eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Palatal & Maxillofacial Surgery
Snoring and Obstructive Sleep Apnea, Prosthetic Management
Updated: Aug 26, 2009
Introduction and Physiology
Sleep-disordered breathing (SDB) is characterized by repetitive upper airway obstruction and consequent oxyhemoglobin desaturation during the deeper stages of sleep. The proposed etiology is a combination of both abnormal upper airway anatomy and a yet-to-be determined aberrant afferent/efferent somatosensory loop.
The health-related consequences of sleep-disordered breathing (SDB) are well documented by large prospective cohort studies and chiefly include hypertension, myocardial infarction, stroke, diabetes, depression, excessive daytime fatigue, and a greater risk of motor vehicle accidents. These associated medical problems place an enormous financial burden on society. Because of the high prevalence of this condition, cost-effective management is essential.
Fortunately, a number of viable options are available. The most common initial treatment for sleep-disordered breathing (SDB) is a continuous positive airway pressure (CPAP) device. CPAP is effective only for patients who can tolerate the device and, unfortunately, affords no permanent cure. Surgical intervention is an alternative form of treatment and involves anatomical reconstruction of the airway. Although more expensive from the outset, it has long-lasting effects because it results in a permanent alteration of the airway.
Illustration of the intraoral placement of 3 pillar implants in the soft palate.
CPAP devices can prove annoying and discomforting to many patients, and, for some patients, may be entirely intolerable. Additionally, the prospect of surgery may not appeal to all patients. Prosthetic devices are available as effective and low-cost treatment options for those patients that cannot tolerate CPAP and do not wish to undergo surgery.
Although primary hypoventilation may be an underlying cause of sleep-disordered breathing (SDB), the most important factor is the anatomy of the upper airway. In general, obstruction of the airway may be found at 3 primary sites (ie, nose, velopharynx, hypopharynx). During normal awake respiration, the obstructive tendency of the negative inspiratory pressure within the upper airway is balanced by the outward force of pharyngeal dilator muscle activity under central nervous system control. Reduction of tone in this musculature and loss of compensatory reflex dilator mechanisms during deep sleep result in the pathologic obstruction. Snoring, a common symptom of sleep-disordered breathing (SDB), is a repetitive sound caused by vibration of upper airway structures during sleep. Snoring is a good indicator of increased upper airway resistance.
Patients who have obstructive sleep apnea generally have smaller upper airways than normal individuals. Increased parapharyngeal fat, a large tongue, an elongated palate, thickened lateral pharyngeal walls, as well as maxillofacial skeletal deficiencies may all play a role. Lateral pharyngeal wall encroachment by the peritonsillar pillars and tonsillar tissue is also an important etiology of obstructive sleep apnea. This tissue bulk may direct the airway anteroposteriorly, as opposed to the normal lateral orientation, forcing the pharyngeal muscles to act at a disadvantage. Greater pharyngeal length increases collapsibility, which may explain why men are more susceptible to obstructive sleep apnea than women.
Hundreds of devices have been patented for treatment of snoring and sleep apnea, with the intent of directly or indirectly opening the airway. This article discusses general principles involved and primarily discusses the most effective prosthetic devices in controlling sleep-disordered breathing (SDB), which are adjustable oral appliances (OAs).
Presenting signs and symptoms/physical exam ination
- Signs
- Increased body mass index in about 75% of patients
- Increase in blood pressure
- Increased neck circumference and waist-hip ratio
- Symptoms
- Loud snoring or struggling efforts to breathe, often reported by sleep partner
- Choking episodes during sleep
- Awakening with early morning headaches
- Chronic fatigue, feeling of drowsiness, or needing frequent napping during the day
- Depressed mood
- Falls or automobile accidents, in serious cases
- Bedwetting in children
- Nocturia (rare)
- Exam
- Elevated BMI, hypertension, and large neck circumference
- Upper airway exam to evaluate for a low hanging bulky soft palate, large tonsils, large tongue, dental malocclusion, low hyoid position, or maxillo-mandibular deficiency
- Summary of tests
- Polysomnography (testing in a sleep laboratory) is the gold standard test used to establish the diagnosis.
- The multiple sleep latency test (MSLT) is used to establish how rapidly the patient falls asleep, to distinguish from narcolepsy.
- The Epworth Sleepiness Scale is a questionnaire used to screen for sleep apnea that relies on the patient's description of symptoms.
- Lateral cephalometric radiographs reveal the dimensions of the airway column, the position of the hyoid bone, and the craniofacial skeleton for any maxillomandibular deficiencies.
- Flexible fiberoptic nasopharyngoscopy examines in real-time the 3-dimensional structure of the airway revealing any anatomic sites of obstruction.
Positioning and Nasal Airway
Positioning of the patient during sleep is a useful method to control simple snoring. Snoring is often resolved when the patient assumes a nonsupine position. The physiology is intuitively simple: the soft palate and tongue fall posteriorly due to gravity and relaxation of the genioglossus. When the mouth opens, the tongue is even more retrodisplaced. Airway obstruction results in subsequent oxyhemoglobin desaturation if apnea occurs. The effect of positioning is demonstrated by polysomnogram, which usually shows more frequent and severe disordered breathing events when the patient is supine.
In mild cases, nonsupine positioning may relieve the obstruction. The classic remedy of attaching a tennis ball to the back of the individual's pajamas actually may help some patients. However, most patients with significant sleep-disordered breathing (SDB) show apnea in all positions; thus, this technique is seldom useful for patients with more than simple snoring.
A snoring pillow may help some patients with snoring problems. Used appropriately, it positions the head so that the mouth is closed and the jaw is held forward. Unfortunately, movement during sleep minimizes the pillow's effectiveness.
In the normal airway, the limen nasi is the site of the highest resistance to airflow. Collapsed alae, a severely deviated septum, or hypertrophied turbinates may affect airflow substantially. Nasal valve surgery has been demonstrated to improve snoring for many patients whose primary problem is nasal airway obstruction.
Although surgical therapy is effective for treating nasal valve obstruction, devices that splay the alae (externally or internally) have also demonstrated success in improving nasal airflow and decreasing snoring. Studies disagree on whether significant improvement occurs. Although anecdotal reports describe patients whose sleep apnea may have been controlled by alar splaying devices, no statistical difference in patients using the devices compared with controls has been demonstrated. These devices are benign, inexpensive, and available at any pharmacy. For patients with minimal problems and noticeable nasal airway obstruction, devices that splay the alae are easy to obtain and test.
Nasal trumpets may be useful for short-term management in select patients. Trumpets are commonly used in postanesthesia airway management. They bypass any nasal, soft palate, and, often, tongue base obstructions. However, few patients are willing to use the trumpets nightly to control sleep-disordered breathing (SDB).
Oral Appliances
Patients with significant sleep-disordered breathing (SDB) almost always have some component of soft palate or tongue base obstruction (typically both). A number of oral appliances (OA) have been developed over the years to treat snoring and obstructive sleep apnea. Wide varieties of OAs exist and are made to address the entire range of pathological processes resulting in apnea.
OAs can advance the soft palate, tongue, or mandible, thus opening the airway. Those that advance the soft palate seldom are employed, most likely because of gag, discomfort, and the success of laser and radio frequency soft-palate procedures. Probably for similar reasons, and because of the success of adjustable OAs, devices that advance the tongue alone rarely are used.
During obstructive apneas, the collapsed pharynx prevents airflow, which leads to continued negative pressure generated by respiratory efforts. The vicious cycle continues until the patient is aroused. Traditional devices work by downwardly rotating, and in some cases advancing, the mandible. By altering the position of upper airway structures, these devices serve to enlarge the airway and/or reduce collapsibility. OAs that fixate and/or alter the relative position of the mandible to the maxilla affect the pharyngeal soft tissues by increasing the airway space, stabilizing the mandible in an anterior and closed position, advancing the tongue, and increasing genioglossus muscle activity.
Variations in design include restricted elastic bands, clasps, or tubes for opening the mouth. These modifications act to relieve pressure and produce posterior extension of the maxillary component so as to modify the position of the soft palate or tongue. Dental impressions are generally required for mandibular advancing devices and anterior tongue retainers; however, prefabricated models can now be found. Proper fitting and alignment as well as regular patient follow-up are important components of therapy.
Compared to other treatment modalities, OA therapy has several advantages, including simplicity, reversibility, cost-effectiveness, and broad applicability for varying degrees of SDB. An OA can be used to treat simple snoring, upper airway resistance syndrome (UARS), and full-blown obstructive sleep apnea (OSA). OA therapy offers the most logical way to initiate treatment in most cases as it is readily accepted by most patients. It can also be used in conjunction with other forms of treatment.
To date, more than 40 different OAs have been patented. They can be divided into 2 basic categories, fixed OAs and adjustable OAs. Each group can be subdivided into noncustom devices (ie, mass produced/one-size-fits-all) and custom devices (ie, fabricated from specific patient impressions). While most appliances superficially appear similar because they share the same physiologic principles, they are actually quite different due to basic design features.
The advantages of OAs over other sleep apnea treatment options include relatively low cost, good success rates (efficacy comparable to uvulopalatopharyngoplasty [UPPP] but less efficacious than CPAP), increased rates of compliance (ranging from 50-100%, more preferred than CPAP), a more benign adverse-effect profile, rapid effect, and easy termination without sequelae. Additionally, OA insertion can be performed as a single-stage procedure in an outpatient setting. OAs are recommended for mild-to-moderate obstructive sleep apnea and in patients with BMIs less than or equal to 30 who fail or cannot tolerate CPAP.
A newer treatment option is the Pillar Palatal Implant system. Originally developed for the treatment of snoring, recent studies have demonstrated some efficacy in treating mild to moderate sleep apnea. This system involves the placement of three mesh polyethylene terephthalate implants, 18mmx2mm each, within the soft palate muscles under local anesthesia. These permanent implants improve snoring by stiffening the palate and decreasing its vibratory movement during inspiration.
Features Affecting the Success of Oral Appliances
Retention
Oral appliances (OAs) must fit accurately, comfortably, and remain in position all night. Some OAs are made of hard acrylics that wedge against the height of contour of each tooth. Rigid OAs periodically require realigning, which is a labor-intensive process. If the patient neglects realigning and continues to wear the device, movement and misalignment of teeth can occur.
Some appliances use orthodontic retentive mechanisms (ie, ball clasps, Adams clasps) that use undercuts on a select number of teeth. Since only a few, usually interproximal, areas are involved (typically 4 in each arch), movement of teeth frequently occurs.
Recently, heat-sensitive elastomeric materials have been used. These materials have proven to be the most effective in OA retention. They allow contact with more dental surface area, including undercuts and portions of interproximal areas resulting in a more uniform fit and higher rates of appliance retention.
Most noncustom OAs are made of soft boil-and-bite elastometrics that usually fail to maintain adequate retention for long when expected to attach to both maxillary and mandibular dentitions.
Although Pillar implants are a relatively newer modality, short term studies have shown good retention. One long term study demonstrated a 17.8% partial extrusion rate.
Adjustability
OAs should be able to variably adjust mandibular position. Many methods are available, such as interchangeable shims, incremental slots, and rotational mechanisms. Both shim and slot methods can be limiting due to the distance required of the mandible (seldom <1 mm and often 2 mm), which may initiate muscular and/or joint sensitivity. Increments this large may jeopardize clinicians' ability to optimize treatment.
Increased efficacy can be achieved with a rotational mechanism that allows for more precise positioning of the mandible.
Pillar implants are not adjustable, and once inserted should remain in place.
Adaptability
OAs must be adaptable to dentition changes (ie, fillings, crowns). Pillar implants are placed into the soft palate, near the junction of the hard palate. Consequently, they are adaptable to all patients without palate clefts or fistulas.
Factors that influence a positive outcome with OAs include younger age, lower BMI, smaller neck size, positional OSAHS, and lower AHI.
Indications And Contraindications
OAs are indicated for patients with the following:
- Simple snoring problems
- UARS
- Mild, moderate, or severe OSA
OAs are contraindicated for patients with the following:
- No dentition
- Limited dentition (highly dependent on number, placement, and condition of remaining teeth to anchor the device)
- Active dental disease
- Minimal protrusive range
- Childhood age
- Acute temporomandibular joint dysfunction (TMJD) symptoms (case-by-case basis)
- TMJD arthritis
- Obvious psychological aversion to structures in the oral cavity
- Moderately limited dexterity
- Limited mental capacity
Close collaboration with a dentist is recommended.
Tongue position and tonsil size can influence the success of the Pillar implants; however, no other contraindications have been identified to date.
Treatment Sequence and Associated Problems
Treatment begins with initial consult and examination. Acquire available dental records. Thoroughly instruct the patient in OA use and care and follow up in 2-4 weeks. An objective analysis of progress includes pulse oximetry and polysomnogram. Follow-up at 6-month intervals for as long as the OA is used is recommended to check status of the patient, dentition, and device.
Expected sequelae or problems
Some patients may be unable to tolerate OAs. Many develop temporary adverse sensitivities of teeth, mastication muscles, and TMJD. Consider these problems a normal part of insertion, adjustment, and removal transition phases that should improve with time. Temporary bite changes after removal of the device last 5-60 minutes. Such changes always should resolve in a reasonable time with no discomfort. Some patients experience increased salivary production. Individuals who breathe through their mouths often experience dry mouth.
Pillar implants may extrude over time, although the frequency of this occurrence is low (less than 1% according to the manufacturer). The inflammatory reaction that ensues after insertion usually binds the three implants together and stabilizes their positions permanently.
Possible adverse effects
Many unusual problems may develop with the fitting or use of an OA. Complications often are prevented from becoming significant issues by simple recognition of their possibility and appropriate response to initial complaints. Possible adverse effects include the following:
- Excessive salivation
- Temporary discomfort with initial use (typically subsiding with regular use and adjustment of fit)
- Temporomandibular joint (TMJ) discomfort
- Broken and/or loosened teeth
- Dislodgment of existing dental restorations
- Tooth movement
- Mouth sores
- Periodontal complications
- Root resorption
- Muscle spasms
- Otalgia
- Permanent change in bite (anterior migration of mandible)
- Ingestion of broken OA pieces
- Changes in occlusive alignment
- Xerostomia
Furthermore, the risk of worsening upper airway function (ie, worse apnea-hypopnea frequency), though rare, should be considered. Long-term consequences of oral appliance use are not well studied, but it is suggested that permanent tooth movement causing change in mandibular posture is common.
Adverse effects specific to soft palate implants include difficulty speaking or swallowing and ear or jaw pain, all secondary to initial post-procedural swelling. A foreign body sensation may also occur over time. These implants may also be extruded requiring replacement.
Conditions and situations affecting long-term oral appliance success
As weight increases, sleep-disordered breathing (SDB) symptoms intensify. With weight loss, SDB symptoms diminish. With age, muscles in the pharyngeal area atrophy, thus increasing obstruction. Congestion and sinus drainage contribute to nasal and pharyngeal inflammation, constricting the airway and aggravating SDB. CNS depressants and muscle relaxants may have a counterproductive sedative or relaxant effect.
Proper sleep hygiene is desirable, with 8 hours total sleep time considered optimal. Maintenance of a consistent sleep schedule also mitigates problems. Obstruction is more prevalent in a supine position. Environmental factors (eg, temperature, lighting, noise, comfort) affect quality and length of sleep.
Clinical Trials
Oral appliances
Oral appliances (OAs) find their greatest success when utilized for simple snoring, upper airway resistance syndrome (UARS), and mild-to-moderate obstructive sleep apnea (OSA). Improvement of snoring occurs in a high proportion of patients, with complete resolution in a smaller subset. A large literature review by Lowe showed that, as a group, OAs were effective in mild-to-moderate OSA with a 75% compliance rate.{Ref13}
A recent study by Pancer et al, on the Thornton anterior positioner (TAP) demonstrated effectiveness of the adjustable device.[1 ]In this study, 75 patients were evaluated by polysomnogram, with and without the appliance. A responder was defined as having an apnea/hypopnea index (AHI) lower than 10 with the device. In 38 of 75 patients, OSA was abolished with the device alone. In an additional 31 patients, the AHI was reduced from 54 ± 31 to 20 ± 12. Three snorers without apnea had unchanged scores. Univariate regression analysis showed an inverse correlation between percent improvement of AHI and both baseline AHI and body mass index (BMI). No correlation with age was noted.
Responders had a baseline AHI of 39 ± 21, while nonresponders had a baseline AHI of 54 ± 31. Baseline low-oxygen saturations were similar (78 ± 15 vs 78 ± 12), but responders improved to 89 ± 5, while nonresponders had no significant change. These findings confirm that the TAP works best in patients with mild-to-moderate SDB. (Note that all treatments yielded best results in patients with mild disease). In this study, 86% of patients continued to use the appliance after a mean follow-up time of 350 days. These patients were very satisfied (60%) or moderately satisfied (27%) with the device. Complications occurred in 26% of patients but were minor and expected (eg, tooth and/or jaw discomfort, excess salivation).
Although not a clinical trial, a recent cohort study of 35 patients evaluated the efficacy of the Dynamax oral appliance in mild-to-moderate OSA treatment.[2 ]An overall compliance rate of 60% was reported with bed partners describing an "improved snoring" rate of 70%. Ten patients had tried CPAP before the OA, and 80% of these patients cited easier tolerance of the OA. Epworth scores were improved, as were overnight oximetry measurements. Polysomnography was not used to evaluated changes in OSA parameters such as AHI.
Subjective improvements in snoring are reported in most case series with oral appliances, in which approximately 50% achieve an AHI less than 10, and patient-reported compliance rates are 75-90%.
Pillar implants - snoring
One study assessed the efficacy of Pillar implants in patients with socially significant snoring, without a history of obstructive sleep apnea. The outcome was assessed by the change in snoring severity measured by the bed partner using a 10-cm visual analog scale, with 10 representing snoring that was unbearable. Snoring, rated by the bed partner, had a baseline mean value of 8.5, which decreased to 5 at 30 days and 4.4 at 90 days post-treatment. All patients tolerated the procedure well. At 90 days, 75% of patients and 90% of their bed partners advocated the procedure.
Pillar implants – obstructive sleep apnea
A 2006 clinical trial assessing the efficacy of Pillar implants in mild to moderate obstructive sleep apnea demonstrated that 80% of patients achieved reductions in AHI values.[3 ]Nearly 60% of these patients achieved resolution of apnea. Two subsequent randomized control trials have compared Pillar implants to sham procedures and placebo in treating mild to moderate sleep apnea.[4,5 ] Both of these trials found a statistically significant change in AHI, quality of life questionnaire scores and subjective snoring scores. However, the clinical significance of Pillar efficacy alone in treating mild to moderate OSA remains questionable since very few patients in these trials had a reduction of their sleep parameters to the often accepted definition of surgical "cure" (AHI decrease by >= 50% to pre-surgery AND AHI < 20). Further studies regarding the efficacy of Pillar implants in OSA are certainly required.
Conclusion
Millions of Americans are affected by sleep disordered breathing. Various treatments are available, depending on disease severity, patient anatomy, and natural inclination regarding treatment options. Some patients are claustrophobic and cannot use CPAP but can tolerate OAs. Others may fear surgery or simply want surgery as the last option. OAs are simple, effective, and inexpensive and should be considered as potential treatment by any otolaryngologist who treats patients with snoring or sleep apnea.
Multimedia
Media file 1: Illustration of the intraoral placement of 3 pillar implants in the soft palate.
Media file 2: Illustration of the technique of placing Pillar implants into the soft palate.
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Keywords
snoring, sleep apnea, apnea, obstructive sleep apnea, OSA, sleep-disordered breathing, SDB, prosthetic management of sleep apnea, sleep apnea management, upper airway resistance syndrome, UARS, sleep disorder, adjustable oral appliance, OA, dental appliance, oral device, dental device, jaw thrust device, Thornton anterior positioner, TAP sleep apnea device, Pillar implants, Palatal implants
Contributor Information and Disclosures
Author
Jason Chau, MD, MPH, FRCSC, Clinical Instructor, Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine
Jason Chau, MD, MPH, FRCSC is a member of the following medical societies: Canadian Medical Association and Canadian Society of Otolaryngology-Head & Neck Surgery
Disclosure: Nothing to disclose.
Coauthor(s)
Arjun S Joshi, MD, Assistant Professor of Surgery, Division of Otolaryngology–Head and Neck Surgery, George Washington University School of Medicine and Health Sciences
Arjun S Joshi, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Association of Clinical Anatomists, American Association of Physicians of Indian Origin, American College of Surgeons, American Head and Neck Society, American Medical Association, and American Thyroid Association
Disclosure: Nothing to disclose.
Steven A Bielamowicz, MD, Professor of Surgery, Chief, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, George Washington University
Steven A Bielamowicz, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Christian Medical & Dental Society, Phi Beta Kappa, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society, and Voice Foundation
Disclosure: Nothing to disclose.
Alan A Z Alexander, MD, MS, George Washington University School of Medicine
Alan A Z Alexander, MD, MS is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, and American Psychiatric Association
Disclosure: Nothing to disclose.
John M Truelson, MD, FACS, Chairman, Division of Head and Neck Surgery, Associate Professor, Department of Otorhinolaryngology, University of Texas Southwestern Medical Center at Dallas
John M Truelson, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, Phi Beta Kappa, and Texas Medical Association
Disclosure: Nothing to disclose.
D Heath Roberts, DDS, Director, Department of Oral Appliance Therapeutics, Sleep Medicine Associates of Texas
D Heath Roberts, DDS is a member of the following medical societies: American Dental Association and American Sleep Disorders Association
Disclosure: Nothing to disclose.
Medical Editor
Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Managing Editor
Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York, Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society
Disclosure: GE Healthcare Honoraria Review panel membership
CME Editor
Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position
Clinical guidelines
Scottish Intercollegiate Guidelines Network (SIGN). Management of obstructive sleep apnoea/hypopnoea syndrome in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003 Jun. 35 p. (SIGN publication; no. 73).
University of Texas, School of Nursing, Family Nurse Practitioner Program. Screening for obstructive sleep apnea in the primary care setting. Austin (TX): University of Texas, School of Nursing; 2006 May. 13 p.
Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 2006 Feb 1;29(2):240-3.[ 6 ]
Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of obstructive sleep apnea in adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Jun. 55 p.
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