“Odontological Management in Obstructive Sleep Apnea Patients: A Literature Review”

Rivera Chavarría - Liliana Vianney1, Tarín Rivera - Marlette Pamela1, Giner Reyes – Denys

Fernanda1, Ortiz Mao - Martha Patricia*1

1. Facultad de Odontología, Av. Pascual Orozco s/n, Universidad, Campus I, Tel. +52 (614) 439

1834, [email protected], www.fo.uach.mx, Chihuahua, Chih. México,

Abstract

Background and Objective: Obstructive sleep apnea (OSA) is a prevalent disorder characterized by

repeated upper airway obstruction during sleep, causing arousals and oxygen desaturation. A

common finding in adults with OSA is tooth wear, linked to orofacial pain, oral dryness,

gastroesophageal reflux (GERD), and sleep bruxism. These interconnected disorders create

complex associations that complicate understanding their impact. Given the rising prevalence of

OSA, exploring effective rehabilitation strategies is essential, as sleep-disordered breathing can lead

to teeth grinding and wear. This study reviews the origins, evolution, and essential components of

dental management in OSA, emphasizing a multidisciplinary, patient-centered approach.

Materials and Methods: A comprehensive literature review was conducted through PubMed,

Cochrane Library, and ResearchGate using keywords such as Sleep apnea, Mandibular

advancement device, Odontological management, Oral Rehabilitation, Oral Health, and Dental

wear. The search initially identified 21,771 results, which, after applying filters for peer-reviewed

studies and recent publications, was narrowed to 1,053. Of these, 103 articles relevant to dental

interventions for OSA were selected, particularly those on oral appliances.

Results: The proposed dental management for OSA includes promoting nasal breathing and mouth

taping to alleviate symptoms.

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Conclusion: This review underscores the growing importance of dental interventions, particularly

oral appliances, in managing OSA. By addressing airway patency and oral health, dental

professionals play a significant role in enhancing patient outcomes for OSA treatment.

Key words:

Sleep apnea, Mandibular advancement device, Odontological management, Oral Rehabilitation,

Oral Health, Dental wear.

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 1. Background

1.1 Sleep apnea

Sleep consists of two main neurophysiological states: rapid eye movement (REM) and non-rapid

eye movement (NREM) (1). In humans, NREM is divided into four stages. Stage 1 marks the

gradual fading of conscious awareness, while stage 2 involves a complete loss of consciousness (2).

Stages 3 and 4 are known as "deep sleep” (2). REM sleep, which alternates periodically with

NREM, shows brain activity patterns similar to the desynchronized state seen in stage 1 and

wakefulness (2). In individuals with obstructive sleep apnea (OSA), episodes can occur during both

NREM and REM sleep. During REM, reduced muscle tone in the upper airway increases the

likelihood of airway obstruction (3).

The term "apnea" originates from the Greek language and translates to "breathless" or "out of

breath" (4). An apnea is characterized by a complete absence of inspiratory airflow lasting at least

10 seconds(4). In contrast, hypopnea refers to a partial reduction in airflow that also persists for 10

seconds or more (5); Both conditions can be classified as either obstructive or central. The type

depends on neural output patterns: OSA occurs when the upper airway is fully blocked (resulting in

no airflow and the tongue falling backward) despite continued effort from the inspiratory thoracic

pump muscles (5). On the other hand, central sleep apnea (CSA) arises when the pontomedullary

pacemaker temporarily reduces its generation of the breathing rhythm. This typically happens due

to changes in the partial pressure of CO2 (PCO2), where levels drop below the apneic threshold, a

point at which breathing halts (3).

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OSA is classified under the broader category of sleep-disordered breathing (SDB), which also

includes conditions like central sleep apnea and snoring (6). OSA is characterized by repetitive

episodes of upper airway collapse during sleep, leading to recurrent drops in oxygen levels,

nighttime awakenings, and disrupted sleep patterns (6, 7). Common symptoms in individuals with

OSA include snoring, waking up choking, non-refreshing or poor-quality sleep, and even micro-

sleep episodes while driving (6). According to the 1993 Wisconsin Sleep Cohort Study, the

prevalence of OSA was 4% in middle-aged men and 2% in women within the same age group (30-

60 years) (9). More recent studies indicate that prevalence rates are higher in high-income countries,

reaching approximately 20% in men and 10% in women (8, 9).

Sleep apnea (SA) is a respiratory condition involving repeated episodes of reduced airflow

(hypopnea) or complete cessation of breathing (apnea) that can last several seconds to minutes and

occur frequently during sleep (10, 11). OSA is often worsened by factors such as aging, obesity,

neurological disorders, impaired respiratory reflexes, alcohol use, smoking, and craniofacial

abnormalities (12, 13). This condition is linked to increased mortality rates and other significant

health risks (14). Furthermore, OSA negatively impacts quality of life and heightens the risk of

motor vehicle accidents due to cognitive dysfunction (14).

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1. 2 Sleep apnea related to systemic diseases

OSA is becoming a significant public health concern (15). Notably, its prevalence is gradually rising

in parallel with the epidemics of obesity and type 2 diabetes mellitus (T2DM) (15). OSA affects

nearly 1 billion adults globally (16). The association between OSA and diabetes mellitus (DM)

increases the risk of cardiovascular disease, partly due to the presence of other vascular risk factors

like hypertension (HT) and/or dyslipidemia OSA and HT often co-occur, and their connection is of

growing concern because they are recognized as a dangerous combination (16). In 2019, it was

estimated that about one billion adults worldwide had OSA, with approximately half of all OSA

patients also having coexisting HT (17).

Multiple studies have demonstrated that OSA is linked to hypertension (HT) and type 2 diabetes

mellitus (DM), with obesity serving as a common factor in the development of all these conditions

(18). There is strong evidence suggesting that OSA can lead to both short-term and long-term

negative effects on the heart and blood vessels, through mechanisms such as intermittent hypoxia

(IH), sudden decreases in intrathoracic pressure, activation of the sympathetic nervous system, and

inflammatory disruptions (19). These conditions share overlapping risk factors, including age,

obesity, and metabolic syndrome, which complicate the identification of a precise

pathophysiological mechanism linking them (20).

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Among the various factors contributing to this issue, obesity, smoking, and gastroesophageal reflux

disease (GERD) stand out as prominent risk factors (21). Research has shown that the gradual

increase in the prevalence of OSA correlates with higher body mass index, neck circumference, and

waist-to-hip ratio, even among non-obese individuals (22). According to studies by the American

Academy of Sleep Medicine, this condition is related to sleep apnea in 90% of cases (23). However,

OSA should not be dismissed simply because a patient does not fit this stereotype (22).

Another factor to consider is the craniofacial structure and upper airway anatomy (24, 25). In

certain subgroups of patients, skeletal or soft tissue abnormalities, such as dysmorphisms related to

the size and position of the jaw or maxilla, narrowing of the nasal passages, and enlarged tonsils,

play a key role in the development of sleep apnea (22). Those can lead to abnormal growth patterns

in the lower face and jaw (known as adenoid facies), which may predispose individuals to

obstructive sleep apnea later in life (26). In such cases, surgical correction may be a treatment

option (26).

Possible mechanisms that could explain the influence of smoking on obstructive sleep apnea

include inflammation of the airways and tobacco-related diseases, as well as how decreased nicotine

levels in the blood affect sleep stability (26). Furthermore, both smoking and obstructive sleep

apnea increase the risk of cardiovascular diseases, as they both induce oxidative stress, endothelial

dysfunction, and heightened inflammatory response (22, 27). Additionally, there is evidence that

each of these conditions negatively impacts the other, potentially leading to increased comorbidity

(28).

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Similarly, hormonal factors may also play a role in this condition, as hormonal variations are

thought to explain the difference in the prevalence of obstructive sleep apnea between sexes (28).

Given that levels of sex hormones undergo significant changes during menarche, pregnancy, and

menopause, it is reasonable to assume that these fluctuations can alter the risk of developing

obstructive sleep apnea (22). Experimental studies show an acute effect of alcohol on the frequency

of apnea and hypopnea; however, the impact of long-term alcohol consumption on the development

or progression of apnea remains unknown (22, 29). Likewise, nighttime nasal congestion, whether

caused by allergic rhinitis, acute upper respiratory infections, or anatomical factors, has been

associated with snoring and obstructive sleep apnea in experimental and epidemiological studies

(30, 31).

GERD and sleep disorders are common health problems that frequently occur together (32). It has

been proposed that there is a bidirectional relationship between GERD and sleep disorders, where

GERD can contribute to sleep difficulties, and conversely, poor sleep can exacerbate GERD,

creating a vicious cycle (33). However, the link between GERD and OSA is still not well

understood. It remains uncertain whether the co-occurrence of these conditions is due to a causal

relationship or simply reflects shared risk factors(32, 33).

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1.3 Oral factors related to sleep apnea.

1.3.1 Periodontal diseases:

The pathological relationship between periodontitis and OSA is not fully established (34, 35).

Intermittent hypoxemia in patients with OSA causes damage from anoxia and reperfusion, leading

to increased production of reactive oxygen species and other systemic inflammatory mediators (36).

Additionally, the risk of periodontitis in these patients appears to rise with the elevation of these

inflammatory mediators in serum (35). The decrease in oxygen saturation in patients with OSA may

also trigger systemic inflammatory changes that affect periodontal tissue (37). On the other hand,

oral breathing, common among those suffering from OSA, tends to dry the oral mucosa, increasing

the likelihood of bacterial colonization, raising plaque levels, and consequently worsening the risk

of periodontal disease (35).

1.3.2 Bruxism

Studies have shown that bruxism can cause sleep disorders, which are another feature of OSA (38).

As a protective reflex to continue breathing, the arousal response triggered by bruxism can

temporarily restore muscle tone in the upper airways, thereby reopening the airways (39). On the

other hand, this activity can also lead to sleep fragmentation, exacerbating the overall sleep disorder

associated with OSA (40). Along with jaw problems, periodontal diseases, and increased dental

sensitivity due to the high pressures exerted on the periodontium (40). Therefore, it is essential to

improve detection methods in the fields of sleep medicine and dentistry to address the complex

interactions between these two conditions, as well as to implement multidisciplinary treatment

approaches (40).

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1.3.3 Palatal and dental changes

In individuals with OSA, the relationship between palatal and dental changes is crucial for oral

health, as it impacts both the severity of the condition and the patient's prognosis (41). A narrow,

high-arched hard palate, which constricts the nasal airways and increases their resistance and

collapsibility, is a common palatal abnormality seen in OSA patients (42). Furthermore, dental

problems can worsen OSA symptoms (42). Narrow teeth can cause crowding and disrupt the

occlusal plane, which may alter the resting position of the tongue, lead to dental occlusion issues,

and ultimately compromise airway patency during sleep (43).

1.3.4 Taste disorders

Changes in taste perception are a lesser-known but significant oral health issue in individuals with

OSA (44). Particularly when considering the potential effects of intermittent chronic hypoxia, which

is a hallmark of OSA, on the gustatory system (45). Dysgeusia, or a reduction in sensitivity or

alteration in taste perception, is a condition associated with OSA, where the hypoxic environment

may impact the renewal and function of taste bud cells (46). This may indirectly influence dietary

preferences, leading individuals to choose sweeter or more flavorful foods, such choices could

negatively affect oral health outcomes, including periodontal disease and dental caries (47).

Furthermore, by influencing saliva flow, changes in taste can have an indirect effect on oral health

(48).

Changes in taste perception, although less well-known, represent a significant oral health concern

for individuals with OSA (44). This is particularly relevant when considering the potential effects of

intermittent chronic hypoxia, a hallmark of OSA, on the gustatory system (45). Dysgeusia, which

refers to a reduction in taste sensitivity or alterations in taste perception, is a condition linked to

OSA, where the hypoxic environment may affect the renewal and function of taste bud cells (46).

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This can indirectly influence dietary choices, prompting individuals to opt for sweeter or more

flavorful foods—choices that could have a negative impact on oral health, contributing to issues

like periodontal disease and dental caries (47). Additionally, changes in taste perception can affect

saliva production, further influencing oral health in an indirect way (48).

1.4 Treatment

There are many options for treating obstructive sleep apnea including behavioral measures (i.e.,

weight loss, positional therapy), mandibular advancement devices, positive airway pressure therapy

(PAP), and surgery (49). Behavioral strategies involve avoiding alcohol, refraining from sleeping on

the back, engaging in regular aerobic activity, and losing weight (50). For patients with positional

OSA, where the apnea-hypopnea index (AHI) is higher when sleeping on the back, sleeping on the

side or stomach may be an effective approach (51). Weight reduction can significantly improve

OSA and is advised for all individuals who are overweight or obese, in combination with other

treatments (52, 53). In those with minimal or no symptoms, weight loss could be used as the

primary treatment. Improvements in OSA severity have also been linked to lifestyle changes,

bariatric surgery, and weight loss medications (52).

Orofacial myofunctional therapy (OMT) has recently emerged as a treatment option for OSA (54).

It involves isotonic and isometric exercises that focus on the oral and oropharyngeal areas (54). The

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aim is to enhance muscle tone, endurance, and the coordination of movements in the pharyngeal

and surrounding muscles (54). A hypoglossal nerve stimulator is a device placed under the skin in

the upper right chest, designed to produce electrical signals (49). These signals are delivered via a

lead that ends in a cuff surrounding the hypoglossal nerve (49, 55). This newer surgical procedure is

intended to increase the tone of the pharyngeal muscles during sleep (50).

The most effective nonsurgical treatment for OSA is continuous positive airway pressure (PAP),

which delivers a steady stream of air to maintain pharyngeal patency, acting as a splint to prevent

airway collapse during inspiration (56, 57). PAP is the primary therapy for individuals with

symptomatic OSA of any severity (57). PAP devices deliver pressure to the airway through a mask

worn over the nose or the nose and mouth (58). Nonetheless, long-term adherence to CPAP therapy

remains a significant challenge, as many patients find the device uncomfortable or inconvenient to

use regularly (56).

Surgical alteration of the upper airway can be appropriate for certain patients and is typically

advised for those with symptoms who are unable to tolerate PAP therapy (57). While tracheotomy

was once a common method for treating severe OSA before PAP therapy was available, it is now

rarely used (59). The most frequent surgeries for OSA involve modifying the soft tissues of the

upper airway, such as the palate, tongue base, and lateral pharyngeal walls (59).

Uvulopalatopharyngoplasty, which removes part of the uvula and soft palate, is the most well-

researched technique (60). Additional procedures include lateral wall pharyngoplasty and tongue

reduction surgeries (59).

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Oral appliances, also known as mandibular repositioning devices, are effective treatment options,

particularly for individuals with mild to moderate OSA (61). These appliances work by holding the

lower jaw in a more forward position, preventing the tongue and soft tissues from collapsing into

the airway during sleep (62). Studies have shown that oral appliances can significantly improve

sleep quality and reduce daytime sleepiness in many patients with OSA (61, 63). The selection of an

appropriate treatment approach for OSA should be based on the individual patient's specific clinical

characteristics, preferences, and the expertise of the dentist. (61). This review aims to explore the

origins, evolution, and key components of the odontological management of sleep apnea,

emphasizing its multidisciplinary approach and patient-centered strategy.

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Figure 1. Concept map describing sleep apnea, From the center to the left and right, we observe its

definition, the pathophysiology, contributing factors as obesity and craniofacial structure, oral manifestations

as mouth breathing, periodontic disease, xerostomia, signs and symptoms like snoring, fatigue, and gasping.

Finally on the pink square, treatment by surgical and non- surgical approach.

2 Methods

2.1 Search Strategy

Our group of dental students, with guidance from our professors, developed a comprehensive search

strategy to identify studies for our systematic review. We searched various electronic databases,

including PubMed, Cochrane Library, ResearchGate, and Spear Education, covering 2003 to 2024.

We focused on studies investigating the relationship between sleep apnea and oral health,

particularly in oral rehabilitation and dental wear. Our search terms included combinations of

keywords such as “sleep apnea,” “oral rehabilitation,” “oral health,” “dental wear,” “positive airway

13
pressure,” “CPAP,” “oral appliance,” and “mandibular advancement device.” We also manually

screened the reference lists of the identified articles to capture any additional studies that fit our

criteria.

2.2 Inclusion and Exclusion Criteria

We set up clear criteria to guide us in selecting appropriate studies. Studies were included if they:

1. Focused on patients with diagnosed sleep apnea.

2. Explored the impact of sleep apnea or its treatment (such as CPAP or oral appliances) on

oral health.

3. Were published between 2003 and 2024.

We excluded studies that lacked data on oral health outcomes, were case reports, editorials, or

reviews without original data, or involved non-human subjects.

2.3 Study Selection

Two members of our group independently screened the search results to ensure we selected relevant

studies. First, we screened the titles and abstracts to quickly assess whether the studies met our

inclusion criteria. For studies that appeared relevant, we reviewed the full text to confirm eligibility.

If there was any disagreement between us regarding the inclusion of a study, we discussed it within

14
 the group or consulted one of our professors for guidance. We also reviewed the included and

excluded studies lists from previous systematic reviews to identify additional studies. In cases

where published abstracts provided relevant data on our outcomes of interest, we included them in

our analysis.

2.4 Data Extraction and Quality Assessment

Each member of the team contributed to extracting data from the included studies. We gathered

details such as study design, sample size, patient characteristics, types of oral appliances or

treatments used. We reported oral health outcomes, including dental wear or changes in oral

mucosa.

“Summary of recent studies focusing on dental-related interventions and mandibular advancement

devices for obstructive sleep apnea (OSA). This table provides a clear and concise overview of each

article, highlighting its key findings and relevance to the literature review on dental interventions in

patients with obstructive sleep apnea (OSA)."

Author Year Type of Primary Focus Key Findings

Fu W et al. 2023 Meta-analysis Effectiveness of CPAP and Mandibular advancement devices showed
of RCTs Mandibular Advancement improvement in depressive symptoms in

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 Devices on depressive OSA patients.
symptoms
Uniken 2021 Systematic Mandibular advancement Design differences in devices impact patient
Venema Review device design outcomes in OSA comfort and effectiveness in OSA
JAM et al. treatment management.
Van der 2023 Scoping Factors influencing adherence Adherence is influenced by comfort, side
Hoek LH et Review to mandibular advancement effects, and perceived efficacy of the devices.
al. devices
Ou YH et al. 2023 Clinical Trial Comparative effectiveness of The study aims to compare the effects of
Protocol Mandibular Advancement devices on 24-hour blood pressure in
Devices vs CPAP on blood hypertensive OSA patients.
pressure
Shi X et al. 2023 Clinical Effects of mandibular Significant improvements in airway
Investigation advancement on upper airway dimensions were observed in responders
dimensions in OSA patients using mandibular devices.
Berggren K 2022 Qualitative Recognition of oral health Many oral health issues associated with OSA
et al. Study problems linked to OSA in are under-recognized in routine dental
dental care practices.
Ciavarella D 2023 Observational Correlation between dental arch Certain dental arch forms may correlate with
et al. Study form and OSA severity higher OSA severity, suggesting a potential
diagnostic indicator for dental professionals.
Maniaci A et 2024 Literature Oral health implications of OSA significantly impacts oral health; dental
al. Review obstructive sleep apnea interventions may alleviate some of the
associated oral symptoms.
Marchetti E 2020 Literature Role of dentists in OSA Dentists can play a crucial role in early
et al. Review diagnosis and treatment diagnosis and management of OSA,
particularly through screening and the use of
oral appliances.
Hamoda MM 2019 Long-term Long-term effects of oral Oral appliances for OSA may lead to long-
et al. Study appliances on dental structures term changes in dental structures,
highlighting the need for regular monitoring.
Chen A et al. 2022 Observational Effectiveness and side effects of Mandibular advancement devices are
Study mandibular advancement effective in managing OSA symptoms but
devices may cause side effects in dental structures.
Maniaci A et 2024 Literature Oral health implications of OSA significantly impacts oral health; dental
al. Review obstructive sleep apnea interventions may alleviate some associated
oral symptoms.

3. Results

The most significant outcome of this study is the successful implementation of an odontological

management, which initiates with a focus on encouraging nasal breathing and mouth taping to

alleviate symptoms of obstructive sleep apnea (OSA). This foundational step is crucial, as mouth

breathing is common among OSA patients and is associated with issues such as snoring, dry mouth,

16
and fragmented sleep. The management effectiveness is demonstrated through a series of structured

interventions aimed at optimizing airway patency.

Step 1: Nasal Breathing and Mouth Taping

The first step encourages patients to breathe nasally rather than orally during sleep. Mouth

breathing, common in OSA patients, is associated with snoring, dry mouth, and sleep fragmentation

(64). To counter this, the Seattle Protocol recommends mouth taping, using a strip of paper tape

placed vertically over the lips (64). This simple intervention trains the body to breathe through the

nose, potentially reducing snoring and promoting better sleep quality; and this requires a minimum

of 14 days. (64).

Step 2: Temporary Splint for Lower Jaw with Mouth Taping

Once patients adapt to mouth taping, a temporary splint is introduced for the lower jaw. This splint

increases the vertical dimension of the bite, creating more airway space (65). This intervention

addresses the airway obstruction often caused by the collapse of the upper airway during sleep

(65). By increasing airway patency, it may reduce apneic episodes and improve patient comfort; and

this requires a minimum of 2-3 days (66).

Step 3: Temporary Lower Jaw Splint with Forward Positioning and Mouth Taping

If the lower jaw splint alone does not provide significant improvements in sleep quality, the

protocol advances by repositioning the lower jaw forward, about 2-3 mm of protrusion (67). This

anterior repositioning increases both vertical and horizontal airway space, thereby improving

airflow (67). This step may also provide additional space for the tongue, which can obstruct the

airway in patients with OSA, and this requires a minimum of 2-3 days (66).

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Step 4: Temporary Upper and Lower Jaw Splints with Mouth Taping

When further intervention is needed, both upper and lower jaw splints are applied, allowing the jaw

to move freely during sleep (67). This step focuses on increasing vertical airway space without

restricting the jaw muscles to a fixed position (67). This allows for a more comfortable experience

for the patient while continuing to address airway obstruction and this requires a minimum of 2-3

days. (67).

Step 5: Temporary Upper and Lower Jaw Splints with Forward Lower Jaw Positioning and

Mouth Taping

If required, a horizontal component is added by moving the lower jaw forward about 2-3 mm of

protrusion for a minimum of 2-3 days (66). This combination of upper and lower splints with

forward positioning continues to optimize airway patency and may provide further relief for

patients experiencing persistent OSA symptoms (66).

Step 6: Gradual Forward Lower Jaw Positioning with Upper and Lower Jaw Splints and

Mouth Taping

For patients who still experience symptoms of OSA, the final step involves gradually moving the

lower jaw forward until optimal sleep is achieved (66). This fine-tuning process ensures that the

airway remains open throughout the night, leading to improved patient outcomes and reduced

reliance on more invasive treatments (66).

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Figure 2. Outlines the steps of the odontological treatment protocol of OSA. In Step 1, a strip of paper tape

is placed vertically over the patient’s lips for mouth taping. In Step 2, after the patient adjusts to the mouth

tape, a temporary jaw splint is introduced for use during sleep. Step 3 involves the addition of a component

that gently pushes the lower jaw forward by 2-3 mm. In Step 4, the lower jaw advancement is removed, and a

splint for the upper jaw is introduced. Step 5 incorporates a horizontal component, aligning the upper and

lower splints while advancing the mandible by 2-3 mm. Finally, Step 6 focuses on gradually advancing the

lower jaw further, incrementally, until the patient reports feeling well-rested.

4. Discussion

This literature review explored the multidisciplinary approach to managing OSA through dental

interventions Due to OSA’s systemic and oral health implications, an odontological, systemic

approach was explored including airway management. This offers a unique perspective on how

dental professionals can contribute to OSA treatment. OSA has been treated with oral appliances

since many years ago, their use has been studied and well documented (68, 69).

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This review examined the evolving role in managing OSA, with a specific focus on odontological

management and its potential to improve patient outcomes (70). OSA is a significant and growing

health concern, closely associated with a variety of dental and systemic disorders (70). The findings

from this review shed light on how dental interventions, particularly oral appliances, can be

integrated into the management of OSA to address both sleep-disordered breathing and associated

oral conditions such as bruxism, tooth wear, and TMD (70).

Although this odontological management consists of six steps, patients may not necessarily go

through the entire process; 40-50% of patients find resolution in Step 1 (64). The purpose of the

management is to identify which step provides the best relief (64). Typically, as the process

progresses, the airway requires more support (64). This is a gradual, gentle, and reversible approach

that helps identify solutions for patients with airway problems and assesses how these issues affect

dental health; it not only aims to improve sleep quality but also promotes overall health and well-

being (64).

4.1 Association between OSA and Oral Health

As discussed in the introduction, OSA is often associated with several dental manifestations,

including tooth wear, bruxism, orofacial pain, and GERD (71). These conditions are interconnected

and frequently exacerbate each other, complicating both diagnosis and treatment (71). For instance,

sleep bruxism is a common finding in OSA patients and may contribute to further airway instability,

increasing the severity of sleep disturbances (71). The proposed protocol, through its progressive,

20
stepwise approach, aims to address both airway patency and these related dental issues by

modifying the mandibular position and encouraging nasal breathing. This integration is critical, as it

acknowledges the dual impact of OSA on both systemic and oral health, providing a more holistic

approach to patient care.

The review highlights how dental interventions, especially oral appliances, play a pivotal role in

managing OSA, particularly in patients unable or unwilling to tolerate continuous positive airway

pressure (CPAP) therapy (72, 73). Mandibular advancement devices (MADs) are an effective

alternative to CPAP, especially in mild to moderate OSA cases (69, 74). By holding the lower jaw

forward, these devices increase the airway space, preventing airway collapse during sleep (74). In

three reviewed studies, MADs were useful in 63% of the cases (75-77). In another study, the

mandibular advancement appliance reduced snoring significantly and improved daytime sleepiness

(78).

The studied protocol further enhances this approach by gradually adjusting the position of the jaw

and splints to optimize patient outcomes. This protocol underscores the importance of patient-

specific treatment strategies, as each step is designed to build upon the previous one, with a focus

on addressing airway patency. The integration of simple interventions, like nasal breathing and

mouth taping, ensures that patients start with non-invasive techniques that promote better sleep

quality and reduced oral symptoms such as dry mouth and snoring. This aligns with the growing

21
body of evidence supporting the effectiveness of conservative interventions in managing sleep-

disordered breathing.

4.2. Impact of Dental Interventions on Sleep-Disordered Breathing

In line with the goals outlined in the introduction, this review emphasizes the role of dental

interventions, particularly MADs, in improving sleep-disordered breathing. MADs have been

shown to effectively increase the airway space, reducing the frequency of apnea and hypopnea

episodes (79, 80). The Odontological protocol discussed as object of this study, enhances this

concept by gradually increasing the vertical and horizontal dimensions of the airway in small

increments (79). The progressive adjustment allows the dental team to carefully monitor patient

responses and adapt treatment accordingly. This patient-centered strategy, as highlighted in the

introduction, is essential for ensuring that interventions not only improve breathing but also address

related dental issues such as erosion, TMD, and tooth wear (79). Several guidelines exist to

diagnose and treat OSA (81).

4.3. Benefits and Challenges of the odontological management.

The odontological management offers a structured, patient-centered approach, integrating non-

invasive interventions to progressively treat airway obstruction (82). Furthermore, the incremental

steps allow for close monitoring and adjustment, reducing the risk of overtreatment or patient

22
discomfort (78)(83). However, several challenges remain. First, adherence to oral appliances and

mouth taping can be variable among patients, particularly in the early stages (58). Ensuring patient

compliance through education and close follow-up is crucial for the protocol’s success. Second,

while the protocol provides a non-surgical option for OSA treatment, it may not be sufficient for all

patients, especially those with severe OSA or complex airway anatomy (84).

This is particularly important as OSA has systemic implications, including its association with

cardiovascular diseases, type 2 diabetes, and hypertension, all of which can be influenced by oral

health (81).(85). The stepwise nature of the odontological management ensures that the treatment is

not only comprehensive but also tailored to the specific needs of each patient, an approach that is

especially valuable given the individual variability in OSA severity and patient response to

treatment (86).

The gradual implementation of the treatment beginning with non-invasive techniques such as nasal

breathing and mouth taping before progressing to mandibular splints and repositioning, helps ensure

patient comfort and compliance (66, 82, 87). This is particularly important given the high dropout

rates often associated with more invasive or uncomfortable OSA treatments, such as continuous

positive airway pressure (CPAP) therapy (88, 89). By addressing the airway in stages, the

23
odontological management improves both sleep quality and oral health outcomes, while

minimizing patient discomfort (90, 91).

4.4. Comparison with Other Treatment Modalities

The odontological management emphasis on gradual, tailored interventions distinguishes it from

other more aggressive or singular approaches, such as surgery or exclusive reliance on CPAP (92).

While CPAP remains the gold standard for OSA treatment, it is well-documented that long-term

adherence is a significant barrier to success (93). The review supports the idea that oral appliances,

particularly when applied systematically as in the odontological, provide a viable alternative or

adjunct to CPAP, with fewer side effects and greater patient acceptability (94). As noted in the

introduction, OSA is a complex condition with multiple contributing factors, including obesity, age,

and metabolic syndrome (95).

Dental interventions, while effective for many patients, may not be sufficient for those with severe

OSA or specific anatomical limitations (96). Patients may require a combination of therapies,

including CPAP or surgical interventions (97). Education and regular follow-up are critical to

ensuring compliance and long-term success (14). Moreover, while the odontological offers a

structured, stepwise approach, its effectiveness has not been as widely studied in comparison to

24
more established treatments like CPAP or surgical procedures (50). Further research is necessary to

validate its long-term efficacy and to refine its application across different patient populations (97).

4.5 Implications for Dental Practice and Future Research

This review emphasizes the need for further research to validate the long-term effectiveness of the

odontological management and to examine its application in various patient populations with OSA.

Given the increasing prevalence of OSA and its association with systemic diseases such as

hypertension, type 2 diabetes, and cardiovascular issues, dental interventions like the odontological

management may become increasingly significant in managing both oral and systemic health.

Future studies should also focus on enhancing the odontological management, particularly

regarding the optimization of intervention sequences and the integration of advanced technologies

such as digital airway analysis (98).

The growing recognition of the role dental professionals can play in managing OSA opens new

opportunities for interdisciplinary collaboration (99). As demonstrated in this review, the

odontological management illustrates how dental care can be integrated into the overall approach to

treating OSA. The protocol’s focus on airway management through dental devices also has

important implications for routine dental practice (100). By being more vigilant about potential

25
signs of OSA, such as bruxism or unexplained tooth wear, dentists can play a crucial role in early

detection and intervention (101).

Moving forward, research should aim to refine the odontological management, particularly in terms

of patient selection and treatment customization (102). Comparative studies evaluating the

odontological management against other OSA interventions, such as CPAP or surgery, will be

essential in determining its broader applicability (103). Furthermore, more research is needed to

understand the long-term effects of oral appliance therapy on OSA severity and oral health

outcomes (104).

5. Conclusion

This odontological management focuses on identifying the appropriate type of splint; however, this

is not the last step in patient care. A splint serves merely as a temporary solution. Patients are never

left with just a splint; instead, their choice of splint guides the dental team in determining what

additional treatments may assist in achieving lasting benefits. This management is designed not to

26
create the "perfect bandage" but to function as a diagnostic tool that aids the dentist in developing

long-term solutions to address the patient's issues rather than merely managing them. A

comprehensive resolution strategy is provided for the patient afterward, which may include

therapies such as myofunctional therapy, orthodontic arch expansion, ear, nose or throat surgery,

restorative dentistry, weight loss, or dietary changes.

In summary, this review highlights the growing relevance of dental interventions, particularly oral

appliances, in the multidisciplinary management of OSA. By addressing both airway patency and

oral health issues, dental professionals can make a significant contribution to improving patient

outcomes in OSA treatment. However, it is crucial to conduct more studies to validate the

effectiveness of odontological management and to better understand its application in different

patient populations. While challenges related to patient adherence and the complexity of OSA

remain, this odonatological management provides a promising, stepwise approach that integrates

dental care into a holistic strategy for managing sleep-disordered breathing.

6. Acknowledgements

We would like to express our gratitude to Dr. Mercedes Bermudez and Dr. Carlos Villegas for their

input throughout the research process. Their expertise and guidance were instrumental in shaping

this article, providing the tools and knowledge necessary to delve into the subject matter effectively.

27
We would also like to thank our families for their support and encouragement, which provided the

foundation for this work.

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