Adjunct Therapies for Use with Oral Appliances in Treating Obstructive Sleep Apnea
Weight loss, positional therapy, and avoidance of alcohol and sedatives before bedtime are the primary adjunct therapies that should be used in conjunction with oral appliances for the treatment of obstructive sleep apnea. 1
Behavioral Adjunct Therapies
- Weight loss should be recommended for all overweight OSA patients using oral appliances, as successful dietary weight loss may improve the AHI in obese patients with OSA 1
- Positional therapy (using devices that keep patients in non-supine positions) is an effective secondary therapy for patients who have a lower AHI in non-supine versus supine positions 1
- Avoidance of alcohol and sedatives before bedtime is essential as these substances can worsen OSA by reducing upper airway muscle tone 1
- Exercise can complement oral appliance therapy by improving overall sleep quality and potentially reducing OSA severity 1, 2
Implementation of Positional Therapy
- A positioning device such as an alarm, pillow, backpack, or tennis ball should be used when initiating positional therapy 1
- To establish efficacy of a positioning device at home, providers should consider using an objective position monitor 1
- Because not all patients normalize AHI when non-supine, correction of OSA by position should be documented with polysomnography before initiating this form of treatment as a primary therapy 1
Monitoring Adjunct Therapies
- Self-reported compliance, objective position monitoring, side effects, and symptom resolution should be assessed for positional therapy 1
- After substantial weight loss (10% or more of body weight), a follow-up polysomnography is indicated to determine if oral appliance adjustments are necessary 1
- Regular follow-up with both a qualified dentist and sleep physician is essential to monitor the efficacy of both the oral appliance and adjunct therapies 1
Pharmacologic Options for Residual Sleepiness
- For patients with residual excessive daytime sleepiness despite effective oral appliance therapy, modafinil or armodafinil may be considered 2
- Before considering pharmacologic options, clinicians must rule out suboptimal oral appliance adherence, insufficient sleep, poor sleep hygiene, other sleep disorders, and depression 2
- Methylphenidate, dextroamphetamine, or caffeine (with the last dose before 4:00 pm) may be options for refractory daytime sedation 2
Myofunctional Therapy
- Myofunctional therapy may be considered as an adjunctive treatment to oral appliance therapy for OSA 1, 3
- This therapy focuses on exercises that target the tongue, soft palate, and lateral pharyngeal walls to improve muscle tone and function 3
Clinical Considerations
- Custom, titratable oral appliances are more effective than non-custom devices and should be the preferred choice when implementing adjunct therapies 1, 3
- A multidisciplinary approach involving sleep physicians and qualified dentists is essential for optimal outcomes when combining oral appliances with adjunct therapies 1, 3
- Follow-up sleep testing is necessary to confirm the efficacy of both the oral appliance and adjunct therapies 1
- Adherence to oral appliance therapy is typically better than CPAP, but can be further improved when combined with appropriate adjunct therapies 3, 4
Potential Pitfalls and Considerations
- Relying solely on subjective improvement in symptoms is insufficient; objective assessment through sleep testing is necessary to confirm treatment efficacy 1
- Initial side effects of oral appliances (jaw discomfort, tooth tenderness, excessive salivation) may reduce adherence and should be addressed promptly 3
- Long-term dental changes can occur with oral appliance use, necessitating regular follow-up with a qualified dentist 1, 3
- Not all patients will respond adequately to oral appliances even with adjunct therapies; approximately one-third may experience no therapeutic benefit 4