Cigarette smoking and other behaviors

Because cigarette smoking is an independent risk factor for snoring and may be associated with OSA, smoking cessation is an essential part of OSA therapy.19 Smoking is known to increase inflammation and fluid retention in the upper airway, which can further aggravate OSA. 

Persons with OSA also should be advised to avoid alcohol, sleeping pills, and other sedatives, as these substances can relax throat muscles and contribute to airway collapse during sleep. 

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Oral appliances

Some patients may be candidates for customized nighttime oral or dental appliances to reduce snoring and apnea. These devices can enlarge the upper airway and/or decrease airway collapsibility, thus improving OSA.20 Mandibular advancement devices (MADs) move the lower jaw forward slightly, which tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep (Figure 1). 

Figure 1. Mandibular advancement device moves lower jaw forward.

Evidence has shown CPAP to reduce AHI and arousal index (number of arousals per hour during sleep) scores and increase oxygen saturation to a greater degree than do MADs.21 In 2013 the American College of Physicians (ACP) recommended CPAP as initial therapy for persons with a diagnosis of OSA, but also recommended MADs as an alternate therapy to patients who prefer MADs over CPAP or who experience adverse effects with CPAP.21 In the extensive literature review that formed the basis of the ACP recommendations, the most commonly reported adverse effects with MADs were tooth loosening, dental crown damage, and temporomandibular joint (TMJ) pain. No long-term consequences were reported.

According to practice parameters established by the American Academy of Sleep Medicine, oral appliances for the treatment of snoring or OSA should be fitted and checked regularly by qualified dental personnel.22 (Dental sleep medicine specialists can be located through the American Academy of Dental Sleep Medicine website: Device efficacy should be assessed by means of follow-up polysomnography or an attended cardiorespiratory sleep study.22 Such testing also may be needed if OSA symptoms worsen or recur.

Oral appliance therapy reportedly relieves apnea in 20% to 70% of patients, and reduces AHI to normal in 50% to 60% of patients.23 These devices have been reported to be well-tolerated by most patients, but may cause frequent yet generally minor and temporary side effects, including but not limited to excessive salivation, dry mouth, gum irritation, tooth pain, TMJ pain, myofascial pain, and bite changes.20