal EPAP Therapy – 217
14.2.3 Oral Pressure Therapy – 218
14.2.4 Hypoglossal Nerve Stimulation – 219
14
References – 220
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_14