Management of obstructive sleep apnea

describes sleep apnea and prosthodontic management

1. Management of Snoring and Obstructive Sleep Apnea with Mandibular Repositioning Appliances: A Prosthodontic Approach Preceptor- Dr Siddhi Tripathi Presenter-Dr Megha Sabharwal Barewal RM, Hagen CC. Management of Snoring and Obstructive Sleep Apnea with Mandibular Repositioning Appliances: A Prosthodontic Approach.Dent Clin N Am 2014;58: 159–180 Date- 4 th June 2020

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3. INTRODUCTION Dentists are becoming increasingly aware of the importance of detection and management of obstructive sleep apnea . Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that involves a decrease or complete halt in airflow despite an ongoing effort to breathe. It occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and block the upper airway. 3

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6. OSA 1 is defined as the occurrence of 5 or more episodes of complete ( apnea ) or partial ( hypopnea ) upper airway obstruction per hour of sleep ( apnea-hypopnea index [AHI]) and is estimated to occur in around 24% of middle aged men and 9% of women. Obstructive sleep apnea (OSA) results in sleep fragmentation and oxygen desaturation 1.Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5. Definitions 6

7. Apnea is defined as a cessation of airflow (breathing) lasting for at least 10 seconds. Hypopnea is a 50% reduction in airflow for 10 seconds or more, usually associated with a fall in blood oxygen saturation. The Apnea Index (AI) is the number of apneic episodes per hour of sleep. The total number of apneic and hypopneic episodes per hour of sleep is referred to as the Apnea-Hypopnea Index (AHI) or the Respiratory-Disturbance Index (RDI). 7

8. SLEEP ARCHITECTURE The two main divisions of a normal cycle are non-rapid eye movement (non-REM) and rapid eye movement (REM) 2 Non-REM consists of four stages. Transitional stage . This is the time when one is falling asleep, and it usually represents only 5 percent of sleep time. Light sleep stage . This stage accounts for 50 percent of normal sleep time. 3. The delta and slow-wave stages . These stages represent about 20 percent of sleep time and are the stages in which one experiences a deep and relaxing state of rest. 2.Weaver and Millman , Broken sleep. Am J Nurse 1986; 88:146-50 8

9. After the non-REM cycle is complete, one usually enters into REM sleep. Restful sleep continues during this cycle. It is also the period in which one dreams. This stage accounts for the final 25 percent of a normal sleep cycle. To experience a restful night sleep, one must spend sufficient time in deep sleep A person suffering from sleep apnea cannot do this because they are constantly awakened throughout the night. 9

10. CLASSIFICATION 3 Sleep apnea is classifed as : Central - Although the airway remains open, the chest wall muscles make no effort to create airflow Obstructive -This is the cessation of airflow due to a total airway collapse despite a persistent effort to breathe. Mixed -This term is used when both central and obstructive episodes are observed during a sleep study. 3. Tsara V, Amfilochiou A.Definition and classification of sleep related breathing disorders in adults. Different types and indications for sleep studies (Part 1) HIPPOKRATIA 2009; 13(3): 187-191 10

11. 4. Barewal RM, Hagen CC.Management of Snoring and Obstructive Sleep Apnea with Mandibular Repositioning Appliances: A Prosthodontic Approach Dent Clin N Am2014: 159–180 CLASSIFICATION OF SDB. UARS,UPPER AIRWAY RESISTANCE SYNDROME 11

12. OBJECTIVES To review the diagnosis,risk factors,treatment approach,indications and contraindications for treatment,appliance design of obstructive sleep apnea . To emphasize the role of a prosthodontist because of established training in TMD, removable appliance therapy, and occlusion & the management of sleep apnea with oral appliances 12

13. WHO ALL ARE AT RISK? 13

14. PREVALENCE OSA can occur in any age group, but prevalence increases between middle and older age. OSA with resulting daytime sleepiness occurs in at least 4 percent of men and 2 percent of women About 24 percent of men and 9 percent of women have the breathing symptoms of OSA with or without daytime sleepiness . 14

15. INDIA Vijayan & Patial (2006)-males-4.4% Females-2.5% Reddy et al (2009) Males- 13.5% Females- 5.6% Obese individuals -4 times higher risk than non obese individuals 5.Karl OE. Obstructive sleep apnea is a common disorder in the population—a review on the epidemiology of sleep apnea J Thorac Dis 2015; 7(8):1311–1322 15

16. People who are overweight (Body Mass Index of 25 to 29.9) and obese (Body Mass Index of 30 and above) Men and women with large neck sizes : 17 inches or more for men, 16 inches or more for women Middle-aged and older men, and post-menopausal women Ethnic minorities 16

17. Down Syndrome large tonsils and adenoids Anyone who has a family member with OSA Endocrine disorders such as Acromegaly and Hypothyroidism Smokers and alcoholics nocturnal nasal congestion due to abnormal morphology , rhinitis or both. 17

18. OBSTRUCTIVE SLEEP APNEA AND OBESITY: Obese individuals (BMI >30 kg/m(2)) are at higher risk for OSA compared with non-obese individuals and up to 75% of OSA patients are obese. It is hypothesized that obese individuals have large deposits of fat in the neck that cause the upper airway to collapse in the supine position during sleep. The observations reported from several studies support the hypothesis that AHIs (or RDIs) are significantly reduced with weight loss in obese individuals. 18

19. Why intervention is necessary? 19

20. Why intervention is needed?? Reccurent ecurrent episodes affects organs systems, mainly the brain and the cardiovascular system, and alter the body metabolic balance 6 clinical sequelae accepted as the OSA syndrome .Daytime sleepiness ,due to nocturnal sleep fragmentation. causing impaired performance at work and major work-related and road accidents. patients develop cognitive and neurobehavioral dysfunction , inability to concentrate , memory impairment and mood changes. if left untreated insulin resistance , type II diabetes and altered serum lipid profile ,can represent a further risk of cardiovascular morbidity 4 & mortality 6.Guilleminault C., Quo S.  Sleep-disordered breathing. A view at the beginning of the new Millennium. Dent Clin North Am 2001 ;13(3): 643–656. 20

21. The clinical history should document the following : 1. Presence and severity of snoring 2. Presence and severity of witnessed apneic events 3. Presence and severity of excessive daytime sleepiness 4. Energy level during day 5. Quality of sleep (provide a scale of 1–10) 6. Quantity of sleep (number of hours of sleep per night) 7. Number of awakenings per night 8. Sleep position: side, back, stomach 21

22. 9 . Presence of other symptoms a. Recent weight gain b. Bruxism c. Morning headache d. Gastroesophageal reflux disease e. Depression f. Impotence g. Nasal congestion DETAILED DENTAL HISTORY & EXAMINATION 22

23. HISTORY A complete dental history is required, which includes any orthodontic or periodontal treatment rendered. A complete intra-oral examination will provide an assessment of risks to treatment . Caries assessment, a periodontal examination, and TMJ evaluation including the muscles of mastication, occlusal analysis, and parafunctional habits. Current dental radiographs , cephalometric evaluation ,MRI and computed tomography to assess the efficacy of oral appliances. 23

24. POLYSOMNOGRAPHY 7 –Gold Standard Polysomnography is essential to yield a clear diagnosis of OSA. It combines electrophysiologic indices of sleep stage,electromechanical parameters contrasting respiratory effort with actual ventilation and measurements reflecting the consequences of abnormal respiratory events. A tracing is produced showing the duration and number of obstructive and hypoxic events during six to eight hours of sleep. 24

25. The average number of desaturation episodes per hour can be measured using PSG and is called the oxygen desaturation index (ODI). Desaturation episodes are generally described as a decrease in the mean oxygen saturation of ≥4% (over the last 120 seconds) that lasts for at least 10 seconds. Respiratory Effort Related Arousal -An event that causes an arousal or a decrease in oxygen saturation, without qualifying as an apnea or hypopnea .  Respiratory Disturbance Index -This is your combined number of apneas , hypopneas , and RERAs per hour of sleep. Arousal index- number of arousals per night 7. Billings ME. Interpreting Sleep Study Reports: A Primer for Pulmonary Fellows. AASM SCORE2014;2(1) 25

26. GRADING OF OSA 26

27. HOME SLEEP APNEA TESTING DEVICES New generations of portable sleep apnea testing devices have become increasingly accurate with better sensitivity and better specificity. allow the application of sensors by patients themselves at home & the patient can perform the recording themselves at home. the recorded data are downloaded from the device and are scored by the sleep technician in order to check for sleep time . 27

28. QUESTIONNAIRE 28

29. Berlin Questionnaire 29

30. UPDATED STOP BANG QUESTIONNAIRE The dentist should ideally apply specific questionnaires for all “patients with suspected OSA”; the most recommended ones are: EPWORTH questionnaire / or STOPBANG questionnaire 7 30

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33. The Epworth Sleepiness Scale (ESS) How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing 33

34. SITUATION CHANCE OF DOZING (0–3) Sitting and reading Watching television Sitting inactive in a public place (e.g. a theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic 34

35. TOTAL SCORE Score Results : 1-6 Congratulations, you are getting enough sleep! 7-8 Your score is average 9 and up Very sleepy and should seek medical advice 35

36. Modified Mallampati score. Class 1, complete visualization of the soft palate; class 2, complete visualization of the uvula; class 3, visualization of only the base of the uvula; class 4, soft palate is not visible at all. Ginapp T. Ask the clinical instructor.Cath Lab Digest 2012;20(7) 36

37. Oral anatomic variables potentially directly or indirectly affecting airway space 15 Mallampati score - Score of 3 or 4, probability of OSA is 58%–82%. Tonsillar size Mandibular tori Macroglossia Impingement of oral space for the tongue Obstructive size effect 37

38. Serrations on lateral border of tongue Steep soft palate drape Indications of tongue size/arch size discrepancy, and possible nocturnal clenching 38 In combination with a large tongue, the soft palate can reduce airway dimension especially in the supine position

39. 39 Retrognathia and micrognathia Negative effect on pharyngeal airway dimension

40. Loss of vertical dimension of occlusion V-shaped arch forms Overall reduction of oral volume Reduction of tongue space and reduction of pharyngeal airway dimension 40

41. TREATMENT OPTIONS 1.Behavioral modification: weight loss, alcohol avoidance, alteration of sleeping position 2. Positive airway pressure (PAP) 3.Upper airway surgical procedure 4. Pharmacologic treatment 5. Oral appliances 41

42. BEHAVIOURAL CHANGES -- Weight loss- Remains a highly effective method 10 – 15 % reduction in weight can lead to an approximately 50 % reduction in sleep apnea severity in moderately obese male patients Avoid alcohol and sedatives Avoid sleep deprivation Avoid supine sleep position Stop smoking 42

43. Positive airway pressure (PAP) 8 Nasal continuous positive airway pressure ( nCPAP ) is considered the “gold standard” for treatment of OSA . It helps keep the airway open during sleep through a continuous stream of air under light pressure, applied to the pharynx through a nasal mask. It should be used for a minimum six hours everynight and is virtually always effective if used regularly . 8.Beecroft J, Zanon S, Lukic D. Oral continuous positive airway pressure for sleep apnea : effectiveness, patient preference, and adherence. Chest 2003; 124:2200–8. 43

44. Drawbacks - Noisy Tolerance 3. The application of a face mask can be a hindrance to patients may find it suffocating. 4. Drying of the airway mucosa often occurs which can be overcome by the inclusion of a humidifier. 5. Bulky 44

45. Reconstruct upper airway Uvulopalatopharyngoplasty (UPPP )- is a surgical procedure to enlarge the airspace of the oropharynx of OSA patients This enlargement is accomplished by excising redundant soft tissue of the palate, uvula, tonsils, and posteriorand lateral pharyngeal walls. Laser-assisted uvulopalatopharyngoplasty (LAUP) Radiofrequency Mandibular advancement & tissue volume reduction ( somnoplasty ) Genioglossal advancement Mandibular advancement Nasal reconstruction Tonsillectomy SURGICAL INTERVENTION 9 9. Jack B,Meyer JR .The sleep apnea syndrome. Part II. Treatment March 1990;63(3):883-9 45

46. Bypass upper airway Tracheostomy - Tracheostomy is one of the most effective surgical measures because it provides an airway below the level of obstruction.Even though a tracheostomy often results in immediate relief of symptoms, it is poorly accepted by patients because of long-term morbidity 9. Jack B,Meyer JR .The sleep apnea syndrome. Part II. Treatment March 1990;63(3):883-9 46

47. DRUG THERAPY 9 9. Jack B,Meyer JR .The sleep apnea syndrome. Part II. Treatment March 1990;63(3):883-9 47

48. ORAL APPLIANCE THERAPY Oral appliance therapy has emerged as an alternative to CPAP for snoring, and mild to moderate OSA in patients who refuse or fail to adhere to the use of the CPAP device. Although mandibular repositioning appliances (MRAs) seem to be less efficacious than CPAP, in instances when both treatments are effective, patients usually prefer oral appliances over CPAP. 48

49. OBJECTIVES of APPLIANCE THERAPY Reduce snoring to a subjectively acceptable level Resolution of clinical signs and symptoms of OSA Normalization of the AHI and oxyhemoglobin saturation levels 49

50. MECHANISM OF ACTION Oral appliance therapy functions by repositioning the tongue and mandible forward and downwards to reduce airway collapse . The treatment aims to widen the lateral aspects of the upper airways to improve the upper airway patency and reduce snoring and OSA. The upper airway can be defined by 3 regions : the velopharynx oropharynx hypopharynx 50

51. TYPES OF ORAL APPLIANCES 3 broad classes – MRA Tongue retaining devices ( TRD) Soft palate lifters 51

52. SNORE-AIDE PLUS SILENCER SYSTEM THORNTON ADJUSTABLE POSITIONER ELASTIC MANDIBULAR ADVANCEMENT (EMA) APPLIANCE 52

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54. MRAs are further subdivided into – Titratable ( 2 piece appliance ) Non titratable ( 1 piece appliance ) Also as Custom made appliance Pre fabricated there is a superior treatment response with MRAs that are custom-made over prefabricated designs. 54

55. The requirements of an MRA are as follows: 1. Good retention form to 1 or 2 arches 2. Sufficient protrusion of the mandible at an increased vertical dimension 3. Appliances that do not restrict jaw movement laterally or vertically are optimal for temporomandibular joint (TMJ) comfort. 55

56. CHOOSING AN APPROPRIATE DESIGN 10 Various aspects should be considered when choosing the appropriate oral appliance: oral condition (number, location and health of remaining teeth, periodontal tissues status etc.) anticipated dental restorative needs; cranio -facial structures; the presence of allergies and / or sensitivities; patient’s manual dexterity, visual acuity and cognitive ability; patient’s comfort; financial considerations . 56

57. There are more than 100 models of oral appliances available on the medical market ( Monoblock , Klearway ; IST – Intraoral Snoring Appliance; TAP-T Thornton Adjustable Positioner ; Erkodent – Silensor ; Somnodent ; boil and bite – ready-made splints), therefore the dentist must select the proper oral appliances for specific clinical cases. It is advisable, however, that a custom, titratable appliance be used over non-custom oral devices 10.Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773–827 57

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59. ADVANTAGES OF ORAL APPLIANCES 1 . Nonintrusive 2. Lack of noise 3. Simplicity 4. Reversible treatment modality 5. Smaller and more portable than CPAP devices 6. No need for power source 7. Comfortable: fits inside the mouth 8. Potentially lower cost of treatment 59

60. ADVERSE EFFECTS Side effects can be grouped into 2 broad categories : 1. Minor in severity and temporary : tend to resolve during a short adaptive period of 6 to 8 weeks or are tolerable and do not resolve. Frequency reported from 6% to 86%.64 2. Moderate to severe and continuous : these side effects can occur at any stage during treatment and might lead to intolerance and discontinuation of the appliance 60

61. 11. Ferguson KA, Cartwright R, Rogers R. Oral appliances for snoring and obstructive sleep apnea : a review. Sleep 2006;29:244–62. 61

62. DEGREE OF PROTRUSION 12 Protrusion of the mandible is required to make the MRA effective unless it is being used as a stabilizing appliance in conjunction with CPAP when the requirement is more reduction of pressure. Reports of effective degrees of advancement range from 6 to 10 mm, or from 65% to 70% of maximum protrusive potential 12. Mehta A, Qian J, Petocz P. A randomized controlled study of a mandibular advancement splint for obstructive sleep apnea . Am J Respir Crit Care Med 2001;163:1457–61 62

63. The value of a titratable appliance is the opportunity to initiate therapy at a mandibular position that is no more than 50% of maximum protrusion, which although may be below optimal level, would allow for slow advancement thereby reducing negative side effects such as muscular tension or TMD. Patients can remain at this level during an adaptive period of 1 to 8 weeks during which period most if not all of the transient negative side effects resolve . RAPID ADVANCEMENT SIDE EFFECTS REJECTION 63

64. TIME LINE BY VISIT NUMBER 64

65. HIGH RISK OF OSA PT COMPLAINS OF SYMPTOMS SELF REPORTING QUESTIONNAIRES POSITIVE FOR SLEEP DISORDERS SYMPTOMS OSA SLEEP EVALUATION (SLEEP SPECIALIST) SLEEP STUDY PSG PORTABLE MONITOR AHI>5 WITH SYMPTOMS AHI> 15 EVALUATION FOR OTHER DISEASES TREATMENT OPTIONS CPAP OFFERED ALTERNATIVE THERAPIES CPAP GIVEN LIFESTYLE CHANGES ORAL APPLIANCE BEHAVIOURAL /POSITIONAL THERAPY SURGERY Flow chart for evaluation and treatment of patients suspected of having OSA. pt, patient 65

66. Critical Analysis Comparision of efficacy of oral appliance therapy with other treatment modalities was absent. No mention of the fabrication techniques for dentulous and edentulous patients No comparison of different customized appliances. No affirmation about measurement of mandibular advancement and vertical opening. 66

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68. ORAL APPLIANCES COMPARED TO CPAP 11 published randomized controlled trials which compare efficacy of OA treatment with CPAP with polysomnography that evaluate aspects of clinical effectiveness . 68

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70. Oral appliances- Customized versus Thermoplastic In a crossover study of 35 patients over 4 months of each device found post-treatment AHI was reduced only with the custom-made OA. The thermoplastic device showed a much lower rate of treatment success (60% vs. 31%). Lower adherence to the thermoplastic appliance was also due to insufficient retention of the appliance during sleep. Majority of patients (82%) preferred the customized OAm at the end of the study. Hence customization to a patient’s dentition is a key component of treatment success . Vanderveken OM, Devolder A, Marklund M. Comparison of Custom-made and Thermoplastic Oral Appliance. Am J Respir Crit Care Med2008;178(2):197-202. 70

71. Objective : To compare three different oral appliances: a mandibular advancement device ( Snoreguard ), a tongue retaining device, and a soft palate lift, for treatment of OSAS. Methods : Eight patients with a mean apnea hypopnea index (AHI) of 72.1 (SD+/-39.9) were studied. Polysomnographic measures during each of the treatment nights were compared to baseline. Results : Eight out of 8 patients completed the mandibular advancement device (MAD) night; 5/8 tolerated the tongue retaining device (TRD); only 2/8 could sleep with the soft palate lift (SPL) in place. Improvement using the MAD reached significance: overall AHI (mean+/-SD) decreased from 72.1+/-39.9 at baseline to 35.5+/-39.4 with the appliance in place (P<0.02). Conclusions : A mandibular advancement device is an effective treatment alternative in some patients with severe OSAS. In comparison, the tongue retaining device and the soft palate lift do not achieve satisfactory results. 71

72. A 49-year-old man was referred from the Ear, Nose and Throat Department with a history of intrusive snoring and obstruction. Sleep endoscopy showed evidence of a retrognathic mandible with marked obstruction to 68%. There was obvious tongue base collapse at rest, with an associated component from the lateral pharyngeal wall and uvula. In view of the retrognathic mandible, it was determined that a mandibular advancement splint should be fabricated to bring the mandible forward, which in turn would enlarge the posterior pharyngeal space 72

73. STEPS Preliminary Impressions Definitive impressions Wax rims Maxillomandibular relation was recorded maintaining the patient’s existing vertical dimension of occlusion. Vertical marks were made bilaterally on both of the wax occlusion rims in the canine region at the CR position. The patient was then asked to protrude maximally, and another line was marked on the maxillary rim corresponding to the centric relation line in the mandibular rim 73

74. relation was recorded at that position with occlusal registration paste. After articulation, the casts were duplicated with duplicating silicone & vacuum formed clear bases were fabricated on the duplicated casts. these were then placed on the articulated casts, and 2 wax blocks were adapted on either side, in the position of the wax rims. they were processed with heat-polymerized clear acrylic resin 74 Protrusion achieved with no increase in vertica dimension

75. they were processed with heat polymerized clear acrylic resin. vent holes were placed in the middle of the heat-polymerized acrylic resin blocks, which were then adapted onto the vacuum-formed bases and sealed with autopolymerizing acrylic resin. 75

76. Instructions - 1-3 hours a day for first week ,after followup visit regulary at night. At the first monthly review, the patient reported his sleep had improved at night and his daytime somnolence had diminished. 76

77. Conservative treatment of obstructive sleep apnea (OSA) includes weight loss, changes in sleep posture, drug therapy, nasal continuous positive airway pressure (CPAP),and placement of an intraoral prosthesis. This article describes a technique for fabrication of sleep apnea prosthesis for dentate patients. 77

78. Fig. 1. Blocked out master casts with outline of design. Pig. 2. Blocked out master casts mounted with wax interocclusal record. Pig. 3. Occlusal view of wax-up on duplicated casts. Pig. 4. Anterior view of wax4rp on duplicated casts. 78

79. Fig. 5. Sleep apnea prosthesis polished and fitted to mounted master casts. Fig. 6. Maxillary and mandibular segments joined with visible light-cured resin. Fig. 7. Sleep apnea prosthesis in place. Fig. 8. Sleep apnea prosthesis with clasps. 79

80. Approach for treating the soft palate in those patients diagnosed with mild to moderate OSA. Palatal implantsare made of polyethylene terephthalate (PET), a linear, aromatic polyester. Shows the following characteristics: biostability , promotion of tissue in-growth, a well-characterized fibrotic response. Each soft palate implant is cylindrical in shape, measures 18 mm -1.8 mm, and is made of porous and braided PET. 80

81. Three palatal implants are placed in the upper portion of the soft palate under local anesthesia in a single office visit. Placement of the implants increases the rigidity of the soft palate. Increased rigidity has a substantial impact on pharyngeal closing pressure. A more negative value implies a less collapsible airway . 81

82. 82 DO YOU KNOW? Pillows to encourage side sleeping(with ridges) Wedge pillows. CPAP Mask pillows Realignment pillows(cervical repositioning to avoid airway compression) Smart Pillows

83. CONCLUSION Because of established training in TMD, removable appliance therapy, and occlusion, prosthodontics is uniquely suited to educating dental students in sleep disorders and oral appliance therapy. Prosthodontists can set a new standard by developing more in-depth dental sleep medicine training within prosthodontic residency programs with access to multidisciplinary teams and to ensuring that dental sleep medicine continues to strive for excellence in the management of sleep apnea with oral appliances 83

84. References 1 . Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5. 2. Weaver and Millman , Broken sleep. Am J Nurse 1986; 88:146-50 3. Tsara V, Amfilochiou A.Definition and classification of sleep related breathing disorders in adults. Different types and indications for sleep studies (Part 1) HIPPOKRATIA 2009; 13(3): 187-191 4. Barewal RM, Hagen CC.Management of Snoring and Obstructive Sleep Apnea with Mandibular Repositioning Appliances: A Prosthodontic Approach Dent Clin N Am2014: 159–180 5. Karl OE. Obstructive sleep apnea is a common disorder in the population—a review on the epidemiology of sleep apnea J Thorac Dis 2015; 7(8):1311–1322 6. Guilleminault C., Quo S.  Sleep-disordered breathing. A view at the beginning of the new Millennium. Dent Clin North Am 2001 ;13(3): 643–656. 84

85. 7. Billings ME. Interpreting Sleep Study Reports: A Primer for Pulmonary Fellows. AASM SCORE2014;2(1) 8.Beecroft J, Zanon S, Lukic D. Oral continuous positive airway pressure for sleep apnea : effectiveness, patient preference, and adherence. Chest 2003; 124:2200–8. 8. Beecroft J, Zanon S, Lukic D. Oral continuous positive airway pressure for sleep apnea : effectiveness, patient preference, and adherence. Chest 2003; 124:2200–8. 9. Jack B,Meyer JR .The sleep apnea syndrome. Part II. Treatment March 1990;63(3):883-9 10.Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773–827 11. Ferguson KA, Cartwright R, Rogers R. Oral appliances for snoring and obstructive sleep apnea : a review. Sleep 2006;29:244–62 12. Mehta A, Qian J, Petocz P. A randomized controlled study of a mandibular advancement splint for obstructive sleep apnea . Am J Respir Crit Care Med 2001;163:1457–61 85

86. 13.Sutherland k,Vendervekan OM. Oral Appliance Treatment for Obstructive Sleep Apnea : An Update. American Academy of Sleep Medicine 10(2):215-227 14.Barthlen GM ,Brown LK. Comparison of three oral appliances for treatment of severe obstructive sleep apnea syndrome. Sleep Medicine2000;1(4):299-305 15.Nayar s,Jeremy k. Management of obstructive sleep apnea in an edentulous patient with a mandibular advancement splint: A clinical report. J Prosthet Dent2005;94:108-11 16.Knudson R,DMD,Meyer JB Sleep apnea prosthesis for dentate patients J Prosthet Dent1992;68:109-11 17.Walker RP,Levine HL. Palatal implants: A new approach for the treatment of obstructive sleep apnea . Otolaryngology–Head and Neck Surgery 2006;135, 549-554 86

87. Thank you