Sleep Apnea (Obstructive)

Obstructive sleep apnea (OSA) is a common condition and the most prevalent form of sleep apnea, accounting for over 80% of sleep-related breathing disorders diagnosed in the United States.¹ During sleep, individuals with OSA experience repetitive narrowing or collapse of the upper airway with intermittent breathing cessations (apneas) or partial obstructions (hypopneas) with diminished airflow.^2-4

The onset of sleep leads to decreased muscle tone and activity in the pharyngeal airway,⁵ which can result in airway narrowing or collapsibility that impairs normal ventilation.³ Individuals with anatomic or other risk factors (e.g., obesity, retrognathia, large tongue) may have increased risk of experiencing the often-cyclical respiratory events associated with OSA, as well as significant sleep fragmentation (due to repeated arousals from impaired breathing) and excessive daytime sleepiness.^{3, 4, 6}

An obstructive apnea is a cessation or near cessation of breathing (≥90% reduction in baseline airflow) despite respiratory effort that lasts at least 10 seconds during sleep.⁷ Apneas usually last between 10-30 seconds, although some may extend to 60 seconds or more. Obstructive respiratory events commonly terminate with a cortical arousal or microarousal to restore breathing,⁸ along with neural activation of upper airway muscles to maintain patency.^{4, 6} Each night, patients with severe OSA may experience hundreds of apneas, hypopneas or respiratory effort-related arousals.

Some individuals at high risk for OSA may present to clinicians without any clear, identifiable symptoms.⁹ Simple snoring (noisy breathing during sleep) is common but not always present in patients with OSA^10,11 since it does not involve full (or near) cessation of breathing (snorers may also have normal results in sleep studies).¹² Nevertheless, excessive daytime sleepiness and loud or irregular snoring are considered two hallmark symptoms of OSA,¹³ particularly when snoring is followed by a complete halt in breathing (apnea) that may be accompanied by choking or gasping.¹⁰ Habitual or persistent snoring has been identified as a symptom suggestive of OSA in children.^14-16

A conventional overnight sleep test (polysomnography) with standard multi-channel recording has traditionally been considered the gold standard for comprehensive sleep evaluation and OSA diagnosis.^{3, 17} Time-synchronized video recording is included during the overnight sleep study, plus sound recording to assess breathing and snoring levels. Home sleep apnea tests are also available to assist in measuring breathing patterns in uncomplicated adult patients who present with symptoms of sleep-related breathing disorders.³

Obstructive sleep apnea is often undiagnosed and untreated,^18-22 but common signs and symptoms of OSA can be identified in various clinical settings, including dental practice. Dentists can work collaboratively with primary care physicians and sleep specialists, as part of a multidisciplinary care team, to assist in providing optimal long-term care of patients with OSA,²³ with the ultimate goals of improving health and quality of life and reducing the incidence of OSA-related morbidity and mortality.

OSA is highly prevalent in the general population, both in the United States and globally.^{24, 25} Prevalence estimates of OSA in patient populations are highly variable, depending on the definitions for OSA diagnosis and criteria for estimating its prevalence and severity.²⁶ An epidemiologic review of studies over a 20-year period reported mean OSA prevalence levels of 22% for men and 17% for women.²⁷ Data from a U.S. cohort study estimated the prevalence of moderate to severe OSA (defined as an apnea-hypopnea index [AHI] of ≥15 events per hour) to be approximately 13% for adult men and 6% for women.²⁸

The prevalence of OSA tends to increase progressively with age.^{29, 30} In one study, OSA incidence increased from 3% of younger adults aged 20 to 44 years to 11.8% of middle-aged adults (aged 45 to 64 years) and over 23% of adults aged 65 years and older.³¹ The prevalence of OSA in patients older than 65 years of age has been estimated to range between 13 and 32%.³²

OSA is also more prevalent among men, particularly middle-aged men who exceed the minimum threshold for obesity (i.e., body-mass index [BMI] greater than or equal to 30).²⁸ Due to the increased morbidity and all-cause mortality associated with OSA,³³ the condition is a recognized public health issue.³⁴

Common symptoms associated with OSA include one or more of the following: nocturnal choking or gasping,¹⁰ loud or irregular snoring,¹³ observed apneas during sleep (e.g., by spouse or bed partner),³⁵ excessive daytime sleepiness,^{36, 37} nocturia,³⁸ dry mouth on awakening³⁹ and morning headache.⁴⁰

There is certainly variability among individuals with OSA, and some may present without any complaints or identifiable symptoms.⁹ The pathogenesis of OSA is considered multifactorial,⁴¹ and no single physical (anatomic) sign or symptom related to OSA can be viewed as a definitive indicator that the condition is present.⁴² As an example, excessive daytime sleepiness is a commonly reported symptom of OSA,^{36, 43} but it is not always present in individuals who are diagnosed with the condition.^{27, 44} Two systematic reviews concluded that another risk factor, alcohol consumption, can increase risk of developing OSA by 25%, and is associated with worsening OSA symptoms or complications.^{45, 46}

Examples of risk factors associated with increased risk of OSA are summarized in Table 1.

Table 1. Risk Factors Associated with Obstructive Sleep Apnea

Overweight/obesity ^10,47-51

Retrognathia⁵² micrognathia⁵³

Large tongue⁵⁴

High arched palate^{37, 55}

Male gender^{56, 57}

Enlarged neck circumference⁵⁸

Narrowing in regions of the upper airway (e.g., increased volume of lateral pharyngeal walls, tongue and total soft tissue)⁵⁹

Older age⁶⁰

Enlarged tonsils or adenoids (adenotonsillar hypertrophy)^{61, 62} [note: higher Mallampati airway classification is typically associated with increased risk of OSA]^{10, 63}

Nasal obstruction (e.g., chronic nasal inflammation, allergic rhinitis)⁴¹

Alcohol consumption^{45, 46}

Family history of OSA⁶⁴

Ethnicity (e.g., African-American adults appear to have higher prevalence)^{65, 66}

Patients may be unaware of their own sleep-disordered breathing and the extent or severity of their repetitive (or transient) airway obstructions, arousals and awakenings during sleep. Patients may also be aware of their own snoring, daytime sleepiness or other OSA-related symptoms, but may not share that information with their physician or dentist.²¹

Untreated OSA results in cycles of breathing cessations and “micro-arousals” during sleep that induce oxidative stress, along with intermittent drops in blood oxygen saturation.⁶⁷ Increasing levels of OSA severity are associated with greater systemic oxidative stress⁶⁸ and increased risk of all-cause mortality.³³ The condition can also exert a significant impact on overall health, neurocognitive performance, personal relationships and routine daily functioning.^{69, 70} Examples of short- and long-term health complications associated with OSA are presented in Table 2.

Table 2. Health Complications Associated with Obstructive Sleep Apnea

Stroke and transient ischemic attacks^71-74

Cardiovascular disease⁷³ (including atrial fibrillation, acute coronary syndrome and potentially fatal cardiovascular events)^{33, 75-78}

Potentially increased cancer incidence and mortality^{6, 28, 33, 79-83}

Hypertension (present in nearly half of OSA cases)²⁷

Type 2 diabetes⁸⁴

Cognitive impairment⁸⁵

Dementia^{82, 86}

Depression^{57, 87} or mood and anxiety disorders⁸⁸

Sexual dysfunction^{89, 90}

Patients with OSA may report feelings of excessive daytime sleepiness or fatigue, two common symptoms of sleep fragmentation or poor sleep that are often directly attributable to OSA.⁹¹ Studies have shown that individuals with OSA have two to three times higher risk of experiencing a motor vehicle accident,^92-94 plus concomitant risks associated with drowsy driving.

Sedation and Anesthesia: Patients with OSA should notify all health care providers, including dentists and surgeons, of their status and condition with regard to OSA (e.g., severity, extent of symptoms) to help ensure optimal patient safety during surgical procedures, including when conscious sedation or anesthesia is utilized.

Diagnosis of OSA is made by a physician or trained sleep specialist after comprehensive assessment of the patient, including medical history, physical examination and diagnostic testing. Sleep-related considerations that may be addressed in a detailed health history include an assessment of sleep quality, history of snoring and awareness of gasping, choking, snorting or other breathing disturbances. The health history-taking may also include any prior sleep-related diagnosis and use of (or recommendations for) PAP therapy. Other OSA-related symptoms during wake periods can also be evaluated, such as daytime sleepiness, fatigue or impaired concentration or focus during activities that require attentiveness (e.g., driving a vehicle).

Dentists may supplement the patient’s comprehensive physical examination by providing a full examination of the oral cavity and the craniofacial region, including identification of structural abnormalities or physiologic indicators associated with OSA (e.g., large tongue or tonsils, retrusive jaw, large neck circumference).^{10, 95}

The reference standard for OSA diagnosis is an overnight, attended sleep study (polysomnogram). This single-night study includes multichannel recordings of breathing patterns and airflow, duration of various stages of sleep, respiratory events (apneas and hypopneas), brain-wave activity, oximetry, muscle activity and cardiovascular function (e.g., electrocardiogram).^{96, 97}

An in-laboratory sleep study quantifies obstructed breathing events using the apnea-hypopnea index (AHI), which presents an average measure of apneas and hypopneas recorded per hour of sleep. The AHI is commonly used for categorizing OSA severity. AHI scores of 5, 15 and 30 events per hour are the standard “cutoffs” for mild, moderate and severe OSA, respectively.⁷

At-home sleep tests are also available and may provide a more convenient or cost-effective option for some individuals. These portable home-monitoring devices generally track breathing patterns or disturbances during sleep rather than overall sleep quality. Clinical guidelines recommend that home sleep apnea tests only be used by uncomplicated adults who present with signs and symptoms that indicate an increased risk of moderate to severe OSA,³ and that they be used in conjunction with a comprehensive sleep evaluation.⁹⁸ Additionally, one clinical practice guideline on childhood obstructive sleep apnea advises clinicians to screen all children and adolescents for snoring.⁶¹

Clinical questionnaires⁹⁹ to assist with conducting OSA risk assessment are presented in Table 3.

Table 3. Questionnaires for Obstructive Sleep Apnea Risk Assessment

STOP-Bang Questionnaire
An eight-question checklist of symptoms associated with increased risk of OSA, which has been recommended as a screening tool with moderate-quality evidence.³ Positive answers to three of the eight questions identify individuals who meet the minimum threshold for intermediate OSA risk; five or more positive replies identify persons at severe risk.¹⁰⁰

Berlin Questionnaire
The Berlin questionnaire¹⁰¹ evaluates both daytime alertness and sleep variables (e.g., snoring, breathing disruptions during sleep), as well as other risk factors such as high body mass index and hypertension.

Epworth Sleepiness Scale (ESS)
A subjective questionnaire that provides a general measure of an individual’s daytime sleepiness, a common symptom of sleep apnea.¹⁰³ The ESS asks individuals to report how likely they are to fall asleep during eight different scenarios (e.g., watching television).

Pittsburgh Sleep Quality Index
A self-report questionnaire that measures sleep disturbances and sleep habits over a one-month period.

Physicians and sleep specialists serve as the primary health care providers in the diagnosis and management of OSA and other sleep-related breathing disorders. In the event oral appliances are the prescribed therapy, managing physicians may work with each patient’s dentist to ensure that a comprehensive oral clinical examination has been obtained when necessary, including assessment of intraoral and extraoral findings.

Behavioral Modification: As an initial treatment option, patients with mild-to-moderate OSA may begin with behavioral interventions or changes in lifestyle (diet, weight loss, exercise), particularly obese or overweight individuals with OSA or strongly suspected of having the condition.¹⁰⁴ Reducing alcohol consumption, especially before bedtime, may also provide therapeutic and preventive value.⁴⁵ Supplementary education can also be offered to advise patients of the negative impact on OSA therapy that may result from use of alcohol or recreational drugs.¹⁰⁵

Positional Sleep: Patients may also be advised that sleeping in a supine position (horizontal position with face and torso facing up) has been found to increase episodes of airway obstruction and aggravate OSA-related symptoms.^{106, 107} This condition is known as position-dependent obstructive sleep apnea, and researchers estimate that up to half of all OSA-related cases in adults could be classified as supine-related OSA.¹⁰⁷

For some adults, sleeping on one’s side (positional therapy) may assist in improving AHI levels and sleepiness measures (per the Epworth Sleepiness Scale).¹⁰⁸ For individuals with mild to moderate OSA, mild head-of-bed elevation may also assist in reducing OSA severity.¹⁰⁹ A patient’s primary care physician or sleep specialist may advise whether positional therapy might assist in providing therapeutic benefit and improved breathing stability.

PAP Therapy: Positive airway pressure is recommended as a primary therapy for managing adult OSA.^110,111 PAP devices use air pressure from a mechanical device to counteract airway narrowing through the delivery of compressed air to the oropharynx. Air pressure is delivered through an air-tight attachment (e.g., a mask covering the sleeper’s nose), which splints the airway with increased air pressure to maintain patency during sleep.¹¹² PAP devices are available in a wide range of machine sizes and mask types. Based on the available evidence, PAP can provide patients with improved sleep patterns and quality of life when used consistently and properly.¹¹²

Although PAP devices are commonly prescribed for the treatment of adult OSA, there are significant issues with patient compliance and adverse events (e.g., mask discomfort, mouth dryness, nasal congestion).¹¹³ PAP therapy has a persistently low rate of adherence, ranging from 17% to 60% (with adherence defined as greater than four hours of PAP use on 70% of nights).^114-116 The use of PAP also may not fully resolve an individual’s OSA or sufficiently reduce its severity.¹¹² To improve patient comfort and adherence to PAP therapy, an American Academy of Sleep Medicine (AASM) guideline¹¹¹ recommends the use of heated humidification with PAP devices, which can assist in reducing oral dryness and other PAP-related side effects. In adults with OSA, the AASM guideline¹¹¹ also recommends that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy, which have shown clinically significant improvements in patient compliance with PAP therapy over time.^{117, 118}

As an alternative course of treatment, physicians may refer OSA patients who formerly used PAP to their dentist for assessment for oral appliance therapy, a common treatment modality for individuals with mild to moderate OSA.

Oral Appliances: Individuals with OSA can also consult with their physician and dentist to determine if an oral appliance would serve as an effective therapeutic option for treating the condition. Oral appliances may be custom-fitted by a dentist for placement in the mouth during sleep to help stabilize the mandible and prevent oropharyngeal tissue and the base of the tongue from recurrent collapse and blockage of the upper airway.¹¹⁹

Numerous oral appliances are available today, and they generally move the mandible, tongue and soft palate forward to increase pharyngeal airway space and reduce the risk of airway collapse.^{120, 121} Many terms are used to describe oral appliance therapies for obstructive sleep apnea, including mandibular advancement devices (also called mandibular advancement splints), upper airway devices and tongue-retaining devices.

Oral appliances provide therapeutic benefit by repositioning and stabilizing the mandible, tongue, hyoid bone and soft palate in a forward position.^{122, 123} Current guidelines from the field of sleep medicine recommend that when physicians prescribe oral appliance therapy for adults with OSA, the dentist should use a custom, titratable oral appliance rather than a non-custom appliance, and should also evaluate for dental adverse effects of oral appliance use over time.¹²⁰ One recent systematic review concluded that custom-fabricated mandibular advancement devices performed more favorably than thermoplastic devices in terms of treatment outcomes (e.g., improved AHI and subjective sleepiness scores), primarily due to improved patient preference and better compliance.¹²⁴

Oral appliances have been viewed as a simpler therapeutic option for patients with OSA,¹²⁵ particularly for patients with mild to moderate OSA or patients with severe OSA who have difficulty tolerating PAP therapy. Patients with OSA should be advised to use their oral appliances nightly (or during each sleep session) to help achieve optimal control of OSA symptoms.

Patients using oral appliance therapy for OSA may benefit from having an initial evaluation of the temporomandibular joint (TMJ) region to help reduce risks of adverse effects associated with long-term use of oral appliances (e.g., symptoms of TMJ disorders, changes in dental occlusion).¹²⁶ Oral appliance therapy has been associated with progressive dental changes over time (e.g., reductions in overbite, overjet or mandibular crowding),¹²⁷ as well as TMJ issues (e.g., transient morning jaw pain), hypersalivation or irritation of oral soft tissues.^{126, 128} Oral appliances can be modified to help ensure optimal fit and help the patient avoid mouth breathing, which can cause dry mouth symptoms.

Based on the available evidence, oral appliances—specifically custom-made, titratable oral appliances--have been found to improve OSA in adult patients compared to no therapy or placebo devices.¹²⁵ It is appropriate for dentists to work closely with patients with OSA to determine their individual treatment needs and preferences (e.g., oral appliance recommendations may vary for heavy bruxing patients). Additional information on oral appliance therapy for OSA is presented in a 2016 Evidence Brief: Oral Appliances for Sleep-Related Breathing Disorders, which was developed by an expert panel organized by the ADA.

Surgical Options: Surgery may be recommended for patients who do not improve or respond to non-surgical therapies for OSA. Surgical procedures are used to adjust structures (bone or soft tissues) to reduce obstruction in the upper airways, or for implantation of neurostimulator devices.

One surgical procedure for OSA is uvulopalatopharyngoplasty, which removes or shortens the uvula, excessive tissue in the throat as well as the tonsils. Maxillary-mandibular advancement surgery is another option for expanding an individual’s upper and lower pharyngeal airway to reduce airway obstruction. Tracheostomy is another surgical intervention for OSA, but it is typically reserved for use as a potential interim treatment in select circumstances (e.g., individuals with severe OSA, or cases when other clinical options have failed or do not exist).¹²⁹ Individuals with moderate-to-severe OSA who are unable to tolerate PAP therapy may be considered for hypoglossal nerve stimulation, which uses an implantable neurostimulator device to move the patient’s tongue forward during sleep for improved airway patency.^{130, 131}

A dentist can be consulted throughout the process of OSA diagnosis and treatment for patients across the lifespan. The spectrum of dental care with patients diagnosed with OSA (or at high risk for the condition) may include comprehensive oral examination, evaluation of oral anatomy and the appropriateness of providing oral appliance therapy, and other considerations.

Health history-taking can be supplemented with use of one or more of the OSA-specific screening questionnaires, including the STOP-Bang Questionnaire and others. OSA may be considered in dental patients who report sleepiness as a common symptom. Appropriate evaluation and patient assessment, including a thorough medical and dental history, are important steps to help identify individuals at risk for clinically significant OSA. Patients determined to have significant risk of OSA (e.g., through a screening questionnaire like STOP-Bang) may be referred to a physician or sleep specialist for further evaluation.

When conducting a standard evaluation of the patient’s oral cavity, dentists are ideally positioned to identify oral or craniofacial abnormalities or other anatomical factors (e.g., abnormalities or deviations in oral structures and tissues) that are common signs of OSA or potential risk for the condition. Features within the oral cavity that can be evaluated include large tongue, retrusive jaw, or enlarged tonsils (grade 3 or higher associated with increased risk of OSA).⁶³ A manual examination of the TMJ muscles and region is also recommended for evaluation of normal joint function and any associated pain.¹³² Dentists may also evaluate patients for airway obstruction in accordance with the Mallampati Scale,¹³³ as well as neck circumference and severe overjet.¹³⁴

Patients can be educated about the strong association between OSA and systemic hypertension, coronary artery disease and increased risk of stroke, atrial fibrillation and type 2 diabetes. Obstructive sleep apnea is commonly linked with obesity,⁴⁹ and increased body weight is associated with higher risk for OSA and increased progression and severity of the condition. When appropriate, patients suspected of having OSA should be referred to their primary care physician or sleep specialist. Some patients may benefit from seeing a registered dietician for nutritional counseling.

Generally, dentists are advised to maintain a high level of awareness when evaluating or treating patients who present with signs or symptoms suggestive of OSA (e.g., excessive daytime sleepiness; breathing pauses during sleep that are accompanied by snorting or gasping).^{10, 135, 136} Patients with OSA may be advised to visit their dentist regularly for thorough assessment of their dental and periodontal condition, as well as fabrication and maintenance of properly fitted oral appliances that can be used safely over time.

American Dental Association

Adopted 2019 (2019: 270)

1. Morgenthaler TI, Kagramanov V, Hanak V, Decker PA. Complex sleep apnea syndrome: Is it a unique clinical syndrome? Sleep 2006;29(9):1203-9.
2. Ross SD, Allen IE, Harrison KJ, et al. Systematic review of the literature regarding the diagnosis of sleep apnea. Evid Rep Technol Assess (Summ) 1998(1):1-4.
3. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2017;13(3):479-504.
4. Ayappa I, Rapoport DM. The upper airway in sleep: Physiology of the pharynx. Sleep Med Rev 2003;7(1):9-33.
5. Fogel RB, Trinder J, White DP, et al. The effect of sleep onset on upper airway muscle activity in patients with sleep apnoea versus controls. J Physiol 2005;564(Pt 2):549-62.
6. Dempsey JA, Veasey SC, Morgan BJ, O'Donnell CP. Pathophysiology of sleep apnea. Physiol Rev 2010;90(1):47-112.
7. Sleep-related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of Sleep Medicine task force. Sleep 1999;22(5):667-89.
8. Liu JV, Qin L, Yaggi HK. 0138 physiological effects of respiratory events that terminate without arousals during sleep. Sleep 2019;42(Supplement_1):A56-A57.
9. Gray EL, McKenzie DK, Eckert DJ. Obstructive sleep apnea without obesity is common and difficult to treat: Evidence for a distinct pathophysiological phenotype. J Clin Sleep Med 2017;13(1):81-88.
10. Myers KA, Mrkobrada M, Simel DL. Does this patient have obstructive sleep apnea?: The rational clinical examination systematic review. JAMA 2013;310(7):731-41.
11. Bearpark H, Elliott L, Grunstein R, et al. Snoring and sleep apnea. A population study in Australian men. Am J Respir Crit Care Med 1995;151(5):1459-65.
12. Bernstein P, Ebba JH. Snoring versus obstructive sleep apnea: A case report. Perm J 2006;10(1):21-3.
13. Maimon N, Hanly PJ. Does snoring intensity correlate with the severity of obstructive sleep apnea? J Clin Sleep Med 2010;6(5):475-8.
14. Nixon GM, Davey M. Sleep apnoea in the child. Aust Fam Physician 2015;44(6):352-5.
15. Nieminen P, Tolonen U, Löppönen H. Snoring and obstructive sleep apnea in children: A 6-month follow-up study. JAMA Otolaryngology–Head & Neck Surgery 2000;126(4):481-86.
16. Kaditis AG, Alonso Alvarez ML, Boudewyns A, et al. Obstructive sleep disordered breathing in 2- to 18-year-old children: Diagnosis and management. Eur Respir J 2016;47(1):69-94.
17. Baker-Smith CM, Isaiah A, Melendres MC, et al. Sleep-disordered breathing and cardiovascular disease in children and adolescents: A scientific statement from the American Heart Association. J Am Heart Assoc 2021;10(18):e022427.
18. Kapur V, Blough DK, Sandblom RE, et al. The medical cost of undiagnosed sleep apnea. Sleep 1999;22(6):749-55.
19. Sullivan F. Hidden health crisis costing America billions. American Academy of Sleep Medicine. 2016:1-25.
20. Kapur V, Strohl KP, Redline S, et al. Underdiagnosis of sleep apnea syndrome in U.S. communities. Sleep Breath 2002;6(2):49-54.
21. Jonas DE, Amick HR, Feltner C, et al. Screening for obstructive sleep apnea in adults. JAMA 2017;317(4):415.
22. Caplan IF, Glauser G, Goodrich S, et al. Undiagnosed obstructive sleep apnea as a predictor of 30-day readmission for brain tumor patients. J Neurosurg 2019:1-6.
23. Tietjens JR, Claman D, Kezirian EJ, et al. Obstructive sleep apnea in cardiovascular disease: A review of the literature and proposed multidisciplinary clinical management strategy. J Am Heart Assoc 2019;8(1):e010440.
24. Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev 2017;34:70-81.
25. Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis. Lancet Respir Med 2019;7(8):687-98.
26. Zinchuk AV, Gentry MJ, Concato J, Yaggi HK. Phenotypes in obstructive sleep apnea: A definition, examples and evolution of approaches. Sleep Med Rev 2017;35:113-23.
27. Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis 2015;7(8):1311-22.
28. Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013;177(9):1006-14.
29. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328(17):1230-5.
30. Ancoli-Israel S, Kripke DF, Klauber MR, et al. Sleep-disordered breathing in community-dwelling elderly. Sleep 1991;14(6):486-95.
31. Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med 1998;157(1):144-8.
32. Glasser M, Bailey N, McMillan A, Goff E, Morrell MJ. Sleep apnoea in older people. Breathe 2011;7(3):248-56.
33. Marshall NS, Wong KK, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea and 20-year follow-up for all-cause mortality, stroke, and cancer incidence and mortality in the Busselton health study cohort. J Clin Sleep Med 2014;10(4):355-62.
34. Institute of Medicine Committee on Sleep Medicine Research. The National Academies collection: Reports funded by National Institutes of Health. In: Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US), National Academy of Sciences; 2006.
35. Goyal M, Johnson J. Obstructive sleep apnea diagnosis and management. Mo Med 2017;114(2):120-24.
36. Garbarino S, Scoditti E, Lanteri P, et al. Obstructive sleep apnea with or without excessive daytime sleepiness: Clinical and experimental data-driven phenotyping. Front Neurol 2018;9:505.
37. Chang JL, Goldberg AN, Alt JA, et al. International consensus statement on obstructive sleep apnea. Int Forum Allergy Rhinol 2022. Published September 2022. Available at: https://scholarlycommons.henryford.com/otolaryngology_articles/232/
38. Romero E, Krakow B, Haynes P, Ulibarri V. Nocturia and snoring: Predictive symptoms for obstructive sleep apnea. Sleep Breath 2010;14(4):337-43.
39. Oksenberg A, Froom P, Melamed S. Dry mouth upon awakening in obstructive sleep apnea. J Sleep Res 2006;15(3):317-20.
40. Suzuki K, Miyamoto M, Miyamoto T, et al. Sleep apnoea headache in obstructive sleep apnoea syndrome patients presenting with morning headache: Comparison of the ICHD-2 and ICHD-3 beta criteria. J Headache Pain 2015;16:56.
41. Wilhelm CP, deShazo RD, Tamanna S, Ullah MI, Skipworth LB. The nose, upper airway, and obstructive sleep apnea. Ann Allergy Asthma Immunol 2015;115(2):96-102.
42. Herer B, Roche N, Carton M, et al. Value of clinical, functional, and oximetric data for the prediction of obstructive sleep apnea in obese patients. Chest 1999;116(6):1537-44.
43. Foster SN, Hansen SL, Scalzitti NJ, et al. Residual excessive daytime sleepiness in patients with obstructive sleep apnea treated with positive airway pressure therapy. Sleep Breath 2019.
44. Sforza E, Pichot V, Martin MS, Barthelemy JC, Roche F. Prevalence and determinants of subjective sleepiness in healthy elderly with unrecognized obstructive sleep apnea. Sleep Med 2015;16(8):981-6.
45. Simou E, Britton J, Leonardi-Bee J. Alcohol and the risk of sleep apnoea: A systematic review and meta-analysis. Sleep Med 2018;42:38-46.
46. Kolla BP, Foroughi M, Saeidifard F, et al. The impact of alcohol on breathing parameters during sleep: A systematic review and meta-analysis. Sleep Med Rev 2018;42:59-67.
47. Jehan S, Zizi F, Pandi-Perumal SR, et al. Obstructive sleep apnea and obesity: Implications for public health. Sleep Med Disord 2017;1(4).
48. Jehan S, Myers AK, Zizi F, et al. Obesity, obstructive sleep apnea and type 2 diabetes mellitus: Epidemiology and pathophysiologic insights. Sleep Med Disord 2018;2(3):52-58.
49. Ahlin S, Manco M, Panunzi S, et al. A new sensitive and accurate model to predict moderate to severe obstructive sleep apnea in patients with obesity. Medicine (Baltimore) 2019;98(32):e16687.
50. Chung ST, Onuzuruike AU, Magge SN. Cardiometabolic risk in obese children. Ann N Y Acad Sci 2018;1411(1):166-83.
51. Bonsignore MR, McNicholas WT, Montserrat JM, Eckel J. Adipose tissue in obesity and obstructive sleep apnoea. European Respiratory Journal 2012;39(3):746-67.
52. Ngo R, Pullano E, Peacock ZS, Lahey ET, August M. Does the medical comorbidity profile of obstructive sleep apnea patients treated with maxillomandibular advancement differ from that of obstructive sleep apnea patients managed nonsurgically? J Oral Maxillofac Surg 2018;76(9):1999.e1-99.e8.
53. Cielo CM, Taylor JA, Vossough A, et al. Evolution of obstructive sleep apnea in infants with cleft palate and micrognathia. J Clin Sleep Med 2016;12(7):979-87.
54. Al-Jewair TS, Nazir MA, Al-Masoud NN, Alqahtani ND. Prevalence and risks of habitual snoring and obstructive sleep apnea symptoms in adult dental patients. Saudi Med J 2016;37(2):183-90.
55. Lavigne GJ, Herrero Babiloni A, Beetz G, et al. Critical issues in dental and medical management of obstructive sleep apnea. Journal of Dental Research 2020;99(1):26-35.
56. Lin CM, Davidson TM, Ancoli-Israel S. Gender differences in obstructive sleep apnea and treatment implications. Sleep Med Rev 2008;12(6):481-96.
57. Kim J-Y, Ko I, Kim D-K. Association of obstructive sleep apnea with the risk of affective disorders. JAMA Otolaryngology–Head & Neck Surgery 2019 Nov 1;145(11):1020-1026.
58. Cho JH, Choi JH, Suh JD, Ryu S, Cho SH. Comparison of anthropometric data between Asian and Caucasian patients with obstructive sleep apnea: A meta-analysis. Clin Exp Otorhinolaryngol 2016;9(1):1-7.
59. Schwab RJ, Pasirstein M, Pierson R, et al. Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med 2003;168(5):522-30.
60. McMillan A, Morrell MJ. Sleep disordered breathing at the extremes of age: The elderly. Breathe (Sheff) 2016;12(1):50-60.
61. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130(3):576-84.
62. Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: Outcome evaluated by pre- and postoperative polysomnography. Laryngoscope 2007;117(10):1844-54.
63. Liistro G, Rombaux P, Belge C, et al. High Mallampati score and nasal obstruction are associated risk factors for obstructive sleep apnoea. Eur Respir J 2003;21(2):248-52.
64. Mathur R, Douglas NJ. Family studies in patients with the sleep apnea-hypopnea syndrome. Ann Intern Med 1995;122(3):174-8.
65. Chen H, Yagi K, Almeida FR, Pliska BT, Lowe AA. A pilot study on the dentoalveolar and skeletal effects of two functional appliances in Class II, Division 1 growing children. Int J Orthod Milwaukee 2015;26(2):15-20.
66. Johnson DA, Guo N, Rueschman M, et al. Prevalence and correlates of obstructive sleep apnea among African Americans: The Jackson heart sleep study. Sleep 2018;41(10).
67. Yamauchi M, Nakano H, Maekawa J, et al. Oxidative stress in obstructive sleep apnea. Chest 2005;127(5):1674-9.
68. Cekerevac I, Petrovic M, Lazic Z, Novkovic L, Cupurdija V. Severity of obstructive sleep apnea and oxidative stress. European Respiratory Journal 2015;46(suppl 59):PA2324.
69. Naegele B, Thouvard V, Pepin JL, et al. Deficits of cognitive executive functions in patients with sleep apnea syndrome. Sleep 1995;18(1):43-52.
70. Ayalon L, Ancoli-Israel S, Drummond SP. Obstructive sleep apnea and age: A double insult to brain function? Am J Respir Crit Care Med 2010;182(3):413-9.
71. Yaranov DM, Smyrlis A, Usatii N, et al. Effect of obstructive sleep apnea on frequency of stroke in patients with atrial fibrillation. Am J Cardiol 2015;115(4):461-5.
72. Yaggi HK, Concato J, Kernan WN, et al. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005;353(19):2034-41.
73. Dong JY, Zhang YH, Qin LQ. Obstructive sleep apnea and cardiovascular risk: Meta-analysis of prospective cohort studies. Atherosclerosis 2013;229(2):489-95.
74. Bassetti CLA, Randerath W, Vignatelli L, et al. EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur Respir J 2020;55(4).
75. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study. Lancet 2005;365(9464):1046-53.
76. Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: Eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008;31(8):1071-8.
77. Nakashima H, Kurobe M, Minami K, et al. Effects of moderate-to-severe obstructive sleep apnea on the clinical manifestations of plaque vulnerability and the progression of coronary atherosclerosis in patients with acute coronary syndrome. Eur Heart J Acute Cardiovasc Care 2015;4(1):75-84.
78. Abumuamar AM, Dorian P, Newman D, Shapiro CM. The prevalence of obstructive sleep apnea in patients with atrial fibrillation. Clin Cardiol 2018;41(5):601-07.
79. St-Onge MP, Grandner MA, Brown D, et al. Sleep duration and quality: Impact on lifestyle behaviors and cardiometabolic health: A scientific statement from the American Heart Association. Circulation 2016;134(18):e367-e86.
80. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342(19):1378-84.
81. Mansukhani MP, Kolla BP, Somers VK. Hypertension and cognitive decline: Implications of obstructive sleep apnea. Front Cardiovasc Med 2019;6:96.
82. Baril AA, Carrier J, Lafreniere A, et al. Biomarkers of dementia in obstructive sleep apnea. Sleep Med Rev 2018;42:139-48.
83. Gozal D, Kheirandish-Gozal L. Sleep apnea in children--treatment considerations. Paediatr Respir Rev 2006;7 Suppl 1:S58-61.
84. Reichmuth KJ, Austin D, Skatrud JB, Young T. Association of sleep apnea and type ii diabetes: A population-based study. Am J Respir Crit Care Med 2005;172(12):1590-5.
85. Mubashir T, Abrahamyan L, Niazi A, et al. The prevalence of obstructive sleep apnea in mild cognitive impairment: A systematic review. BMC Neurol 2019;19(1):195.
86. Yaffe K, Laffan AM, Harrison SL, et al. Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. JAMA 2011;306(6):613-9.
87. Peppard PE, Szklo-Coxe M, Hla KM, Young T. Longitudinal association of sleep-related breathing disorder and depression. Arch Intern Med 2006;166(16):1709-15.
88. Sateia MJ. Update on sleep and psychiatric disorders. Chest 2009;135(5):1370-79.
89. Cho JW, Duffy JF. Sleep, sleep disorders, and sexual dysfunction. World J Mens Health 2019;37(3):261-75.
90. Stavaras C, Pastaka C, Papala M, et al. Sexual function in pre- and post-menopausal women with obstructive sleep apnea syndrome. Int J Impot Res 2012;24(6):228-33.
91. Vgontzas AN, Bixler EO, Chrousos GP. Obesity-related sleepiness and fatigue: The role of the stress system and cytokines. Ann N Y Acad Sci 2006;1083:329-44.
92. Smolensky MH, Di Milia L, Ohayon MM, Philip P. Sleep disorders, medical conditions, and road accident risk. Accid Anal Prev 2011;43(2):533-48.
93. Stoohs RA, Guilleminault C, Itoi A, Dement WC. Traffic accidents in commercial long-haul truck drivers: The influence of sleep-disordered breathing and obesity. Sleep 1994;17(7):619-23.
94. Findley LJ, Levinson MP, Bonnie RJ. Driving performance and automobile accidents in patients with sleep apnea. Clin Chest Med 1992;13(3):427-35.
95. Posnick JC, Adachie A, Singh N, Choi E. "Silent" sleep apnea in dentofacial deformities and prevalence of daytime sleepiness after orthognathic and intranasal surgery. J Oral Maxillofac Surg 2018;76(4):833-43.
96. Stoberl AS, Schwarz EI, Haile SR, et al. Night-to-night variability of obstructive sleep apnea. J Sleep Res 2017;26(6):782-88.
97. Ibanez V, Silva J, Cauli O. A survey on sleep assessment methods. PeerJ 2018;6:e4849.
98. Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable monitoring task force of the American Academy of Sleep Medicine. J Clin Sleep Med 2007;3(7):737-47.
99. Chiu HY, Chen PY, Chuang LP, et al. Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, STOP, and Epworth sleepiness scale in detecting obstructive sleep apnea: A bivariate meta-analysis. Sleep Med Rev 2017;36:57-70.
100. Chung F, Liao P, Elsaid H, et al. Oxygen desaturation index from nocturnal oximetry: A sensitive and specific tool to detect sleep-disordered breathing in surgical patients. Anesth Analg 2012;114(5):993-1000.
101. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med 1999;131(7):485-91.
102.  
103. Johns MW. A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep 1991;14(6):540-5.
104. van der Spuy I, Zhao G, Karunanayake C, Pahwa P. Predictors of sleep apnea in the Canadian population. Can Respir J 2018;2018:6349790.
105. Kolla BP, Hayes L, Cox C, et al. The effects of cannabinoids on sleep. Journal of Primary Care & Community Health 2022;13:21501319221081277.
106. Ravesloot MJL, White D, Heinzer R, Oksenberg A, Pepin JL. Efficacy of the new generation of devices for positional therapy for patients with positional obstructive sleep apnea: A systematic review of the literature and meta-analysis. J Clin Sleep Med 2017;13(6):813-24.
107. Joosten SA, O'Driscoll DM, Berger PJ, Hamilton GS. Supine position related obstructive sleep apnea in adults: Pathogenesis and treatment. Sleep Med Rev 2014;18(1):7-17.
108. Srijithesh PR, Aghoram R, Goel A, Dhanya J. Positional therapy for obstructive sleep apnoea. Cochrane Database Syst Rev 2019;5:Cd010990.
109. Souza F, Genta PR, de Souza Filho AJ, Wellman A, Lorenzi-Filho G. The influence of head-of-bed elevation in patients with obstructive sleep apnea. Sleep Breath 2017;21(4):815-20.
110. Spicuzza L, Caruso D, Di Maria G. Obstructive sleep apnoea syndrome and its management. Ther Adv Chronic Dis 2015;6(5):273-85.
111. Patil SP, Ayappa IA, Caples SM, et al. Treatment of adult obstructive sleep apnea with positive airway pressure: An American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2019;15(2):301-34.
112. Balk EM, Moorthy D, Obadan NO, et al. AHRQ comparative effectiveness reviews. Diagnosis and treatment of obstructive sleep apnea in adults. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011.
113. Sunwoo BY, Light M, Malhotra A. Strategies to augment adherence in the management of sleep-disordered breathing. Respirology 2020 Apr;25(4):363-371.
114. Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: A flattened curve. J Otolaryngol Head Neck Surg 2016;45(1):43.
115. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: The challenge to effective treatment. Proc Am Thorac Soc 2008;5(2):173-8.
116. Weaver TE, Sawyer AM. Adherence to continuous positive airway pressure treatment for obstructive sleep apnoea: Implications for future interventions. Indian J Med Res 2010;131:245-58.
117. Murase K, Tanizawa K, Minami T, et al. A randomized controlled trial of telemedicine for long-term sleep apnea CPAP management. Ann Am Thorac Soc 2019.
118. Hwang D, Chang JW, Benjafield AV, et al. Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The tele-OSA randomized trial. Am J Respir Crit Care Med 2018;197(1):117-26.
119. Scherr S, Dort L, Almeida F, et al. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: A report of the American Academy of Dental Sleep Medicine. J Dent Sleep Med 2014;1(1):39-50.
120. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: An update for 2015. J Clin Sleep Med 2015;11(7):773-827.
121. Sutherland K, Kairaitis K, Yee BJ, Cistulli PA. From CPAP to tailored therapy for obstructive sleep apnoea. Multidisciplinary Respiratory Medicine 2018;13(1):44.
122. Skalna M, Novak V, Buzga M, et al. Oral appliance effectiveness and patient satisfaction with obstructive sleep apnea treatment in adults. Med Sci Monit 2019;25:516-24.
123. Fransson A. A mandibular protruding device in obstructive sleep apnea and snoring. Swed Dent J Suppl 2003(163):1-49.
124. Venema JAU, Rosenmöller BR, De Vries N, et al. Mandibular advancement device design: A systematic review on outcomes in obstructive sleep apnea treatment. Sleep Medicine Reviews 2021;60:101557.
125. Chan AS, Lee RW, Cistulli PA. Dental appliance treatment for obstructive sleep apnea. Chest 2007;132(2):693-9.
126. Schell TG. Avoiding and managing oral appliance therapy side effects. Sleep Med Clin 2018;13(4):503-12.
127. Pliska BT, Nam H, Chen H, Lowe AA, Almeida FR. Obstructive sleep apnea and mandibular advancement splints: Occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med 2014;10(12):1285-91.
128. Nishigawa K, Hayama R, Matsuka Y. Complications causing patients to discontinue using oral appliances for treatment of obstructive sleep apnea. J Prosthodont Res 2017;61(2):133-38.
129. Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep 2010;33(10):1408-13.
130. Wray CM, Thaler ER. Hypoglossal nerve stimulation for obstructive sleep apnea: A review of the literature. World Journal of Otorhinolaryngology - Head and Neck Surgery 2016;2(4):230-33.
131. Strohl MM, Yamauchi M, Peng Z, Strohl KP. Insights since FDA approval of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea. Curr Sleep Med Rep 2017;3(3):133-41.
132. Levine M BK, Cantwell M, Postol K, Schwartz D. Dental sleep medicine standards for screening, treating and managing adult patients with sleep-related breathing disorders. Journal of Dental Sleep Medicine 2018;5(3):61-69.
133. Ruangsri S, Jorns TP, Puasiri S, et al. Which oropharyngeal factors are significant risk factors for obstructive sleep apnea? An age-matched study and dentist perspectives. Nat Sci Sleep 2016;8:215-9.
134. Miyao E, Noda A, Miyao M, Yasuma F, Inafuku S. The role of malocclusion in non-obese patients with obstructive sleep apnea syndrome. Intern Med 2008;47(18):1573-8.
135. Veasey SC, Rosen IM. Obstructive sleep apnea in adults. New England Journal of Medicine 2019;380(15):1442-49.
136. Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet 2014;383(9918):736-47

Professional Resources

• Evidence Brief: Oral Appliances for Sleep-Related Breathing Disorders (July 2016)
• ADA Store: Do You Have Sleep Apnea? Talk with Your Dentist About Snoring (Product Code W168)
• ADA Library: Members-only journal database (ADA Member login required)
• JADA Archives: Sleep Apnea
  

Patient Resources

• MouthHealthy.org: Sleep Apnea and Snoring

• American Academy of Sleep Medicine: Sleep Apnea: Overview & Facts
• American Sleep Apnea Association: Sleep Apnea Information
• National Sleep Foundation: Sleep Apnea
• American Thoracic Society: Oral Appliances for Sleep Apnea in Adults
• American Academy of Dental Sleep Medicine: Oral Appliance Therapy
• National Heart, Lung and Blood Institute: Sleep Apnea