# **ORAL APPLIANCE THERAPY FOR**
**SNORING & OBSTRUCTIVE SLEEP APNOEA**
Ramesh Balasubramaniam OAM
DENT5310
Orofacial Pain and Dental Sleep Medicine Module
1st May 2026
Ramesh Balasubramaniam OAM
DENT5310
Orofacial Pain and Dental Sleep Medicine Module
1st May 2026
| **DISCLOSURES** |
| :--- |
| **Ramesh Balasubramaniam OAM** |
| Associate Professor |
| Discipline Lead in Oral Medicine |
| UWA Dental School |
| The University of Western Australia |
Neither **I** nor my immediate family have any **financial** interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation.
#### Professional Affiliations
- **Ramesh Balasubramaniam OAM**
- Associate Professor
- Discipline Lead in Oral Medicine
- UWA Dental School
- The University of Western Australia
#### Conflict of Interest Statement
Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation.
<table>
<tr>
<th>AGENDA</th>
</tr>
<tr>
<td>
ROLE OF DENTISTRY IN SLEEP MEDICINE <br><br>
↓<br><br>
SCREENING FOR SLEEP DISORDERED BREATHING <br><br>
↓<br><br>
ORAL APPLIANCE THERAPY FOR SLEEP DISORDERED BREATHING <br><br>
↓<br><br>
TAKE HOME MESSAGE
</td>
</tr>
</table>
#### Presentation Agenda
1. Role of Dentistry in Sleep Medicine
2. Screening for Sleep Disordered Breathing
3. Oral Appliance Therapy for Sleep Disordered Breathing
4. Take Home Message
![]()
Flowchart diagram outlining an agenda with four sequential steps indicated by downward arrows. The steps are: 'ROLE OF DENTISTRY IN SLEEP MEDICINE', 'SCREENING FOR SLEEP DISORDERED BREATHING', 'ORAL APPLIANCE THERAPY FOR SLEEP DISORDERED BREATHING', and 'TAKE HOME MESSAGE'. Each step is contained within a blue rectangular box.
# AGENDA
```mermaid
graph TD
A[ROLE OF DENTISTRY IN <br> SLEEP MEDICINE] --> B[SCREENING FOR <br> SLEEP DISORDERED BREATHING]
B --> C[ORAL APPLIANCE THERAPY FOR <br> SLEEP DISORDERED BREATHING]
C --> D[TAKE HOME MESSAGE]
```
#### Presentation Flow
- Role of Dentistry in Sleep Medicine
- Screening for Sleep Disordered Breathing
- Oral Appliance Therapy for Sleep Disordered Breathing
- Take Home Message
![]()
Flowchart diagram titled 'AGENDA' showing a sequential process for a dental sleep medicine presentation. It starts with 'ROLE OF DENTISTRY IN SLEEP MEDICINE', followed by 'SCREENING FOR SLEEP DISORDERED BREATHING', then 'ORAL APPLIANCE THERAPY FOR SLEEP DISORDERED BREATHING', and concludes with 'TAKE HOME MESSAGE'. Each step is connected by a gold downward arrow indicating progression through the agenda.
# ROLE OF DENTISTRY IN SLEEP MEDICINE
**• Snoring & Obstructive Sleep Apnoea**
**• Sleep Bruxism**
**• Orofacial Pain and Sleep**
**• Xerostomia**
**• Gastro-eosophageal reflux disease**
## Discipline of Dental Sleep Medicine
**First described in Lavigne et al. (1999):**
‘Sleep disorders and the dental patient: an overview.’<sup>1</sup>
¹ Lavigne GJ et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Sep;88(3):257-72.
#### Core Clinical Areas
Dental sleep medicine encompasses the management and study of several conditions that intersect dental practice and sleep health:
- Snoring and Obstructive Sleep Apnoea
- Sleep Bruxism
- Orofacial Pain and Sleep
- Xerostomia
- Gastro-oesophageal reflux disease
#### Discipline Definition
The discipline was formally described by Lavigne et al. (1999) in the publication "Sleep disorders and the dental patient: an overview."
<div>
ROLE OF DENTISTRY IN SLEEP MEDICINE:
SCOPE OF PRACTICE
International Classification of Sleep Disorders (3rd Ed)
7 Major Categories
60 Diagnoses
Other sleep disorders
Sleep-related breathing disorders
Sleep-related movement disorders
Central disorders of hypersomnia
Insomnia
Parasomnias
Circadian rhythm sleep-wake disorders
* Stay within the scope of practice for dental practitioners
* Engage in education and training in Dental Sleep Medicine
* Communicate and collaborate with medical practitioners
</div>
International Classification of Sleep Disorders, 3rd edn. American Academy of Sleep Medicine, Darien, IL, 2014.
#### International Classification of Sleep Disorders (3rd Ed)
The American Academy of Sleep Medicine identifies 60 diagnoses across 7 major categories:
1. Sleep-related breathing disorders
2. Sleep-related movement disorders
3. Central disorders of hypersomnia
4. Insomnia
5. Parasomnias
6. Circadian rhythm sleep-wake disorders
7. Other sleep disorders
#### Professional Responsibilities and Scope
Dental practitioners operating within this field must adhere to the following professional standards:
- Stay within the defined scope of practice for dental practitioners.
- Engage in ongoing education and training specifically in Dental Sleep Medicine.
- Communicate and collaborate effectively with medical practitioners.
![]()
Labelled diagram illustrating the International Classification of Sleep Disorders (3rd Ed). A large orange cloud shape on the left contains the text 'International Classification of Sleep Disorders (3rd Ed)', '7 Major Categories', and '60 Diagnoses'. This cloud is connected via small red dots to a cluster of overlapping yellow circles. Each circle represents a specific category of sleep disorder with corresponding labels: 'Other sleep disorders', 'Sleep-related breathing disorders', 'Central disorders of hypersomnia', 'Insomnia', 'Parasomnias', 'Sleep-related movement disorders', and 'Circadian rhythm sleep-wake disorders'.
# AGENDA
* **Role of Dentistry in Sleep Medicine**
* **Screening for Sleep Disordered Breathing**
* **Oral Appliance Therapy for Sleep Disordered Breathing**
* **Take Home Message**
#### Presentation Agenda
- Role of Dentistry in Sleep Medicine
- Screening for Sleep Disordered Breathing
- Oral Appliance Therapy for Sleep Disordered Breathing
- Take Home Message
![]()
A flowchart diagram illustrating the presentation agenda. It features a sequence of four rectangular blocks arranged in a descending step-like pattern, connected by gold-colored arrows pointing downwards to indicate progression. The top block is titled 'AGENDA' on a gold background. The subsequent steps are: 'ROLE OF DENTISTRY IN SLEEP MEDICINE', 'SCREENING FOR SLEEP DISORDERED BREATHING', 'ORAL APPLIANCE THERAPY FOR SLEEP DISORDERED BREATHING', and finally 'TAKE HOME MESSAGE'. This visual structure organizes the lecture topics logically.
SCREENING FOR SLEEP DISORDERED BREATHING
**THE DENTAL PERSPECTIVE!!!**
THE DENTAL PERSPECTIVE!!!
![]()
Clinical photo showing an intraoral view of the oropharynx. The image is framed by the tongue in the foreground and teeth at the top left and bottom right corners. The soft palate and uvula are visible in the upper central region. The context 'SCREENING FOR SLEEP DISORDERED BREATHING' and 'THE DENTAL PERSPECTIVE!!!' suggests this visual demonstrates anatomical features relevant to airway obstruction assessment.
| | | |
| :--- | :--- | :--- |
| SCREENING FOR SLEEP DISORDERED BREATHING | | |
| MEDICAL HISTORY | Examination | Validated Questionnaire |
| Snoring | Crowded airway | Epworth Sleepiness Scale |
| Witnessed Apnoea | • Retrognathia | STOP-Bang Questionnaire |
| Tiredness | • Neck circumference | OSA-50 |
| Comorbidities | • Large tongue | Berlin Questionnaire |
| • Hypertension | • Long soft palate | |
| • Diabetes | • Elongated / Oedematous uvula | |
| • Depression | • Enlarged tonsils | |
| • Obesity | | |
#### Medical History
- Snoring
- Witnessed Apnoea
- Tiredness
- Comorbidities
- Hypertension
- Diabetes
- Depression
- Obesity
#### Clinical Examination
- Crowded airway
- Retrognathia
- Neck circumference
- Large tongue
- Long soft palate
- Elongated / Oedematous uvula
- Enlarged tonsils
#### Validated Questionnaires
- Epworth Sleepiness Scale
- STOP-Bang Questionnaire
- OSA-50
- Berlin Questionnaire
![]()
A multi-panel flowchart diagram titled 'SCREENING FOR SLEEP DISORDERED BREATHING' featuring three main vertical columns represented by green arrow shapes. The left column is labeled 'MEDICAL HISTORY' and lists symptoms (Snoring, Witnessed Apnoea, Tiredness) and Comorbidities (Hypertension, Diabetes, Depression, Obesity). The center column is labeled 'Examination' and details physical findings under the subheading 'Crowded airway', including Retrognathia, Neck circumference, Large tongue, Long soft palate, Elongated / Oedematous uvula, and Enlarged tonsils. The right column is labeled 'Validated Questionnaire' and lists specific scales: Epworth Sleepiness Scale, STOP-Bang Questionnaire, OSA-50, and Berlin Questionnaire.
The title text in the header banner is white. The text in the content boxes is white.
# **EPWORTH SLEEPINESS SCALE**
How likely are you to nod off or fall asleep in the following situations, in contrast to **feeling just tired?** This refers to your usual way of life in recent time.
Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can.
Use the following table.
<table>
<thead>
<tr>
<th></th>
<th><b>Would never nod off</b><br/><strong>0</strong></th>
<th><b>Slight chance of nodding off</b><br/><strong>1</strong></th>
<th><b>Moderate chance of nodding off</b><br/><strong>2</strong></th>
<th><b>High chance of nodding off</b><br/><strong>3</strong></th>
</tr>
</thead>
<tbody>
<tr>
<td>Sitting and reading</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Watching TV</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Sitting, inactive, in a public place (e.g., in a meeting, theater, or dinner event)</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>As a passenger in a car for an hour or more without stopping for a break</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Lying down to rest when circumstances permit</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Sitting and talking to someone</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Sitting quietly after a meal without alcohol</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>In a car, while stopped for a few minutes in traffic or at a light</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>
**Add up your points to get your total score.**
**A score of 10 or greater raises concern:** you may need to get more sleep, improve your sleep practices, or seek medical attention to determine why you are sleepy.
Johns MW. Sleep 1991 Dec;14(6):540-5.
#### Epworth Sleepiness Scale (ESS)
How likely are you to nod off or fall asleep in the following situations, in contrast to **feeling just tired?** This refers to your usual way of life in recent time.
Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can.
**Scoring Scale:**
- 0 = Would never nod off
- 1 = Slight chance of nodding off
- 2 = Moderate chance of nodding off
- 3 = High chance of nodding off
**Situations:**
1. Sitting and reading
2. Watching TV
3. Sitting, inactive, in a public place (e.g., in a meeting, theater, or dinner event)
4. As a passenger in a car for an hour or more without stopping for a break
5. Lying down to rest when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after a meal without alcohol
8. In a car, while stopped for a few minutes in traffic or at a light
**Results Interpretation:**
Add up your points to get your total score.
**A score of 10 or greater raises concern:** you may need to get more sleep, improve your sleep practices, or seek medical attention to determine why you are sleepy.
![]()
A structured table titled 'EPWORTH SLEEPINESS SCALE'. The table has a header row with columns for ratings: 'Would never nod off (0)', 'Slight chance of nodding off (1)', 'Moderate chance of nodding off (2)', and 'High chance of nodning off (3)'. Below the header are rows listing various situations such as 'Sitting and reading', 'Watching TV', 'As a passenger in a car...', etc. Each cell under the rating columns is empty, indicating it is a form to be filled out.
<table>
<tr>
<td>
<h1>
<b>
STOP-BANG QUESTIONNAIRE
</b>
</h1>
<p>
</p>
<p>
0x0.
</p>
<div>
<h3>
Snoring?
</h3>
<p>
Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
</p>
<p>
0x0.
</p>
</div>
<div>
<h3>
Tired?
</h3>
<p>
Do you often feel Tired, Fatigues, or Sleepy during the daytime (such as falling asleep during driving)?
</p>
<p>
0x0.
</p>
</div>
<div>
<h3>
Observed?
</h3>
<p>
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
</p>
<p>
0x0.
</p>
</div>
<div>
<h3>
Pressure?
</h3>
<p>
Do you have or are being treated for High Blood Pressure?
</p>
<p>
0x0.
</p>
</div>
<div>
<h3>
Body Mass Index more than 35kg/m2?
</h3>
<p>
0x0.
</p>
</div>
<div>
<h3>
Age older than 50 years old?
</h3>
<p>
0x0.
</p>
</div>
<div>
<h3>
Neck size large? (Measured around Adams apple) For male, is your shirt collar 17 inches/43 cm or larger?
</h3>
<p>
0x0.
</p>
</div>
<div>
<h3>
Gender = Male?
</h3>
<p>
0x0.
</p>
</div>
<div>
<h3>
For general population:
<br/>
Low risk of obstructive sleep apneoa (OSA): Yes to 0-2 questions
<br/>
Intermediate risk of OSA: Yes to 3-4 questions
<br/>
High risk of OSA: Yes to 5-8 questions
<br/>
Or: Yes to 2 or more STOP questions + male gender
<br/>
Or: Yes to 2 or more of 5 STOP questions + BMI &gt; 35 kg/m2
<br/>
Or: Yes to 2 or more of 4 STOP questions + neck circumference (17″/43cm in male, 16″/41cm in female)
</h3>
<p>
0x0.
</p>
</div>
<p>
Modified from Chung F et al. Anaesthesiology 2008; 108:812-21.
<br/>
Chung F et al. Br J Anaesth 2012; 108:768-75.
</p>
</td>
</tr>
</table>
#### STOP-BANG Questionnaire
1. **Snoring?** Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
2. **Tired?** Do you often feel Tired, Fatigues, or Sleepy during the daytime (such as falling asleep during driving)?
3. **Observed?** Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
4. **Pressure?** Do you have or are being treated for High Blood Pressure?
5. **Body Mass Index** more than 35kg/m2?
6. **Age** older than 50 years old?
7. **Neck size large?** (Measured around Adams apple) For male, is your shirt collar 17 inches/43 cm or larger?
8. **Gender** = Male?
#### Risk Assessment Scoring
**For general population:**
- **Low risk of obstructive sleep apneoa (OSA):** Yes to 0-2 questions
- **Intermediate risk of OSA:** Yes to 3-4 questions
- **High risk of OSA:** Yes to 5-8 questions
**High Risk Criteria Alternatives:**
- Yes to 2 or more STOP questions + male gender
- Yes to 2 or more of 5 STOP questions + BMI > 35 kg/m2
- Yes to 2 or more of 4 STOP questions + neck circumference (17″/43cm in male, 16″/41cm in female)
![]()
A structured table presenting the STOP-BANG Questionnaire. The table is organized into rows corresponding to the questionnaire items: Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, and Gender. Each row contains a bolded question label followed by a descriptive text explaining the criteria for that specific risk factor (e.g., 'Do you Snore Loudly...', 'Body Mass Index more than 35kg/m2?'). Below the questions, a distinct section labeled 'For general population:' outlines the scoring interpretation for risk levels (Low, Intermediate, High) based on the number of 'Yes' answers.
<table>
<colgroup>
<col width="133" />
<col width="160" />
<col width="273" />
<col width="206" />
<col width="352" />
</colgroup>
<thead>
<tr><td style="text-align:right; vertical-align:top"><strong>Device</strong></td><td style="text-align:right; vertical-align:top"><strong>Sleep vs Wake Sensitivity</strong></td><td style="text-align:right; vertical-align:top"><strong>Stage Classification Sensitivity*</strong></td><td style="text-align:right; vertical-align:top"><strong>Precision / Bias Notes</strong></td><td style="text-align:right; vertical-align:top"><strong>Comments & Limitations</strong></td></tr></thead>
<tbody>
<tr><td style="text-align:right; vertical-align:top"><strong>Oura Ring Gen 3</strong></td><td style="text-align:right; vertical-align:top">≥95% for sleep detection</td><td style="text-align:right; vertical-align:top">76.0-79.5% sensitivity across stages (light/deep/REM)</td><td style="text-align:right; vertical-align:top">Very close to PSG estimates — no significant overestimation / underestimation of wake, light, deep, or REM</td><td style="text-align:right; vertical-align:top">Best performers in head-to-head comparisons. But tested in healthy adults, single night.</td></tr>
<tr><td style="text-align:right; vertical-align:top"><strong>Fitbit Sense 2</strong></td><td style="text-align:right; vertical-align:top">≥95% for sleep detection</td><td style="text-align:right; vertical-align:top">61.7-78% sensitivity across stages</td><td style="text-align:right; vertical-align:top">Overestimate light sleep by ≈18mins.<br/>Underestimate deep sleep by ≈15 mins.</td><td style="text-align:right; vertical-align:top">Good for overall sleep vs wake.<br/>Stage estimates show systematic bias.</td></tr>
<tr><td style="text-align:right; vertical-align:top"><strong>Apple Watch Series 8</strong></td><td style="text-align:right; vertical-align:top">≥95% for sleep detection</td><td style="text-align:right; vertical-align:top">50.5-86.1% sensitivity (wider spread)</td><td style="text-align:right; vertical-align:top">Underestimate wake by ~7mins.<br/>Underestimate deep sleep by ~43mins.<br/>Overestimate light sleep by ~45mins.</td><td style="text-align:right; vertical-align:top">More variability and bias in stage estimates.<br/>Reasonably good at distinguishing sleep vs wake.</td></tr>
</tbody>
</table>
Robbins R et al. Sensors (Basel). 2024 Oct 10;24(20):6532.
#### Wearable Device Performance Comparison
| Device | Sleep vs Wake Sensitivity | Stage Classification Sensitivity* | Precision / Bias Notes | Comments & Limitations |
| :--- | :--- | :--- | :--- | :--- |
| **Oura Ring Gen 3** | ≥95% for sleep detection | 76.0-79.5% sensitivity across stages (light/deep/REM) | Very close to PSG estimates — no significant overestimation / underestimation of wake, light, deep, or REM | Best performers in head-to-head comparisons. But tested in healthy adults, single night. |
| **Fitbit Sense 2** | ≥95% for sleep detection | 61.7-78% sensitivity across stages | Overestimate light sleep by ≈18mins. Underestimate deep sleep by ≈15 mins. | Good for overall sleep vs wake. Stage estimates show systematic bias. |
| **Apple Watch Series 8** | ≥95% for sleep detection | 50.5-86.1% sensitivity (wider spread) | Underestimate wake by ~7mins. Underestimate deep sleep by ~43mins. Overestimate light sleep by ~45mins. | More variability and bias in stage estimates. Reasonably good at distinguishing sleep vs wake. |
![]()
A table titled 'WEARABLE DEVICES FOR SLEEP TRACKING' comparing three devices: Oura Ring Gen 3, Fitbit Sense 2, and Apple Watch Series 8. Columns include Device, Sleep vs Wake Sensitivity, Stage Classification Sensitivity*, Precision / Bias Notes, and Comments & Limitations. Each row contains specific performance metrics for the respective device.
**AGENDA**
| ROLE OF DENTISTRY IN SLEEP MEDICINE --> SCREENING FOR SLEEP DISORDERED BREATHING --> ORAL APPLIANCE THERAPY FOR SLEEP DISORDERED BREATHING --> TAKE HOME MESSAGE |
#### Clinical Workflow and Objectives
- Role of Dentistry in Sleep Medicine
- Screening for Sleep Disordered Breathing
- Oral Appliance Therapy for Sleep Disordered Breathing
- Take Home Message
![]()
Flowchart diagram titled 'AGENDA' showing a vertical sequence of four steps in sleep medicine. The flow starts with 'ROLE OF DENTISTRY IN SLEEP MEDICINE', followed by 'SCREENING FOR SLEEP DISORDERED BREATHING', then 'ORAL APPLIANCE THERAPY FOR SLEEP DISORDERED BREATHING', and ends with 'TAKE HOME MESSAGE'. Each step is connected by downward-pointing arrows indicating progression.
### **DEFINITIONS**
**Snoring**
* Sound generated by vibration of the oropharyngeal tissues during sleep that typically occurs with inspiration.
**Hypopnoea**
* Reduction of airflow (30-50%) and/or effort with associated reduction in SaO₂ (3-4%) and/or arousal from sleep.
**Apnoea**
* Cessation of airflow for ≥10 seconds.
**Obstructive Sleep Apnoea**
* Repetitive episodes of complete or partial airway obstruction during sleep resulting in the cessation of airflow despite continuing respiratory efforts.
#### Clinical Definitions
- **Snoring**: Sound generated by vibration of the oropharyngeal tissues during sleep that typically occurs with inspiration.
- **Hypopnoea**: Reduction of airflow (30-50%) and/or effort with associated reduction in SaO₂ (3-4%) and/or arousal from sleep.
- **Apnoea**: Cessation of airflow for ≥10 seconds.
- **Obstructive Sleep Apnoea**: Repetitive episodes of complete or partial airway obstruction during sleep resulting in the cessation of airflow despite continuing respiratory efforts.
Imagine a baby sleeping peacefully, dreaming of the future.
The voice of a sleeping child is like a lullaby, soft and gentle.
```html
<table border="1" cellspacing="0">
<tr> <td> <b>Painful Acoustic Trauma</b> <b>140</b> <b>Shotgun blast</b> </td> </tr>
<tr> <td rowspan="4"> <b>Extremely Loud</b> </td> <td> <b>130</b> </td> <td> <i>Jet engine 100 feet away</i> </td> </tr>
<tr> <td> <b>120</b> </td> <td> <i>Rock concert</i> </td> </tr>
<tr> <td> <b>110</b> </td> <td> <i>Car horn, snowblower</i> </td> </tr>
<tr> <td> <b>100</b> </td> <td> <i>Blow dryer, subway, helicopter, chainsaw</i> </td> </tr>
<tr> <td rowspan="3"> <b>Very Loud</b> </td> <td> <b>90</b> </td> <td> <i>Motorcycle, lawn mower, convertible ride on highway</i> </td> </tr>
<tr> <td rowspan="3"> <b>Loud</b> </td> <td> <b>80</b> </td> <td> <i>Factory, noisy restaurant, vacuum, screaming child</i> </td> </tr>
<tr> <td> <b>70</b> </td> <td> <i>Car, alarm clock, city traffic</i> </td> </tr>
<tr> <td rowspan="3"> <b>Moderate</b> </td> <td> <b>60</b> </td> <td> <i>Conversation, dishwasher</i> </td> </tr>
<tr> <th rowspan="2"> <b>Faint</b> </th> <th> <b>50</b> </th> <th> <i>Moderate rainfall</i> </th> </tr>
<tr> <td> <b>40</b> </td> <td> <i>Refrigerator</i> </td> </tr>
<tr> <td rowspan="2"> <b></b> </td> <th> <b>30</b> </th> <th> <i>Whisper, library</i> </th> </tr>
<tr> <td> <b>20</b> </td> <td> <i>Watch ticking</i> </td> </tr>
</table>
```
Imagine a baby sleeping peacefully, dreaming of the future. The voice of a sleeping child is like a lullaby, soft and gentle.
#### Comparative Sound Levels (Decibels)
- **Painful Acoustic Trauma (140 dB)**: Shotgun blast
- **Extremely Loud**:
- 130 dB: Jet engine 100 feet away
- 120 dB: Rock concert
- 110 dB: Car horn, snowblower
- 100 dB: Blow dryer, subway, helicopter, chainsaw
- **Very Loud**:
- 90 dB: Motorcycle, lawn mower, convertible ride on highway
- **Loud**:
- 80 dB: Factory, noisy restaurant, vacuum, screaming child
- 70 dB: Car, alarm clock, city traffic
- **Moderate**:
- 60 dB: Conversation, dishwasher
- **Faint**:
- 50 dB: Moderate rainfall
- 40 dB: Refrigerator
- 30 dB: Whisper, library
- 20 dB: Watch ticking
![]()
A labeled table showing decibel levels (dB) categorized by sound intensity: Painful Acoustic Trauma (140 dB), Extremely Loud (130-100 dB), Very Loud (90-70 dB), Moderate (60-40 dB), and Faint (30-20 dB). Each row includes examples such as shotgun blast, jet engine, rock concert, car horn, factory noise, conversation, refrigerator, whisper, and watch ticking.
![]()
A photograph of a koala sleeping peacefully in a tree branch, used to illustrate the concept of snoring or quiet sleep.
![]()
A photograph of a man sleeping with his mouth open, likely snoring, next to a woman who appears disturbed by the noise. This image visually represents the human experience of snoring.
# TYPICAL SIGNS & SYMPTOMS OF OSA
- **Snoring**
- Daytime sleepiness
- Gasping / choking sensation
- Non-restorative sleep
- Poor memory
- Decrease concentration
- Dry mouth
- Morning headaches
- Restless sleep
<img>Woman sleeping on desk with one eye
#### Common Clinical Presentations
- Snoring
- Daytime sleepiness
- Gasping / choking sensation
- Non-restorative sleep
- Poor memory
- Decrease concentration
- Dry mouth
- Morning headaches
- Restless sleep
![]()
Clinical photo showing a woman sleeping on a desk with her head resting on a laptop keyboard while holding a white mug. She is wearing glasses and appears to be snoring or asleep during the day, illustrating the 'Daytime sleepiness' symptom of OSA.
**THE HIDDEN SIGNS OF OSA**
* **Reflux**
* **Low mood & depression**
* **Insomnia**
* **Libido & erectile dysfunction**
* **Nocturia**
* **Personality changes**
* **Relationship and work problems**
* **Nocturnal angina or palpitations**
* **Vivid dreams**
#### Comorbidities and Associated Conditions
- Reflux
- Low mood & depression
- Insomnia
- Libido & erectile dysfunction
- Nocturia
- Personality changes
- Relationship and work problems
- Nocturnal angina or palpitations
- Vivid dreams
![]()
Black and white clinical photo depicting a person in a hunched posture with head down, visually representing the symptoms of 'Low mood & depression' listed in the slide context.
<table>
<thead>
<tr>
<th>Effect</th>
<th>Magnitude Odds ratio (95% CI)</th>
<th>Study</th>
</tr>
</thead>
<tbody>
<tr>
<td><strong>Cardiovascular</strong></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Incident hypertension</td>
<td>2.89 (1.46-5.64)<sup>1</sup></td>
<td><sup>1</sup>Peppard et al. (2000)</td>
</tr>
<tr>
<td>Prevalent coronary artery disease</td>
<td>1.27 (0.99-1.62)<sup>2</sup></td>
<td><sup>2</sup>Shahar et al. (2001)</td>
</tr>
<tr>
<td>Incident stroke</td>
<td>3.08 (0.74-12.81)<sup>3</sup></td>
<td><sup>3</sup>Arzt et al (2005)</td>
</tr>
<tr>
<td>Prevalent congestive heart disease</td>
<td>2.38 (1.22-4.62)<sup>2</sup></td>
<td></td>
</tr>
<tr>
<td><strong>Metabolic</strong></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Prevalent impaired fasting glucose</td>
<td>1.35 (1.04-1.76)<sup>1</sup></td>
<td><sup>1</sup>Stamatakis et al. (2008)</td>
</tr>
<tr>
<td>Prevalent diabetes</td>
<td>2.3 (1.28-4.11)<sup>2</sup></td>
<td><sup>2</sup>Reichmuth et al. (2005)</td>
</tr>
<tr>
<td><strong>Neurocognitive</strong></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Motor vehicle accidents</td>
<td>7.2 (2.4-21.8)<sup>1</sup></td>
<td><sup>1</sup>Teran-Santos et al. (1999)</td>
</tr>
<tr>
<td>Occupational accidents</td>
<td>2.2 (1.3-3.8)<sup>2</sup></td>
<td><sup>2</sup>Lindberg et al. (2001)</td>
</tr>
<tr>
<td>Incident depression</td>
<td>2.6 (1.7-3.9)<sup>3</sup></td>
<td><sup>3</sup>Peppard et al. (2006)</td>
</tr>
<tr>
<td><strong>Mortality</strong></td>
<td></td>
<td></td>
</tr>
<tr>
<td>All cases (Hazard ratio)</td>
<td>3.0 to 4.4<sup>1,2</sup></td>
<td><sup>1</sup>Marshall et al. (2008)</td>
</tr>
<tr>
<td>Cardiovascular</td>
<td>2.87 (1.17-7.51)<sup>3</sup></td>
<td><sup>2</sup>Young et al (2008)<br><sup>3</sup>Marin et al. (2005)</td>
</tr>
</tbody>
</table>
#### Health Risks and Odds Ratios
| Effect | Magnitude Odds ratio (95% CI) | Study |
| :--- | :--- | :--- |
| **Cardiovascular** | | |
| Incident hypertension | 2.89 (1.46-5.64) | Peppard et al. (2000) |
| Prevalent coronary artery disease | 1.27 (0.99-1.62) | Shahar et al. (2001) |
| Incident stroke | 3.08 (0.74-12.81) | Arzt et al (2005) |
| Prevalent congestive heart disease | 2.38 (1.22-4.62) | Shahar et al. (2001) |
| **Metabolic** | | |
| Prevalent impaired fasting glucose | 1.35 (1.04-1.76) | Stamatakis et al. (2008) |
| Prevalent diabetes | 2.3 (1.28-4.11) | Reichmuth et al. (2005) |
| **Neurocognitive** | | |
| Motor vehicle accidents | 7.2 (2.4-21.8) | Teran-Santos et al. (1999) |
| Occupational accidents | 2.2 (1.3-3.8) | Lindberg et al. (2001) |
| Incident depression | 2.6 (1.7-3.9) | Peppard et al. (2006) |
| **Mortality** | | |
| All cases (Hazard ratio) | 3.0 to 4.4 | Marshall et al. (2008); Young et al (2008) |
| Cardiovascular | 2.87 (1.17-7.51) | Marin et al. (2005) |
![]()
A summary table titled with columns 'Effect', 'Magnitude Odds ratio (95% CI)', and 'Study'. The table is organized into four main categories: Cardiovascular, Metabolic, Neurocognitive, and Mortality. It lists specific health outcomes (e.g., Incident hypertension, Prevalent diabetes) alongside their corresponding statistical odds ratios and citations from various studies (e.g., Peppard et al., Shahar et al.). A red handwritten mark resembling an asterisk or scribble is visible in the top left corner.
POLYSOMNOGRAPHY
Physical measurements:
* brain waves- EEG
* eye movements- EOG
* leg and jaw movements- EMG
* heart rate and rhythm- ECG
* air movement through nose/mouth-
thermistor, CO2
* chest/abdomen movement- strain
gauges
* blood SaO2- pulse oximeter
#### Physical Measurements in Polysomnography
- **Brain waves**: EEG
- **Eye movements**: EOG
- **Leg and jaw movements**: EMG
- **Heart rate and rhythm**: ECG
- **Air movement through nose/mouth**: Thermistor, CO2
- **Chest/abdomen movement**: Strain gauges
- **Blood SaO2**: Pulse oximeter
![]()
Labeled diagram of a patient undergoing polysomnography. Illustrates sensor placement including: 'Sensor at nose to measure air flow', 'Sensors on face and scalp measure eye movement and brain activity', 'Elastic belt sensors around chest and belly measure amount of effort to breath', 'Sensor on finger measures amount of oxygen in blood'. Text notes that wires transmit data to a computer monitored by a technician.
![]()
Polysomnogram record chart (over time) displaying four simultaneous physiological waveforms: 'Blood oxygen level' (showing decrease after an event), 'Breathing event' (vertical bars indicating airflow), 'REM sleep stage' (Top levels = wake/REM sleep, Bottom levels = deep sleep). Includes annotations for event height and length.
# AMBULATORY MONITORING
<table>
<thead>
<tr>
<th>Type</th>
<th>Number of Channels</th>
</tr>
</thead>
<tbody>
<tr>
<td>II</td>
<td>Similar to Type I but no video recording</td>
</tr>
<tr>
<td>III</td>
<td>2 - 4 Channels</td>
</tr>
<tr>
<td>IV</td>
<td>1 Channel</td>
</tr>
</tbody>
</table>
#### Ambulatory Monitoring Classifications
| Type | Number of Channels |
| :--- | :--- |
| II | Similar to Type I but no video recording |
| III | 2 - 4 Channels |
| IV | 1 Channel |
![]()
A table titled 'AMBULATORY MONITORING' with two columns: 'Type' and 'Number of Channels'. It lists three types (II, III, IV) and their corresponding channel configurations. Type II is described as 'Similar to Type I but no video recording', Type III has '2 - 4 Channels', and Type IV has '1 Channel'.
**MONITORED VS UNMONITORED PSG**
### Table
| Sleep Study Type | Description |
| :--- | :--- |
| **Level 1** | PSG is considered the reference standard against which other respiratory sleep monitors are evaluated. Recordings are made in a sleep laboratory with **trained sleep laboratory staff in attendance**. 12-13 recording channels are routinely recorded: 2 EEG, 2 EOG, submental EMG, ECG, bilateral leg movements, arterial oxygen saturation, sound, respiratory thoraco-abdominal movements, airflow (nasal pressure and oronasal thermocouples), and body position. |
| **Level 2** | Minimum of seven channels, including EEG, EOG, chin EMG, ECG or heart rate, airflow, respiratory effort, oxygen saturation. This type of monitor allows for sleep staging and therefore calculation of an AHI. It is configured in a fashion that allows studies to be performed in the home. *These are unattended by trained sleep laboratory staff.* |
| **Level 3** | Minimum of four channels monitored, including ventilation or airflow (at least two channels of respiratory movement, or respiratory movement and airflow), heart rate or ECG and oxygen saturation. *These are unattended by trained sleep laboratory staff.* |
| **Level 4** | Monitors of this type measure a single parameter or two parameters – for example oxygen saturation or airflow. *These are unattended by trained sleep laboratory staff.* |
#### Comparison of Sleep Study Levels
- **Level 1**: PSG reference standard. Recorded in a sleep laboratory with trained staff in attendance. Includes 12-13 channels: 2 EEG, 2 EOG, submental EMG, ECG, bilateral leg movements, arterial oxygen saturation, sound, respiratory thoraco-abdominal movements, airflow (nasal pressure and oronasal thermocouples), and body position.
- **Level 2**: Minimum of seven channels (EEG, EOG, chin EMG, ECG/heart rate, airflow, respiratory effort, oxygen saturation). Allows for sleep staging and AHI calculation. Performed unattended in the home.
- **Level 3**: Minimum of four channels (ventilation/airflow, heart rate/ECG, and oxygen saturation). Performed unattended in the home.
- **Level 4**: Measures a single parameter or two parameters (e.g., oxygen saturation or airflow). Performed unattended in the home.
![]()
Table comparing Sleep Study Types (Level 1 through Level 4) with detailed descriptions of PSG channels and monitoring attendance requirements.
![]()
Clinical photo showing a patient lying in bed wearing a sleep study monitor. The setup includes a nasal cannula for airflow measurement, a chest belt to measure respiratory effort, and electrodes on the face and head for EEG/EOG signals.
![]()
Clinical photo showing a patient lying in bed with a portable sleep monitor device attached to their chest. Wires connect the device to various sensors placed on the body, including a nasal cannula for airway monitoring.
![]()
Clinical photo showing a patient lying in bed with a simplified sleep monitoring setup. The patient wears a single chest belt, likely for measuring respiratory effort or movement, demonstrating a less invasive monitoring method compared to the other setups.
<APNOEA-HYPOPNOEA-INDEX>
**AHI** = (Number of Apnoeas + Number of Hypop noeas) / Number Hours of Sleep
**Example:** 25 Apnoeas + 25 Hypopnoeas 5 Hours Sleep
AHI: 50/5 = 10
**DIAGNOSTIC CRITERIA: COPY**
5-15 = Mild
15-30 = Moderate
>30 = Severe
* Respiratory Disturbance Index (RDI): The number of apnoeas, hypopnoeas & RERAs per hour
</APNOEA-HYPOPNOEA-INDEX>
#### Apnoea-Hypopnoea Index (AHI) Calculation
**Formula**: AHI = (Number of Apnoeas + Number of Hypopnoeas) / Number Hours of Sleep
**Example**:
- 25 Apnoeas + 25 Hypopnoeas / 5 Hours Sleep
- AHI: 50 / 5 = 10
#### Diagnostic Severity Criteria
- **Mild**: 5-15
- **Moderate**: 15-30
- **Severe**: >30
**Respiratory Disturbance Index (RDI)**: The number of apnoeas, hypopnoeas & RERAs per hour.
POLYSOMNOGRAM
C3A2
A1A2
EOG
EMG
SpO2
PFlow
Therm
Thor
Abd
Leg(R)
Leg(L)
Snore
Body
Slumber Sound
#### Polysomnogram Channel Identifiers
- C3A2 / A1A2 (EEG)
- EOG
- EMG
- SpO2
- PFlow
- Therm
- Thor
- Abd
- Leg(R) / Leg(L)
- Snore
- Body
- Slumber Sound
![]()
Polysomnogram monitoring chart displaying multiple synchronized physiological waveforms over a time period from approximately 1:30 AM to 5:30 AM. The chart includes labeled channels for C3A2 (EEG), A1A2 (EEG), REOG (EOG), EMG, SpO2 (oxygen saturation with values like 95-99%), PFlow (nasal airflow showing distinct peaks), Therm (temperature), Thor (thoracic movement), Abd (abdominal movement), Leg(R) and Leg(L) (leg movement), Snore, Body position index, and Sound. The bottom axis shows seconds within a 2-minute segment. This visual is essential for diagnosing sleep disorders by analyzing patterns in brain activity, breathing, oxygen levels, and body movements.
![]()
Black-and-white clinical photo from Room1, timestamped 2014-07-11 03:17:20 AM, showing a patient lying in bed during the polysomnography session. The image provides visual context for the physiological data displayed in the adjacent chart, allowing clinicians to correlate physical behavior (e.g., restlessness, positioning) with recorded signals such as snoring or apnea events.
# POLYSOMNOGRAM
POLYSOMNOGRAM
![]()
Polysomnogram chart displaying multiple physiological waveforms and event markers. The chart includes channels for EEG (C3A2, A1A2), EOG (REO0), EMG (EMG 0), SpO2, PFlow, Therm, Thoracic movement (Thor), Abdominal movement (Abd), Leg movements (Leg(R)0, Leg(L)0), Snore audio waveform, Body temperature, and Sound level. Event annotations such as 'RERA', 'Hypopnea', 'Obstructive Apnea', 'Arousal', and 'Relative Desaturation' are highlighted with colored boxes. The x-axis represents time in hours and minutes, while the y-axis shows different physiological signals. The chart is labeled 'POLYSOMNOGRAM' at the top.
# Perth Sleep Clinic
Suite 27, 146 Mounts Bay Road, PERTH 6000
email: admin@perthsleep.com.au
Tel: 94812244 Fax: 94812255
## Diagnostic Polysomnography Report
### Study Information
**Date of Study:** 23/01/2012
**Name:** [REDACTED]
**DOB:** [REDACTED]
**Sex:** M
**Referred by:** Dr MG Prichard
**Usual GP:** [REDACTED]
<table>
<tr>
<td>Height (cm)</td>
<td>182.5</td>
<td>BMI (kg/m2)</td>
<td>24.17</td>
<td>Night B.P.</td>
<td>122/74</td>
</tr>
<tr>
<td>Weight (kg)</td>
<td>80.5</td>
<td>Neck (cm)</td>
<td>n/a</td>
<td>Morn B.P.</td>
<td>117/84</td>
</tr>
</table>
**Indications:** Observed apnoeas, nocturnal epilepsy, palpitations, reflux
### Sleep Data
<table>
<tr>
<td>Time in Bed</td>
<td>482.0 min</td>
<td>REM Latency</td>
<td>77.5</td>
<td>Stage N1 (5%)</td>
<td>1.7 %</td>
</tr>
<tr>
<td>Sleep Time</td>
<td>431.0 min</td>
<td>REM Time</td>
<td>118.5 min</td>
<td>Stage N2 (50%)</td>
<td>58.7 %</td>
</tr>
<tr>
<td>Sleep Efficiency</td>
<td>89.3 %</td>
<td>REM (25%)</td>
<td>27.5 %</td>
<td>Stage N3 (20%)</td>
<td>12.1 %</td>
</tr>
<tr>
<td>Sleep Latency</td>
<td>7.5 min</td>
<td>Wake Time after SO</td>
<td>23.5 min</td>
<td>Wake after SO</td>
<td>5.2 %</td>
</tr>
</table>
### Respiratory Data
<table>
<tr>
<th>Measurement</th>
<th>REM</th>
<th>NREM</th>
<th>Total Sleep</th>
</tr>
<tr>
<td>Apnoea Hypopnoea Index (AHI) (# /hr)</td>
<td>31.9 (44.6)</td>
<td>8.4 (16.7)</td>
<td>14.9 (24.4)</td>
</tr>
<tr>
<td>Supine AHI (Supine RDI) (# /hr)</td>
<td>42.2 (56.0)</td>
<td>12.2 (22.5)</td>
<td>21.4 (32.7)</td>
</tr>
<tr>
<td>Obstructive Apnoeas (#, max. dur sec)</td>
<td>27 (37.0)</td>
<td>3 (35.0)</td>
<td>30 (37.0)</td>
</tr>
<tr>
<td>Obstructive Hypopnoea (#, max. dur sec)</td>
<td>33 (63.5)</td>
<td>38 (88.0)</td>
<td>71 (88.0)</td>
</tr>
<tr>
<td>Central Apnoea Index (#, max. dur sec)</td>
<td>0 (0.0)</td>
<td>2 (22.0)</td>
<td>2 (22.0)</td>
</tr>
<tr>
<td>Mixed Apnoea (#, max. dur sec)</td>
<td>3 (34.5)</td>
<td>1 (32.5)</td>
<td>4 (34.5)</td>
</tr>
<tr>
<td>Time in Apnoeas/Hypopnoea (min)</td>
<td></td>
<td></td>
<td>61.8</td>
</tr>
<tr>
<td>Average O2 Saturation while awake (%)</td>
<td></td>
<td></td>
<td>95</td>
</tr>
<tr>
<td>Average O2 Saturation while asleep (%)</td>
<td>96</td>
<td>95</td>
<td>95</td>
</tr>
<tr>
<td>Minimum O2 Saturation while asleep (%)</td>
<td></td>
<td></td>
<td>88</td>
</tr>
<tr>
<td>Sleep Time with SaO2 < 85% min</td>
<td></td>
<td></td>
<td>0.0</td>
</tr>
<tr>
<td>Number of snoring episodes</td>
<td></td>
<td></td>
<td>185</td>
</tr>
<tr>
<td>Total duration with snoring (% sleep time)</td>
<td></td>
<td></td>
<td>65.3 min (15.2%)</td>
</tr>
</table>
### Arousal and Sleep Disturbance Data
<table>
<tr>
<th>Measurement</th>
<th>REM</th>
<th>NREM</th>
<th>Total Sleep</th>
</tr>
<tr>
<td>Arousal Index (number/hour of sleep)</td>
<td>31.4</td>
<td>16.9</td>
<td>20.6</td>
</tr>
<tr>
<td>Spontaneous Arousals (total #)</td>
<td>18</td>
<td>46</td>
<td>65</td>
</tr>
<tr>
<td>Respiratory Arousal (total #)</td>
<td>39</td>
<td>34</td>
<td>142</td>
</tr>
<tr>
<td>Leg Arousal (total #)</td>
<td>0</td>
<td>3</td>
<td>3</td>
</tr>
<tr>
<td>Arousals > 15 sec</td>
<td></td>
<td></td>
<td>69</td>
</tr>
<tr>
<td>Awakenings (total #)</td>
<td>10</td>
<td>13</td>
<td>23</td>
</tr>
<tr>
<td>Respiratory Awakenings</td>
<td>10</td>
<td>7</td>
<td>17</td>
</tr>
</table>
### Leg Movements
<table>
<tr>
<th>Measurement</th>
<th>REM</th>
<th>NREM</th>
<th>Total Sleep</th>
</tr>
<tr>
<td>Total number of limb movements</td>
<td></td>
<td></td>
<td>14</td>
</tr>
<tr>
<td>Limb movements/hr sleep</td>
<td></td>
<td></td>
<td>1.9</td>
</tr>
<tr>
<td>PLM index (#/hr sleep)</td>
<td></td>
<td></td>
<td>0.8</td>
</tr>
</table>
**Comments:**
The patient stated that he slept worse than usual. Sleep efficiency was normal, sleep latency was short, REM latency was normal with normal sleep architecture. He woke 23 times during the night; 17 times occurring after upper airway obstruction. There were moderate numbers of obstructive apnoeas and hypopnoeas up to 88 seconds in duration, tending to be more frequent in REM sleep, as well as additional prudes of inspiratory flow limitation terminated by arousals, resulting in mild oxygen desaturation and moderate sleep fragmentation. There were no significant cardiac events or leg movements. No neurological events noted.
**Conclusion:** Moderate obstructive sleep apnoea/hypopnoea, severe in REM sleep. Recommend MAS therapy or as an alternative nasal CPAP therapy.
(Signature)
**MICHAEL G PRICHARD MB BS FRACP**
**RESPIRATORY AND SLEEP PHYSICIAN**
#### Diagnostic Polysomnography Report
**Patient Metrics**:
- **Height**: 182.5 cm | **Weight**: 80.5 kg | **BMI**: 24.17
- **Night B.P.**: 122/74 | **Morn B.P.**: 117/84
- **Indications**: Observed apnoeas, nocturnal epilepsy, palpitations, reflux
**Sleep Architecture**:
- **Sleep Efficiency**: 89.3%
- **Sleep Latency**: 7.5 min
- **REM Latency**: 77.5 min
- **Stages**: N1 (1.7%), N2 (58.7%), N3 (12.1%), REM (27.5%)
**Respiratory Data**:
- **Total AHI (RDI)**: 14.9 (24.4)
- **REM AHI (RDI)**: 31.9 (44.6)
- **Supine AHI (RDI)**: 21.4 (32.7)
- **Oxygen Saturation**: Average 95%, Minimum 88%
- **Snoring**: 185 episodes (15.2% of sleep time)
**Arousal Data**:
- **Arousal Index**: 20.6 /hr
- **Respiratory Arousals**: 142
- **Respiratory Awakenings**: 17
**Clinical Conclusion**:
Moderate obstructive sleep apnoea/hypopnoea, severe in REM sleep. Recommend MAS therapy or as an alternative nasal CPAP therapy.
![]()
Patient demographic and clinical data table containing height (182.5 cm), weight (80.5 kg), BMI (24.17 kg/m²), night blood pressure (122/74), morning blood pressure (117/84), and indications for the study.
![]()
Sleep Data summary table presenting metrics such as Time in Bed (482.0 min), Sleep Time (431.0 min), Sleep Efficiency (93.3%), REM Latency (77.5), REM Time (118.5 min), Stage N1 (1.7%), Stage N2 (58.7%), Stage N3 (12.1%), and Wake after SO (5.2%).
![]()
Respiratory Data table comparing Apnoea Hypopnoea Index (AHI) and related metrics across REM sleep, NREM sleep, and Total Sleep columns. Key values include AHI of 31.9 (#/hr) in REM and 14.9 (#/hr) in Total Sleep, with detailed counts for obstructive and central apnoeas.
![]()
Arousal and Sleep Disturbance Data table detailing Arousal Index (31.4 in REM, 16.9 in NREM), Spontaneous Arousals (18 total in REM, 46 in NREM), Respiratory Arousals (39 total in REM, 34 in NREM), and Leg Arousals (0 total in REM, 3 in NREM).
![]()
Leg Movements table showing Total number of limb movements (14) and Limb movements/hr sleep (1.9) recorded during Total Sleep.
**RB**
Perth Sleep Clinic
Suite 27/146 Mounts Bay Road, PERTH 6000
<img>
**Polysomnography Data**
<img>
**W**
**R**
**N1**
**N2**
**N3**
**Pos**
**SpO2%**
**HR, BPM**
**arousal, sec**
**OA, sec**
**MA, sec**
**HYPO, sec**
**MIC, sec**
**RERA, sec**
**LogMvt, sec**
9:47:45 PM ... 5 AM
#### Polysomnography Data Tracing Labels
- **W**: Wake
- **R**: REM
- **N1, N2, N3**: Sleep Stages
- **Pos**: Position
- **SpO2%**: Oxygen Saturation
- **HR, BPM**: Heart Rate
- **arousal, sec**: Arousal duration
- **OA, sec**: Obstructive Apnoea
- **MA, sec**: Mixed Apnoea
- **HYPO, sec**: Hypopnoea
- **MIC, sec**: Microarousal
- **RERA, sec**: Respiratory Effort Related Arousal
- **LogMvt, sec**: Leg Movement
**Timeframe**: 9:47:45 PM to 5:00:00 AM
![]()
Polygraph chart titled 'Polysomnography Data' from Perth Sleep Clinic. The visual displays multiple time-series waveforms tracking sleep parameters over a night cycle (approx. 9:47 PM to 5 AM). Top section shows Stage of Sleep (W, R, N1, N2, N3) and Body Position (Pos: S, L, R). Middle sections include SpO2%, HR (BPM), and arousal events. Lower sections track specific event durations in seconds for Obstructive Apnea (OA), Mixed Apnea (MA), Hypopnea (HYPO), Micro-Arousals (MIC), Respiratory Effort-Related Arousal (RERA), and Leg Movements (LogMvt). The chart visually correlates respiratory events and sleep stages throughout the recording period.
# ORAL APPLIANCE THERAPY FOR SNORING AND OBSTRUCTIVE SLEEP APNOEA
**2 Categories:**
- Mandibular advancement appliance
- **Tongue retaining device:** engage and hold the tongue in a forward position without affecting the mandible or teeth
ORAL APPLIANCE THERAPY FOR SNORING AND OBSTRUCTIVE SLEEP APNOEA
#### Categories of Oral Appliances
- **Mandibular advancement appliance**
- **Tongue retaining device:** Designed to engage and hold the tongue in a forward position without affecting the mandible or teeth.
![]()
Labeled anatomical diagram of a mandibular advancement appliance. The illustration shows a side view of the head with an intraoral device (blue) holding the lower jaw forward. A yellow arrow indicates the direction of mandibular advancement, and a teal line traces the airflow path through the open airway.
![]()
Clinical photograph demonstrating a tongue retaining device. The image shows a close-up profile of a person's mouth with a bulbous blue silicone device protruding from the lips, mechanically engaging and holding the tongue in a forward position.
# **MECHANISM OF ACTION**: **MANDIBULAR ADVANCEMENT APPLIANCE**
**Increases pharyngeal space and reduces collapsibility, thus improving pharyngeal airflow**
## **Anterior movement of the mandible and tongue**
## **Lateral increase in velopharyngeal airway space**
#### Physiological Effects
Mandibular advancement appliances increase pharyngeal space and reduce collapsibility, thereby improving pharyngeal airflow through:
- Anterior movement of the mandible and tongue
- Lateral increase in velopharyngeal airway space
![]()
Sagittal anatomical cross-section diagram of the upper airway and jaw. The image illustrates the mechanism of action for a mandibular advancement appliance, showing the anterior displacement of the mandible and tongue to widen the airway.
INDICATIONS: MANDIBULAR ADVANCEMENT APPLIANCE
-
• Primary snoring
• Mild to Moderate Obstructive Sleep Apnoea
• Severe OSA who have failed CPAP trial
#### Clinical Indications
- Primary snoring
- Mild to Moderate Obstructive Sleep Apnoea (OSA)
- Severe OSA in patients who have failed a CPAP trial
![]()
Clinical photo of a Mandibular Advancement Appliance (Mandibular Splint) displayed on a dental model. The appliance is semi-transparent blue and red with a visible mechanical hinge mechanism in the center. A green arrow points upwards through the hinge, demonstrating the mandibular advancement function.
![]()
Clinical photo of a patient sleeping in bed wearing a CPAP (Continuous Positive Airway Pressure) mask. This image visually represents an alternative treatment or failed trial context mentioned in the text ('Severe OSA who have failed CPAP trial').
Oral appliance therapy for snoring and obstructive sleep apnoea: a Practical Guide for Clinical Care
Australian Journal of Dental Research
**R Balasubramaniam*,† K McCloy,‡ FR Almeida,§**† PA Cistulli*,**
**FEFBF**
**(Department of Oral Health Science, Faculty of Dentistry, Western Australian School of Medicine; Center for Sleep Research, Telethon Kids Institute, Perth, Western Australia, Australia)**
**(Division of Orthodontics and Maxillofacial Surgery, Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada)**
**(Faculty of Medicine and Health, University of Sydney, Kings New South Wales Hospital, Leuvenia, New South Wales, Australia)**
**Sleep Investigation Laboratory, Royal Prince Alfred Hospital, St Leonards, New South Wales, Australia)**
**ABSTRACT**
Obstructive sleep apnoea (OSA) is a disorder associated with multiple cardiovascular, metabolic and neuropsychiatric comorbidities which impact the health and quality of life of patients. Dentists trained in dental sleep medicine have a significant role in the management of OSA. Based on the recommendations of the medical team and the patient's preference, dentists have a primary role in the provision of oral appliance (OA) therapy for OSA. This narrative review provides a practical guide for OA therapy for snoring and OSA.
**Keywords:** Mandibular advancement appliance, mandibular advancement splint, mandibular advancement device, oral appliance, obstructive sleep apnoea, snoring, dental sleep medicine.
**Abbreviations and acronyms:** AHI = apnoea-hypopnoea index; BMI = body mass index; MDA = mean difference deviation; NREM = non-rapid eye movement; OA = oral appliance; OHS = obstructive sleep apnoea; PSG = polysomnography; REM = rapid eye movement; TSDM = type 2 diabetes mellitus; TMD = temporomandibular disorders; TMJ = temporal-mandibular joint.
**(Accepted for publication 23 January 2024.)**
**CLINICAL RELEVANCE**
Provision of an oral appliance (OA) can improve the health and quality of life of patients with respect to obstructive sleep apnoea (OSA). This narrative review explores the current scientific evidence and best practice principles to establish a practical guideline for OA therapy for snoring and OSA.
**INTRODUCTION**
Oral appliance (OA) therapy involves the provision of a removable appliance worn over the maxillary and mandibular teeth to preserve (advance) the mandible during sleep to treat snoring and obstructive sleep apnoea (OSA). These appliances may be referred to as a mandibular advancement appliance, a mandibular advancement device or an oral appliance in the literature and in clinical practice. The term OA is interrogated by a consensus of international experts. However, OA appears to be a generally accepted term internationally as a generic term for an appliance to treat snoring and OSA in the field of dental sleep medicine.
In Australia, the prevalence of primary snoring is estimated to be 2%. The estimated prevalence of moderate to severe OSA (apnoea-hypopnoea index (AHI) ≥15) is 10% among 30- to 49-year-old men; 17% among 50- to 70-year-old men; 3% among 30- to 49-year-old women; and 9% among 50- to 70-year-old women. Untreated OSA is associated with a range of cardiovascular, metabolic, and neurocognitive comorbidities and a significantly increased risk for mortality.¹² There is a complex interplay between OSA and its comorbidities, which necessitates a comprehensive approach to diagnosis and
**684**
@2024 The Author(s). Australian Dental Journal published by John Wiley & Sons Australia Ltd on behalf of Australian Dental Association.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and redistribution in any medium, provided the original work is properly cited.
#### Introduction to Oral Appliance Therapy
Oral appliance (OA) therapy involves a removable appliance worn over the maxillary and mandibular teeth to advance the mandible during sleep. This treatment is used for snoring and obstructive sleep apnoea (OSA). While various terms exist (mandibular advancement device/splint), OA is the generally accepted generic term in dental sleep medicine.
#### Prevalence of OSA in Australia
- **Primary Snoring:** Estimated at 2%.
- **Moderate to Severe OSA (AHI ≥15):**
- Men (30–49 years): 10%
- Men (50–70 years): 17%
- Women (30–49 years): 3%
- Women (50–70 years): 9%
Untreated OSA is linked to cardiovascular, metabolic, and neurocognitive comorbidities, increasing mortality risk.
<table>
<thead>
<tr>
<th rowspan="2">Study (Year)</th>
<th rowspan="2">N</th>
<th colspan="2">Baseline AHI / MAA AHI</th>
</tr>
<tr>
<th>Baseline AHI</th>
<th>MAA AHI</th>
</tr>
</thead>
<tbody>
<tr>
<td>Mehta et al. (2001)</td>
<td>24</td>
<td>30</td>
<td>14</td>
</tr>
<tr>
<td>Gotsopoulos et al. (2002)</td>
<td>73</td>
<td>27</td>
<td>12</td>
</tr>
<tr>
<td>Johnston et al. (2002)</td>
<td>20</td>
<td>38</td>
<td>23</td>
</tr>
<tr>
<td>Barnes et al. (2004)</td>
<td>80</td>
<td>21</td>
<td>14</td>
</tr>
<tr>
<td>Naismith et al. (2005)</td>
<td>73</td>
<td>24</td>
<td>12</td>
</tr>
<tr>
<td>Lam et al. (2007)</td>
<td>34</td>
<td>21</td>
<td>11</td>
</tr>
<tr>
<td>Vanderveken et al. (2008)</td>
<td>35</td>
<td>14</td>
<td>6</td>
</tr>
<tr>
<td>Deane et al. (2009)</td>
<td>27</td>
<td>27</td>
<td>12</td>
</tr>
<tr>
<td>Schutz et al. (2013)</td>
<td>9</td>
<td>31</td>
<td>9</td>
</tr>
<tr>
<td>Uniken Venema et al. (2020)</td>
<td>14</td>
<td>32</td>
<td>10</td>
</tr>
<tr>
<td>Silva et al. (2021)</td>
<td>25</td>
<td>9</td>
<td>4</td>
</tr>
</tbody>
</table>
#### Impact of Mandibular Advancement Appliances (MAA) on AHI
| Study (Year) | N | Baseline AHI | MAA AHI |
| :--- | :--- | :--- | :--- |
| Mehta et al. (2001) | 24 | 30 | 14 |
| Gotsopoulos et al. (2002) | 73 | 27 | 12 |
| Johnston et al. (2002) | 20 | 38 | 23 |
| Barnes et al. (2004) | 80 | 21 | 14 |
| Naismith et al. (2005) | 73 | 24 | 12 |
| Lam et al. (2007) | 34 | 21 | 11 |
| Vanderveken et al. (2008) | 35 | 14 | 6 |
| Deane et al. (2009) | 27 | 27 | 12 |
| Schutz et al. (2013) | 9 | 31 | 9 |
| Uniken Venema et al. (2020) | 14 | 32 | 10 |
| Silva et al. (2021) | 25 | 9 | 4 |
![]()
A structured table titled 'Randomised Placebo, Controlled Studies on Mandibular Advancement Appliance Therapy for OSA'. The table contains columns for 'Study (Year)', 'N' (sample size), 'Baseline AHI', and 'MAA AHI'. It lists data from 11 studies spanning from 2001 to 2021, including authors like Mehta et al., Gotsopoulos et al., Johnston et al., Barnes et al., Naismith et al., Lam et al., Vanderveken et al., Deane et al., Schutz et al., Uniken Venema et al., and Silva et al. Each row provides specific numerical values for sample size and AHI scores at baseline and after mandibular advancement appliance therapy.
<div style="text-align:center; width:100%;">
**Randomised, Cross-Over Studies if Mandibular Advancement Appliance compared to CPAP for OSA**
</div>
<table border="1" style="width:100%; text-align:center;">
<thead>
<tr>
<th>Reference</th>
<th>N</th>
<th>AHI<sub>base</sub></th>
<th>AHI<sub>appl</sub></th>
<th>AHI<sub>CPAP</sub></th>
<th>Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td style="text-align:left;">Ferguson et al. (1996)</td>
<td>19</td>
<td>20</td>
<td>10</td>
<td>10</td>
<td>68% satisfied with OAm</td>
</tr>
<tr>
<td style="text-align:left;">Clark et al. (1996)</td>
<td>21</td>
<td>34</td>
<td>20</td>
<td>11</td>
<td>OAm preferred</td>
</tr>
<tr>
<td style="text-align:left;">Ferguson et al. (1997)</td>
<td>20</td>
<td>25</td>
<td>14</td>
<td>4</td>
<td>65% preferred OAm</td>
</tr>
<tr>
<td style="text-align:left;">Randerath et al. (2002)</td>
<td>20</td>
<td>18</td>
<td>14</td>
<td>4</td>
<td>OAm easier to use</td>
</tr>
<tr>
<td style="text-align:left;">Engleman et al. (2002)</td>
<td>48</td>
<td>31</td>
<td>15</td>
<td>8</td>
<td>Neither treatment preferred</td>
</tr>
<tr>
<td style="text-align:left;">Tan et al. (2002)</td>
<td>24</td>
<td>22</td>
<td>8</td>
<td>3</td>
<td>OAm preferred</td>
</tr>
<tr>
<td style="text-align:left;">Barnes et al. (2004)</td>
<td>80</td>
<td>21</td>
<td>14</td>
<td>5</td>
<td>CPAP more difficult to use; but more effective</td>
</tr>
<tr>
<td style="text-align:left;">Gagnadoux et al. (2009)</td>
<td>59</td>
<td>34</td>
<td>6</td>
<td>2</td>
<td>OAm preferred</td>
</tr>
<tr>
<td style="text-align:left;">Phillips et al. (2013)</td>
<td>132</td>
<td>26</td>
<td>11</td>
<td>5</td>
<td>OAm preferred</td>
</tr>
</tbody>
</table>
- CPAP better improvement of AHI compared to Mandibular Advancement Appliance
- Mandibular Advancement Appliance preferred to CPAP
## Efficacy + Compliance = Mean Disease Alleviation (Effectiveness)
Vanderveken OM et al. Thorax. 2013 Jan;68(1):91-6.
#### Comparison: Mandibular Advancement Appliance vs. CPAP
| Reference | N | AHI Base | AHI Appl | AHI CPAP | Comments |
| :--- | :--- | :--- | :--- | :--- | :--- |
| Ferguson et al. (1996) | 19 | 20 | 10 | 10 | 68% satisfied with OAm |
| Clark et al. (1996) | 21 | 34 | 20 | 11 | OAm preferred |
| Ferguson et al. (1997) | 20 | 25 | 14 | 4 | 65% preferred OAm |
| Randerath et al. (2002) | 20 | 18 | 14 | 4 | OAm easier to use |
| Engleman et al. (2002) | 48 | 31 | 15 | 8 | Neither preferred |
| Tan et al. (2002) | 24 | 22 | 8 | 3 | OAm preferred |
| Barnes et al. (2004) | 80 | 21 | 14 | 5 | CPAP more effective but difficult |
| Gagnadoux et al. (2009) | 59 | 34 | 6 | 2 | OAm preferred |
| Phillips et al. (2013) | 132 | 26 | 11 | 5 | OAm preferred |
#### Clinical Effectiveness
- CPAP shows better improvement in AHI compared to Mandibular Advancement Appliances.
- Mandibular Advancement Appliances are generally preferred by patients over CPAP.
- **Mean Disease Alleviation (Effectiveness) = Efficacy + Compliance.**
![]()
A summary table titled 'Randomised, Cross-Over Studies if Mandibular Advancement Appliance compared to CPAP for OSA'. Columns include Reference, N (sample size), AHI_base, AHI_appl (Appliance), AHI_CPAP, and Comments. Data rows list studies such as Ferguson et al. (1996) through Phillips et al. (2013), showing that while CPAP generally results in lower AHI scores (better efficacy), the Mandibular Advancement Appliance is often preferred by patients.
![]()
A conceptual diagram or slide section summarizing clinical findings with two bullet points: 'CPAP better improvement of AHI compared to Mandibular Advancement Appliance' and 'Mandibular Advancement Appliance preferred to CPAP'. Below this, a concluding statement reads 'Efficacy + Compliance = Mean Disease Alleviation (Effectiveness)', visually synthesizing the trade-off between treatment effectiveness and patient preference.
![]()
A partial data table continuing from the previous section, listing two specific studies: Gagnadoux et al. (2009) and Phillips et al. (2013). It shows sample sizes (N=59 and N=132 respectively), baseline AHI values, and final AHI scores for both appliances, noting in comments that OAm was preferred in both cases.
**Mandibular Advancement Appliance:**
**Subjective Health Outcomes**
**Evidence:**
⭐ Weak
⭐⭐ Good
⭐⭐⭐ Excellent
* **Snoring** ⭐⭐ ⭐
* **Mood** ⭐
* **Quality of life** ⭐⭐ ⭐
* **Sleepiness** ⭐ ⭐
* **Neurocognitive function** ⭐
Johal A et al. Eur Respir Rev. 2023 Jun 21;32(168):220257.
Trzepizur W et al. Sleep. 2021 Jul 9;44(7):zsab015.
#### Subjective Health Outcomes
Evidence levels for Mandibular Advancement Appliances:
- **Snoring:** Excellent (⭐⭐⭐)
- **Quality of Life:** Excellent (⭐⭐⭐)
- **Sleepiness:** Good (⭐⭐)
- **Mood:** Weak (⭐)
- **Neurocognitive Function:** Weak (⭐)
![]()
Evidence legend box displaying a star rating scale. The top row shows one yellow star labeled 'Weak'. The second row shows two yellow stars labeled 'Good'. The third row shows three yellow stars (representing the highest level of evidence).
![]()
Central Venn diagram consisting of four overlapping translucent blue circles. This visual structure represents the intersection or relationship between different health outcomes.
![]()
Label node for 'Mood' with one yellow star indicator below it.
![]()
Label node for 'Snoring' with three yellow star indicators: two in a blue bar and one isolated below.
![]()
Label node for 'Quality of life' with three yellow star indicators: two in a blue bar and one isolated below.
![]()
Label node for 'Sleepiness' with two yellow star indicators: one in a blue bar and one isolated below.
![]()
Label node for 'Neurocognitive function' with one yellow star indicator in a dark blue bar.
# MANDIBULAR ADVANCEMENT APPLIANCE: OBJECTIVE HEALTH OUTCOMES
<table>
<thead>
<tr>
<th>Health Outcome</th>
<th>Evidence Level</th>
</tr>
</thead>
<tbody>
<tr>
<td>Sleepiness</td>
<td>Weak (★)</td>
</tr>
<tr>
<td>Psychomotor Speed</td>
<td>Weak (★)</td>
</tr>
<tr>
<td>Driving Simulator Performance</td>
<td>Good (★★)</td>
</tr>
<tr>
<td>Cardiovascular Outcomes</td>
<td>Weak (★)</td>
</tr>
<tr>
<td>Mortality</td>
<td>Weak (★)</td>
</tr>
</tbody>
</table>
**Evidence Legend:**
- ★ Weak
- ★★ Good
- ★★★ Excellent
**References:**
- Johal A et al. Eur Respir Rev. 2023 Jun 21;32(168):220257.
- Trzepizur W et al. Sleep. 2021 Jul 9;44(7):zsab015.
#### Objective Health Outcomes
| Health Outcome | Evidence Level |
| :--- | :--- |
| Driving Simulator Performance | Good (★★) |
| Sleepiness | Weak (★) |
| Psychomotor Speed | Weak (★) |
| Cardiovascular Outcomes | Weak (★) |
| Mortality | Weak (★) |
![]()
Evidence Legend Chart: A blue box containing a key for interpreting evidence levels. It displays 'Weak' next to one star, 'Good' next to two stars, and three stars for the highest level.
![]()
Sleepiness Evidence Label: A blue rectangular label reading 'Sleepiness' accompanied by a single yellow star symbol below it.
![]()
Mortality Evidence Label: A dark blue rectangular label reading 'Mortality' accompanied by a single yellow star symbol below it.
![]()
Psychomotor Speed Evidence Label: A blue rectangular label reading 'Psychomotor Speed' accompanied by a single yellow star symbol at the right end.
![]()
Cardiovascular Outcomes Evidence Label: A dark blue rectangular label reading 'Cardiovascular Outcomes' accompanied by a single yellow star symbol below it.
![]()
Driving Simulator Performance Evidence Label: A blue rectangular label reading 'Driving Simulator Performance' accompanied by two yellow star symbols at the right end.
<table>
<tr>
<th style="text-align:center; vertical-align:middle;">
<span style="float:right; font-size:3em; color:#9daabb;">
<b><i>RB</i></b>
</span>
<h1 style="font-size:1.8em; font-style:normal; margin:0; padding-right:0px; font-weight:700; line-height:1.3; text-align:center; color:white; text-shadow:0px 3px 5px rgba(0,0,0,0.6),0px 0px 2px rgba(255,248,233,0.24842100087928773); background-color:#253457;">
MANDIBULAR ADVANCEMENT APPLIANCE: <br>
TREATMENT RESPONDERS
</h1>
</th>
</tr>
<tr>
<th><div style="padding-left:10px; text-align:center;">Characteristics</div></th>
<th><div style="padding-left:5px; text-align:center;">Responders</div></th>
<th><div style="padding-left:5px; text-align:center;">Non-Responders</div></th>
</tr>
<tr>
<td nowrap>
<b>
<div style="padding-left:5px;">Clinical</div>
</b><br>
<br>
<span style="font-family:'Comic Sans MS';">
<ul style="list-style-type: disc;">
<li><span style="font-family:monospace">
Younger individuals
</span></li>
<li><span style="font-family:monospace">Lower BMI</span></li>
<li><span style="font-family:monospace">Gender – female</span></li>
<li><span style="font-family:monospace">Lower prevalence of cardiovascular disease</span></li>
</ul>
</span>
</td>
<td nowrap>
<span style="font-family:'Comic Sans MS';">
<ul style="list-style-type: disc;">
<li><span style="font-family:monospace">Older individuals</span></li>
<li><span style="font-family:monospace">Higher BMI</span></li>
<li><span style="font-family:monospace">Larger neck circumference</span></li>
<li><span style="font-family:monospace">Gender – male</span></li>
<li><span style="font-family:monospace">Increased cardiovascular burden</span></li>
</ul>
</span>
</td>
</tr>
<tr>
<td nowrap>
<b>
<div style="padding-left:5px;">Anatomical</div>
</b><br>
<br><span style="font-family:'Comic Sans MS';">
<ul style="list-style-type: disc;">
<li>Retracted maxilla or mandible</li>
<li>Lower anterior and posterior facial height</li>
<li>Shorter distance from the hyoid bone to the third cervical vertebrae</li>
<li>Shorter airway length</li>
<li>Forward movement tongue</li>
</ul>
</span>
</td>
<td nowrap>
<span style="font-family:'Comic Sans MS';">
<ul style="list-style-type: disc;">
<li>Nasal abnormalities</li>
<li>Minimal movement of tongue</li>
</ul>
</span>
</td>
</tr>
<tr>
<td nowrap>
<b>
<div style="padding-left:5px;">Polysomnographic Parameters</div>
</b><br><br><span style="font-family:'Comic Sans MS';">
<ul style="list-style-type: disc;">
<li>Low loop gain</li>
<li>Low AHI</li>
<li>Higher arousal threshold</li>
</ul>
</span>
</td>
<td nowrap>
<span style="font-family:'Comic Sans MS';">
<ul style="list-style-type: disc;">
<li>Lower oxygen desaturations</li>
</ul>
</span>
</td>
</tr>
<tr>
<td nowrap>
Modified & Reproduced from Johal A et al. Eur Respir Rev. 2023 Jun 21;32(168):220257.
</td>
<td colspan="2" align="center">
</td>
</tr>
</table>
#### Treatment Responders vs. Non-Responders
**Clinical Characteristics**
- **Responders:** Younger individuals, lower BMI, female gender, lower prevalence of cardiovascular disease.
- **Non-Responders:** Older individuals, higher BMI, larger neck circumference, male gender, increased cardiovascular burden.
**Anatomical Characteristics**
- **Responders:** Retracted maxilla or mandible, lower facial height, shorter airway length, forward tongue movement.
- **Non-Responders:** Nasal abnormalities, minimal tongue movement.
**Polysomnographic Parameters**
- **Responders:** Low loop gain, low AHI, higher arousal threshold.
- **Non-Responders:** Lower oxygen desaturations.
![]()
A structured comparison table titled 'MANDIBULAR ADVANCEMENT APPLIANCE: TREATMENT RESPONDERS'. The table is divided into three main columns: 'Characteristics', 'Responders', and 'Non-Responders'. It categorizes patient traits under three sections: Clinical (e.g., age, BMI, gender), Anatomical (e.g., facial height, airway length), and Polysomnographic Parameters (e.g., loop gain, AHI). Each cell contains bulleted lists of specific findings. The source citation at the bottom reads: 'Modified & Reproduced from Johal A et al. Eur Respir Rev. 2023 Jun 21;32(168):220257.'.
**MANDIBULAR ADVANCEMENT APPLIANCE: ADHERENCE AND COMPLIANCE**
* Self reported adherence (7.2h) = objective findings (7.1h) <sup>1</sup>
* Adherence influenced by patient characteristics, appliance type, psychosocial factors and side effects. <sup>2</sup>
First 20 days of usage predicts usage after 60 days <sup>4</sup>
**Effectiveness (Mean Disease Alleviation) = Efficacy + Compliance** <sup>3</sup>
<sup>1</sup>de Vries GE et al. J Clin Sleep Med. 2019 Nov 15;15(11):1655-1663.
<sup>2</sup>Tallamraju H et al. J Clin Sleep Med. 2021 Jul 1;17(7):1485-1498.
<sup>3</sup>Vanderveken OM et al. Thorax. 2013 Jan;68(1):91-6.
<sup>4</sup>Sutherland K et al. J Clin Sleep Med. 2021 Sep 1;17(9):1785-1792.
#### Adherence Patterns
- Self-reported adherence (7.2h) aligns closely with objective findings (7.1h).
- Usage during the first 20 days is a strong predictor of usage at 60 days.
- Adherence is influenced by patient characteristics, appliance type, psychosocial factors, and side effects.
**Effectiveness Formula:**
Effectiveness (Mean Disease Alleviation) = Efficacy + Compliance
![]()
Clinical photo showing a mandibular advancement appliance (Mandibular Advancement Device) on dental stone models. The device is a clear plastic splint with a blue bite block, demonstrating the mechanical separation of the upper and lower jaws.
![]()
Clinical photo showing a patient wearing a Mandibular Advancement Appliance in situ. A red sensor button labeled 'DENTITRAC BRAEBON' is attached to the lower jaw appliance for objective adherence monitoring. A blue thought bubble callout points to this image stating: 'First 20 days of usage predicts usage after 60 days', referencing citation 4.
*Mandatory disclaimer: The Medical Disclaimer on this website is important for understanding this site.*
*Please read before you start
Mandatory disclaimer: The Medical Disclaimer on this website is important for understanding this site. Please read before you start.
![]()
A graphic box labeled 'CYA' (Cover Your Ass), likely serving as a mnemonic or acronym for the procedural steps shown in the diagram.
![]()
Clinical photograph of a patient's lower face and jaw. The patient is holding their jaw with their hand, suggesting discomfort or pain in the mandibular region, illustrating a potential side effect of the appliance.
MANDIBULAR ADVANCEMENT APPLIANCE: HOW COMMON ARE SIDE EFFECTS?
**PERCENTAGE**
| Side Effect | Percentage |
| :--- | :--- |
| Difficulty chewing | 19 |
| Excessive salivation | 60 |
| Dry mouth | 86 |
| Tooth discomfort | 59 |
| Tongue discomfort | 8 |
| Jaw discomfort | 41 |
| Gingiva discomfort | 2 |
| Headache | 27 |
| Occlusion changes | 41 |
| TMJ pain | 37 |
| Masseter muscle pain | 45 |
Source: Hoffstein V. Sleep Breath. 2007 Mar;11(1):1-22.
#### Prevalence of Side Effects
| Side Effect | Percentage |
| :--- | :--- |
| Dry mouth | 86 |
| Excessive salivation | 60 |
| Tooth discomfort | 59 |
| Masseter muscle pain | 45 |
| Jaw discomfort | 41 |
| Occlusion changes | 41 |
| TMJ pain | 37 |
| Headache | 27 |
| Difficulty chewing | 19 |
| Tongue discomfort | 8 |
| Gingiva discomfort | 2 |
![]()
Bar chart titled 'MANDIBULAR ADVANCEMENT APPLIANCE: HOW COMMON ARE SIDE EFFECTS?' displaying the prevalence of various side effects. The Y-axis represents 'Percentage' ranging from -10 to 100. The X-axis lists specific side effects including Difficulty chewing (19%), Excessive salivation (60%), Dry mouth (86%), Tooth discomfort (59%), Tongue discomfort (8%), Jaw discomfort (41%), Gingiva discomfort (2%), Headache (27%), Occlusion changes (41%), TMJ pain (37%), and Masseter muscle pain (45%). Source cited at bottom: Hoffstein V. Sleep Breath. 2007 Mar;11(1):1-22.
### LONG- VS SHORT-TERM SIDE EFFECTS WITH MANDIBULAR ADVANCEMENT APPLIANCE
**Short-term**
* Dental & Craniofacial Changes
* Oral, Gingiva or Teeth Discomfort
* Jaw Tenderness / TMD
* Salivation: Excessive vs Dry
**Long-term**
* **Craniofacial Changes**
* Mandible rotates backwards & anterior facial height increases
* **Dental Changes**
* Decrease overjet, overbite and mandibular teeth crowding
* Posterior Open bite
#### Duration of Side Effects
**Short-term**
- Dental and craniofacial changes
- Oral, gingiva, or teeth discomfort
- Jaw tenderness / TMD
- Salivation changes (excessive or dry)
**Long-term**
- **Craniofacial Changes:** Mandible rotates backwards and anterior facial height increases.
- **Dental Changes:**
- Decreased overjet, overbite, and mandibular teeth crowding.
- Development of posterior open bite.
MONDEBULAR ADVANCEMENT APPLIANCE:
TMJ RELATED SIDE EFFECTS?
7 male patients
evaluated before &
with MAA titration &
MRI of TMJs
AHI reduction from
12.21 to 5.64 related
degree of mandibular
protrusion
6 of 7 patients,
condylar translation
with MAA ≤ maximal
open position
No significant TMJ
morphological
alterations during 1
year study period
6 mild-moderate OSA
patient treated with
Klearway MAA
#### TMJ Morphological Observations
In a study of patients treated with Klearway MAA:
- AHI reduction (12.21 to 5.64) was related to the degree of mandibular protrusion.
- Condylar translation with MAA was typically less than or equal to the maximal open position.
- No significant TMJ morphological alterations were observed during a 1-year study period.
![]()
Anatomical illustration of the Temporomandibular Joint (TMJ). The image depicts the condyle within the glenoid fossa with associated ligaments and disc structures. A Mandibular Advancement Appliance (MAA) is shown inserted into the mouth to demonstrate the mandibular protrusion mechanism.
![]()
Clinical photograph of a Klearway Mandibular Advancement Appliance (MAA). The transparent dental appliance is resting on a white base against a blue background, demonstrating the device used in the study for treating OSA.
# MANDIBULAR ADVANCEMENT APPLIANCE ON TMD:
## A SYSTEMATIC REVIEW & META-ANALYSIS
* Mandibular Advancement Appliance **NOT** absolute risk for TMD
* TMD may initially occur with mandibular advancement (typically **transient**)
* **If TMD present:** treat the TMD first
* **If chronic TMD:** mandibular advancement is not a contraindication
* **New onset TMD** related to mandibular advancement appliance: diagnose and treat
Alessandri-Bonetti A et al. Sleep Med Rev. 2019 Dec;48:101211.
#### Systematic Review Findings
- Mandibular advancement appliances are **not** an absolute risk for TMD.
- TMD symptoms may occur initially but are typically **transient**.
- **Clinical Management:**
- If TMD is present, treat it before starting MAA.
- Chronic TMD is not a contraindication for therapy.
- New onset TMD should be diagnosed and treated promptly.
OCCURRENC
OF TMD AMONG PATIENTS
UNDERGOING MAA FOR OSAS
### TMD With MAA
**A Systematic Review**
conducted according to
PRISMA guidelines and the
Cochrane handbook for
systematic reviews of
interventions
13 Studies
**Significant reduction in**
severity & frequency of
TMD symptoms
**No significant changes in TMD**
symptoms or TMJ-related
parameters from baseline to
follow-up intervals
**Temporary increases in TMJ-**
related pain or symptoms at
early follow-up period, which
later subsided
**Langaliya A et al. J Oral Rehabil. 2023 Dec;50(12):1554-1563.**
### Additional Note:
- "RB" logo in top left corner.
#### TMD Symptom Progression
Based on a systematic review of 13 studies:
- Many patients experience a significant reduction in the severity and frequency of TMD symptoms.
- Some patients show no significant changes from baseline.
- Temporary increases in TMJ-related pain may occur in the early follow-up period but usually subside.
![]()
Infographic diagram summarizing findings on 'TMD With MAA' (Temporomandibular Disorder with Mandibular Advancement Appliance). The visual is structured around a central dark blue label 'TMD With MAA'. Surrounding this center are four colored quadrants detailing specific study outcomes: top-left (blue) notes the systematic review methodology and 13 studies; top-right (green) indicates significant reduction in TMD symptoms; bottom-left (dark green) states no significant changes from baseline to follow-up; bottom-right (medium green) mentions temporary early increases in TMJ-related pain that later subsided. The entire graphic serves as a summary of the Langaliya A et al. J Oral Rehabil. 2023 paper.
**MANDIBULAR ADVANCEMENT APPLIANCE: OCCLUSAL CHANGES**
Posterior(open(bite
• Altered occlusal contacts: posterior open bite
• Incisor changes: decrease overjet and overbite
• Altered position of mandibular canines & molars
• Interproximal gaps
Farah, Balasubramaniam, McCullough (Eds) Contemporary Oral Medicine 2019 Springer
#### Common Occlusal Changes
- **Posterior Open Bite:** Altered occlusal contacts.
- **Incisor Changes:** Decrease in overjet and overbite.
- **Positional Changes:** Altered position of mandibular canines and molars.
- **Interproximal Gaps:** Development of spaces between teeth.
![]()
Lateral view diagram illustrating the dental occlusion relationship between upper and lower teeth. It includes labeled annotations for 'Overjet' (horizontal overlap) and 'Overbite' (vertical overlap). This visual corresponds to the OCR context regarding 'Incisor changes: decrease overjet and overbite'.
![]()
Clinical intraoral photograph showing a patient's mouth with the mandible advanced forward. The image demonstrates the physical result of using a Mandibular Advancement Appliance, visually confirming the text points about 'Altered occlusal contacts' and 'posterior open bite' where back teeth do not touch while front teeth are in contact.
![]()
Occlusal view diagram of posterior dentition showing the arrangement of molars and premolars. It includes a red label 'Posterior(open(bite)' pointing to the gap between upper and lower teeth. This illustrates the specific type of altered occlusion mentioned in the bullet point 'Altered occlusal contacts: posterior open bite'.
**IMMEDIATELY ABOVE: CANCERGIF NECKLYST**
**OVERJET**
**OVERBITE**
**Tier 1 (2): Bondemark 1999 (Monoblock, n=30); Doff et al. 2013 (TAP n=29)**
**Tier 3 (4): Fransson et al. 2004 (Monoblock, n=65); Fritsch et al. 2001 (Herbst, Monoblock, n=22); Hammond et al. 2007 (Somnomed n=45)**
**Tier 6 (5): Rose et al. 2002 (Adjustable activator n=34); Robertson et al. 2003 (Monoblock, n=20)**
**Tier 4 (6): Ghazal et al. 2008 (TAP, n=24); Hou et al. 2006 (Monoblock, n=67)**
**Tier 16 (7): Battagel et al. 2005 (Herbst n=30)**
**Tier 34 (8): Ringqvist et al. 2003 (Monoblock, n=30)**
**Tier 26 (9): Wang et al. 2015 (Silencor, n=42)**
**Tier 15 (11): Marklund 2006 (Monoblock, n=156)**
**Tier 30 (15): Martinez-Gomis et al. 2010 (Herbst, n=15)**
#### Research Tiers on Overjet and Overbite Changes
Various studies have documented dental changes across different appliance types (Monoblock, TAP, Herbst, Somnomed, Silencor):
- Bondemark (1999)
- Doff et al. (2013)
- Fransson et al. (2004)
- Marklund (2006)
- Wang et al. (2015)
![]()
Scatter plot chart titled 'OVERJET'. Y-axis represents 'Average overjet change (mm)' ranging from 0 to -2.6. X-axis shows age in years (2, 3, 4, 5, 7, 11, 16). The chart displays multiple colored circles representing different studies listed in the legend on the right (e.g., Bondemark 1999, Doff et al. 2013, Fransson et al. 2004, etc.).
![]()
Scatter plot chart titled 'OVERBITE'. Y-axis represents 'Average overbite change (mm)' ranging from 0 to -2.6. X-axis shows age in years (2, 3, 4, 5, 7, 11, 16). The chart displays multiple colored circles representing different studies listed in the legend on the right (e.g., Bondemark 1999, Doff et al. 2013, Fransson et al. 2004, etc.).
**My Fault**
**Baseline**
**After 3 Years of Mandibular Advancement Appliance Therapy**
Farah, Balasubramaniam, McCullough: Contemporary Oral Medicine 2019 Springer
#### Long-term Case Observation (3 Years)
Comparison of dental alignment from baseline to after 3 years of Mandibular Advancement Appliance therapy.
![]()
Clinical photo labeled 'Baseline' showing an intraoral view of the patient's teeth and gums from a side angle. The image displays the dental arch with visible gingival tissue.
![]()
Clinical photo labeled 'Baseline' showing an anterior intraoral view (likely using a cheek retractor) displaying the full set of upper and lower teeth in occlusion.
![]()
Clinical photo labeled 'After 3 Years of Mandibular Advancement Appliance Therapy' showing an intraoral view similar to the baseline, demonstrating the state of the dentition after treatment.
![]()
Clinical photo labeled 'After 3 Years of Mandibular Advancement Appliance Therapy' showing an anterior intraoral view (using a cheek retractor), demonstrating the final state of the dentition following therapy.
# Yup It Was Me!!
### Baseline
### After 3 Months of Mandibular Advancement Appliance Therapy
#### Short-term Case Observation (3 Months)
Comparison of dental alignment from baseline to after 3 months of Mandibular Advancement Appliance therapy.
![]()
Clinical comparison photo panel showing a patient's dental occlusion before and after treatment. The top row is labeled 'Baseline' (top-left) and displays three views of the initial malocclusion with crowding and spacing issues. The bottom row is labeled 'After 3 Months of Mandibular Advancement Appliance Therapy' (bottom-center) and shows improved alignment in corresponding views. The images demonstrate the therapeutic effect of the appliance on tooth positioning.
# Oops I Did It Again!!!
### Baseline
### After 5 Years of mandibular advancement appliance therapy
#### Extended Case Observation (5 Years)
Comparison of dental alignment from baseline to after 5 years of Mandibular Advancement Appliance therapy.
![]()
Clinical intraoral photo labeled 'Baseline' showing a right lateral view of the dentition with significant crowding and misalignment.
![]()
Clinical intraoral photo labeled 'Baseline' showing a left lateral view of the dentition with significant crowding and misalignment.
![]()
Clinical intraoral photo from the 'After 5 Years' set showing a right lateral view of the dentition demonstrating improved alignment compared to baseline.
![]()
Clinical intraoral photo from the 'After 5 Years' set showing a frontal (anterior) view of the dentition demonstrating improved alignment and occlusion.
![]()
Clinical intraoral photo from the 'After 5 Years' set showing a left lateral view of the dentition demonstrating improved alignment compared to baseline.
MANDIBULAR ADVANCEMENT APPLIANCE:
OCCLUSAL CHANGES IN PERSPECTIVE
"When treating a serious and sometimes life-threatening disorder as OSAS, therapeutic efficacy should supersede the maintenance of a patients' baseline craniofacial morphology."
"Discontinuation of oral appliance therapy because of the development of dental side effects should only be considered in patients who are able to tolerate or accept another effective treatment modality for their OSAS."
Doff et al. Clin Oral Investig. 2013;17(2):475-82.
#### Clinical Perspective on Dental Changes
- Therapeutic efficacy for a life-threatening disorder like OSA should supersede the maintenance of baseline craniofacial morphology.
- Discontinuation of therapy due to dental side effects should only be considered if the patient can tolerate another effective treatment modality.
|
|:---:|
| COMPLEX MODEL OF CARE |
|
| **Patient presents with snoring (with or without witnessed apneas or daytime sleepiness)** |
|↓|
| Patient referred to sleep physician or medical general practitioner |
|↓|
| Physician request and interpret overnight polysomnography or overnight home sleep testing |
|↓|
| **Snorer (no OSA)** | **Mild to Moderate** | **Severe OSA** |
|↓|↓|↓|
| Behavioral treatment: weight loss, postural modification, avoid sedatives | **Choice of OAm or CPAP** | Behavioral treatment concurrent with CPAP treatment |
|↓|↓|↓|
| **OAm** | CPAP treatment |
|↓|↓|
| Clinical assessment, insertion and titration of OAm and behavioral treatment | **Intolerant** |
|↓|↓|
| **Intolerant** |
|↓|
| Annual follow-up by dental practitioner |
|
|
|
|
|
| **Multi-Disciplinary Treatment Protocol For Mandibular Advancement Appliance for Snoring and OSA** |
| Adapted and modified from College of Dental Surgeons of British Columbia 2014 |
#### Multi-Disciplinary Treatment Protocol
1. **Initial Presentation:** Patient presents with snoring, apnoeas, or sleepiness.
2. **Medical Referral:** Referred to a sleep physician or GP for PSG or home sleep testing.
3. **Diagnosis-Based Pathways:**
- **Snorer (No OSA):** Behavioral treatment (weight loss, position) and OAm.
- **Mild to Moderate OSA:** Choice of OAm or CPAP.
- **Severe OSA:** CPAP treatment; behavioral treatment.
4. **Dental Implementation:** Clinical assessment, insertion, and titration of OAm.
5. **Follow-up:** Annual review by a dental practitioner.
![]()
Clinical photo showing a patient sleeping in bed with an alarm clock visible in the foreground. This image illustrates the context of snoring and sleep disturbance.
![]()
Flowchart titled 'COMPLEX MODEL OF CARE' detailing the multi-disciplinary treatment protocol for snoring and OSA. The diagram starts with patient presentation and referral, branches into diagnostic results (Snorer/no OSA, Mild to Moderate, Severe OSA), and maps out treatment pathways including behavioral therapy, CPAP, and Mandibular Advancement Appliance (OAm). It includes decision points for intolerance and annual follow-ups.
# Slide Overview: Study on Treating Obstructive Sleep Apnea with Multiple Modalities
## Study Details
**Title:** STEPWISE ADD-ON AND ENDOTYPE-INFORMED TARGETED COMBINATION THERAPY TO TREAT OBSTRUCTIVE SLEEP APNEA: A PROOF-OF-CONCEPT STUDY
**Reference:** Aishah A et al. Ann Am Thorac Soc. 2023 Sep;20(9):1316-1325.
## Treatment Algorithm
| Input / Context | Action Step | | Output / Outcome |
| :--- | :--- | :--- | :--- |
| **23 Severe OSA**<br>(AHI:41.9) treated<br>with **MAA** | ↓<br>(OSA endotypes<br>based on sleep study) | | |
| | ↓ | ↓ | |
| | Next Therapy | ⇓ | Treatment group |
| | **EPAP + supine avoidance therapy +**<br> | | **MAA + EPAP + Supine Avoidance** |
| | | | | 10/20 participants |
| | Residual OSA<br>(AHI>10) | **+ O2 (4L/min)**<br>+ atomoxetine-<br>oxybutynin 80/5mg | **... + O2** |
| | | | | 5/20 participants |
| | | | | | 1/20 participants |
| | | | | | 1/20 participant |
| | | | | | MAA + EPAP + CPAP |
## Study Outcome Statistics
**20 completed the study:**
* **19** successfully treated
* **17/20** without CPAP
* **10/20**: MAA + EPAP + Supine Avoidance
* **5/20**: As above + O2
* **1/20**: As above + Meds
* **1/20**: As above + O2 + Meds
#### Combination Therapy Study (Aishah A et al. 2023)
Proof-of-concept study for severe OSA (Baseline AHI: 41.9) using stepwise add-on therapy:
- **Step 1:** MAA + EPAP + Supine Avoidance (10/20 participants successfully treated).
- **Step 2:** Add Oxygen (5/20 participants).
- **Step 3:** Add Medications (Atomoxetine-Oxybutynin) (1/20 participants).
- **Step 4:** Combination of all above (1/20 participants).
**Results:** 19/20 participants were successfully treated; 17/20 were treated without requiring CPAP.
![]()
Clinical photo of a patient sleeping in bed, used to illustrate the context of Obstructive Sleep Apnea (OSA) treatment.
![]()
Flowchart node labeled '23 Severe OSA (AHI:41.9) treated with MAA', representing the initial study cohort and intervention.
![]()
Flowchart node labeled 'OSA endotypes based on sleep study', indicating the stratification step for patients.
![]()
Flowchart node labeled 'Residual OSA (AHI>10)', defining the criteria for patients requiring further therapy.
![]()
Flowchart node labeled 'EPAP + supine avoidance therapy', representing the first tier of combination therapy.
![]()
Flowchart node labeled 'O2 (4L/min) + atomoxetine-oxybutynin 80/5mg', representing the second tier of add-on therapy.
![]()
Flowchart node labeled 'MAA + EPAP + CPAP', representing the third tier or control group comparison.
![]()
Clinical product photograph showing three injection pens (Ozempic, Mounjaro, Wegovy) stacked horizontally. These are GIP/GLP-1 receptor agonists used for weight loss and OSA.
![]()
Comparison photo showing a 'before' state on the left (obese abdomen) and an 'after' state on the right (lean, muscular abdomen). This visual demonstrates the effect of weight loss treatments like those shown above.
# GIP/GLP-1 Receptor Agonists and Oral Appliance Therapy for OSA
### Obesity Related OSA
* Sustained weight loss (18-20%)
* Reduce fat deposition
around airway
* Reduces AHI
by 14.45
### Obesity Related Comorbidities
* Lowers blood pressure
* Reduces MACE
* Improves metabolic profiles
* Reduces systemic inflammation
### Combination Therapy
* CPAP
(ResMed shares ↓13%)
* 40-50% ceased CPAP
* Incretins + Oral Appliance Therapy
El-Solh AA et al. Expert Opin Pharmacother. 2025 Jan;26(1):51-62.
#### GIP/GLP-1 Receptor Agonists and OA Therapy
**Obesity-Related OSA Management:**
- Sustained weight loss (18-20%) reduces fat deposition around the airway.
- Reduces AHI by an average of 14.45.
- Improves metabolic profiles and reduces systemic inflammation.
**Combination Therapy Trends:**
- Incretins (weight loss meds) combined with Oral Appliance Therapy are emerging as an alternative for those ceasing CPAP.
# AI IN ORAL APPLIANCE THERAPY FOR SNORING AND OSA
Verma RK et al. World J Clin Cases. 2023 Dec 6;11(34):8106-8110.
```mermaid
graph TD
subgraph Diagnosis
D1[Automated sleep studies]
D2[Risk stratification]
D3[Self diagnosis]
D4[Personalised therapy]
end
subgraph Personalised_Oral_Appliance_Therapy[Personalised Oral Appliance Therapy]
P1[Predict responders]
P2[Optimise design & titration]
P3[Monitoring]
P4[Engagement Support]
end
subgraph Research
R1[Big data]
end
subgraph Australia
A1["AUD > 2 billion market by 2030"]
A2[30% time saved]
A3[40% of health businesses use AI]
end
Diagnosis --- Personalised_Oral_Appliance_Therapy
Personalised_Oral_Appliance_Therapy --- Research
Research --- Australia
Australia --- Diagnosis
style Diagnosis fill:#4a90e2,color:white
style Personalised_Oral_Appliance_Therapy fill:#0077cc,color:white
style Research fill:#335599,color:white
style Australia fill:#cc0000,color:white
```
#### Artificial Intelligence in Dental Sleep Medicine
AI applications include:
- **Diagnosis:** Automated sleep studies and risk stratification.
- **Personalised Therapy:** Predicting responders and optimising appliance design/titration.
- **Monitoring:** Patient engagement support and big data research.
- **Market Impact:** Projected AUD >2 billion market in Australia by 2030 with significant time savings for clinicians.
![]()
A circular diagram divided into four quadrants with a cyclical arrow indicating a process flow. The top-left quadrant is labeled 'Diagnosis' in white text on a blue background; the top-right is 'Personalised Oral Appliance Therapy'; the bottom-right is 'Research'; and the bottom-left is 'Australia'. Each quadrant is associated with an external rectangular text box containing bullet points detailing specific aspects (e.g., 'Automated sleep studies', 'Predict responders', 'Big data', 'AUD > 2 billion market by 2030').
![]()
A clinical photograph of an elderly woman wearing glasses and a pink sweater, sitting at a desk using a laptop computer while holding a telephone receiver to her ear.
# CLINICAL PRACTICE
```mermaid
graph TD
A[History] --> B[Clinical Examination]
A --> C[Imaging?]
B & C --> D[Discussion with Patient]
D --> E[Appliance Selection]
D --> F[Side Effects & Consent]
E & F --> G[Scans & Bite Registration]
G --> H[Delivery]
G --> I[Titration]
G --> J[Follow-up]
```
#### Clinical Workflow
1. History and Clinical Examination (including Imaging).
2. Discussion with Patient regarding options.
3. Appliance Selection, Side Effects discussion, and Informed Consent.
4. Scans and Bite Registration.
5. Delivery, Titration, and Follow-up.
![]()
Flowchart diagram illustrating the 'CLINICAL PRACTICE' workflow. The chart consists of three main stages connected by downward arrows: 'History' (subdivided into 'Clinical Examination' and 'Imaging?'), 'Discussion with Patient' (subdivided into 'Appliance Selection' and 'Side Effects & Consent'), and 'Scans & Bite Registration' (subdivided into 'Delivery', 'Titration', and 'Follow-up').
| HISTORY | |
| :--- | :--- |
| **Chief Complaint & Sleep Study** | **Snoring | Tiredness** |
| | **Headache | Fatigue** |
| | **Lethargy | Drowsiness** |
| | **Epworth** |
| **Medical / Dental History** | **Past Treatments** |
#### Patient History Requirements
- **Chief Complaints:** Snoring, tiredness, headache, fatigue, lethargy, drowsiness.
- **Screening:** Epworth Sleepiness Scale.
- **History:** Comprehensive medical and dental history, including past treatments.
![]()
A clinical flowchart diagram illustrating the components of a medical history assessment. The diagram features four dark grey text boxes connected by light blue arrows indicating a workflow sequence: 'Chief Complaint & Sleep Study' points to a list of symptoms including 'Snoring', 'Tiredness', 'Headache', 'Fatigue', 'Lethargy', 'Drowsiness', and 'Epworth'; this flows down to 'Past Treatments', which then points left to 'Medical / Dental History'. A background photo of a man yawning in a car is visible behind the boxes.
# EXAMINATION
| Mandibular Function | TMJs & Muscles | Occlusion | Dentition | Soft Tissue |
| :--- | :--- | :--- | :--- | :--- |
| • Mouth Opening & Lateral | • Pain | • Classification | • Missing teeth | • Tongue |
| • Protrusion | • Clicking / catching | • Midlines | • Crown height | • Palate |
| | • Locking | • Occlusal contacts | • Caries | • Uvula |
| | | | • Periodontal disease | • Tonsils |
#### Clinical Examination Components
- **Mandibular Function:** Mouth opening, lateral movement, and protrusion.
- **TMJs & Muscles:** Pain, clicking, catching, or locking.
- **Occlusion:** Classification, midlines, and occlusal contacts.
- **Dentition:** Missing teeth, crown height, caries, and periodontal health.
- **Soft Tissue:** Tongue, palate, uvula, and tonsils.
![]()
Anatomical diagram of the human skull showing the mandible and jaw joint area. This visual corresponds to the 'Mandibular Function' category.
![]()
Anatomical diagram of the human skull highlighting the red-colored masseter muscle and temporalis muscle. This visual corresponds to the 'TMJs & Muscles' category.
![]()
Clinical photograph showing a close-up view of upper and lower teeth in occlusion (bite). The image illustrates the alignment of dental arches, corresponding to the 'Occlusion' category.
![]()
Clinical photograph showing a patient's mouth with a finger pointing towards the front teeth. This visual demonstrates the inspection of dentition, corresponding to the 'Dentition' category.
# TREATMENT PLAN
```mermaid
graph TD
A[Candidate or Not?<br>• Other options] --> B[How MAA work?<br>Designs<br>Effectiveness]
B --> C[Side Effects<br>• Consent]
```
#### Treatment Planning Discussion
- Determine if the patient is a suitable candidate and discuss other options.
- Explain how MAA works, different designs, and expected effectiveness.
- Review potential side effects and obtain informed consent.
![]()
Labeled flowchart diagram illustrating the Treatment Plan process. An orange curved arrow flows from bottom-left to top-right with three yellow circular nodes marking key stages. The first node is labeled 'Candidate or Not? • Other options'. The second node is labeled 'How MAA work? Designs Effectiveness'. The third node is labeled 'Side Effects • Consent'. A photograph of a hand signing an 'INFORMED CONSENT' document is positioned at the bottom right, visually reinforcing the consent stage.
# WHICH IS THE BEST?
#### Appliance Selection
Determining the most appropriate device for the individual patient.
# WHICH IS THE BEST MANDIBULAR ADVANCEMENT APPLIANCE?
## Appliance - Efficacy
**No GOAT Appliance!!**
<table>
<tr>
<th>Study / Appliance</th>
<th>Without MAD (AHI)</th>
<th>With MAD 1 (AHI)</th>
<th>With MAD 2 (AHI)</th>
</tr>
<tr>
<td>Bloch 2000 Fixed-Herbst</td>
<td>~23</td>
<td>~8</td>
<td>~9</td>
</tr>
<tr>
<td>Rose 2002 Karwetsky-Silensor</td>
<td>~16</td>
<td>~5</td>
<td>~8</td>
</tr>
<tr>
<td>Lawton 2005 Herbst-Twin-block</td>
<td>~44</td>
<td>~24</td>
<td>~34</td>
</tr>
<tr>
<td>Gauthier 2008 Silencer-Klearway</td>
<td>~10</td>
<td>~5</td>
<td>~7</td>
</tr>
<tr>
<td>Vanderveken 2008 Custom-...</td>
<td>~14</td>
<td>~6</td>
<td>~11</td>
</tr>
<tr>
<td>Ghazal 2009 IST-TAP</td>
<td>~22</td>
<td>~5</td>
<td>~9</td>
</tr>
<tr>
<td>Zhou 2012 Fixed-Silent-Nite</td>
<td>~26</td>
<td>~7</td>
<td>~10</td>
</tr>
<tr>
<td>Bishop 2014 TAP-Klearway</td>
<td>~17</td>
<td>~8</td>
<td>~10</td>
</tr>
<tr>
<td>Johal 2017 Custom-made-prefab</td>
<td>~13</td>
<td>~4</td>
<td>~10</td>
</tr>
<tr>
<td>Umemoto 2017 Twinblock-Fixed</td>
<td>~21</td>
<td>~11</td>
<td>~15</td>
</tr>
</table>
#### Comparative Efficacy of Appliances
There is no single "best" appliance; multiple designs show significant AHI reduction:
- **Herbst Designs:** Reduced AHI from ~23 to ~8 (Bloch 2000).
- **TAP Designs:** Reduced AHI from ~22 to ~5 (Ghazal 2009).
- **Silensor/Klearway:** Consistent reductions across various studies.
- **Custom vs. Prefab:** Custom-made appliances generally show superior AHI reduction (Johal 2017).
![]()
Bar chart titled 'Appliance - Efficacy' comparing AHI (Apnea-Hypopnea Index) values across 10 different mandibular advancement appliance studies. The x-axis lists studies (e.g., Bloch 2000, Lawton 2005), and the y-axis shows AHI from 0 to 50. Three bars per study represent conditions: 'Without', 'With MAD 1', and 'With MAD 2'. Notable data point: Lawton 2005 shows high AHI (~44 without, ~24 with MAD 1). Red text box overlay states 'No GOAT Appliance!!'.
**SCANS & BITE REGISTRATION**
**Extraoral & Intraoral Photos**
#### Documentation
- Extraoral and intraoral photography.
- Digital or physical records for appliance fabrication.
![]()
Clinical photo showing a dental professional taking extraoral and intraoral photos of a patient. The image demonstrates the procedure for capturing visual records during scans and bite registration.
# SCANS & BITE REGISTRATION
Maxillary and Mandibular
- polyvinyl siloxane impressions
- intraoral digital scans
#### Impression Techniques
Maxillary and Mandibular records can be obtained via:
- Polyvinyl siloxane (PVS) impressions.
- Intraoral digital scans.
![]()
Clinical photo demonstrating the intraoral digital scanning procedure. A dental professional wearing a mask and gloves is holding a white handheld scanner inside a patient's mouth to capture maxillary or mandibular impressions.
![]()
Informational figure listing methods for Maxillary and Mandibular registration: polyvinyl siloxane impressions and intraoral digital scans.
SCANS & BITE REGISTRATION
Protrusive bite registration
• George Gauge
George PT. J Clin Orthod. 1992 Nov;26(11):721-
#### Bite Registration
- Protrusive bite registration is typically performed using a George Gauge.
![]()
Clinical procedure photograph demonstrating protrusive bite registration. The image shows a close-up of a patient's open mouth with gloved hands manipulating the jaw and teeth. A grey metal orthodontic instrument, identified as a 'George Gauge' from the OCR context, is positioned between the upper and lower anterior teeth to register the bite.
**DELIVERY OF APPLIANCE**
**Fit Appointment:**
comfortable and easy for the patient
to insert and remove
**Instructions**
Adjustment Period:
1st week get use to it; Then
begin titration
Care and keep away from “Pets”
Reiterate potential side-effects
#### Fitting and Patient Education
- **Fit Appointment:** Ensure the appliance is comfortable and the patient can insert/remove it easily.
- **Adjustment Period:** Use the first week to habituate before beginning titration.
- **Maintenance:** Instructions on care (e.g., keeping away from pets).
- **Review:** Reiterate potential side effects.
**TITRATION PROTOCOL**
#### Titration Protocol
Systematic advancement of the appliance to achieve optimal clinical results.
![]()
Flowchart node for 'Initial follow-up' at 4 weeks. Includes associated text: 'Based on symptoms may need further titration' and 'necessary and able protocol'. Arrow points right.
![]()
Flowchart node for '8–12 weeks follow-up'. Includes associated text: 'Stop advancement once optimal symptomatic improvement'. Arrow points right.
**WHAT IS SUCCESS?**
| Patient's Goal | Subjective |
| :--- | :--- |
| • Happy wife? | • Cessation of |
| • Can go camping | snoring |
| • Refreshed | • Awakening more |
| • Longevity | refreshed |
| | • Decreased lethargy |
| | **Objective** |
| | • Polysomnography |
| | – after optimally |
| | titrated |
#### Defining Treatment Success
**Subjective Success**
- Cessation of snoring.
- Awakening more refreshed.
- Decreased lethargy.
- Meeting patient goals (e.g., lifestyle improvements, partner satisfaction).
**Objective Success**
- Polysomnography results after the appliance has been optimally titrated.
![]()
Clinical photograph of a sleeping elderly man with grey hair and a blue plaid shirt, used as the background context for the slide titled 'WHAT IS SUCCESS?'. The image serves to visually represent the patient population (likely sleep apnea sufferers) discussed in the overlaying text boxes.
![]()
A green diagrammatic box labeled 'Patient's Goal' listing specific outcomes: 'Happy wife?', 'Can go camping', 'Refreshed', and 'Longevity'. An arrow points from this box towards the central yellow circle, indicating it is an input factor defining success.
![]()
A blue diagrammatic box labeled 'Subjective' listing criteria: 'Cessation of snoring', 'Awakening more refreshed', and 'Decreased lethargy'. An arrow points from this box to the central yellow circle, identifying subjective measures as components of success.
![]()
A purple diagrammatic box labeled 'Objective' containing the text 'Polysomnography – after optimally titrated'. An arrow points from this box to the central yellow circle, designating objective testing results as a component of success.
# AGENDA
```mermaid
graph TD
A[ROLE OF DENTISTRY IN <br> SLEEP MEDICINE] --> B[SCREENING FOR <br> SLEEP DISORDERED BREATHING]
B --> C[ORAL APPLIANCE THERAPY FOR <br> SLEEP DISORDERED BREATHING]
C --> D[TAKE HOME MESSAGE]
```
#### Clinical Workflow Agenda
1. **Role of Dentistry in Sleep Medicine**
2. **Screening for Sleep Disordered Breathing**
3. **Oral Appliance Therapy for Sleep Disordered Breathing**
4. **Take Home Message**
![]()
Flowchart diagram showing the agenda structure with four sequential steps connected by downward arrows. Steps include: 'ROLE OF DENTISTRY IN SLEEP MEDICINE', 'SCREENING FOR SLEEP DISORDERED BREATHING', 'ORAL APPLIANCE THERAPY FOR SLEEP DISORDERED BREATHING', and 'TAKE HOME MESSAGE'. The first three are in light gray boxes, while the last is highlighted in dark blue.
# **TAKE HOME MESSAGE**
* Educate and train in Dental Sleep Medicine
* Sleep Medicine is complex beyond snoring and OSA
* Dental practitioners may screen for sleep disordered breathing
* Role of dentistry in OSA crucial given the evidence for mandibular advancement appliance therapy
* Mean Disease Alleviation is emerging as the standard for assessing treatment effectiveness
* Side effects with mandibular advancement appliance therapy do occur, but manageable!
#### Key Clinical Considerations
- Educate and train in Dental Sleep Medicine
- Sleep Medicine is complex beyond snoring and OSA
- Dental practitioners may screen for sleep disordered breathing
- Role of dentistry in OSA crucial given the evidence for mandibular advancement appliance therapy
- Mean Disease Alleviation is emerging as the standard for assessing treatment effectiveness
- Side effects with mandibular advancement appliance therapy do occur, but manageable!
QUESTIONS ?
QUESTIONS?
![]()
A composite photo showing multiple human hands and arms raised with palms facing forward against a solid teal background. The image features diverse skin tones, visually representing a group of people raising their hands in response to the large yellow text 'QUESTIONS ?' displayed above them.
- DENT5310
- Orofacial Pain and Dental Sleep Medicine Module
- 1st May 2026
- Ramesh Balasubramaniam OAM
- THANK YOU!!!
- The University of Western Australia
- Perth Oral Medicine & Dental Sleep Centre
- Perth Children's Hospital
- PERIOGOLD® Helps Improve Oral Health
- Oral Medicine Academy of Australasia
- DSSWA
- ADA Australian Dental Association
- AusAstralasian Sleep Association
[^1]: Original PDF page 1: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=1|L35 Oral Appliance Therapy for Snoring and OSA, p.1]]
[^2]: Original PDF page 2: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=2|L35 Oral Appliance Therapy for Snoring and OSA, p.2]]
[^3]: Original PDF page 3: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=3|L35 Oral Appliance Therapy for Snoring and OSA, p.3]]
[^4]: Original PDF page 4: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=4|L35 Oral Appliance Therapy for Snoring and OSA, p.4]]
[^5]: Original PDF page 5: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=5|L35 Oral Appliance Therapy for Snoring and OSA, p.5]]
[^6]: Original PDF page 6: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=6|L35 Oral Appliance Therapy for Snoring and OSA, p.6]]
[^7]: Original PDF page 7: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=7|L35 Oral Appliance Therapy for Snoring and OSA, p.7]]
[^8]: Original PDF page 8: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=8|L35 Oral Appliance Therapy for Snoring and OSA, p.8]]
[^9]: Original PDF page 9: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=9|L35 Oral Appliance Therapy for Snoring and OSA, p.9]]
[^10]: Original PDF page 10: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=10|L35 Oral Appliance Therapy for Snoring and OSA, p.10]]
[^11]: Original PDF page 11: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=11|L35 Oral Appliance Therapy for Snoring and OSA, p.11]]
[^12]: Original PDF page 12: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=12|L35 Oral Appliance Therapy for Snoring and OSA, p.12]]
[^13]: Original PDF page 13: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=13|L35 Oral Appliance Therapy for Snoring and OSA, p.13]]
[^14]: Original PDF page 14: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=14|L35 Oral Appliance Therapy for Snoring and OSA, p.14]]
[^15]: Original PDF page 15: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=15|L35 Oral Appliance Therapy for Snoring and OSA, p.15]]
[^16]: Original PDF page 16: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=16|L35 Oral Appliance Therapy for Snoring and OSA, p.16]]
[^17]: Original PDF page 17: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=17|L35 Oral Appliance Therapy for Snoring and OSA, p.17]]
[^18]: Original PDF page 18: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=18|L35 Oral Appliance Therapy for Snoring and OSA, p.18]]
[^19]: Original PDF page 19: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=19|L35 Oral Appliance Therapy for Snoring and OSA, p.19]]
[^20]: Original PDF page 20: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=20|L35 Oral Appliance Therapy for Snoring and OSA, p.20]]
[^21]: Original PDF page 21: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=21|L35 Oral Appliance Therapy for Snoring and OSA, p.21]]
[^22]: Original PDF page 22: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=22|L35 Oral Appliance Therapy for Snoring and OSA, p.22]]
[^23]: Original PDF page 23: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=23|L35 Oral Appliance Therapy for Snoring and OSA, p.23]]
[^24]: Original PDF page 24: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=24|L35 Oral Appliance Therapy for Snoring and OSA, p.24]]
[^25]: Original PDF page 25: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=25|L35 Oral Appliance Therapy for Snoring and OSA, p.25]]
[^26]: Original PDF page 26: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=26|L35 Oral Appliance Therapy for Snoring and OSA, p.26]]
[^27]: Original PDF page 27: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=27|L35 Oral Appliance Therapy for Snoring and OSA, p.27]]
[^28]: Original PDF page 28: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=28|L35 Oral Appliance Therapy for Snoring and OSA, p.28]]
[^29]: Original PDF page 29: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=29|L35 Oral Appliance Therapy for Snoring and OSA, p.29]]
[^30]: Original PDF page 30: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=30|L35 Oral Appliance Therapy for Snoring and OSA, p.30]]
[^31]: Original PDF page 31: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=31|L35 Oral Appliance Therapy for Snoring and OSA, p.31]]
[^32]: Original PDF page 32: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=32|L35 Oral Appliance Therapy for Snoring and OSA, p.32]]
[^33]: Original PDF page 33: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=33|L35 Oral Appliance Therapy for Snoring and OSA, p.33]]
[^34]: Original PDF page 34: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=34|L35 Oral Appliance Therapy for Snoring and OSA, p.34]]
[^35]: Original PDF page 35: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=35|L35 Oral Appliance Therapy for Snoring and OSA, p.35]]
[^36]: Original PDF page 36: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=36|L35 Oral Appliance Therapy for Snoring and OSA, p.36]]
[^37]: Original PDF page 37: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=37|L35 Oral Appliance Therapy for Snoring and OSA, p.37]]
[^38]: Original PDF page 38: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=38|L35 Oral Appliance Therapy for Snoring and OSA, p.38]]
[^39]: Original PDF page 39: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=39|L35 Oral Appliance Therapy for Snoring and OSA, p.39]]
[^40]: Original PDF page 40: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=40|L35 Oral Appliance Therapy for Snoring and OSA, p.40]]
[^41]: Original PDF page 41: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=41|L35 Oral Appliance Therapy for Snoring and OSA, p.41]]
[^42]: Original PDF page 42: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=42|L35 Oral Appliance Therapy for Snoring and OSA, p.42]]
[^43]: Original PDF page 43: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=43|L35 Oral Appliance Therapy for Snoring and OSA, p.43]]
[^44]: Original PDF page 44: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=44|L35 Oral Appliance Therapy for Snoring and OSA, p.44]]
[^45]: Original PDF page 45: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=45|L35 Oral Appliance Therapy for Snoring and OSA, p.45]]
[^46]: Original PDF page 46: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=46|L35 Oral Appliance Therapy for Snoring and OSA, p.46]]
[^47]: Original PDF page 47: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=47|L35 Oral Appliance Therapy for Snoring and OSA, p.47]]
[^48]: Original PDF page 48: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=48|L35 Oral Appliance Therapy for Snoring and OSA, p.48]]
[^49]: Original PDF page 49: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=49|L35 Oral Appliance Therapy for Snoring and OSA, p.49]]
[^50]: Original PDF page 50: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=50|L35 Oral Appliance Therapy for Snoring and OSA, p.50]]
[^51]: Original PDF page 51: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=51|L35 Oral Appliance Therapy for Snoring and OSA, p.51]]
[^52]: Original PDF page 52: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=52|L35 Oral Appliance Therapy for Snoring and OSA, p.52]]
[^53]: Original PDF page 53: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=53|L35 Oral Appliance Therapy for Snoring and OSA, p.53]]
[^54]: Original PDF page 54: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=54|L35 Oral Appliance Therapy for Snoring and OSA, p.54]]
[^55]: Original PDF page 55: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=55|L35 Oral Appliance Therapy for Snoring and OSA, p.55]]
[^56]: Original PDF page 56: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=56|L35 Oral Appliance Therapy for Snoring and OSA, p.56]]
[^57]: Original PDF page 57: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=57|L35 Oral Appliance Therapy for Snoring and OSA, p.57]]
[^58]: Original PDF page 58: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=58|L35 Oral Appliance Therapy for Snoring and OSA, p.58]]
[^59]: Original PDF page 59: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=59|L35 Oral Appliance Therapy for Snoring and OSA, p.59]]
[^60]: Original PDF page 60: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=60|L35 Oral Appliance Therapy for Snoring and OSA, p.60]]
[^61]: Original PDF page 61: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=61|L35 Oral Appliance Therapy for Snoring and OSA, p.61]]
[^62]: Original PDF page 62: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=62|L35 Oral Appliance Therapy for Snoring and OSA, p.62]]
[^63]: Original PDF page 63: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=63|L35 Oral Appliance Therapy for Snoring and OSA, p.63]]
[^64]: Original PDF page 64: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=64|L35 Oral Appliance Therapy for Snoring and OSA, p.64]]
[^65]: Original PDF page 65: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=65|L35 Oral Appliance Therapy for Snoring and OSA, p.65]]
[^66]: Original PDF page 66: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=66|L35 Oral Appliance Therapy for Snoring and OSA, p.66]]
[^67]: Original PDF page 67: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=67|L35 Oral Appliance Therapy for Snoring and OSA, p.67]]
[^68]: Original PDF page 68: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=68|L35 Oral Appliance Therapy for Snoring and OSA, p.68]]
[^69]: Original PDF page 69: [[L35 Oral Appliance Therapy for Snoring and OSA.pdf#page=69|L35 Oral Appliance Therapy for Snoring and OSA, p.69]]