Dr. Denbar has used Oral Appliance Therapy to treat sleep disordered breathing for 24 years in the Austin area. He has treated thousands of cases, ranging from the simplest to the most difficult. Dr. Denbar is a credentialed, in-network medical provider for most major medical insurance companies. These insurance carriers include Aetna, Humana, United Healthcare, Cigna, Seton Healthcare and Scott & White Healthcare. Dr. Denbar is also a Medicare and Tricare provider. Our office provides the most extensive medical insurance coverage for this therapy in Central Texas.

Links to Related Articles

The Significance of the Delivery System During Infant Feeding and Nurturing

Breastfeeding: Reducing the Risk for Obstructive Sleep Apnea

The Influence of Breastfeeding on the Development of the Oral Cavity: A Commentary

The Uniqueness of the Human Airway (Part 1)

Prevention - The key to treating OSA/SDB - (Part II)

Research Articles

Obstructive Sleep Apnea Therapy

J Dent Res87(9):882-887,2008
A. Hoekema, B. Stegenga,P.J. Wijkstra, J.H. van der Hoeven, A.F. Meinesz, and L.G.M. de Bont

Abstract
In clinical practice, oral appliances are used primarily for obstructive sleep apnea patients who do not respond to continuous positive airway pressure (CPAP) therapy. We hypothesized that an oral appliance is not inferior to CPAP in treating obstructive sleep apnea effectively. We randomly assigned 103 individuals to oral appliance or CPAP therapy. Polysomnography after 8-12 weeks indicated that treatment was effective for 39 of 51 persons using the oral appliance (76.5%) and 43 of 52 persons using CPAP (82.7%). For the difference in effectiveness , a 95% two sided confidence interval was calculated. Non-inferiority of oral appliance therapy was considered to be established when the lower boundary of this interval exceeded -25%. The lower boundary of the confidence interval was -21.7%, indicating that oral-appliance therapy was not inferior to CPAP for effective treatment of obstructive sleep apnea. However, a subgroup analysis revealed that oral-appliance therapy was less effective in individuals with severe disease (apnea-hypopnea index >30). Since these people could be at particular cardiovascular risk, primary oral-appliance therapy appears to be supported only for those with non-severe apnea.

Discussion
This randomized parallel trial showed that an oral appliance was not inferior to CPAP for effective treatment of obstructive sleep apnea. Non-inferiority of oral-appliance therapy was supported by a lack of significant differences in most polysomnographic and all neurobehavioral outcomes. However, CPAP was more effective in improving the apnea-hypopnea index and was superior to oral-appliance therapy for patients with severe disease. Since these findings suggest that oral-appliance therapy is indicated primarily for those with non severe obstructive sleep apnea, we recommend that it be considered, alongside CPAP therapy, as treatment for persons with mild to moderate disease. Among those with severe disease, oral-appliance therapy should be considered for individuals unwilling or unable to tolerate CPAP.

Prospective Evaluation of Nocturnal Oximetry for Detection of Sleep-Related Breathing Disturbances in Patients With Chronic Heart Failure

Frederic Series, MD; R. John Kimoff, MD; Debra Morrison, MD; Marie Hene Levlanc, MD; Mark Smilovitch, MD; Jonathan Howlett, MD; Alenander G. Logan, MD; John S. Floras, MD; and T. Douglas Bradley, MD

CHEST/127/5/MAY, 2005

Because patients with chronic heart failure (CHF) can benefit from specific treatment for coexisting obstructive (OSA) and central sleep apnea (CSA), there is need to develop accurate screening tools to identify or exclude these sleep-related breathing disturbances (SRBDs) in patients with CHF.

The primary aims of the present study were to evaluate the diagnostic value of nocturnal oximetry in the identification of SRBDs in CHF patients, and to compare its reliability during home and laboratory recordings. As a secondary end point, we also evaluated whether CSA and OSA can be reliably distinguished based on the evaluation of the SpO2 desaturation-resaturation pattern.

Discussion
The present results establish that overnight home oximetry is a reliable tool to screen for the presence of SRBDs in patients with CHF. Presently, owing to the limited awareness of SRBDs among physicians caring for patients with CHF, as well as limited access to, and the relatively high cost of in-laboratory polysomnography, only a minority of CHF patients benefit form the diagnosis and treatment of SRBDs. Home oximetry therefore provides a readily available, inexpensive means of detecting SRBDs in these patients. Although it does not rule out OSA in the presence of symmetrical SpO2 fluctuations, a positive oximetry recording would assist in prioritizing patients for full polysomnography based on the severity of their SRBD. In this way, many more CHF patients may benefit from the timely diagnosis and treatment of SRBD than might otherwise be the case.

A prospective randomized study of a dental appliance compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnoea.

Acta Otolaryngol 999; 9(4):503-9.

WILHELMSSON B, TEGELBERG A, WALKER-ENGSTROM ML, RINGQVIST M ANDERSSON L, KREKMANOV L, RINGQVIST 1.
Department of Otorhinolaryngology, Central Hospital, Vasteras, Sweden

The enthusiasm for uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnoea (OSA) has declined in recent years, partly because of a lower success rate over time and partly because of adverse effects. Reports on the beneficial effects of dental appliances exist, but only one prospective randomized study has been published comparing dental appliances with nasal continuous positive airway pressure (CPAP)-treatment. No study has been published comparing dental appliance treatment with UPPP. Ninety-five male patients with confirmed OSA, subjective daytime sleepiness and an apnoea index (Al) > 5 were randomized for subsequent treatment with either a dental appliance or UPPP. There were 49 patients in the dental appliance group and 46 in the UPPP group. Thirty-seven patients in the dental appliance group and 43 in the UPPP group completed the I 2-month follow-up. The success rate (rate of patients with at least a 50% reduction in Al) for the dental appliance group was 95%, which was significantly higher (p < 0.01) than the 70% success rate for the UPPP group. According to the criteria for OSA (apnoea index > or = 5 or apnoea/hypopnoea index > or = I 0), 78% of the dental appliance group and 5 1 % of the UPPP group were normalized after 12 months. The difference between the groups was significant (p < 0.05). These findings suggest that the dental appliance technique is useful in the treatment of mild to moderate OSA.

Summary: Oral Appliance therapy had a better success rate in treating Sleep Apnea than did UPPP.

A crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea.

Chest 1996-109(6)-.1477-83 7
CLARK GT, BLUMENFELD 1, YOFFE N, PELED E, LAVIE P
Department of Diagnostic Sciences and Orofacial Pain, School of Dentistry, University of California, Los Angeles, USA

OBJECTIVE: This study compared the efficacy of a removable anterior mandibular positioning (AMP) device to continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) using a fully balanced crossover design. DESIGN-. Twenty-three male subjects with confirmed OSA were recruited from the Technion Sleep Laboratory in Haifa, Israel, from February 18, 1991 to December 17, 1992. Twenty-one of the 23 subjects enrolled completed all aspects of the study. RESULTS: The mean apnea-hypopnea index (AHI) before treatment was 33.86 +/- 14.30. The mean AHI decreased with CPAP to 59.50%, but decreased only 38.91 % With the AMP device. The lowest mean recorded oxygen saturation level for the 21 subjects was 84.30 before treatment, 91.1 0 after CPAP treatment, and 90.20 after AMP treatment. Sleep data revealed a significant decrease in stage I and 2 (p=0.0088) and an increase in rapid eye movement percent (p=0.0066) for both treatments when compared with baseline. Three- to I 0-month posttreatment phone interviews showed that I subject was not using either device, I subject was using CPAP, and 2 subjects were using the AMP device intermittently due to occasional temporomandibular joint pain symptoms. The remaining 17 subjects were all using the AMP device nightly. The symptoms of excessive daytime sleepiness also decreased significantly by both AMP and CPAP. CONCLUSIONS: The AMP device achieved substantial success in most cases, but was less effective than CPAP, especially for the more severe cases. In general, the AMP device was strongly preferred over the CPAP by the subjects of this study.

Snoring, obstructive sleep apnea, and surgery.

Medical Clinics of North America 1999;83(l):85-96
BARTHEL SW, STROME M
Department of Otolaryngology and Communicative Disorders, Cleveland Clinic Foundation, Ohio, USA

Snoring and OSA syndrome are prevalent and important causes of sleep disturbance. Snoring, historically considered to be only a habitual annoyance, has significant physical and social consequences. OSA is now considered to be a major public health concern with significant morbidity and mortality. CPAP is considered the treatment of choice for OSA syndrome, but poor patient acceptance and compliance remain problematic. Surgical procedures have been developed to alter the offending anatomic abnormalities responsible for OSA. Identification of the offending anatomic site with application of the most appropriate surgical procedure is essential for effective surgical treatment of OSA. When the region of the retropalate is correctly identified as the site of obstruction, UPPP can effectively treat OSA in a majority of patients. Surgical correction of nasal obstruction is advocated in conjunction with sleep apnea surgery when nasal obstruction exists. In OSA patients with retrolingual airway obstruction, a number of surgical procedures have been performed, \Mth or without UPPP, with some improvement over UPPP alone. MMO has been effective in the treatment of OSA in patients with significant retrolingual airway obstruction \Mth contributing skeletal abnormalities and in patients who have failed multiple other surgical procedures. MMO, however, is a procedure of considerable magnitude, requiring extensive oromaxillofacial surgical expertise. MMO is likely appropriate only in a limited number of patients. Tracheostomy is completely effective in the treatment of OSA syndrome but is undesirable to patients and is associated with significant physical and emotional morbidity. Nonetheless, tracheostomy can be lifesaving and remains an option for patients with severe OSA with serious associated cardiovascular complications, who cannot tolerate CPAP, and for whom other interventions are ineffective or unacceptable. Effective surgical treatment of snoring has been accomplished with UPPP and LAUP. LAUP is less invasive, less morbid, more cost-effective, and better tolerated and is likely the most appropriate procedure for debilitating symptomatic snoring. Currently, LAUP is not recommended for the treatment of OSA, despite some efficacy in patients with mild OSA. Exclusion of OSA in patients undergoing LAUP for snoring is important.

Laser assisted uvulopalatoplasty: six and eighteen month results.

J Laryngol Otol 1998; 1 12(7):639-41.
WAREING MJ, CALLANAN VP, MITCHELL DB.
Department of Otolaryngology-Head & Neck Surgery, Kent and Canterbury Hospital, U.K.

Our ongoing evaluation of the results of laser assisted uvulopalatoplasty (LAUP) for snoring is presented. Follow-up between 18 and 24 months post-treatment completion, of patients with a successful result at six months, reveals that 22 % of these patients suffer failure of snoring control between these two evaluation points. This equates to an overall success rate at this time of 55%. LAUP, like other surgical remedies for snoring, has a continued relapse rate. This must be considered when counselling patients

Surgical treatment for obstructive sleep apnoea.

Sleep Medicine Reviews 1997;1(2):77-86.
DOUGLAS NJ.

Surgical therapy of the sleep apnoea/hypopnoea syndrome is an attractive option to many patients as it avoids using therapy nightly for the remainder of one's life. This article reviews the outcomes of the surgical options available. The role of uvulopalatopharyngoplasty is not yet clear. It may be useful second line therapy for some patients but cannot at present be advocated as first-line therapy. Mandibular maxillary osteotomy and advancement is an effective therapy of value in a minority of patients. Other procedures such as partial glossectomy and genioglossal advancement may also be of value in some patients. There is an urgent need for more randomized controlled trials examining the outcomes of surgical therapy for the sleep apnoea/hypopnoea syndrome in comparison to continuous positive airway pressure therapy. Copyright 1997 W. B. Saunders Company Ltd.

Enuresis and obstructive sleep apnea in adults.

Chest 1998;114(2):634-7.
KRAMER NR, BONITATI AE, MILLMAN RP.
Division of Pulmonary, Sleep, and Critical Care Medicine, Rhode Island Hospital and Brown University School of Medicine, Providence, RI 02go3, USA

-Adult enuresis is an unusual symptom of obstructive sleep apnea (OSA). Although it is described as a classic symptom of childhood OSA, enuresis is encountered infrequently in adult sleep medicine. Five adults with enuresis associated with sleep apnea presented to our Sleep Disorders Center. In all five cases, the onset of enuresis was associated with the progression of sleep apnea symptoms. In each case, the enuresis resolved with treatment with nasal continuous positive airway pressure. Current medical literature on the postulated mechanisms of nocturia and enuresis in sleep apnea is reviewed. Based on the experience of the authors and review of the medical literature, one may conclude that severe OSA may lead to new-onset enuresis in adults and that effective treatment of OSA is associated with resolution of enuresis.

Prevalence of ischemic heart disease among patients with sleep apnea syndrome.

Psychiatry and Clinical Neurosciences 1998;52(2):219- 20.
MAEKAWA M, SHIOMI T, USUI & SASANABE R, KOBAYASHI T.
The Third Department of Internal Medicine, Aichi Medical University, Japan

We investigated the prevalence of ischemic heart disease (IHD) in sleep apnea syndrome (SAS) and the presence of coronary risk factors involved in the onset of IHD in 386 subjects with suspected SAS due to heavy snoring. The prevalence of IHD among patients with untreated SAS was found to be 23.8%, and the percentage of patients having SAS complicated with IHD was high among those with moderate or severe SAS. Sleep apnea syndrome patients with IHD also showed high prevalences of hypertension and hyperlipideniia. It appears that sleep apnea aggravates the factors that cause coronary vascular disorders, and is involved in the onset of IHD.

A non-urologic cause of nocturia and enuresis--osbtructive sleep apnea syndrome (OSAS)

Scandinavian Journal of Urology and Nephrology 1996-30(2)-.135-7. 1
ULFBERG J, THUMAN R
Department of Internal Medicine, Avesta Hospital, Sweden

Three case reports describe nocturia and enuresis as complications of the obstructive sleep apnea syndrome (OSAS). It is important to recognize the causal relationship since these troublesome symptoms are easily treated by treating the sleep apnea.

Obstructive sleep apnea: oral appliance therapy and severity of condition.

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodonties 1998;85(4):388-92.
COHEN R.
Harvard University School of Dental Medicine, Boston, MA 02115-5888, USA

OBJECTIVE: The purpose of this study was to determine whether an oral appliance can effectively treat severe obstructive sleep apnea. DESIGN: The study was conducted at a tertiary care military facility with an accredited sleep laboratory. Results of the treatment of the first 25 patients with obstructive sleep apnea referred for oral appliance therapy were retrospectively analyzed. Each patient received a mandibular advancement appliance and underwent polysomnography 2 weeks after delivery of the appliance. Patients were divided into two groups: those with slight-to-mild obstructive sleep apnea who had a respiratory disturbance index less than 21, and those with more severe disease. Treatment was considered to be successful if the posttreatment respiratory disturbance index was less than S. RESULTS: Nine (90%) of the 10 patients with slight-to-moderate disease were successfully managed with the oral appliance. Of the 15 patients in the moderate-to-severe group, 9 (60%) were successfully managed. CONCLUSION: Oral appliances have commonly been recommended only for mild obstructive sleep apnea. This study indicates that they may also have a role to play in selected cases in which the condition is more severe. There is a paucity of information about long-term success. This short-term (2-week) study should be followed by others evaluating the effect over longer periods.

[Dental appliances for the treatment of obstructive sleep apnea syndrome]

Chung-Hua Kou Chiang i Hsueh Tsa Chih Chinese Journal of Stomatology 1996;31(1)-12-5.
LIU Y, ZENG X, FU M.
School of Stomatology, Beijing Medical University

This study combined the use of cephalometrics and overnight polysomnographic monitoring to analyze the effects of a dental appliance on airway, sleep and respiratory conditions in 1 0 patients with obstructive sleep apnea. The findings indicated that horizontal and vertical mean changes in mandibular position while the appliance was worn were 1.73 mm and 9.30 mm, respectively, the mean superior airway space increased by 2.80 mm (P < 0.01), while the mean middle airway space increased by 6.75 mm (P = 0.01), the inferior airway space, however, didn't change significantly when the appliance was %urn. The average Apnea Index decreased by 15.98 events per hour when the appliance was worn (P < 0.01), the average Respiratory Disturbance Index decreased from 39.43 to 6.62 events per hour in 9 of IO patients (P < 0.01, one patient didn't have recording of hypoventilation). the lowest SaO2 value increased from 73.87% to 85.50% (P < 0.01). The reduction in the rate of airway obstructive events is attributed to the effect of appliance on the orophargneal structures. The dental appliance is a conservative, successful treatment alternative that could benefit patients with obstructive sleep apnea syndrome.

Evaluation of Variable Mandibular Advancement Appliance for Treatment of Snoring and Sleep Apnea*

(Chest. 1999;1 16:1511-1518.)@ 1999 American College of Chest Physicians
JEFFREY PANCER, DDS; SALEM AL-FAIFI, MD; MOHAMED AL-FAIFI, MD AND VICTOR HOFFSTEIN, PhD, MD, FCCP
* From the Department of Medicine, Respiratory Division, St. Michael's Hospital, University of Toronto, Ontario, Canada.
Correspondence to: Victor Hoffstein, PhD, MD, FCCP, St. Michael's Hospital, 30 Bond St, Toronto, Ontario, Canada M 5 B I W8; e-mail: victor.hoffstein@utoronto.ca

Objective: To evaluate an adjustable mandibular positioning appliance for treatment of snoring and sleep apnea.

Methods: One hundred thirty-four patients with baseline apnea/hypopnea index (AHI) of 37 ± 28 events/h (mean ± SD) received the appliance. The efficacy of the appliance was assessed by the following investigations, performed at baseline and with the appliance: polysomnography, Epworth sleepiness scale, bedpartners' assessment of snoring severity, patients' assessment of side effects, and overall satisfaction.

Results: Thirteen patients were lost to follow-up. An additional 46 patients had no follow-up polysomnography, but answered the questionnaires. A total of 75 patients had polysomnography at baseline and with the appliance. We found a significant reduction in AHI from 44 ± 28 events/h to 1 2 ± 1 5 events/h (p <0.0005) and a reduction in the arousal index from 37 ± 27 events/h to 1 6 ± 1 3 events/h (p < 0.05). epworth scores fell from ii ± 5 to 7 ± 3 (p < 0.0005). bedpartners' assessment revealed marked improvement in snoring. For example, at baseline 96% of patients were judged to snore loudly "often" or "always" by their bedpartners, whereas only 2% were judged so while using dental appliance. The most frequent side effect was teeth discomfort, present "sometimes" or often" in up to 32% of patients. Follow-up clinical assessment in 1 21 patients conducted on the average 350 days after the insertion of the appliance revealed that 86% of patients continued to use the appliance nightly; 60% were very satisfied with the appliance, 27% were moderately satisfied, I I% were moderately dissatisfied, and 2% were very dissatisfied.

Conclusion: We conclude that the adjustable mandibular positioning appliance is an effective treatment alternative for some patients with snoring and sleep apnea.

The following excerpts are taken from recent research articles about oral appliance therapy.

1. The Mandibular Repositioning Device: Role in the Treatment of Obstructive Sleep Apnea. Stuart J. Menn, Daniel I. Loube, Todd D. Morgan, Merrill M. Miller, Joel S. Berger and Milton K Erman. Division of Sleep Disorders, Scripps Clinic and Research Foundation, Pulmonary Service, Walter Reed Army Medical Center. 1996, Sleep, 19(10): 794-800

The role of oral appliances in the routine treatment of obstructive sleep apnea (OSA) is not well defined. This prospective study attempts to clarify the clinical role of a specific oral appliance, the mandibular repositioning device (MRD). This study evaluated the demographic, polysomnographic, and cephalometric radiographic findings predictive of treatment success or failure with the MRD. Twenty-nine patients were diagnosed with mild to severe OSA by nocturnal polysomnography. The majority of these patients were intolerant to nasal continuous positive airway pressure (CPAP) and all were fitted with a MRD. Twenty-three of these patients were compliant initially with MRD use and received post-treatment nocturnal polysomnography at a mean of 104 days after receiving the device. The respiratory disturbance index (RDI) decreased with the MRD use (37+or - 23 versus 18+or- 20 events/hour, p< 0.001), and 16 of the 23 patients (69%) were considered responders (decrease in rdi <or = 50% and posttreatment RDI <or = 20). measurements of subjective and objective daytime sleepiness, nocturnal oxygen desaturation, and snoring were all improved with mrd use. a pre-treatment rdi > 40 was present in four of the seven (67%) non-responders. Age, body mass index, and cephlometric radiographic measurements were not predictive of treatment outcome. Sixteen of 23 patients (70%) continue to use the MRD after 3.4 + or - 0.7 years. This study suggest that the MRD is useful in the long-term treatment of patients with OSA of mild to moderate severity.

2. Oral Appliances for Obstructive Sleep Apnea (OA for OSA). Wolfgang Schmidt-Noware, M.D. Pulmary Division, University of New Mexico. Chest, in press, May 1996.

The advent of oral appliance therapy and the significance of this study need to be placed in a broad perspective. Of the 8 million men and women in this country age 30 and older with OSA (subject with RDI >or = 15, prevalence from Young,et.al., reference 6), most have relatively mild disease. OA therapy provides an important treatment choice in this group, and may be the preferred initial treatment. Clinicians caring for OSA patients should add OA to their vocabulary and OA therapy to their repertoire.

3. Effect of Jaw Position and Posture on Forced Inspiratory Airflow in Normal Subjects and Patients with Obstructive Sleep Apnea. Shin-ichi Masumi, DDS, PHD; Keisuke Nishigawa, DDS, PHD; Adrian J. Williams, MD, FCCP; Frisca L. Yan-Go, MD; and Glenn T. Clark, DDS,MS. Chest 1996; 109: 1484-89.

Objective: This study evaluated whether substantial airflow changes occur by changing both body posture and jaw position in normal subjects and patients with obstructive sleep apnea (OSA).
Results: Both groups had a significant decrease in their forced inspiratory flow25-75 upon reclining, and there were no significant group differences regarding the magnitude of this change. Both groups also had a nearly full recovery of their forced inspiratory flow25-75 airflow when their jaws were positioned forward while reclining.
Conclusions: These data document that when a patient is in a supine position, a 100% protrusive jaw position allows significantly more inspiratory airflow to occur.

4. Evaluation of Anterior Mandibular Positioning Appliances for Treatment of Obstructive Sleep Apnea. J. Pancer and V. Hoffstien. Center for Sleep and Chronobiology, University of Toronto.

Dental appliances are presently the only non-invasive alternative approach for treatment of sleep apnea. Although this treatment modality is not new, it has been somewhat neglected, mainly because of the uncertainties regarding efficacy, acceptance by patients, and dramatic success afforded by treatment with continuous positive airway pressure (CPAP) devices. However, there are many patients with sleep apnea who for various reasons cannot use CPAP. The purpose of this invell patients with sleep apnea or upper airway resistance syndrome presenting to our sleep disorders center. There were 23 patients (22 males and 1 female) who accepted to be fitted for the appliance and subsequently used it at home. All patients had standard nocturnal polysomnography. They were assessed by one dentist (JP) who constructed the TAP appliance for them. They started using it at home, and if there was any discomfort or continued snoring, the appliance was adjusted accordingly, until the patients were able to tolerate it. Prior to treatment patients' bedpartner was asked to fill out a questionnaire dealing with their bedmates snoring. After the appliance was used at home for several weeks, the bedpartner once again filled out the same questionnaire. At the same time the patients filled out a questionnaire dealing with 1) overall comfort of the appliance, 2) possible side affects involving the jaw, teeth, tongue, and gums, and 3)excessive salivation. Nocturnal polysomnography was repeated with the appliance in place throughout the night. The results were analyzed by comparing the apnea/hypopnea indices without and with the appliance using paired t-test, comparing replies of the bedpartners regarding snoring before and with the appliance using chi-square test, and tabulating the replies of the patients dealing with the comfort of the appliance.
Patients ranged in age from 25 to 72 (mean SD = 47+ or - 12 yrs.). Their body mass index was 31 + or - 5 km/m2. We found that apnea/hypopnea index was reduced from 44 + or - 24 without the appliance to 14 + or - 9 with the appliance (p<0.005). bedpartners reported that without the appliance 83% of their bedmates snored either always or often, and 17% snored sometimes. with the appliance, 80% either did not snore or snored only rarely, and 20% snored sometimes. 71% of all patients were very satisfied with the appliance, and 21% were moderately satisfied. teeth discomfort was reported often by 25%, and never, rarely, or sometimes by the remaining 75%. similarly, jaw discomfort was reported often by 25%, and rarely or sometimes by 75%. most patients (75%) reported no tongue discomfort at all, and only 13% reported frequent gum discomfort.
We are encouraged by the subjective and objective efficacy of the appliance, its relatively high acceptance rate, and relatively low incidence of side affects. However, we must be cautious in recommending oral appliances as an initial treatment of sleep apnea in all patients, pending proper evaluation (i.e. efficacy and acceptability) of this appliance in a large group of patients with different severity of sleep apnea.

5. Dental Appliances for the Treatment of Obstructive Sleep Apnea Syndrome. Chung-Hua Chiang i Hsueh Tse Chih. Chinese Journal of Stomatology 1996;31(1):12-5.

This study combined the use of cephalomtrics and overnight polysomnographic monitoring to analyze the effects of a dental appliance on the airway, sleep, and respiratory conditions in 10 patients with obstructive sleep apnea. The findings indicated that horizonal and vertical mean changes in mandibular postion while the appliance was worn were 1.73mm and 9.30 mmm, respectively. The mean superior airway space increased by 2.80 mm (P<0.01), while the mean middle airway space increased by 6.75 mm(p=0.01), the inferior airway space, however, didn't change significantly when the appliance was worn. The average Apnea Index decreased by 15.98 events per hour when the appliance was worn (P<0.01), the average Respiratory Disturbance Index decreased from 39.42 to 6.62 events per hour in 9 of 10 patients (P<0.01, one patient didn't have recording of hypoventilation). the lowest sao2 value increased from 73.87% to 85.50% (p<0.01). the reduction in the rate of airway obstruction events is attributable to the effect of appliance on the orophargneal structures.