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Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 821-825
Obstructive sleep apnea: Diagnose the dental way

1 Department of Prosthodontics, Subharti Dental College, Meerut, Uttar Pradesh, India
2 Department of Prosthodontics, AIMST Dental Institute, AIMST University, Semeling-Bedong, Kedah, Malaysia
3 Department of Oral Medicine and Radiology, AIMST Dental Institute, AIMST University, Semeling-Bedong, Kedah, Malaysia
4 Pharmaceutical Chemistry Unit, AIMST University, Semeling-Bedong, Kedah, Malaysia

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Date of Web Publication5-Oct-2017


Snoring and obstructive sleep apnea syndrome (OSA) can affect both esthetics and health. This review article, describe the role of the dentist in evaluation and treatment of snoring and OSA in adults, with an emphasis on oral appliances as a means to treatment.

Keywords: Obstructive sleep apnea, oral appliances, snoring

How to cite this article:
Makkar S, Jain A, Ugrappa S, Fuloria NK, Fuloria S. Obstructive sleep apnea: Diagnose the dental way. Ann Trop Med Public Health 2017;10:821-5

How to cite this URL:
Makkar S, Jain A, Ugrappa S, Fuloria NK, Fuloria S. Obstructive sleep apnea: Diagnose the dental way. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Apr 7];10:821-5. Available from:

   Introduction Top

The understanding of the complex relationship between sleep, brain, and body function is relatively complex dating back to 1989 when Kryger recognized Sleep Medicine as a separate specialty to treat complex disturbances as related to sleep.[1] Dental sleep medicine is an area of practice that focuses on the management of sleep-related breathing disorders in conjunction with the pulmonologists and otolaryngologists, one of which is obstructive sleep apnea (OSA).[2] An institute of medicine reported 50–70 million Americans suffer from sleep disorders including sleep apnea and vast majority of cases are either undiagnosed or untreated.[3]

OSA is a common sleep disorder characterized by the excessive daytime sleepiness with irregular breathing at night. It is a clinical condition, with recognizable symptoms caused by collapse of the upper airway, either complete with no respiratory airflow (apnea), or partial, with reduction in the cross-sectional area of the upper airway lumen causing hypoventilation (hypopnea).[4] OSA can be diagnosed when 5 or more episodes of complete (apnea) or partial (hypopnea) obstruction of upper airway occurs per hour of sleep. This is otherwise termed as AHI or apnea-hypopnea index.[5] It is a significant public health problem with a prevalence of 3%–7% in men and 2%–5% in women.[6] The aim of this article is to review the role of the dentist in diagnosis and treatment of snoring and OSA, with an emphasis on oral appliances.

   Etiopathogenesis Top

In OSA, the muscle tone of the upper pharyngeal airway decreases leading to its narrowing. This, in turn causes an increase in the inspiratory effort due to reduction in the oxygen delivered to the organs including heart and brain. This leads to transient arousal from deep sleep to a light sleep phase or wakefulness then again restoration of normal muscular tone and sleep. This can occur many hundreds of times throughout the night leading to fragmentation of sleep architecture and the generation of restless and disturbed sleep leading to excessive daytime sleepiness, poor concentration, and a reduction in alertness [Table 1] and [Table 2].[7],[8],[9]
Table 1: Pathophysiology of snoring in obstructive sleep apnea

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Table 2: Signs of obstructive sleep apnea

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Systemic comorbidity coexists with OSA include hypertension, myocardial infarction, coronary artery disease, and arrhythmias. In addition that sleep disturbance leads to neurocognitive impairment, mood changes, fatigue which sums up to reduce the quality of life.[10],[11],[12],[13],[14]

   Diagnosis Top

OSA is a growing concern in health care and sometimes can cause major health problems, thus, dentists should screen their new patients for this disorder. OSA diagnosis is done in a clinical setting by obtaining a full medical history, including a subjective self-assessment through the Epworth Sleepiness Scale (ESS), physical exam, imaging studies, and polysomnography.

Sleep history

A sleep history in patient suspected of OSA should include evaluation of snoring, witnessed apneas, choking episodes, and severity of sleep measured by ESS.[15] The ESS is a validated method of assessing the likelihood of falling asleep. This consists of a short questionnaire, in which the subject is asked to rate his probability of falling asleep on a scale of increasing probability from 0 to 3 in eight different situations. At the end of the questionnaire, the scores for the eight questions are added. The scores from 0 to 9 are considered to be normal while 10–24 indicates a likely sleep disorder [Table 3].[4],[16],[17],[18]
Table 3: Key clinical findings in obstructive sleep apnea

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Laboratory diagnosis

Visual and clinical examinations are helpful in identifying the anatomical characteristics contributing to sleep-disordered breathing. However, establishing a diagnosis of sleep-disordered breathing and determining the severity of the disorder (i.e., snoring, OSA, mild-moderate-severe) require the use of specific diagnostic testing.

Laboratory findings should demonstrate respiratory disturbance index of five or more obstructed breathing events per hour of sleep. These events include any combination of apneas, hypopneas, and respiratory effort-related arousals.[19]

The “gold standard” for the diagnosis of OSA is polysomnography which combines the results of electroencephalogram, electrocardiogram, electrooculogram, and electromyography along with respiration rate, tidal volume, inspiration and expiration volumes, resulting in the patient's AHI. OSA may be classified mild if the AHI is between 5 and 15, moderate if AHI is 15–30 or severe if AHI >30.[20],[21]

   Treatment Modalities Top

OSA is a chronic condition requiring long-term, multidisciplinary treatment approach involving medical, dental, behavioral, and surgical protocols. The most appropriate management of OSA depends on the severity of the condition and the characteristics of an individual patient [Table 4].[22]
Table 4: Management of obstructive sleep apnea

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The most recommended treatment for moderate to severe OSA is continuous positive airway pressure (CPAP). With a 70% acceptance rate, CPAP machines require patients to wear a mask during night-time sleep. The unit introduces air into nasal passage and exerts positive pressure to open the upper airway, which enables the patient to breathe.

In general, surgical interventions for OSA are only indicated when a nonsurgical intervention, such as CPAP, fails.

Oral appliance therapy

Oral appliance therapy has emerged as a treatment option for mild-to-moderate OSA and as alternative for patients with severe OSA who are unwilling or unable to tolerate CPAP.

These appliances aim to increase the upper airway by preventing the tongue and soft tissues of the throat from collapsing into the pharynx while holding the mandible and attached soft tissues, including the tongue base forward, which enlarges the upper airway dimensions by specifically increasing the lateral dimensions of the velopharynx.[23]

Oral appliances may be roughly divided into tongue retaining devices and mandibular repositioning appliances which are the most commonly used devices. Besides these Herbst appliance, Esmarch appliance and snore guard have also been used to treat OSA.

Most randomized trials have shown preference to an oral appliance as compared to other treatment modalities [Table 5] and [Table 6].[24],[25],[26]
Table 5: Pros and cons of oral appliance therapy

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Table 6: American Academy of Sleep Medicine parameters for treatment of obstructive sleep apnea using oral appliances

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Mandibular advancement devices

Mandibular advancement appliances (also called mandibular advancement devices) are now the most widely used oral appliances for sleep disordered breathing. The mandibular advancement appliances are either a one-piece or a two-piece design and can be either prefabricated or custom-made. The prefabricated appliances generally are constructed of a thermolabile material which is warmed and molded by the individual, a so-called “boil and bite” appliance. The custom-made appliances are generally constructed by a dentist through impression making, jaw registration, and then fabrication in a dental laboratory.[27] A recent randomized controlled cross-over trial has shown that the custom-made appliances are superior to the pre-formed appliances in terms of reduction in snoring and apneas.[28]

The appliances can have partial or full occlusal coverage. They may be constructed using a soft or hard material and some permit jaw movement. It is also possible to provide adjustment of protrusion to provide maximum relief of symptoms with minimal side effects. In bruxists, it is advised that a flexible two-piece design is used to permit lateral movement.[29]

There is some debate over the amount of jaw opening provided by the appliance, as too much opening increases the chance of posterior displacement of the tongue and soft palate, although it also may improve upper airway patency by stretching palatoglossus and the superior pharyngeal constrictor muscles.[30] One randomized controlled crossover study [31] compared appliances which provided 4 and 14 mm of jaw opening. Although there was no difference in efficacy in the short-term of the study, 78% of patients preferred the appliance with less increase in vertical dimension.

Efficacy of oral appliances

Mandibular advancement appliances are reported to reduce snoring by 73%–100%.[32] It is also noted that these appliances improve snoring according to bed partners, and this is probably the most relevant outcome measure.[33] Hoffstein [34] reviewed the evidence on the efficacy of oral appliances for the treatment of sleep apnea found that 21% of 1577 patients from 51 studies had a 50% reduction in AHI (response rate) and 54% of 2087 patients from 59 studies had an AHI <10 (success rate.) Only five randomized, crossover, controlled studies of the efficacy of oral appliances have been reported.[34],[35],[36] Four used a control (nonactive) appliance, and one used a drug-placebo. In these studies, 270 patients with mild-to-moderate sleep apnea, the success rate was 50%, and response rate was 14%.

In meta-analysis,[34] 232 patients from seven studies compared CPAP and oral appliances and found that AHI with an oral appliance remained at 14 whereas AHI with CPAP was 6. However, patients, in general, preferred the oral appliance to CPAP.

Side effects of oral appliances

The side effects most commonly reported are dry mouth, excessive salivation, discomfort, occlusal changes, headaches, and temporomandibular joint discomfort. As most patients receive an appliance for mild sleep apnea or chronic snoring, they may be less motivated to wear the appliance, even if the side effects are minimal, as the main complaint may be from the patient's bed partner. If the bed partner was no longer present, or no longer complained of the snoring, the patient is unlikely to wear the appliance.[34] Compliance with mandibular advancement appliances has been reported to range from 4% to 76% at the end of 1 year.[37] Hoffstein [34] reviewed 21 studies with 3107 patients using mandibular advancement appliances, with longer term follow-up of 33 months found compliance rates of 56%–68%.

   Conclusion Top

The role of a dentist in the area of OSA is important both in diagnosis and in referral for further evaluation to other specialists. At the same time, the dentist can act as a provider of treatment in OSA. Oral appliances act as treatment option where other treatments have failed and could be offered as a first choice treatment for patients with snoring and mild-to-moderate OSA, or patients with severe OSA who do not tolerate CPAP therapy. General practitioners and dentists have to work in concord to provide the patient with the best treatment possible, tailored specifically to each individual patient.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Sleep Medicine. Wikipedia. Available from: [Last accessed on 2014 Dec 22].  Back to cited text no. 1
Dental Sleep Medicine. American Academy of Dental Sleep Medicine. Available from: [Last accessed on 2014 Dec 20].  Back to cited text no. 2
Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. p. 3. Extent and Health Consequences of Chronic Sleep Loss and Sleep disorders. Available from:  Back to cited text no. 3
Strollo PJ Jr., Rogers RM. Obstructive sleep apnea. N Engl J Med 1996;334:99-104.  Back to cited text no. 4
Epstein LJ, Kristo D, Strollo PJ Jr., Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5:263-76.  Back to cited text no. 5
Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: A population health perspective. Am J Respir Crit Care Med 2002;165:1217-39.  Back to cited text no. 6
Deegan PC, McNicholas WT. Pathophysiology of obstructive sleep apnoea. Eur Respir J 1995;8:1161-78.  Back to cited text no. 7
Schmidt-Nowara W, Lowe A, Wiegand L, Cartwright R, Perez-Guerra F, Menn S. Oral appliances for the treatment of snoring and obstructive sleep apnea: A review. Sleep 1995;18:501-10.  Back to cited text no. 8
Malhotra A, White DP. Obstructive sleep apnoea. Lancet 2002;360:237-45.  Back to cited text no. 9
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005;353:2034-41.  Back to cited text no. 10
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study. Lancet 2005;365:1046-53.  Back to cited text no. 11
McNicholas WT. Chronic obstructive pulmonary disease and obstructive sleep apnea: Overlaps in pathophysiology, systemic inflammation, and cardiovascular disease. Am J Respir Crit Care Med 2009;180:692-700.  Back to cited text no. 12
Brooks D, Horner RL, Kozar LF, Render-Teixeira CL, Phillipson EA. Obstructive sleep apnea as a cause of systemic hypertension. Evidence from a canine model. J Clin Invest 1997;99:106-9.  Back to cited text no. 13
Rhodes SK, Shimoda KC, Waid LR, O'Neil PM, Oexmann MJ, Collop NA, et al. Neurocognitive deficits in morbidly obese children with obstructive sleep apnea. J Pediatr 1995;127:741-4.  Back to cited text no. 14
Johns MW. A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep 1991;14:540-5.  Back to cited text no. 15
Johns MW. Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth Sleepiness Scale. Chest 1993;103:30-6.  Back to cited text no. 16
Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med 2001;163(3 Pt 1):685-9.  Back to cited text no. 17
Davies RJ, Ali NJ, Stradling JR. Neck circumference and other clinical features in the diagnosis of the obstructive sleep apnoea syndrome. Thorax 1992;47:101-5.  Back to cited text no. 18
Gottlieb DJ, Whitney CW, Bonekat WH, Iber C, James GD, Lebowitz M, et al. Relation of sleepiness to respiratory disturbance index: The Sleep Heart Health Study. Am J Respir Crit Care Med 1999;159:502-7.  Back to cited text no. 19
AHI. American Academy of Sleep Medicine. Available from: [Last accessed on 2014 Dec 21].  Back to cited text no. 20
Roure N, Gomez S, Mediano O, Duran J, Peña Mde L, Capote F, et al. Daytime sleepiness and polysomnography in obstructive sleep apnea patients. Sleep Med 2008;9:727-31.  Back to cited text no. 21
Kryger MH. Management of obstructive sleep apnea. Clin Chest Med 1992;13:481-92.  Back to cited text no. 22
Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev 2004;18:CD004435.  Back to cited text no. 23
Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: A randomized, controlled trial. Am J Respir Crit Care Med 2002;166:743-8.  Back to cited text no. 24
Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy reduces blood pressure in obstructive sleep apnea: A randomized, controlled trial. Sleep 2004;27:934-41.  Back to cited text no. 25
Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: A review. Sleep 2006;29:244-62.  Back to cited text no. 26
Lindman R, Bondemark L. A review of oral devices in the treatment of habitual snoring and obstructive sleep apnoea. Swed Dent J 2001;25:39-51.  Back to cited text no. 27
Vanderveken OM, Devolder A, Marklund M, Boudewyns AN, Braem MJ, Okkerse W, et al. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med 2008;178:197-202.  Back to cited text no. 28
Henke KG, Frantz DE, Kuna ST. An oral elastic mandibular advancement device for obstructive sleep apnea. Am J Respir Crit Care Med 2000;161 (2 Pt 1):420-5.  Back to cited text no. 29
George PT. Selecting sleep-disordered-breathing appliances. Biomechanical considerations. J Am Dent Assoc 2001;132:339-47.  Back to cited text no. 30
Pitsis AJ, Darendeliler MA, Gotsopoulos H, Petocz P, Cistulli PA. Effect of vertical dimension on efficacy of oral appliance therapy in obstructive sleep apnea. Am J Respir Crit Care Med 2002;166:860-4.  Back to cited text no. 31
Schmidt-Nowara WW, Meade TE, Hays MB. Treatment of snoring and obstructive sleep apnea with a dental orthosis. Chest 1991;99:1378-85.  Back to cited text no. 32
Bonham PE, Currier GF, Orr WC, Othman J, Nanda RS. The effect of a modified functional appliance on obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1988;94:384-92.  Back to cited text no. 33
Hoffstein V. Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath 2007;11:1-22.  Back to cited text no. 34
Johnston CD, Gleadhill IC, Cinnamond MJ, Gabbey J, Burden DJ. Mandibular advancement appliances and obstructive sleep apnoea: A randomized clinical trial. Eur J Orthod 2002;24:251-62.  Back to cited text no. 35
Naismith SL, Winter VR, Hickie IB, Cistulli PA. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: A randomized controlled trial. J Clin Sleep Med 2005;1:374-80.  Back to cited text no. 36
Jauhar S, Lyons MF, Banham SW, Cameron DA, Orchardson R. Ten-year follow-up of mandibular advancement devices for the management of snoring and sleep apnea. J Prosthet Dent 2008;99:314-21.  Back to cited text no. 37

Correspondence Address:
Ajay Jain
Department of Prosthodontics, Faculty of Dentistry, AIMST Dental Institute, AIMST University, Kedah
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_520_16

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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