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. 2025 Aug 21;35(3):e70179. doi: 10.1111/jsr.70179

Clinical Insights Regarding Oral Health Among Untreated and Positive Airway Pressure Treated Obstructive Sleep Apnea Patients

K Berggren 1,2,✉, H Ahonen 1,2, U Lindmark 3, A Broström 4,5, O Sunnergren 1,6,7,8
PMCID: PMC13193370  PMID: 40841349

ABSTRACT

Oral health‐related side effects are common in patients with both untreated and PAP‐treated OSA and can hinder adherence to PAP treatment. Despite extensive research on OSA and PAP, oral health experiences of PAP professionals remain unexplored. The aim was to describe PAP professionals' experiences and management of symptoms and treatment effects on oral health in patients with OSA before and during PAP treatment. The study has a qualitative design with an inductive approach, where 17 strategically selected PAP professionals (physicians, nurses, and biomedical scientists) at nine Swedish PAP clinics participated in semi‐structured in‐depth interviews. The data was analysed with content analysis. Four categories described PAP professionals' experiences before and during PAP treatment. The categories Acknowledging oral health aspects when exploring the clinical data and Exploring the patients' oral health‐related experiences described the OSA diagnosis, intra‐oral visual features, and shared signs between OSA and oral health. The categories Adjusting the PAP device related to oral health and Managing oral health‐related situations during PAP treatment described the oral health‐related challenges in patient collaboration and individualised PAP treatment. In conclusion, oral dryness was an oral health‐related symptom of OSA and a side effect of PAP treatment, noted by PAP professionals. Management of oral health‐related situations and treatment effects was difficult as there was a lack of knowledge and no established remedial routine.

Keywords: healthcare, management, oral signs, OSA, PAP, practitioner

1. Introduction

Obstructive sleep apnea [OSA] is a sleep‐related breathing disorder manifested by complete (apnea) or partial (hypopnea) obstructions of the upper airway (Gottlieb and Punjabi 2020). The global prevalence of OSA is estimated to be 54% and the highest prevalence is found in middle‐aged men, with women being more susceptible after menopause (de Araujo Dantas et al. 2023). Significant risk factors for OSA are obesity, diabetes type 2, smoking, and hypothyroidism (Senaratna et al. 2017). Untreated OSA increases the risk for hypertension [HT], cardiovascular diseases [CVD] and diabetes type 2 (De Vega Sanchez et al. 2017). Positive Air Pressure [PAP] treatment is the first‐line treatment for OSA patients. PAP treatment reduces sleep‐related upper airway obstructions by delivering positive airway pressure through a mask that covers the nose, mouth, or both (Patil et al. 2019) with or without a humidifier (Palm et al. 2018). To achieve sufficient PAP treatment effect, the patient must adhere to the treatment at least 4 h/night (Chaplin and Ward 2022; Fujita et al. 2024). Professionals responsible for initiating and following up on the treatment deal with various critical situations and must possess expertise in medical, technical, and behavioural areas (Karlsson et al. 2015).

In Swedish clinical practice, OSA diagnosis and PAP treatment are managed by a multiprofessional team often consisting of physicians, nurses, and biomedical scientists. Even though the condition of the oral cavity and upper airway is integral to both general and oral health (Glick et al. 2016), oral health professionals are seldom involved in this team. The lack of oral healthcare expertise may be a weakness as oral health‐related symptoms, such as oral dryness, are common in both untreated (Makeeva et al. 2021) and PAP‐treated OSA patients (Maniaci et al. 2024; Pico‐Orozco et al. 2020). Oral side‐effects such as gingival bleeding and halitosis can appear at the beginning of treatment and may also occur or worsen throughout the treatment (Tsuda et al. 2016; Ulander et al. 2014) and periodontitis has been reported in individuals with severe OSA (Arango Jimenez et al. 2023). Furthermore, oral dryness can negatively affect adherence to PAP treatment (Park et al. 2017; Patil et al. 2019) and patients with long‐term experience of PAP treatment experience both negative effects such as oral dryness and orofacial pain, and positive effects such as reduced xerostomia (Ahonen et al. 2022).

OSA patients require tailored treatment based on their specific needs, personal characteristics, orofacial structures, and conditions (Bonsignore et al. 2019; Fujita et al. 2024). Medical professionals involved in PAP treatment, who often possess expertise in both medicine and nursing, are usually well equipped for the task but may lack knowledge or experience in oral health‐related symptoms that may affect therapeutic adherence in PAP‐treated OSA patients (Broström et al. 2018). Since oral health is an integral part of general health and includes surrounding orofacial structures (Glick et al. 2016), understanding oral health in untreated and PAP‐treated OSA patients is essential for creating optimal treatment conditions. OSA is a condition requiring ongoing treatment, and previous studies have shown that oral health‐related symptoms can be a concern for patients (Ahonen et al. 2022; Nordin et al. 2016; Pico‐Orozco et al. 2020; Ulander et al. 2014). Even if Sweden's adult population often attends regular dental check‐ups (The National Board of Health and Welfare 2024), an enhanced understanding of oral health symptoms can increase adherence, guide future interventions, and improve collaboration among different professions. Therefore, studying PAP professionals who manage these patients is highly relevant. From our perspective, this study is the first qualitative study, in this case conducted in a Swedish PAP setting, to describe PAP professionals' experiences regarding management and treatment effects on oral health in OSA patients with or without PAP treatment. Previous research on oral healthcare professionals' experiences with OSA and oral health has identified knowledge gaps, highlighting the need for increased awareness and collaboration between oral health and medical care professionals (Berggren et al. 2022). In this study, the aim was to describe PAP professionals' experiences and management of symptoms and treatment effects on oral health in patients with OSA before and during PAP treatment.

2. Material and Methods

A qualitative, explorative inductive approach was used for the data collection where data was analysed by content analysis (Lindgren et al. 2020). The Consolidated Criteria for Reporting Qualitative Research (Tong et al. 2007) elements were considered when the study was planned, conducted, and completed.

2.1. Participants and Sampling

Registered physicians, registered nurses, and biomedical scientists involved in PAP treatment were eligible for participation. A strategic selection of participants, as described by Kvale et al. (2014), was conducted in two steps. First, seven PAP professionals working at geographically nearby clinics were contacted. Secondly, 19 participants were identified in the nationwide Swedish Sleep Apnea Register [SESAR] (SESAR 2021) with the intention to strategically include participants of various professions, ages, and sexes working at clinics of various sizes. The participants were contacted by e‐mail with information about the study. Of the 26 invited PAP professionals, 17 agreed to participate at nine sleep apnea clinics in Sweden, as shown in Table 1.

TABLE 1.

Overview of the study sample characteristics (n = 17).

Participants Physicians Nurses Biomedical scientists
Profession (n) 4 11 2
Women (n) 4 9 2
Men (n) 2
Oral health education No No No
Years since graduation (md, min–max)

md 13.5

min 6

max 22

md 26

min 23

max 36

md 22

min 4

max 40
Experience in PAP care. Years (md, min–max)

md 10.5

min 2

max 19

md 7

min 1

max 27

md 2.5

min 2

max 3
Workplace

  1. Small‐size clinic

 4 6 2
  • B

    Medium‐size clinic

 3
  • C

    Large‐size clinic

 2
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Note: (A) Small‐size clinic (Clinics with 0–249 OSA patients/year), (B) Medium‐size clinic (Clinics with 250–600 OSA patients/year), (C) Large‐size clinic (Clinics with > 600 OSA patients/year).

2.2. Interview Procedures

The semi‐structured interviews were conducted from October 2022 to April 2023. An interview guide with 24 open‐ended questions followed by probing questions was used to obtain an in‐depth understanding of the participants' experiences of oral health‐related symptoms as both treated and non‐treated OSA patients. The session started with questions about the participants' education, graduation year, and work experience in OSA and PAP care. To get a wide variety of experiences from the participants and rich descriptions of these experiences, a vignette technique was used (Azman and Mahadhir 2017). Three fictitious scenarios were constructed based on the authors' subject area, oral health (K.B., H.A., U.L.) and OSA (A.B, O.S), where text and photographs describing oral health‐related symptoms in patients with untreated and PAP‐treated OSA were used to stimulate participants' recall of their experiences (Appendix A). The participants received time to read and reflect upon the three scenarios before the interviews began. By using follow‐up questions such as ‘Do I understand you correctly?’, and ‘Can you explain this more?’, credibility was ensured. Two pilot interviews (face‐to‐face) were performed to test the scenarios and the interview guide. No changes were needed, and the pilot interviews were included in the study. As the rest of the participants were scattered across Sweden, the remaining interviews were conducted via a digital meeting room with camera and sound. Before the interviews started, each participant was given a verbal, transparent, detailed description of the study to ensure trustworthiness. The interviews ranged in duration from 25 to 40 min and were recorded with an external dictaphone and continued until no further information could be obtained. The interviews were transcribed verbatim by the first author (five interviews) and by a professional transcriber (12 interviews).

2.3. Data Analysis

Data analysis was performed using content analysis as described by Lindgren et al. (2020). The analysis aimed to identify variations and patterns by interpretation and abstraction in different steps, seeking to extract manifest content with an underlying latent message. First, the transcript (total 147 A4 pages, 74,007 words) was read several times by the first author [K.B.] to obtain familiarity with the content and find meaning units. The identified meaning units were condensed by removing repetitions and unnecessary words while preserving the content of each unit. Next, the condensed meaning units were coded in words close to the original text. By sorting codes related to the study aim, two of the authors [K.B. & H.A.] categorised the data into subcategories and categories, describing PAP professionals' experiences and management of symptoms and treatment effects on oral health before and during PAP treatment. The analysis process was discussed repeatedly among the multidisciplinary author group until consensus was achieved. Finally, categories with subcategories reflecting the interviews were established. Quotations were selected to strengthen the content of each subcategory.

2.4. Ethical Considerations

According to guiding documents from the Swedish Research Council (2024), a study carried out on health care personnel, not focusing on ethically sensitive aspects, does not need ethical approval. All participants received written and verbal information about the study, and written consent was obtained. The interview questions were based on professionals' experiences, and no personal data regarding third parties were collected. Only the interviewer knew the participants' identities, while the other authors worked with deidentified data transcripts. All data were stored on a safe, password‐protected hard drive at the university where the study was conducted. The presentation of text in the results and the selection of quotations were implemented in such a manner to decrease the risk of identification of the participants. The guidelines for medical research involving human subjects in the Declaration of Helsinki were followed (World Medical Association 2013).

3. Results

Of the 17 PAP professionals (11 nurses, four physicians, and two biomedical scientists) interviewed, experience in PAP care ranged from one to 27 years. None had further education in dental care (Table 1). The findings are presented in four categories and 10 subcategories, including quotations related to before (Figure 1) and during PAP treatment (Figure 2).

FIGURE 1.

FIGURE 1

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Categories, subcategories, and examples of quotations concerning oral health‐related experiences before PAP treatment, as described by PAP professionals (n = 17).

FIGURE 2.

FIGURE 2

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Categories, subcategories, and examples of quotations concerning oral health‐related experiences during PAP treatment, as described by PAP professionals (n = 17).

3.1. Experiences and Management of Oral Health Before PAP Treatment

As shown in Figure 1, the categories Acknowledging oral health aspects when exploring the clinical data and Exploring oral health‐related experiences were integral to the first meetings with the patient before PAP treatment.

3.2. Acknowledging Oral Health Aspects When Exploring the Clinical Data

Predominantly, experiences from physicians were based on the initial patient meeting, i.e., the clinical examination, when deciding and providing the diagnosis and initiating the treatment. Nurses and biomedical scientists mostly described their experiences based on patients' medical records.

3.2.1. Visual Inspection of the Orofacial Complex

The visual inspection consisted of a nasal and oral overview by the physicians, focusing primarily on the oral mucosa, tonsils, and anatomical deviations that may affect the airflow through the upper airway. Deviation markers such as a red, dry tongue could potentially be addressed through alternative blood sampling methods or tests for Sjögren's syndrome. The physicians said that in their experience, most patients with OSA have regular dental public care contact like any other patient group. However, patients with poor oral health status often felt ashamed to open their mouths when asked. The physicians experienced that patients with adequate oral health habits were generally more open to discussing their overall dental status. Physicians described how they could observe patients and inform them about the condition of their teeth, regardless of the patient's oral health status.

3.2.2. Lack of Information Related to Oral Health

Dental status was mostly examined when an oral appliance was considered a treatment option. The dental examination was not seen as necessary when the patient was more likely to need PAP treatment. The physicians' main focus was not the patient's oral health, but they described how they had observed that poorer dental status was linked to financial constraints and was often not prioritised by the patients, even when they recommended the patient seek dental healthcare. In the medical record, physicians primarily focused on information about OSA diagnoses and further treatment, and oral health was described in less detail. As nurses and biomedical scientists in PAP care do not examine the patient's oral health, the medical records provide important information from both an OSA and an oral health perspective.

3.3. Exploring the Patient's Oral Health‐Related Experiences

Common oral health‐related experiences of untreated OSA, recognised by the PAP professionals before PAP treatment, were oral dryness, nasal congestion, and mouth breathing. Despite this, a lack of or limited overall routines for addressing questions or providing information about oral health was described. In addition, participants perceived themselves to have limited knowledge about the relationship between OSA and oral health.

3.3.1. Relying on What the Patient Shares About Oral Health

Nurses and biomedical scientists said that information on oral health was seldom mentioned in the medical record notes made by physicians. The participants described routines that involved asking the patient about comorbidities, but these seldom included oral health‐related symptoms. When they inquired about general health and medications, patients frequently attributed their oral dryness to the medications they were taking. The participants also reported that patients mentioned experiences of oral dryness as a problem in the morning, and some expressed concerns about potential tooth damage caused by this condition. By actively listening to the patient's description, symptoms such as discomfort in the throat, nasal congestion, and oral dryness could nevertheless be identified. The realisation that questions about oral health were not addressed was experienced as an embarrassment by the participants and was described as something that should be considered a natural part of their work. There was uncertainty about who in the team (physicians, nurses, or biomedical scientists) should be responsible for addressing and handling oral health‐related symptoms.

3.3.2. Noticing the Unspoken Signs of Mouth Breathing

Nurses and biomedical scientists said that observations of mouth breathing during the conversation with the patients were part of the nursing process. Mouth breathing during the day was associated with mouth breathing at night and was considered a sign of snoring. Oral dryness was something silently accepted by both the participants and, they sensed, by the patients. The association between snoring and oral dryness in the morning was recognised as a sign of OSA.

3.3.3. Reflecting on a Causal Relationship Between OSA and Oral Health

PAP professionals lacked experience of the harmful effects of oral dryness on the teeth, even though they expressed an understanding of its potential impact. Oral dryness was mostly linked to causes other than OSA, such as medications or diseases, including Sjögren's syndrome. The relations between OSA and comorbidities such as CVD and diabetes type 2 were well understood, but not the link between OSA and oral health. Comorbidity with other diseases was considered an important factor when initiating PAP treatment, especially for younger patients. On the other hand, participants described the long‐term effects of PAP treatment on overall health and its impact on oral health, as well as its potential implications for PAP treatment. The experience was that OSA patients went for regular dental check‐ups more frequently than they visited healthcare facilities. The participants reported a lack of knowledge and perceived that oral and dental symptoms were not easy areas to address in healthcare. Overall, the goal was to advise on PAP treatment and assist in selecting appropriate masks to effectively manage OSA, rather than to handle oral health‐related symptoms.

3.4. Experiences and Management of Oral Health During PAP Initiation and Follow‐Up Visits

The appointment focused on the diagnosis and management of OSA‐related and oral health‐related symptoms during PAP initiation and follow‐up visits. As shown in Figure 2, the two categories Adjusting the PAP device related to oral health and Managing oral health‐related situations describe the start and ongoing PAP treatment as well as the cooperative management of oral health‐related symptoms and situations.

3.5. Adjusting the PAP Device Related to Oral Health

The PAP professionals uniformly recognised oral dryness to be a common problem both in untreated and PAP‐treated patients. Their main object was to initiate PAP treatment and to find a suitable mask to minimise the risk of mask leakage. They also recognised the need to prevent oral dryness. Therefore, most participants used PAP devices with humidifiers. Meticulous mask fitting was also recognised as a strategy to prevent or treat oral dryness; mask leakage was recognised to be a major risk factor for poor compliance with the PAP treatment.

3.5.1. Identification of Orofacial Markers When Adjusting the Mask

The choice among PAP mask alternatives depended on oral health‐related factors such as nasal congestion, mouth breathing, facial anatomy and dental prosthetics. The functional aspect was recognised as crucial to the effectiveness of the treatment. The PAP professionals described experiences of patients adjusting the mask too tightly, which resulted in marks on the face but also pain in the mandible and teeth. Mask replacement was often needed to reduce oral dryness to achieve optimal treatment. During mask testing, the patient could say whether they had a prosthetic replacement such as a partial or full prosthesis, but no specific inquiries were made regarding this aspect. The experiences concerning how prosthetic replacements could affect the orofacial anatomy and mask fitting varied, resulting in differences in the choice of PAP masks, with some participants being more aware of the impact of prosthetic replacement than others.

3.5.2. Utilising Humidifiers to Decrease Oral Dryness

The participants revealed that it was common to recommend a humidifier, while for others, the humidifier was introduced at a later stage and only for patients with a dry mouth. The reason for the delayed integration of the humidifier was its perceived high cost. Taking measures to optimise the humidifier and recommending the use of products to moisturise the oral and nasal mucosa were common strategies to increase PAP treatment adherence. Other experiences and reflections concerned how to maintain a humidifier with the correct moisture setting and mask hygiene, which was an important aspect of well‐functioning PAP treatment. Humidifiers were described as being effective in preventing oral dryness, but they could also aggravate symptoms of dry mouth. The PAP professionals also observed that patients with oral dryness before PAP treatment had specific expectations that the moisturising effect of the PAP treatment would improve this condition.

3.6. Managing Oral Health‐Related Situations During PAP Treatment

The participants described oral health‐related symptoms as challenging. Mostly, those challenges were associated with the patient's expectations of PAP treatment related to oral comfort and how to advise on oral health.

3.6.1. Identifying Oral Health‐Related Challenges

The participants reported that patients often described tough and slimy saliva, a problem usually present even before treatment began. An increased need to swallow saliva in the morning was more commonly experienced by older patients than younger ones. Although patients did not report bad breath, the participants reflected on the link between dry mouth and halitosis. However, many patients complained of a bad taste in the mouth, which the professionals associated with the humidifier water, so they recommended bottled water instead of tap water. Oral health symptoms were rarely observed, except for periodontitis. The participants considered it the patient's responsibility to make regular public dental care visits. Rare findings such as tongue sores or angular cheilitis were occasionally noted, and patients were advised to consult a physician or dentist if observed.

3.6.2. Talking About and Giving Advice on Oral Health‐Related Symptoms

The participants perceived that their ability to alleviate or cure oral dryness was limited and often deficient. In addition to ambitious mask fitting, the use of PAP devices with humidification, and applying moisturisers to the nasal‐ and oral mucosa, patients could be referred to dental care. Other recommendations could be to have a glass of water beside the bed and to use saliva‐stimulating products. Patients with habitual mouth breathing during the night could be recommended to sleep in a non‐supine position. Experiences with poor mask hygiene and concerns about poor oral health were commonly expressed. However, they found it challenging to discuss these issues with patients; these discussions were therefore often avoided. For example, it was experienced as easier to talk about a patient's overweight than oral health‐related challenges such as tooth brushing. However, the experiences of the efficacy of PAP treatment with or without a humidifier varied. They expressed a need for more knowledge in the field to give patients better care regarding oral health.

3.6.3. Identifying the Need for Increased Cooperation

There was a sense of responsibility for oral health among the participants. When unexpected symptoms, such as a sore or more severe oral health‐related symptoms than oral dryness, were observed, consulting colleagues or dental care was a natural course of action. At present, addressing oral health‐related questions was difficult due to their lack of knowledge. Education and cooperation with public dental care were seen as valuable and much‐needed alternatives. The desire for cooperation was essential for achieving optimal, person‐centred care; but implementing it in practice posed a challenge. There was also an understanding that not all patients could undergo oral health examinations before PAP treatment, and the ability to identify at‐risk patients was considered important.

4. Discussion

This study aimed to describe PAP professionals' experiences and management of symptoms and treatment effects on oral health in patients with OSA before and during PAP treatment. Before PAP treatment, the professionals described the OSA diagnosis procedure, intra‐oral visual features, and shared signs between OSA and oral health. During the PAP treatment, the professionals expressed oral health‐related challenges in patient collaboration and individualised PAP treatment. Awareness of oral dryness was common before and during PAP‐treated OSA, a finding consistent with previous studies identifying it as a side effect of both OSA and ongoing PAP treatment (Ahonen et al. 2022; Tsuda et al. 2016; Ulander et al. 2014). However, routines for addressing oral health‐related questions were deficient both before and during the PAP treatment. Experiences of how untreated or PAP‐treated OSA affects oral health, and connections between oral and general health, were lacking. The findings in this study regarding a knowledge gap and lack of cooperation were also identified in a previous study by Berggren et al. (2022) but from the dental care professionals' perspective.

Insights into and strategies for addressing oral health before PAP treatment were based on the information shared by the patient and the PAP professionals' previous experiences. Oral dryness was confirmed and well known as a natural symptom of OSA and a side effect of PAP treatment. A key issue for the professionals was the lack of routines regarding oral health‐related symptoms, such as oral dryness, and uncertainty about how and who should address this condition. The OSA diagnosis and choice of treatment were based on the Swedish guidelines, and a more extensive assessment of the patients' dental status was mainly performed when an oral appliance was considered as a treatment option (The National Board of Health and Welfare 2024). Thus, when PAP treatment was considered, oral health was given less priority. According to the participants, the medical record, which should focus on patient information, often provides only superficial details about oral health, leaving nurses and biomedical scientists uninformed about the patient's oral health status. This feeling of uncertainty extended to unclear responsibilities and roles within the team regarding oral health, which the participants themselves associated with obliviousness. According to the Sunnybrook framework for interprofessional teams, involving professionals and patients, role clarification and communication are essential for safe and effective care (McLaney et al. 2022). In the current study, the PAP professionals described patient‐reported oral dryness and throat discomfort as common symptoms. Person‐centred care requires a supportive environment and effective system management, including thorough documentation, to establish necessary routines, making medical records a crucial communication tool in this context (McCormack and McCance 2021). Although oral health was not thoroughly documented in the medical record, there was awareness of the well‐established benefits of PAP treatment.

PAP professionals' experiences and strategies during the initiation and follow‐up visits were essential for ensuring patient adherence and effectively reducing long‐term cardiovascular risks. As PAP treatment is the gold standard for OSA (Patil et al. 2019) the professionals were aware of the negative impact of untreated OSA on general health and the benefits of effective PAP treatment. This approach aligns with Bonsignore et al. (2019), who emphasised the role of PAP in preventing metabolic and cardiovascular diseases. Their primary focus was to ensure a comfortable mask fit to improve adherence, aiming for the recommended minimum of 4 h/night. Based on the patient's facial structure and breathing patterns, appropriate masks were selected; however, less attention was given to oral prosthetic replacements, which can impact mask functionality (Park et al. 2017). A proper mask fit is essential to avoid leakage (Patil et al. 2019), highlighting the need to discuss oral health status before and during PAP treatment, as oral health can change over time (Glick et al. 2016).

Besides oral dryness, uncertainties about how OSA and PAP treatment affected the patients' oral health were described. Even if the patients had described periodontal problems and changed saliva during PAP treatment, the professionals had taken limited action. One reason could be the assumption that PAP‐treated OSA patients visit public dental care services regularly for oral health examinations, treatments, and advice. Although most of Sweden's adult population attend regular dental check‐ups (The National Board of Health and Welfare 2024), the results of the current study indicate a risk that some patients may not receive the oral healthcare they need, particularly concerning untreated or PAP‐treated OSA. A recently published interview study (Berggren et al. 2022) revealed that dental professionals had limited knowledge of the relationship between PAP‐treated OSA and oral health‐related symptoms, even though oral dryness was addressed regardless. This highlights the need for increased knowledge about the relationship between oral health and PAP‐treated OSA for dental and PAP professionals. Thus, the findings of this study were in line with Berggren et al. (2022) regarding the identified need for increased collaboration between PAP and oral health professionals, which could positively influence the care of patients. Oral healthcare professionals can play a crucial role in identifying OSA patients through screening instruments (Kale et al. 2018). Similarly, PAP professionals can be a valuable resource in identifying and managing oral health‐related symptoms. Studying self‐reported functional limitation, discomfort, and disability attributed to oral conditions (Larsson et al. 2004) could also be useful for identifying oral health‐related quality‐of‐life aspects in a clinic and a research context in OSA and PAP‐treated patients.

The collaboration and access to oral healthcare professionals were not always apparent, although there were reflections on the possibility and willingness to collaborate. Thus, to support patient adherence, identifying oral symptoms such as oral and nasal dryness and swallowing difficulties before or during PAP treatment is essential. Given the benefits of PAP use, symptoms such as oral dryness (Ahonen et al. 2022) and PAP‐mask‐induced skin impressions may indicate reduced adherence. Based on the experiences of the participants in this study, oral dryness could lead patients to discontinue PAP treatment, as previously reported (Karlsson et al. 2015; Ulander et al. 2014). Although routines for managing common symptoms like oral dryness were uncommon, the PAP professionals mentioned offering superficial advice, such as using lubrication products or adjusting the humidifier. In the event of extensive oral health‐related symptoms, like mouth sores, a physician or dentist was always consulted. Recommendations to seek advice from a pharmacy for oral dryness were commonly expressed. However, a study revealed that pharmacists desired more training regarding managing oral health conditions such as oral dryness (Mann et al. 2015).

Given the current study's overall results, the PAP professional's role concerning oral health‐related areas needs to be clarified, particularly regarding routines and responsibilities for managing oral health‐related symptoms before and during PAP treatment. Oral dryness is a well‐known side effect for both untreated and PAP‐treated OSA patients, potentially impacting everyday functions such as talking, smiling, breathing, and swallowing (Glick et al. 2016). By enhancing their specific knowledge of oral health, implementing routines and identifying patients with risk factors, collaboration and person‐centred care can be significantly improved.

4.1. Strengths and Limitations

As the study used a nationwide geographic sample derived from nine PAP clinics of varying sizes, including 17 PAP professionals (i.e., comprising four physicians, 11 nurses and two biomedical scientists) with a wide range of experience in PAP care, the sample is considered to reflect the wider population of Swedish PAP professionals. This also increased the credibility and the transferability of the study (Graneheim et al. 2017). The qualitative method used in this study made it possible to capture the PAP professionals' own experiences regarding oral health‐related symptoms in untreated and PAP‐treated patients through in‐depth interviews. However, even if the sample reflects variations among Swedish PAP professionals, the specific findings in the result might be limited to the Swedish PAP context as healthcare systems and practices may vary across countries. By using a digital interview platform, a large geographical area was reached, which was both time‐efficient and useful in the fictitious patient cases where the computer screen was shared. The use of three different scenarios gave a high recognition factor, which strengthened the credibility. In this study, combining vignettes with the interview guide helped to identify symptoms and knowledge gaps in this field. Using a qualitative AI‐based software was considered an option for the coding. However, we chose to analyse the data manually, using a step‐by‐step procedure in line with content analysis (Lindgren et al. 2020). Beforehand, to avoid bias in the analysis, the preunderstanding among all involved researchers was discussed. The main analysis was conducted by two persons in the research team. Using a step‐by‐step procedure including repeated discussions in the multidisciplinary author group on how to interpret the data limited bias and ensured rigorous conclusions. These actions contributed to increasing the trustworthiness of the results (Graneheim et al. 2017).

4.2. Clinical Implications

This study highlights the challenges faced by PAP professionals in untreated and PAP‐treated OSA patients. The findings can contribute to having clinical implications such as:

  • Increasing knowledge regarding oral health‐related symptoms linked to untreated and PAP‐treated OSA among PAP professionals.

  • Establishing routines regarding questionnaires to identify patients at higher risk for oral health‐related symptoms.

  • Assisting the development of structured routines related to oral health, outlining when and how PAP professionals seek assistance from one another.

  • Improving collaboration between PAP professionals and oral healthcare professionals to assess at‐risk individuals, thereby improving oral health and promoting stable compliance with PAP treatment in OSA patients.

5. Conclusions

Oral dryness was a known symptom before and during PAP treatment, while oral health‐related routines were lacking for identifying symptoms and assessing treatment effects. Knowledge gaps in managing oral health situations and a need for increased collaboration between health and public dental care were pronounced among PAP professionals.

Author Contributions

K. Berggren: conceptualization, data curation, formal analysis,writing – original draft, methodology, investigation, funding acquisition, project administration, visualization. H. Ahonen: conceptualization, formal analysis, methodology, supervision, writing – review and editing. U. Lindmark: conceptualization, supervision, writing – review and editing, methodology, validation. A. Broström: conceptualization, supervision, writing – review and editing, methodology, validation. O. Sunnergren: conceptualization, supervision, writing – review and editing, methodology, validation.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

On behalf of the authors, we would like to thank the study participants, who made this study possible.

Appendix A.

Example one of the three patient cases.

Patient Case 1: Referral for Respiratory Recording.

Your next patient is Marita. Today is your first consultation with her.

Marita is a 60‐year‐old woman who is short and significantly overweight. You notice she is breathing heavily after the short walk from the waiting room couch to the examination room.

Marita has been married for 35 years. She took early retirement 1 year ago as her job in retail had become too physically demanding.

Her medical record indicates that she has had high blood pressure for 8 years and experienced a blood clot in her right eye 3 years ago.

The referral states that Marita feels particularly tired in the afternoons and often takes'a little na'.

‘My husband says I snore a lot. He has also noticed that I sometimes stop breathing during the night, which he finds concerning. That is why I sought treatment and have been referred to you. My most bothersome symptom is my dry mouth when I wake up. I take good care of my teeth and have invested a lot of time and money in them over the years.’

You observe that Marita has dry lips. You note a dry oral mucosa and suspect a dry mouth when she yawns.

Note: The photo was removed for ethical reasons. The image depicted a red tongue and dry lips.

Berggren, K. , Ahonen H., Lindmark U., Broström A., and Sunnergren O.. 2026. “Clinical Insights Regarding Oral Health Among Untreated and Positive Airway Pressure Treated Obstructive Sleep Apnea Patients.” Journal of Sleep Research 35, no. 3: e70179. 10.1111/jsr.70179.

Funding: This work was supported by the Forskningsrådet i Sydöstra Sverige (FORSS‐977649).

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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