What are the treatment options for Obstructive Sleep Apnea (OSA)?

Treatment of Obstructive Sleep Apnea (OSA)

CPAP therapy is the gold-standard treatment for moderate to severe symptomatic OSA and should be the first-line intervention for these patients. 1

Treatment Algorithm by Disease Severity

Mild OSA (AHI 5-15/h)

• Mandibular advancement devices (MADs) are recommended as first-line therapy for patients with mild OSA who have no significant comorbidities 1
• MADs reduce AHI, arousal index, daytime sleepiness, and improve quality of life measures 1
• Behavioral modifications should be implemented concurrently (see below) 1

Moderate OSA (AHI 15-30/h)

• MADs are recommended for patients without comorbidities 1
• CPAP therapy should be initiated if significant comorbidities exist (cardiorespiratory disease, neuromuscular conditions, stroke history) 1
• Although CPAP is superior to MADs in normalizing respiratory parameters, both demonstrate comparable effects on symptoms and quality of life 1

Severe OSA (AHI ≥30/h)

• CPAP therapy is the treatment of choice 1
• MADs are an accepted alternative only for patients who are intolerant to CPAP or request alternative therapy 1
• Adherence with MADs is generally better than CPAP in OSA patients 1

Essential Behavioral Interventions (All Patients)

Weight loss to BMI ≤25 kg/m² should be aggressively pursued as it improves breathing pattern, sleep quality, and daytime sleepiness 1

Additional behavioral modifications include:

• Physical exercise programs 1
• Positional therapy using positioning devices (alarm, pillow, backpack, tennis ball) for patients with positional OSA, though compliance is poor long-term 1
• Avoidance of alcohol and sedatives before bedtime 1
• Weight reduction surgery in selected cases 1

Surgical Options

Primary Surgical Treatment

Surgery may be considered as primary treatment only in mild OSA with severe correctable obstructing anatomy (e.g., tonsillar hypertrophy obstructing the pharyngeal airway) 1

Secondary Surgical Treatment (After PAP/MAD Failure)

Surgical procedures to consider when PAP or MAD therapy fails 1:

Nasal procedures:

• Septoplasty, functional rhinoplasty, turbinate reduction, nasal polypectomy 1, 2
• Intranasal corticosteroids improve mild to moderate OSA in patients with co-existing rhinitis and/or adenotonsillar hypertrophy 1

Oropharyngeal procedures:

• Tonsillectomy can be recommended in the presence of tonsillar hypertrophy in adults 1
• Uvulopalatopharyngoplasty (UPPP) is effective only in carefully selected patients with obstruction limited to the oropharyngeal area, but frequent long-term side-effects (velopharyngeal insufficiency, dry throat, abnormal swallowing) limit its use 1
• Laser-assisted uvulopalatoplasty is NOT recommended for OSA treatment 1

Advanced procedures:

• Maxillomandibular advancement can improve PSG parameters comparable to CPAP in the majority of patients 1
• Hypoglossal nerve stimulation can be considered in selected adult patients seeking alternative treatments (conditional recommendation) 1
• Tracheostomy can eliminate OSA but is rarely used 1

Adjunctive Therapies

Myofunctional therapy can be considered for specific cases seeking alternative treatments (conditional recommendation) 1

Medical treatment of ENT diseases with pharmacological therapy should be considered 1

Therapies NOT Recommended

• Drug therapy is NOT recommended for OSA treatment 1
• Nasal dilators are NOT recommended 1
• Tongue-retaining devices (TRDs) cannot be recommended 1
• Apnea-triggered muscle stimulation is NOT recommended 1

Critical Follow-Up Requirements

All patients using MADs must undergo polysomnography or attended cardiorespiratory sleep study with the oral appliance in place after final adjustments to ensure satisfactory therapeutic benefit 1

Post-surgical patients require sleep specialist follow-up for long-term management after surgical treatment is completed 1

Important Caveats

• Treatment decisions should always be made by a multidisciplinary team including qualified dental personnel, sleep unit, and sleep physician 1
• AHI alone should not drive treatment decisions; hypoxic burden, hypoxia load, obstruction severity, and phenotypes based on symptoms and comorbidities should be considered together 1
• Most sleep apnea surgeries are rarely curative but may improve clinical outcomes (mortality, cardiovascular risk, motor vehicle accidents, function, quality of life) 1
• Sleep-disordered breathing tends to worsen and does not cure spontaneously 1