obstructive sleep apnea and its applications in dentitry

Introduction

Sleep is an essential physiological process necessary for tissue repair, memory consolidation, cardiovascular regulation, and overall homeostasis. Disturbances in sleep architecture can significantly impair health and quality of life. Among sleep-related breathing disorders, Obstructive Sleep Apnea (OSA) is the most prevalent and clinically significant condition. It is characterized by repetitive episodes of upper airway collapse during sleep, leading to reduced (hypopnea) or complete cessation (apnea) of airflow despite continued respiratory effort. These recurrent events result in intermittent hypoxemia, sleep fragmentation, autonomic instability, and daytime symptoms such as excessive sleepiness, fatigue, and neurocognitive impairment.

The clinical significance of OSA extends far beyond sleep disruption, as it is associated with increased risk of cardiovascular morbidity, metabolic dysfunction, neurocognitive impairment, and decreased quality of life. Moreover, OSA has important implications in dentistry and prosthodontics, as oral appliances and maxillomandibular advancement procedures play key roles in treatment.

This essay provides a detailed account of OSA, including its definition, prevalence, risk factors, pathophysiology, clinical features, diagnostic strategies, complications, and management, with a focus on evidence-based approaches.

Definition

Obstructive Sleep Apnea (OSA):
A disorder characterized by recurrent episodes of partial or complete upper airway obstruction during sleep, resulting in reduced (hypopnea) or absent (apnea) airflow despite persistent respiratory effort, leading to oxygen desaturation and arousals from sleep.

Key terms:

Apnea: Complete cessation of airflow for ≥10 seconds.

Hypopnea: Reduction in airflow (≥30%) for ≥10 seconds associated with oxygen desaturation (≥3–4%) or arousal.

Apnea–Hypopnea Index (AHI): The number of apneas and hypopneas per hour of sleep, used to define severity.

Severity classification based on AHI (American Academy of Sleep Medicine):

Mild OSA: AHI 5–15 events/hour

Moderate OSA: AHI 15–30 events/hour

Severe OSA: AHI >30 events/hour

Epidemiology

OSA is highly prevalent worldwide, with growing recognition due to increasing obesity rates and greater awareness.

Global prevalence: Estimated at 9–38% of the general adult population.

Gender differences: More common in men (13–33%) than women (6–19%). However, post-menopausal women show increased risk.

Age: Prevalence increases with age, peaking between 50–70 years.

Children: Pediatric OSA affects 1–5% of children, commonly due to adenotonsillar hypertrophy.

OSA remains significantly underdiagnosed, with estimates suggesting that up to 80% of moderate to severe cases remain unrecognized.

Etiology and Risk Factors

OSA results from a complex interplay between anatomical susceptibility and neuromuscular control dysfunction during sleep.

Major Risk Factors

Obesity:

Strongest risk factor.

Fat deposition in the n

1. OBSTRUCTIVE SLEEP APNEA GUIDED BY : DR VIVEK CHOUKSE DR DURGA RAJU MACHA DR ASHWIN AIDASANI DR ABHAY NARAYANE DR RANJEET GANDAGULE DR ABHILASHA MASIH DR KRISHNA NANDA DR ANUJA KUNTURKAR PRESENTED BY : DR. KASHIVISHWESHWAR KASTURE PG 1 ST YR - PROSTHODONTICS 1/6/2024 OSA 1

2. CONTENT Introduction Terms used to describe OSA Role of edentulism in pathogenesis of OSA Sleep Disordered Breathing Adverse outcomes of OSA Objective testing Diagnosis – Berlin questionnaire Epworth sleepiness scale Treatment Nonsurgical – miniimplant assisted RME Surgical – UPPP Tracheostomy Staged or phasic protocol for OSA Hypoglossal nerve stimulation Oral appliances – MRA TRD Soft palate lifters Conclusion References 1/6/2024 OSA 2

3. INTRODUCTION Dentists are becoming increasingly aware of the importance of detection and management of obstructive sleep apnea. Sleep-related breathing disorders are complex problems that decrease quality of life and increase morbidity and mortality in patients. Obstructive sleep apnea (OSA) is a common chronic sleep-related breathing disorder characterized by repetitive upper airway collapse during sleep, which causes sleep fragmentation, oxygen desaturation, and excessive daytime sleepiness. 1/6/2024 OSA 3

4. Other adverse health outcomes associated with untreated OSA include cardiovascular disease, cerebrovascular events, diabetes, and cognitive impairment, severe hypoxemia . Although continuous positive airway pressure (CPAP) remains the first line of treatment for sleep apnea, there is an important role for mandibular advancement devices, which require dentists to have a good understanding of occlusion, temporomandibular disorders (TMD), and removable appliance therapy. 1/6/2024 OSA 4

5. Edentulism or loss of all permanent teeth is the final outcome of multifactorial process. Changes in mandibular position, oral hypo-innervation, decreased neuromuscular coordination, neuromuscular impairment favoring upper airway collapse by deactivation of pharyngeal dilator muscles in response to stimuli, prominent alterations in upper airway size, its elasticity and function, increased upper airway collapsibility, decreased retropharyngeal space, reduced tonicity of the pharyngeal musculature , interplay of all these factors predisposes to the development of obstructive sleep apnea (OSA) of varying severity. Tripathi A, Gupta A, Rai P, Sharma P, Tripathi S. Correlation between duration of edentulism and severity of obstructive sleep apnea in elderly edentulous patients. Sleep Science. 2022 Apr;15(Spec 2):300. 1/6/2024 OSA 5

6. Sanders et al. (2016) found edentulism to be an independent risk factor for OSA. Bucca et al. (1999, 2006) reported that complete tooth loss worsened OSA and that nocturnal wearing of dentures improved the apnea-hypopnea index (AHI) of such patients. OSA may be a potential risk marker for adverse oral health conditions, particularly dental pain . 1/6/2024 OSA 6

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8. Annapurna K, Suganya S, Vasanth R, Kumar PR. Prosthodontic approach to treat obstructive sleep apnea. Annals of medical and health sciences research. 2014;4(4):481-6. 1/6/2024 OSA 8

9. Role of edentulism in pathogenesis of OSA While edentulism has been linked to a wide range of health outcomes, its possible association with OSA has assumed greater significance due to the immense prosthodontic implications on sleep medicine. Edentulism has been shown to produce anatomical changes in craniofacial structures, and hypothesized to increase obstructive sleep apnea (OSA). 1/6/2024 OSA 9

10. The following anatomical changes ensue due to loss of teeth : Decrease in vertical dimension of occlusion Change in position of mandible Change in position of hyoid bone Impaired function of oropharyngeal musculature such as loss of tone in soft palate and pharynx, macroglossia etc Mohan SM, Gowda EM, Banari AS. Obstructive sleep apnea (OSA): A prosthodontic perspective. medical journal armed forces india . 2015 Dec 1;71:S395-9. 1/6/2024 OSA 10

11. Bucca et al (1999) had confirmed that removal of denture significantly decreases the retropharyngeal space, and sleeping without dentures significantly increases AHI, and decreases arterial hemoglobin saturation. Pivetti et al (1999), reported that edentulism may dramatically worsen severity of obstructive sleep apnea (OSA) and advised edentulous patients to wear dentures while sleeping. Thus, in edentulous subjects, removing dentures during sleep may favor respiratory disorders, and increase the risk for hypertension and cardiovascular disease. Mohan SM, Gowda EM, Banari AS. Obstructive sleep apnea (OSA): A prosthodontic perspective. medical journal armed forces india . 2015 Dec 1;71:S395-9. 1/6/2024 OSA 11

12. Erovigni et al (2005) demonstrated that wearing denture induces modifications in the position of the tongue, mandible and pharyngeal airway space which can favor the reduction of apnea episodes. The disadvantages of wearing dentures during sleep are due to the fact that they are associated with chronic inflammatory changes, leading to irritation and alveolar bone resorption in the denture-supporting area. In addition, increasing the vertical dimension of occlusion can cause strain on temporomandibular joint and the patient may need more time for adaptation to the same. Mohan SM, Gowda EM, Banari AS. Obstructive sleep apnea (OSA): A prosthodontic perspective. medical journal armed forces india . 2015 Dec 1;71:S395-9. 1/6/2024 OSA 12

13. Sleep-disordered breathing (SDB ) 1/6/2024 OSA 13

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15. OBJECTIVE TESTING The “gold standard” for the diagnosis of OSA is attended PSG- POLYSOMNOGRAPHY. PSG requires the recording by technical personnel with sleep-related training and the monitoring of the following physiologic signals Electroencephalogram Electrooculogram Nasal pressure Oral or oronasal thermistor Oxygen saturation Respiratory effort Electrocardiogram Electromyogram Audio, video 1/6/2024 OSA 15

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17. S T O P – B A N G questionnaire S T O P – B A N G 1/6/2024 OSA 17

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21. Annapurna K, Suganya S, Vasanth R, Kumar PR. Prosthodontic approach to treat obstructive sleep apnea. Annals of medical and health sciences research. 2014;4(4):481-6. 1/6/2024 OSA 21

22. OSA MANAGEMENT IN ADULTS Managements for OSA include behavioural modification, weight loss, medication, continuous positive airway pressure, oral appliance therapy ( eg , use of tongue-retaining devices or use of orthodontic or mandibular advancing appliances), and surgical procedures ( eg , tracheostomy, uvulopalatopharyngoplasty , laser-assisted uvulopalatoplasty, surgically assisted rapid maxillary expansion, maxillomandibular advancement, and hypoglossal nerve stimulation). Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12 1/6/2024 OSA 22

23. Behavioral treatments address factors that may exacerbate the potential for OSA. Avoidance of alcohol and sedatives is recommended for all OSA patients. For some patients, weight loss favorably affects airway patency by minimizing apneic events and snoring. Avoidance of the supine position during sleep may reduce the frequency of sleep apnea events in some patients. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 23

24. Nonsurgical treatments for adult OSA | Continuous positive airway pressure The first-line treatment for OSA is nasal continuous positive airway pressure (CPAP), in which the upper airway is splinted open to improve patency during sleep. Appropriate regular use of CPAP effectively reduces symptoms of sleepiness and improves quality of life measures in moderate-to-severe OSA. The CPAP is considered the preferred treatment option for moderate-to-severe OSA and has a success rate of approximately 75%. Nonetheless, treatment alternatives are needed for patients who refuse or cannot tolerate CPAP. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 24

25. Mini-implant assisted rapid maxillary expansion Recent evidence suggests that rapid maxillary expansion (RME) is an effective treatment for OSA in children with maxillary constriction. The maxillary skeletal expander (MSE) can enlarge the size of the nasal cavity and substantially increase the airflow through the nasal airway . Although RME can produce some maxillary skeletal expansion, it often produces large unwanted tooth movements, especially in mature patients. Furthermore, RME is effective for expansion of the anterior and inferior parts of the maxilla but is much less effective for the posterior and superior regions of the maxilla. Surgically assisted rapid maxillary expansion may be helpful. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 25

26. Surgical treatments for adult OSA | Uvulopalatopharyngoplasty One of the most common OSA surgical treatments is uvulopalatopharyngoplasty (UPPP), which involves removal of the tonsils, uvula, and posterior velum. Since UPPP does not consistently achieve normalization of AHI, however, the AASM does not recommend UPPP as a sole procedure for treating moderate to severe OSA. A meta-analysis evaluated predictors for successful UPPP and found that only Friedman stage I (large tonsils and relatively normal palatal position) were predictors of surgical success; in contrast, Friedman stage III and low hyoid position were predictors of surgical failure. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 26

27. 1/7/2024 OSA 27 FRIEDMANN PALATAL POSITIONS

28. Tracheostomy From the late 1960s to the early 1980s, tracheostomies were the primary surgical modality for treating OSA subjects when other medical managements have failed. Although tracheostomy has the advantage of bypassing upper airway obstructions and can substantially improve OSA, it is considered a last resort surgical procedure . The ideal tracheostomy candidates are patients whose medical managements have failed, who are not candidates for soft tissue surgery, and/or have refused maxillomandibular advancement (MMA) surgery. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 28

29. Maxillomandibular advancement surgery The reported success rate of MMA ranges from 75% to 100%, which makes it the most effective surgical treatment for OSA (second to tracheostomy). Most patients with high residual AHI after a failed surgical treatment for OSA are likely to benefit from MMA. Some researchers now consider MMA the gold standard in surgical orthodontic care for OSA Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 29

30. Staged or phasic surgical protocol for OSA It is now generally accepted that the site of upper airway obstruction varies among OSA patients, which includes the soft palate, lateral pharyngeal wall, base of tongue, or hypopharynx. Phase I surgical treatment is based on the level of obstruction, as determined in the presurgical evaluation. Surgical treatment can include UPPP for oropharyngeal obstruction and/or genioglossus advancement with hyoid myotomy or suspension for base-of-tongue obstruction. Approximately 6 months after surgery, repeat PSG is preformed, and patients who do not obtain surgical success or cure, proceed to phase II surgery. Phase II surgical reconstruction is reserved for phase I failures and consists of MMA advancement osteotomy. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 30

31. Hypoglossal nerve stimulation Surgical treatment of OSA has evolved in the era of neurostimulation, including the advent of hypoglossal nerve stimulation. In 2014, the US Food and Drug Administration approved the use of hypoglossal nerve stimulator for treating OSA. Sleep surgeons surgically implant an upper-airway stimulation device in OSA patients who have difficulty tolerating or adhering to CPAP therapy. The success rate of hypoglossal nerve stimulation is apparently highest in patients who have a low body mass index, an AHI less than 50, and an anteroposterior pattern of palatal collapse. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12. 1/6/2024 OSA 31

32. TREATMENT OPTIONS FOR OSA Options for Treatment: Positive airway pressure (PAP) Upper airway surgical procedures Pharmacologic treatment Oral appliances Behavioural modification: weight loss, alcohol avoidance, alteration of sleeping position 1/6/2024 OSA 32

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34. Mechanism of Action of Oral Appliances 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 (hard palate to tip of uvula), oropharynx (tip of uvula to tip of epiglottis), and hypopharynx (tip of epiglottis to vocal cords). The velopharynx is the most common site of primary pharyngeal collapse in OSA. The MRA has a lateral wall widening effect on the velopharyngeal and oropharyngeal space. 1/6/2024 OSA 34

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36. Partial and complete edentulism have long been considered as a contra-indication for oral appliance therapy as retention becomes questionable. Mohan SM, Gowda EM, Banari AS. Obstructive sleep apnea (OSA): A prosthodontic perspective. medical journal armed forces india . 2015 Dec 1;71:S395-9. Mucosa supported oral appliances for completely edentulous patients Meyer & Knudson (1990) were the first to report a clinical and laboratory technique for fabrication of a prosthesis which prevented sleep apnea in edentulous patient. Their technique involved positioning the edentulous mandible 5-8 mm open and anterior to physiologic rest position using a heat-cured acrylic monobloc prosthesis. They concluded that the prosthesis would be effective only if the suspected site of the obstruction is at the level of the base of the tongue and the posterior pharyngeal wall. 1/6/2024 OSA 36

37. Robertson (1998), described “combination appliance” wherein increase in vertical dimension and forward protrusion of mandible prevented obstructive sleep apnea in an edentulous patient. Nayar & Knox (2005), highlighted the paucity of literature on the treatment of OSA in edentulous patients with a mandibular advancement splint and described a clinical and laboratory method for an acrylic monobloc splint without an increase in vertical dimension of occlusion in edentulous OSA patient. They theorized that increasing the occlusal vertical dimension would decrease the space between the base of the tongue and the posterior pharyngeal wall thus negating the benefits to the airway from mandibular advancement, resulting in the further narrowing of the pharyngeal airway. Mohan SM, Gowda EM, Banari AS. Obstructive sleep apnea (OSA): A prosthodontic perspective. medical journal armed forces india . 2015 Dec 1;71:S395-9. 1/6/2024 OSA 37

38. Piskin et al (2010), reported a fabrication method and treatment efficacy of an acrylic, monobloc, modified mandibular advancement device (MAD), which acts by displacing bulky masseter muscles laterally, to provide more space for tongue on totally edentulous patient with severe OSA. Implant supported oral appliances for completely edentulous patients Hoekema et al (2007), described an implant retained two piece mandibular repositioner appliance (MRA) as a viable treatment modality of edentulous obstructive sleep apnea hypopnea syndrome (OSAHS) patients. Patients were instructed to wear the MRA instead of their dentures whenever they slept. 1/6/2024 OSA 38

39. Types of Oral Appliances Three broad classes of appliances have emerged, namely 1. MRA, 2. Tongue Retaining Devices (TRD), and 3. Soft palate lifters. 1/6/2024 OSA 39

40. MRA cover the upper and lower teeth and hold the mandible in an advanced position with respect to the resting position. requirements of an MRA are as follows: Good retention form to 1 or 2 arches Sufficient protrusion of the mandible at an increased vertical dimension Appliances that do not restrict jaw movement laterally or vertically are optimal for temporomandibular joint (TMJ) comfort. In edentulous patients, it is recommended to place the implants in the mandible for MAA fixing. 1/6/2024 OSA 40

41. The device makes the mandible protrude forward, preventing or minimizing the upper airway collapse during sleep. 1/6/2024 OSA 41

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43. Tripathi A, Gupta A, Rai P, Sharma P, Tripathi S. Correlation between duration of edentulism and severity of obstructive sleep apnea in elderly edentulous patients. Sleep Science. 2022 Apr;15(Spec 2):300. 1/6/2024 OSA 43

44. Studies showed an enhancement in the quality of life in many patients who have been treated with oral appliances, and patients in general prefer oral appliances over CPAP therapy or any other treatments for OSA because of its convenience there are many side effects that could accompany OAs, such as TMJ discomfort, tooth discomfort, salivation, dehydrated mouth, and occlusal changes 1/6/2024 OSA 44

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46. Al Mortadi N, Khassawneh B, Khasawneh L, Alzoubi O, Alzoubi KH. Berlin and epworth surveys to predict obstructive sleep apnea for adults on biomimetic oral appliance therapy: A nonrandomized clinical trial. International Journal of Dentistry. 2022 May 6;2022. 1/6/2024 OSA 46

47. Epworth Sleepiness Scale, Malampatthy Scale, and questionnaires of BERLIN, STOP, STOP‑BANG support in the evaluation of OSA. Chander NG. Sleep apnea and prosthodontic implications. The Journal of the Indian Prosthodontic Society. 2020 Oct;20(4):335. 1/6/2024 OSA 47

48. Obstructive sleep apnea syndrome (OSAS) is a clinical risk factor for sleep bruxism (SB). This systematic review suggests that there is not enough scientific data to define a clear causative link between OSAS and SB. Although, they appear to share common clinical features. Further studies should focus on the intermediate mechanisms between respiratory and SB events to clarify this relationship . Jokubauskas L, Baltrušaitytė A. Relationship between obstructive sleep apnoea syndrome and sleep bruxism: a systematic review. Journal of oral rehabilitation. 2017 Feb;44(2):144-53. 1/6/2024 OSA 48

49. TRD produce a suction of the tongue into an anterior bulb, thereby widening the upper airway and advancing the tongue. Because the teeth are not used for anchorage of the device, TRDs are proposed as a treatment option for patients with hypodontia, edentulism, and significant periodontal disease. 1/6/2024 OSA 49

50. The tongue retaining device, described by Cartwright (1985), protects against the tongue retraction. This action is possible due to hypotension retaining the tip of the tongue in the anterior part of the device. The device is constructed of a plastic bulb with a tongue-like shape. The tongue placed and sucked into the device is advanced forward so that the anteroposterior size of the throat is expanded. It is used rather infrequently, due to certain discomfort it produces, although the device is very beneficial in edentulous patients. 1/6/2024 OSA 50

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52. 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 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 1/6/2024 OSA 52

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56. The oral appliance appears to enlarge the pharynx to a greater degree in the lateral than in the sagittal plane at the retropalatal and retroglossal levels of the pharynx, suggesting a mechanism for the effectiveness of oral appliances that protrude the mandible Kyung SH, Park YC, Pae EK. Obstructive sleep apnea patients with the oral appliance experience pharyngeal size and shape changes in three dimensions. The Angle Orthodontist. 2005 Jan 1;75(1):15-22. OSA‑Herbst and OSA‑Monobloc are effective therapeutic devices for sleep apnea. OSA‑Monobloc relieved symptoms to a greater extent than the OSA‑Herbst, and was preferred by majority of patients on the basis of its simple application Bloch KE, Iseli A, Zhang JN, Xie X, Kaplan V, Stoeckli PW, Russi EW. A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment. American journal of respiratory and critical care medicine. 2000 Jul 1;162(1):246-51. 1/6/2024 OSA 56

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58. OAs vs Other Treatment Continuous positive airway pressure (CPAP) prevails as the “gold standard” of treatment for OSA. Hence, any other newer approach has to be compared against it. There are almost seven randomized controlled studies that compared OAs with CPAP. In all studies, CPAP showed better results than OAs in bringing the AHI <10. There were several clinical studies that compared OA with UPPP and demonstrated the superiority of OA with 78% reduction in OSA in OA group and 51% in the UPPP group. Annapurna K, Suganya S, Vasanth R, Kumar PR. Prosthodontic approach to treat obstructive sleep apnea. Annals of medical and health sciences research. 2014;4(4):481-6. 1/6/2024 OSA 58

59. Sutherland K, Vanderveken OM, Tsuda H, Marklund M, Gagnadoux F, Kushida CA, Cistulli PA. Oral appliance treatment for obstructive sleep apnea : an update. Journal of Clinical Sleep Medicine. 2014 Feb 15;10(2):215-27. 1/6/2024 OSA 59

60. Tripathi A, Bagchi S, Singh J, Tripathi S, Gupta NK, Arora V. Incidence of obstructive sleep apnea in elderly edentulous patients and the possible correlation of serum serotonin and apnea ‐hypopnea index. Journal of Prosthodontics. 2019 Feb;28(2):e843-8. 1/6/2024 OSA 60

61. PALATO-PHARYNGEAL ASSESSMENT Mallampati Classification 1/6/2024 OSA 61

62. Tonsil Size Some studies have reported a correlation between tonsil size and AHI, whereas others did not. Tonsil size grading ranges from 0 to 4. 1/6/2024 OSA 62

63. ADVERSE EVENTS OF ORAL APPLIANCES Due to the myriad of appliance designs and lack of standard therapeutic protocol in the use of appliances, there is a wide range of side effects with differing occurrence rates found in the literature. 1/6/2024 OSA 63

64. CONCLUSION Despite the growing understanding of OSA, unanswered questions and unresolved problems with proposed OSA treatments remain. Multidisciplinary teams comprising dentists, orthodontists, and oralmaxillofacial surgeons can lay the foundation for addressing these issues by facilitating delivery of maximum quality of health care for OSA patients. Constant communication and follow-up among team members is essential for effective OSA management Marked variability is illustrated in the individual response to OA therapy and hence the treatment outcome is subjective. 1/6/2024 OSA 64

65. long-term edentulism foretells greater morbidity than a mere depletion of esthetics, speech, mastication, and nutrition. It can potentiate OSA and consequent life threatening multiple organic dysfunction. There is much to learn and understand in the rapidly evolving field of sleep medicine. The growing Interest of prosthodontists in sleep medicine has contributed immensely towards effective prevention and treatment of obstructive sleep apnea (OSA) and sleep bruxism. 1/6/2024 OSA 65

66. REFERENCES 1/6/2024 OSA 66 Barewal RM, Hagen CC. Management of snoring and obstructive sleep apnea with mandibular repositioning appliances: a prosthodontic approach. Dental Clinics. 2014 Jan 1;58(1):159-80 . Tripathi A, Bagchi S, Singh J, Tripathi S, Gupta NK, Arora V. Incidence of obstructive sleep apnea in elderly edentulous patients and the possible correlation of serum serotonin and apnea ‐hypopnea index. Journal of Prosthodontics. 2019 Feb;28(2):e843-8. Sutherland K, Vanderveken OM, Tsuda H, Marklund M, Gagnadoux F, Kushida CA, Cistulli PA. Oral appliance treatment for obstructive sleep apnea : an update. Journal of Clinical Sleep Medicine. 2014 Feb 15;10(2):215-27 Annapurna K, Suganya S, Vasanth R, Kumar PR. Prosthodontic approach to treat obstructive sleep apnea. Annals of medical and health sciences research. 2014;4(4):481-6. Bloch KE, Iseli A, Zhang JN, Xie X, Kaplan V, Stoeckli PW, Russi EW. A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment. American journal of respiratory and critical care medicine. 2000 Jul 1;162(1):246-51. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung journal of medical sciences. 2020 Jan;36(1):7-12.

67. 1/6/2024 OSA 67 Jokubauskas L, Baltrušaitytė A. Relationship between obstructive sleep apnoea syndrome and sleep bruxism: a systematic review. Journal of oral rehabilitation. 2017 Feb;44(2):144-53. Chander NG. Sleep apnea and prosthodontic implications. The Journal of the Indian Prosthodontic Society. 2020 Oct;20(4):335. Al Mortadi N, Khassawneh B, Khasawneh L, Alzoubi O, Alzoubi KH. Berlin and epworth surveys to predict obstructive sleep apnea for adults on biomimetic oral appliance therapy: A nonrandomized clinical trial. International Journal of Dentistry. 2022 May 6;2022. Tripathi A, Gupta A, Rai P, Sharma P, Tripathi S. Correlation between duration of edentulism and severity of obstructive sleep apnea in elderly edentulous patients. Sleep Science. 2022 Apr;15(Spec 2):300. Mohan SM, Gowda EM, Banari AS. Obstructive sleep apnea (OSA): A prosthodontic perspective. medical journal armed forces india . 2015 Dec 1;71:S395-9.

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