Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2015 Jul 15;11(7):773-827.
doi: 10.5664/jcsm.4858.

Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015

Kannan Ramar  1 , Leslie C Dort  2 , Sheri G Katz  3 , Christopher J Lettieri  4 , Christopher G Harrod  5 , Sherene M Thomas  5 , Ronald D Chervin  6
Affiliations
Meta-Analysis

Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015

Kannan Ramar et al. J Clin Sleep Med. .

Abstract

Introduction: Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clinical outcomes. The purpose of this new guideline is to replace the previous and update recommendations for the use of OAs in the treatment of obstructive sleep apnea (OSA) and snoring.

Methods: The American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) commissioned a seven-member task force. A systematic review of the literature was performed and a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the quality of evidence. The task force developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms. The AASM and AADSM Board of Directors approved the final guideline recommendations.

Recommendations: 1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD) 2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE) 3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD) 4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE) 5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE) 6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE).

Conclusions: The AASM and AADSM expect these guidelines to have a positive impact on professional behavior, patient outcomes, and, possibly, health care costs. This guideline reflects the state of knowledge at the time of publication and will require updates if new evidence warrants significant changes to the current recommendations.

Keywords: mandibular advancement; obstructive sleep apnea; oral appliance; positive airway pressure; snoring.

PubMed Disclaimer

Figures

Figure 1
Figure 1. Custom, Non-Titratable (C-NT) OAs for Mild to Moderate Adult OSA (AHI/RDI/REI).
Figure 2
Figure 2. Custom, Non-Titratable OAs for Moderate to Severe Adult OSA (AHI/RDI/REI).
Figure 3
Figure 3. Custom, Titratable (C-T) OAs for Mild to Moderate Adult OSA (AHI/RDI/REI).
Figure 4
Figure 4. Custom, Titratable OAs for Moderate to Severe Adult OSA (AHI/RDI/REI).
Figure 5
Figure 5. CPAP for Mild to Moderate Adult OSA (AHI/RDI/REI).
Figure 6
Figure 6. CPAP for Severe Adult OSA (AHI/RDI/REI).
Figure 7
Figure 7. OAs for Primary Snoring (Snoring Loudness).
Figure 8
Figure 8. Summary of Findings (Primary Snoring, Snoring Indices).
Figure 9
Figure 9. OAs for OSA (AHI/RDI/REI).
Figure 10
Figure 10. Custom OAs for OSA (AHI/RDI/REI).
Figure 11
Figure 11. Non-Custom OAs for OSA (AHI/RDI/REI).
Figure 12
Figure 12. Custom, Titratable OAs for OSA (AHI/RDI/REI).
Figure 13
Figure 13. Custom, Non-Titratable OAs for OSA (AHI/RDI/REI).
Figure 14
Figure 14. OAs vs. CPAP for OSA (AHI/RDI/REI).
Figure 15
Figure 15. OAs for OSA (Minimum Oxygen Saturation).
Figure 16
Figure 16. Custom OAs for OSA (Minimum Oxygen Saturation).
Figure 17
Figure 17. Non-Custom OAs for OSA (Minimum Oxygen Saturation).
Figure 18
Figure 18. Custom, Titratable OAs for OSA (Minimum Oxygen Saturation).
Figure 19
Figure 19. Custom, Non-Titratable OAs for OSA (Minimum Oxygen Saturation).
Figure 20
Figure 20. OAs vs. CPAP for OSA (Minimum Oxygen Saturation).
Figure 21
Figure 21. OAs for OSA (Arousal Index).
Figure 22
Figure 22. Custom, Titratable OAs for OSA (Arousal Index).
Figure 23
Figure 23. Custom, Non-Titratable OAs for OSA (Arousal Index).
Figure 24
Figure 24. OAs vs. CPAP for OSA (Arousal Index).
Figure 25
Figure 25. OAs for OSA (Oxygen Desaturation Index; ODI).
Figure 26
Figure 26. Custom, Titratable OAs for OSA (ODI).
Figure 27
Figure 27. Custom, Non-Titratable OA for OSA (ODI).
Figure 28
Figure 28. OAs vs. CPAP for OSA (ODI).
Figure 29
Figure 29. OAs for OSA (% Rapid Eye Movement; %REM).
Figure 30
Figure 30. Custom OAs (%REM).
Figure 31
Figure 31. Custom, Titratable OAs for OSA (%REM).
Figure 32
Figure 32. Custom, Non-Titratable OA for OSA (%REM).
Figure 33
Figure 33. OAs vs. CPAP for OSA (%REM).
Figure 34
Figure 34. OAs for OSA (Sleep Efficiency).
Figure 35
Figure 35. Custom OAs for OSA (Sleep Efficiency).
Figure 36
Figure 36. Non-Custom OAs for OSA (Sleep Efficiency).
Figure 37
Figure 37. Custom, Titratable OA for OSA (Sleep Efficiency).
Figure 38
Figure 38. Custom, Non-Titratable OA for OSA (Sleep Efficiency).
Figure 39
Figure 39. OAs vs. CPAP (Sleep Efficiency).
Figure 40
Figure 40. Summary of Findings: OA Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).
Figure 41
Figure 41. Summary of Findings: Custom OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).
Figure 42
Figure 42. Summary of Findings: Non-Custom OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).
Figure 43
Figure 43. Summary of Findings: Custom, Titratable OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).
Figure 44
Figure 44. Summary of Findings: Custom, Non-Titratable OAs Pre- vs. Post-Treatment of OSA (All Physiologic Sleep Outcome Measures).
Figure 45
Figure 45. Summary of Findings: OAs vs. CPAP for OSA (All Physiologic Sleep Outcome Measures).
Figure 46
Figure 46. OAs for OSA (Epworth Sleepiness Scale; ESS).
Figure 47
Figure 47. Custom OAs for OSA (ESS).
Figure 48
Figure 48. Custom, Titratable OAs for OSA (ESS).
Figure 49
Figure 49. Custom, Non-Titratable OAs for OSA (ESS).
Figure 50
Figure 50. OAs vs. CPAP for OSA (ESS).
Figure 51
Figure 51. Summary of Findings: OAs Pre- vs. Post-Treatment for OSA (ESS).
Figure 52
Figure 52. Summary of Findings: Custom OAs for OSA (ESS).
Figure 53
Figure 53. Summary of Findings: Non-Custom OAs for OSA (ESS).
Figure 54
Figure 54. Summary of Findings: Custom, Titratable OAs for OSA (ESS).
Figure 55
Figure 55. Summary of Findings: Custom, Non-Titratable OAs for OSA (ESS).
Figure 56
Figure 56. Summary of Findings: OAs vs. CPAP for OSA (ESS).
Figure 57
Figure 57. OAs for OSA (Quality of Life, QOL; Short Form-36, SF-36).
Figure 58
Figure 58. Custom, Titratable OAs for OSA (QOL; SF-36).
Figure 59
Figure 59. Custom, Non-Titratable OAs for OSA (QOL; SF-36).
Figure 60
Figure 60. OAs vs. CPAP for OSA (QOL; SF-36).
Figure 61
Figure 61. Summary of Findings: OAs Pre- vs. Post-Treatment for OSA (Quality of Life; QOL).
Figure 62
Figure 62. Summary of Findings: Custom, Titratable OAs for OSA (QOL).
Figure 63
Figure 63. Summary of Findings: Custom, Non-Titratable OAs for OSA (QOL).
Figure 64
Figure 64. Summary of Findings: OAs vs. CPAP for OSA (QOL).
Figure 65
Figure 65. OAs for OSA (Systolic blood pressure).
Figure 66
Figure 66. OAs for OSA (Diastolic blood pressure).
Figure 67
Figure 67. Custom, Titratable OAs for OSA (Systolic blood pressure).
Figure 68
Figure 68. Custom, Titratable OAs for OSA (Diastolic blood pressure).
Figure 69
Figure 69. OAs vs. CPAP for OSA (Systolic blood pressure).
Figure 70
Figure 70. OAs vs. CPAP for OSA (Diastolic blood pressure).
Figure 71
Figure 71. Summary of Findings: OAs for OSA (Hypertension).
Figure 72
Figure 72. Summary of Findings: Custom, Titratable OAs for OSA (Hypertension).
Figure 73
Figure 73. Summary of Findings: Custom, Non-Titratable OAs for OSA (Hypertension).
Figure 74
Figure 74. Summary of Findings: OAs vs. CPAP for OSA (Hypertension).
Figure 75
Figure 75. OAs vs. CPAP for OSA (Adherence).
Figure 76
Figure 76. Summary of Findings: OAs vs. CPAP for OSA (Adherence).
Figure 77
Figure 77. OAs for OSA (Side Effects).
Figure 78
Figure 78. OAs vs. CPAP for OSA (Side Effects).
Figure 79
Figure 79. Summary of Findings: OAs for OSA (Side Effects).
Figure 80
Figure 80. Summary of Findings: OAs vs. CPAP for OSA (Side Effects).
See this image and copyright information in PMC

References

    1. Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;283:1829–36. - PubMed
    1. Beninati W, Harris CD, Herold DL, Shepard JW., Jr The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners. Mayo Clin Proc. 1999;74:955–8. - PubMed
    1. Hu FB, Willett WC, Manson JE, et al. Snoring and risk of cardiovascular disease in women. J Am Coll Cardiol. 2000;35:308–13. - PubMed
    1. Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax. 1997;52:362–8. - PMC - PubMed
    1. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244–62. - PubMed