Oral appliances in the treatment of obstructive sleep apnea

Obstructive sleep apnea has become an increasingly more prominent national health concern, with more than 18 million sufferers in the United States. It has been estimated that more than 30 million Americans snore. The snoring population progressively tends to advance into obstructive sleep apnea, with the associated medical risks. As our population ages, the incidences of obstructive sleep apnea for men and women are on the rise. In men older than age 65, 28% have sleep apnea. Daytime sleepiness is common among 60% of the American population, the result of which is an increase in accidents, injuries, and other risks. Sleep disorders and sleep deprivation take their toll on public health, at a cost annually to the national health care bill of more than $16 billion. Other estimates of the indirect costs of sleep disorders are $41 billion per year from lost productivity, $22 billion per year from motor vehicle accidents, $7 billion per year in work-related accidents, and $4 billion per year in home and public accidents. The prevalence of sleep apnea currently ranks equivalent to diabetes and asthma. Signs and symptoms of obstructive sleep apnea include a chronic history of loud snoring, daytime fatigue, daytime sleepiness, morning/awakening headaches, decreased sex drive, poor memory, personality changes, breathless awakenings, limb jerkiness, witnessed sleep disruption events, gasping and shortness of breath, and labored noisy breathing. Up to 50% of patients who have sleep apnea have high blood pressure, and there is a direct correlation between this disease entity and heart attack, stroke, and cardiovascular disease. Snoring and obstructive sleep apnea can be eliminated or controlled in many of these patients by the use of oral appliances. The diagnosis of obstructive sleep apnea (ICD-9 code 327.23) is based on an overnight polysomnography test. A full sleep study incorporates numerous measurements to assess type of sleep, depth of sleep, amount of REM sleep, oxygen desaturation, and absence of breathing. Cardiac, ocular, respiratory, and electroencephalogram/brainwave measurements are integrated. Respiratory distress is categorized by frequency and duration of the cessation of airflow. Diagnosis should come through a certified sleep center. A baseline polysomnogram must be done with accurate diagnosis before dental intervention for obstructive sleep apnea treatment. The baseline oxygen saturation is contrasted to the lowest oxygen saturation event. Changes in oxygen saturation above 4% with a 30% decrease in airflow are recorded as hypopneas. An 80% or more reduction in airflow for 10 seconds or longer is recorded as an apneic event. An apnea/hypopnea index is derived from the number of apneas and hypopneas per hour. A score of 10 to 20 is indicated as mild apnea, a score of 20 to 40 is considered moderate, and a score of 40 or more is considered severe. Other alternative statistics have indicated 5 to 15 events per hour as mild obstructive sleep apnea, 15 to 30 as moderate, and 30 or more as severe. The goal of therapy, whether surgery, continuous positive airway pressure (CPAP), or oral appliance, is to significantly impact oxygenation and reduce the apnea/hypopnea index. Success rates of oral appliances tend to be higher in the mild to moderate index level compared to the