Treatment options for obstructive sleep apnea

I read with great interest the letters from Drs. Rotenberg and Pang, who are proponents of ear, nose and throat surgery for sleep apnea,¹ and from Dr. Cheryl Laratta and colleagues,² who maintain that continuous positive air pressure (CPAP) remains the gold standard and first choice of treatment for this “epidemic” sleep disorder, in response to the recent review article in CMAJ.³ Obstructive sleep apnea affects about 50% of Canada’s over-50 population.³

As the then director of member services for the British Columbia Dental Association, I was tasked with reviewing the proposed standards and guidelines of the College of Dental Surgeons of BC in the spring of 2013 for the prescribing, fabrication, fitting and titration of mandibular repositioning appliances for the treatment of obstructive sleep apnea. I quickly discovered that the proposed regulatory rules I was reviewing followed standards and guidelines similar to those that were being formulated by the College of Physicians and Surgeons of British Columbia and by a committee of the American Academies of Sleep Medicine and Dental Sleep Medicine. I urge all practising physicians, surgeons and dentists to read the latter’s seminal guideline published in the Journal of Clinical Sleep Medicine.⁴

Based on current data, undiagnosed or untreated obstructive sleep apnea in our senior population may be double that of untreated type 2 diabetes. As it is not adequately treated with either CPAP (because of noncompliance) or surgical interventions (as a result of cost, morbidity, questionable long-term success and other considerations), an obvious first choice is a physician-prescribed, customfitted, titratable mandibular repositioning appliance.⁴ It is recommended⁴ that the oral appliance therapy is followed up by both the dental surgeon who must fabricate the device and the physician who prescribed it.

Since retiring from the British Columbia Dental Association in late 2013, I have returned to “semi-retired” practice as a general practice physician and dentist, and I have been trained to fabricate an approved mandibular repositioning appliance. I have fabricated, inserted and titrated some 70 such appliances in the past four years, and have no “failures” of compliance to date (to my knowledge), but many satisfied patients. Patients with severe obstructive sleep apnea who must at least attempt to adapt to CPAP or bilevel positive airway pressure treatment are still referred to my respiratory therapy colleagues, and I have also seen a few patients who have undergone successful surgical correction with upper airway anatomic disorders to relieve severe obstructive sleep apnea. I work closely with the qualified “sleep specialist” physicians at our local hospital.