10.59987/ads/2015.3-4.81-86
Background. The aim of the present article is to present a set of proposed clinical recommendations aimed at Italian dentists involved in the management of patients with obstructive sleep apnea syndrome or snoring.
Methods. With the purpose of creating a study group, some of the most important Italian scientific societies operating in fields relevant to the issue of sleep medicine in dentistry were asked to appoint a representative. Each member of the study group was required to answer questions regarding the clinical management of OSAS and snoring.
Results. Oral appliances can be used to treat: - simple snoring, in patients who do not respond to, or do not appear to be suitable candidates for behavioral measures such as weight loss or positional therapy; - mild or moderate OSAS, in patients who prefer OAs to continuous positive airway pressure (CPAP) or who are not suitable candidates for CPAP, because of its failure or failure of behavioral approaches like weight loss or positional therapy; - severe OSAS, in patients who do not respond to or do not tolerate CPAP and in whom no indication for either maxillofacial or ENT surgery appears applicable.
Conclusions. The application of oral appliances is highly desirable in cases of simple snoring or mild to moderate OSAS, whereas considerable caution is warranted when treating severe OSAS. It is fundamental to ensure that the patient understands his problem and, at the same time, to present all the various treatment options.
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Annali di stomatologia
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Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS)
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Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS)
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                                                                                                         Review article



    Italian recommendations on dental support
    in the treatment of adult obstructive sleep apnea
    syndrome (OSAS)




                                                                                                                    i
                                                                                                                  al
    Luca Levrini, MD1                                              - mild or moderate OSAS, in patients who prefer




                                                                                                      n
    Franco Sacchi,MD, DDS2                                         OAs to continuous positive airway pressure (CPAP)
    Francesca Milano, DDS3                                         or who are not suitable candidates for CPAP, be-




                                                                                                   io
    Antonella Polimeni, MD4                                        cause of its failure or failure of behavioral approach-
    Paola Cozza, MD5                                               es like weight loss or positional therapy; - severe
    Edoardo Bernkopf, MD, DDS6                                     OSAS, in patients who do not respond to or do not




                                                                       az
    Marzia Segù, MD7                                               tolerate CPAP and in whom no indication for either
    Italian dentist work group about OSAS                          maxillofacial or ENT surgery appears applicable.
    Collaborators: Marco Zucconi, Claudio Vicini,                  Conclusions. The application of oral appliances is
    Enrico Brunello                                                highly desirable in cases of simple snoring or mild




                                                                     rn
                                                                   to moderate OSAS, whereas considerable caution
                                                                   is warranted when treating severe OSAS. It is fun-
    1   Università degli Studi dell’Insubria, Varese, Italy        damental to ensure that the patient understands
    2   Società Italiana Medicina del Sonno Odontoiatrica,         his problem and, at the same time, to present all




                                                                   te
        Milano, Italy                                              the various treatment options.
    3   Società Italiana Medicina del Sonno Odontoiatrica,
        Bologna, Italy                                      In     Key words: obstructive sleep apnea syndrome,
    4   Dipartimento di Scienze Odontostomatologiche e             snoring, guidelines, oral appliance.
        Maxillo Facciali, Università di Roma “Sapienza”,
        Roma, Italy
    5   Università degli Studi di Roma “Tor Vergata”, Ro-          Introduction
                                                   ni
        ma, Italy
    6   Associazione Nazionale Dentisti Italiani, Vicenza, Italy   Recent decades have seen dentists becoming in-
    7   Unità per lo Studio del dolore orofacciale e dei disor-    creasingly involved in the treatment of disorders that
        dini temporomandibolari, University of Pavia, Italy        also fall within the domain of other medical specialists.
                                        io

                                                                   These disorders include obstructive sleep apnea syn-
                                                                   drome (OSAS), sleep bruxism and temporomandibular
    Corresponding author                                           disorders. The fact that dentists today are more aware
                               iz


    Luca Levrini                                                   of sleep disorders, in which they could potentially play
    Università degli Studi dell’Insubria                           a diagnostic and therapeutic role, stems from a grow-
    Via Piatti, 10/a – Velate                                      ing recognition of orofacial characteristics as impor-
                Ed




    21100 Varese, Italy                                            tant developmental factors, and from the realisation
    E-mail: luca.levrini@uninsubria.it                             that they have therapeutic implications in disorders
                                                                   such as OSAS, snoring and bruxism. These trends in-
                                                                   dicate the need for an interdisciplinary approach to
    Summary                                                        these disorders and, therefore, for optimal collabora-
                                                                   tion among the different specialists involved (1-4).
 IC




    Background. The aim of the present article is to               In this paper, we focus on the role of dentists in the
    present a set of proposed clinical recommenda-                 screening and treatment of sleep-disordered breathing
    tions aimed at Italian dentists involved in the man-           (ranging from snoring to OSAS) in adult patients. From
    agement of patients with obstructive sleep apnea               the screening perspective, it can immediately be re-
C




    syndrome or snoring.                                           marked that dentists, on account of their contact with
    Methods. With the purpose of creating a study                  many members of the general population, are ideally
    group, some of the most important Italian scientific           placed to screen for potential OSAS sufferers. This
    societies operating in fields relevant to the issue of         could be done using simple questionnaires. As regards
@




    sleep medicine in dentistry were asked to appoint a            the treatment of sleep-disordered breathing, an in-
    representative. Each member of the study group                 creasing body of published literature reflects the grow-
    was required to answer questions regarding the                 ing worldwide recognition that oral devices have a role
    clinical management of OSAS and snoring.                       to play in the treatment of OSAS. Indeed, the various
    Results. Oral appliances can be used to treat: - sim-          possible therapeutic strategies in adults with OSAS in-
    ple snoring, in patients who do not respond to, or do          clude the application of removable oral appliances simi-
    not appear to be suitable candidates for behavioral            lar to those normally employed in orthodontics. As long
    measures such as weight loss or positional therapy;            ago as 1902 Pierre Robin proposed the “monobloc”, a

    Annali di Stomatologia 2015; VI (3-4): 81-86                                                                         81
    L. Levrini et al.


    device used to obtain mandibular and lingual protrusion          •   Associazione Italiana Medicina del Sonno, Marco
    as a means of increasing the opening of the tracheal                 Zucconi
    and esophageal tract and freeing the oropharynx (the             • Surgical commission, Associazione Italiana Medi-
    “vital confluent” in his conception) and the upper air-              cina del Sonno (ENT representative) and Asso-
    ways from obstruction. The numerous devices market-                  ciazione Otorinolaringologi Ospedalieri Italiani,




                                                                                                                          i
    ed today for the treatment of sleep apnea or snoring                 Claudio Vicini




                                                                                                                        al
    are essentially based on the same principle (5).                 • Collegio dei Docenti di Odontoiatria, Paola Cozza
    As regards the situation in Italy, it is to be considered        • Associazione Nazionale Dentisti Italiani, Edoardo
    that dentists, given the number currently practicing                 Bernkopf




                                                                                                         n
    across the country and their extensive contact with the          • Associazione Italiana Odontoiatri, Marzia Segù
    general population – they see approximately 30% of               • Associazione Italiana Pazienti con Apnee del
    the entire population –, could play an important role in             Sonno, Enrico Brunello.




                                                                                                      io
    terms of the interception and treatment of patients with         Scientific associations were chosen as representative
    sleep disordered breathing, and in this sense could be           of Italian dental sleep medicine, all of which have
    a valuable resource for the country’s national health            been officially directly involved by the Italian Associa-




                                                                         az
    system. During the anamnesis, asking a simple ques-              tion of Sleep Medicine (founded in 1990 and active in
    tion, such as “Do you snore?” or “Do you feel refreshed          promoting scientific research and clinical training for
    in the morning?” could be the first step, of considerable        sleep disorders in Italy). All the study group members
    diagnostic significance, in a complex, diagnostic and            declared that they had no conflicts of interest.




                                                                       rn
    therapeutic process. Involving dentists in this kind of
    activity would also change the way they are viewed by
    patients. Indeed, patients, appreciative of the care re-         Questions
    ceived and finding themselves able to sleep better,




                                                                     te
    would see that they are the focus of clinical attention          Each delegate proposed questions regarding the clin-
    that goes beyond their teeth, and thus develop a differ-         ical management of OSAS and snoring patients; del-
    ent perception of the dentist’s expertise and role. Sub- In      egates were aware that responses would be results
    stantially, they would see the dentist as someone who            of literature, evidence and experience of the working
    provides care and not just treatment. A further consid-          group, in accordance with the indications of the Ital-
    eration, not to be underestimated, is that the treatment         ian national Guidelines program (7). The proposed
    provided by dentists often enhances the patient’s quali-         questions were jointly discussed and the delegates,
                                                ni
    ty of life. This, in itself, is fulfilling, but if we consider   on the basis of these discussions, decided unani-
    that enhanced quality of life promotes wellness and              mously to address the following four questions:
    general health, then it also underlines the status of den-       • What approaches, anamnestic and clinical, might
    tists as full members of the medical profession.                      be helpful to dentists seeking to identify adult pa-
                                      io

    The literature already contains specific and precisely                tients affected by OSAS or snoring?
    defined protocols, both diagnostic and therapeutic,              • When can an intraoral device be applied in an
    for the treatment of adults affected by OSAS and                      adult patient with OSAS or snoring?
                             iz


    snoring (2, 5, 6). However, to provide a customised              • What are the features of a device employed for
    medical service, these protocols need to take into ac-                the treatment of adult patients affected by OSAS
    count the differences between different settings, both                or snoring?
               Ed




    local and national. For this reason, and also because            • What therapeutic process should the dentist fol-
    of the growing number of dentists in Italy becoming                   low in the case of an adult patient affected by
    involved in the treatment of this condition, we decided               OSAS or snoring?
    to propose a set of “Italian guidelines” on adult OSAS
    in dentistry. The German Society of Dental Sleep
    Medicine have issued similar recommendations (3).                Answers
 IC




                                                                     The group coordinator drafted an initial document on the
    Material and methods                                             basis of the delegates’ answers and considerations. A
                                                                     general overview was also drafted. The document was
C




    Study Group                                                      then forwarded to the delegates individually for revision.
                                                                     On the basis of their amendments, a second document
    The head of this project (Luca Levrini, Como, Italy)             was drafted in which the coordinator highlighted the
    appointed the coordinator of the study group (Franco             conclusions that had not been reached unanimously.
@




    Sacchi, Milan, Italy) and also asked the most impor-             The process was repeated, with the coordinator continu-
    tant Italian scientific societies operating in fields rele-      ing to modify the answers, until a final document, ap-
    vant to the issue of sleep medicine in dentistry to ap-          proved by all the delegates, was obtained. The answers
    point delegates willing to take part to this project. The        contained in the final document are based on the avail-
    participating scientific societies and their delegates,          able literature data; where data were absent, conclu-
    who formed the study group, are as follows:                      sions were reached on the basis of a combined evalua-
    • Società Italiana Medicina del Sonno Odontoiatri-               tion of the clinical and practical evidence together with
        ca, Francesca Milano                                         expert opinion. Each conclusion is associated with a lev-

    82                                                                                 Annali di Stomatologia 2015; VI (3-4): 81-86
    Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS)


    el of evidence and a power of recommendation, in ac-          tions and check-ups, professional oral hygiene proce-
    cordance with the indications of the Italian national         dures or other therapies. For this reason, dentists are
    Guidelines program (Piano Nazionale Linee Guida) (7)          ideally placed to perform OSAS screening. An appro-
    the levels of evidence assigned are defined as follows:       priately trained dentist can also evaluate whether or
    • I: evidence based on meta-analysis of random-               not a single patient meets the requirements for treat-




                                                                                                                    i
        ized controlled studies;                                  ment with oral appliances and can also carry out the




                                                                                                                  al
    • II: evidence based on at least one randomized               necessary follow-ups. The dentist must have a role
        controlled study;                                         in screening patients with snoring or OSAS: during in-
    • III: evidence based on at least one controlled non-         terdisciplinary managing, he will decide with the sleep




                                                                                                     n
        randomized study;                                         specialist (in relation to his culture and experience) to
    • IV: evidence based on at least one non-controlled           treat or not patients with snoring or OSAS if he has
        experimental study;                                       characteristics defined by clinical recommendations.




                                                                                                  io
    • V: evidence based on non-experimental descrip-
        tive studies (including comparative studies);
    • VI: evidence based on a high level of consent               Oral appliances




                                                                      az
        and/or experts’ clinical experience.
    The power of recommendation was instead classified            The first descriptions of the use of oral appliances
    as follows:                                                   (OAs) in OSAS treatment date back to the 1980s.
    • A: performance of the specific procedure (or diag-          Many devices have been proposed and, of these, the




                                                                    rn
        nostic test) is highly recommended. “A” indicates a       most widely studied are mandibular advancing de-
        recommendation supported by good quality scientific       vices (MADs) (1-10). These appliances are designed
        evidence, albeit not necessarily type I or II evidence;   to keep the mandible and the tongue in a more ad-




                                                                  te
    • B: there is some doubt over whether the particular          vanced position during the night time, and also to in-
        procedure should always be recommended, but               crease the vertical dimension. As a result of a direct
        the possibility of performing it should always be         mechanical effect, and probably also a reflex muscu-
        given careful consideration;                              lar action, a MAD increases the opening of the lumen
    • C: there is still considerable uncertainty over
                                                           In     of the pharynx, mainly at its lateral portion. Numerous
        whether or not performance of the procedure should        instrumental and clinical studies have assessed the
        be recommended;                                           clinical efficacy of OAs in OSAS and snoring, leading
    • D: performance of the procedure is not recom-               to an increase in the relevant scientific evidence over
                                                   ni
        mended;                                                   recent years. The features of the various devices
    • E: performance of the procedure is highly discour-          have been modified many times and, as a result, to-
        aged.                                                     day’s OAs are much more comfortable, better tolerat-
                                        io

                                                                  ed and less bulky than those of the past. In addition,
                                                                  their side effects have become far less severe. Even
    Results                                                       though continuous positive airway pressure (CPAP)
                               iz


                                                                  has given better results in terms of reducing airway
    General overview                                              obstruction indices, OAs are far more comfortable for
                                                                  patients. As a consequence, compared with the past,
               Ed




    Snoring is common among the general population.               OAs are now recommended internationally for a
    Around 30% of adults are habitual snorers and this            broader spectrum of clinical conditions. In this regard,
    percentage increases rises in those aged 60 years or          it is useful to examine the evolution within the AASM
    more (to up to 60% of males and 40% of females) (2).          (American Academy of Sleep Medicine) over the past
    In addition to being a sometimes severe source of dis-        two decades; indeed, the statements issued by this
    turbance for the individual’s sleeping partner, snoring       organization in 1995, 2005 and 2009 (2, 11,12) seem
 IC




    can be a symptom of OSAS, a frequent (4% preva-               to provide very clear indications.
    lence) (8) and severe disease which is related to a
    possible increase in daytime sleepiness and an in-
    creased risk of developing hypertension, cardiovascu-         Questions and answers
C




    lar diseases and stroke. Not all snorers suffer from
    sleep apnea, however snoring is present in almost             A – What approaches, anamnestic and clinical, might
    every OSAS patient. General population screening can          be helpful to dentists seeking to identify adult patients
    therefore be a useful means of detecting individuals af-      affected by OSAS or snoring?
@




    fected by OSAS, a disease that continues to be diag-          A1. Dentists can make a major contribution to screen-
    nosed and treated in only a small amount of cases (9).        ing for OSAS. This can be done through:
                                                                  a. The inclusion, in the history, of specific questions
                                                                      (1, 6, 12, 13) designed to identify patients with:
    The role of dentists                                              - a history of chronic snoring;
                                                                      - daytime sleepiness and/or non-restful sleep;
    A very high percentage of the general population at-              - nightly awakenings associated with air hunger
    tends a dental office at least once a year for inspec-                and/or apneas reported by the sleeping partner;

    Annali di Stomatologia 2015; VI (3-4): 81-86                                                                        83
    L. Levrini et al.


         -    other OSAS-related symptoms such as mouth            ing an important link and making a valuable contribu-
              dryness, headache, difficult awakening, noc-         tion to the addressing of this important but still very
              turia, chronic weakness, deficit of memory and       little known disorder.
              concentration, libido disorders.                     (Level of evidence 4; Power of recommendation A).
    (Level of evidence 1; Power of recommendation B).              A3. The instrumental procedure (polysomnography or




                                                                                                                        i
    b. The use of specific approved questionnaires that            any other method approved by the AIMS-AIPO diag-




                                                                                                                      al
         can help to quantify daytime sleepiness. These in-        nostic guidelines) (6) allowing diagnosis of OSAS and
         clude the “Epworth Scale” and the “Stop-Bang              assessment of its severity should be performed before
         questionnaire” (1, 14, 15), which allows the risk of      dental treatments. In this way, it is possible to estab-




                                                                                                       n
         OSAS to be determined on the basis of the binary          lish, at the time of the clinical work-up, the certainty of
         (yes/no) answers to 8 simple questions. “Epworth          the diagnosis and the different therapeutic options and
         Scale” or “Stop-Bang questionnaire” (1) allow to          subsequently to evaluate the results obtained, com-




                                                                                                    io
         evaluate and share with the patient the relief of         paring them with the basal conditions (AASM 2009*).
         OSAS symptoms; later the final follow-up for treat-       The assessment of case severity can be considered
         ment evaluation must be performed by a sleep              completed only after evaluation of any comorbidities




                                                                       az
         physician with cardio-respiratory parameters.             present (cardiovascular and respiratory diseases pri-
    (Level of evidence 1; Power of recommendation B).              marily, and also malocclusions) (1, 2, 6, 12, 16, 17).
    c. Evaluation of clinical characteristics frequently associ-   (Level of evidence 1; Power of recommendation A).
         ated with sleep respiratory disorders: for example,




                                                                     rn
         obesity, older age (over 45 years for males or post-      B – When can an intraoral device be applied in an
         menopause for females), hypertrophic tonsils or other     adult patient with OSAS or snoring?
         signs of obstruction of the upper airways, large neck     As regards the use of intraoral devices (or oral appli-




                                                                   te
         circumference and retrognathia. Dentists should also      ances, OAs), we here refer to what was been agreed
         carefully assess patients’ dental and periodontal         by the AASM task force (1). According to its docu-
         health status, dental occlusion, TMJ and masticatory      ment, OAs can be applied in the following conditions:
         muscle function and assess the presence of related        • simple snoring, in patients who do not respond to
                                                           In
         diseases, particularly bruxism, gastroesophageal re-          therapy or do not appear to be suitable candi-
         flux disease and orofacial pain (1, 2, 6, 12).                dates for behavioral measures such as weight
    (Level of evidence 1; Power of recommendation A).                  loss or positional therapy.
    d. In-depth diagnosis with instrumental examination.           • mild or moderate OSAS, in patients who prefer
                                               ni
    (Level of evidence 1; Power of recommendation A).                  OAs rather than CPAP or who are not suitable
    A2. It would be preferable to achieve a multidisciplinary          candidates for CPAP, because of its failure or fail-
    approach to OSAS and snoring that also involves den-               ure of behavioral approaches like weight loss or
                                     io

    tists in the various phases of the diagnostic work-up              positional therapy.
    (clinical and instrumental) and in the treatment strategy      • severe OSAS, in patients who do not respond to
    decision-making process. Reports of instrumental ex-               or do not tolerate CPAP and in whom no indica-
                             iz


    aminations (polysomnography or any other method ap-                tion either for maxillofacial or ENT surgery ap-
    proved by the AIMS-AIPO diagnostic guidelines) (6)                 pears applicable (1, 18-20).
    should be arranged by a specialist in sleep medicine,          (Level of evidence 1; Power of recommendation A).
               Ed




    who would assume full responsibility for them. The den-        The application of OAs is highly desirable in cases of
    tist should be involved in general diagnostic work-up,         simple snoring or mild to moderate OSAS, whereas
    evaluating the patient’s dental, periodontal and func-         considerable caution is warranted when treating se-
    tional status and craniofacial morphology, and should          vere OSAS. It is fundamental to ensure that the pa-
    also contribute to decision making during the treatment-       tient understands his problem and, at the same time,
    planning phase, by identifying predictive factors of           to present all the various treatment options. In other
 IC




    treatment efficacy. In addition, the dentist should partic-    words, it is important, together with the patient, to es-
    ipate in the intercepting of OSAS-affected patients            tablish what his needs are and then to choose, to-
    (screening) (see point A1). The dentist should also as-        gether, the best solution to his disorder.
    sume sole responsibility for the selection, construction       (Level of evidence 6; Power of recommendation A).
C




    and adjustment of OAs, as well as for the management
    of their side effects (point 4) (1, 3, 4).                     C – What are the features of a device employed for the
    (Level of evidence 4, Power of recommendation B).              treatment of adult patients affected by OSAS or snoring?
    If a diagnosis of OSAS or snoring, moderate or mild,           1. Tongue retaining devices (TRD), which seem to be
@




    is confirmed, the dental analysis and the decision re-             less efficacious and are also less comfortable than
    garding the application of an OA, as well as its char-             mandibular advancement devices (MADs); they are
    acteristics, are exclusively within the competence of              indicated in edentulous patients, or patients who
    the dentist, irrespective of his academic training.                cannot tolerate, or do not qualify as candidates for,
    We desire dentists to promote awareness about                      mandibular advancement (1, 20-22).
    OSAS and snoring so as to bring to light affected in-          (Level of evidence 2; Power of recommendation C).
    dividuals among the population. In this way, dentists          2. Mandibular advancement devices (MADs, also re-
    may interface with sleep medicine specialists, provid-             ferred in the literature as mandibular advance-

    84                                                                               Annali di Stomatologia 2015; VI (3-4): 81-86
    Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS)


        ment splints – MASs; mandibular repositioning                extended to cover all the different types of OA,
        devices – MRDs; or mandibular repositioning ap-              since no one device appears to fit all patients.
        pliances – MRAs), which can be:                           • Dentists should monitor the device over time, con-
    3. Boil and bite devices: these are less efficient than          sidering the patient’s adaptation to different de-
        customized devices in terms of reduction of respi-           grees of repositioning of the mandible and its tol-




                                                                                                                      i
        ratory events and also in terms of compliance;               erance to protrusion.




                                                                                                                    al
        these devices are still not indicated as a definitive     • In the case of simple snoring, the assessment of
        treatment for OSAS. There are not sufficient data            efficacy is limited to the amount of information
        available to establish their ability to predict the ef-      provided either by the patient or his/her partner.




                                                                                                       n
        ficacy o customized devices (23, 24).                        In situations in which certain signs or symptoms
    (Level of evidence 2; Power of recommendation C).                of OSAS persist, a more in-depth study of the
    4. Monobloc devices: these are fabricated in the lab             case is required in order to select the best thera-




                                                                                                    io
        starting from the patient’s impressions; with these          py. This may involve the use of a cardiac-respira-
        devices, the interarch relationship can be fixed or          tory monitoring instrument or other approved in-
        slightly modifiable (25-27).                                 strument (AIMS-AIPO guidelines).




                                                                      az
    (Level of evidence 1; Power of recommendation A).             • Once the efficacy of the therapy has been con-
    5. Adjustable advancement devices: these also fab-               firmed, the patient should attend dental check-ups
        ricated in a dental laboratory, customized for each          every 6 weeks for the first year and once a year
        patient. This type of device consists of two parts           thereafter for verification of his/her dental, peri-




                                                                    rn
        kept together by an articulation system (screws or           odontal, functional and occlusal status.
        sliding surfaces) that allows it to be regulated.         • It is the dentist’s responsibility to manage, on the ba-
        The possibility of regulating the advancement of             sis of information provided by the patient, the vari-




                                                                  te
        the mandible and thus gradually modifying its po-            ous OA-related side effects that could arise. These
        sition means that this solution allows the best              include both transitory ones (hypersalivation, dental
        compromise between the different outcomes (ver-              pain, muscular problems, occlusal complications in
        ified by polysomnography or other validated in-              the morning) and more persistent ones (changes in
        strumental examination) and the patient’s comfort
                                                           In        the position of teeth and in occlusion). The dentist
        (19, 26, 28-30).                                             should take steps to limit these side effects as they
    (Level of evidence 1; Power of recommendation A).                are perceived negatively by the patient.
    The term oral appliance is too generic, in the future,        • Dentists involved in the treatment of sleep respi-
                                                   ni
    in both the research and the clinical setting, it will be        ratory disorders, are encouraged to undertake
    necessary to specify the main features of the consid-            continuous and targeted education about these
    ered device.                                                     problems through frequent attendance of refresh-
                                        io

    (Level of evidence 6; Power of recommendation A).                er courses (1, 10, 17, 19, 20, 31).
                                                                  We desire universities to include the subject of “sleep
    D – What therapeutic process should the dentist fol-          dentistry” in their dentistry courses, in particular
                               iz


    low in the case of an adult patient affected by OSAS          Gnathology in the Dental School.
    or snoring?                                                   (Level of evidence 4; Power of recommendation A).
    • It is highly desirable that therapy with OAs be per-
               Ed




        formed exclusively by dentists who have received
        specific training in sleep medicine/dentistry and         Conclusion
        the use of OAs.
    • The dentist should be familiar with the indications         The role of the dentist in sleep-disordered breathing can
        for and contraindications to maxillomandibular ad-        be summarized in the following tasks: screening for
        vancement, and thus able to identify patients             OSAS; management of treatment with OAs, including
 IC




        needing to be referred to a maxillofacial surgeon.        titration of the appliance in order to maximize the results
    • The dentist should be trained to carry out combined         and reduce side-effects; assessment and management,
        treatments involving the use of OAs and soft tissue       within the limits and scope of the dental profession, of
        surgery (otorhinolaryngology), or treatments com-         related pathologies such as sleep bruxism, orofacial
C




        bining OAs with CPAP.                                     pain and related headache. The diagnosis of SDB and
    • To determine whether or not to apply an OA, a               the final follow-up for treatment evaluation must be per-
        preliminary evaluation of the conditions of the oral      formed by a sleep specialist and not by the dentist, also
        mucosa, teeth and periodontal structures and of           for simple snoring. If the doctor in charge of the interdis-
@




        oral function is recommended, focusing especially         ciplinary team, often a sleep physician, has determined
        on the masticatory muscles and TMJ and looking            that therapy with an OA is feasible, then he/she should
        for any malocclusions and dysgnathia.                     inform the dentist of this. It will then be up to the dentist
    • Selection of the device is exclusively the respon-          to establish whether this treatment is advisable, consid-
        sibility of the dentist who will make the choice tak-     ering the conditions of the patient’s teeth and oral tis-
        ing into consideration the peculiarities of the sin-      sues, and what type of device is most appropriate for
        gle case and drawing on his own specific knowl-           the case in question. The application of OAs is highly
        edge. We suggest that this knowledge should be            desirable in cases of simple snoring or mild to moderate

    Annali di Stomatologia 2015; VI (3-4): 81-86                                                                            85
    L. Levrini et al.


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                                                                                                                                      i
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                                                                                 2012;126(4):372-9.




                                                                                                                                    al
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                                                                                                                     n
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