Dental Sleep Medicine Insider December 2015 | Page 24

THE JURY IS OUT; THE BIAS REMAINS
Dental Sleep Masters Answer:

A Patient Centric Model
W
hile oral appliance therapy
has its roots in the early 20th
century, little notice was
taken until tongue retainers
and monoblocks created a
renewed interest in the 1970’s.
But it was the landmark study
of Dr. Schmidt-Norwara in 1995
that inspired sleep physicians
to take note of the potential
significant contribution that
oral appliance therapy could
make in the world of sleep
medicine.
In an attempt to guide treatment
triaging, Dr. Schmidt-Norwara
proclaimed oral appliances
potentially effective in cases of
mild to moderate obstructive
sleep apnea. This claim was
then reiterated in the 2006
Kushida Practice Parameters
paper, which guided the AADSM
and AASM’s recommended
practice policies.
“Oral appliances (OAs) are
indicated for use in patients
with mild to moderate OSA
who prefer them to continuous
positive
airway
pressure
(CPAP) therapy, or who do not
respond to, are not appropriate
candidates for, or who fail
treatment attempts with CPAP.
Until there is higher quality
evidence to suggest efficacy,

CPAP is indicated whenever
possible for patients with
severe OSA before considering
OAs…”
AHI continued to be the single
most important factor used
to attempt to determine the
likelihood of success of oral
appliance therapy for many
years. In retrospect, we now
realize with concern that
compliance was not even being
considered. Neither were other
critically important factors,
such as our patient’s adaptive
capacity
which
included
their genetic resistance to
the metabolic stresses of
obstructive sleep apnea.
“AHI CONTINUED TO BE
THE SINGLE MOST
IMPORTANT FACTOR USED
TO DETERMINE THE
LIKELIHOOD OF SUCCESS
OF ORAL APPLIANCE
THERAPY FOR
MANY YEARS.””
Even back in 1995, SchmidtNorwara noted that despite
the various designs of oral
appliances available, a review
made it clear that the design
didn’t affect the average
reduction from an AHI of 49 to
15.

DR. BARRY GLASSMAN
DENTAL SLEEP MASTERS

It should be noted that the 2006
Practice Parameters guidelines
included patient preference in
the considerations of triaging
patients, and made it clear
that CPAP non-compliance
was a clear indication for the
use of oral appliance therapy.
This conclusion, of course,
didn’t prevent those who were
evaluating
oral
appliance
success with AHI results in
post titration studies from
declaring all patients whose
AHI was greater than 5 with
the oral appliance in place as a
treatment failure.
In 2013 Cistulli re-introduced
the concept of evaluating
an effective AHI. It has been
well established that it is
common for patients who
are considered “compliant”
and “successful” with CPAP
to use the CPAP 4 hours
nightly, therefore sleeping the
remaining hours without the
internal pharyngeal support.
Cistulli, et al demonstrated