Abstracts and Case Reports, Issue 13.3

2026 AADSM Annual Meeting Abstracts and Case Reports

http://dx.doi.org/10.15331/jdsm.7464
 
ABSTRACT #001
OUTCOME BASED COMPARISON BETWEEN MILD, MODERATE AND SEVERE OSA USING AAVOAT (ADAPTIVE ANTERO-VERTICAL OPEN AIRWAY THERAPY)
Raghavendra V Ghuge, MD, DABSM, FAASM, MBA^1
1Sleep Medicine Institute of Texas
 
Introduction: Multi-level airway collapsibility in OSA is a significant factor in failure of treatment. HNS, Hyoid suspension and lift and T&A and multiple OAT/COAT titrations increase cost, delay in effective treatment and increases risk of side effects ultimately resulting in failed outcomes.
 
Methods: Retrospective comparison of 200 consecutive cases of OSA treated with an AAVOAT™ (Adaptive Antero-Vertical Open Airway Therapy device) AIO Breathe®. 
 
Results: DX-AHI, DX-LSAT, RX-AHI and RX-LSAT were tabulated, univariate and multi-variate regression analysis were performed.
 

1. Severe OSA: N = 60. Mean DX-AHI was 41.8, DX-AHI range was 30-80, and the 1 Std. dev. was 13.2. Mean DX-LSAT was 79.8%, DX-LSAT range was 58% - 89%. Mean RX-AHI was 2.4, RX-AHI range was 0 – 4.8 with 1 Std. Dev of 1.7. Mean RX-LSAT was 91.2%, RX-LSAT range was 90% - 95%. DX-Hypoxic Burden (<90%) averaged 37% and RX-hypoxic burden (<90%) was 0.0%. The overall improvement in severe OSA AHI was 94.2%.

 

2. Moderate OSA: N = 100: Mean DX-AHI was 22.5, DX-AHI range was 15-29.7, and the 1 Std. dev. was 4.03. Mean DX-LSAT was 83.5%, range of LSAT was 64% - 89%. Mean RX-AHI was 2.0, RX-AHI range was 0 – 4.5 with 1 Std. Dev of 1.68. Mean RX-LSAT was 91.2%, RX-LSAT range was 90% - 95%. DX-Hypoxic Burden (<90%) averaged 28% and RX-hypoxic burden (<90%) was 0.0%. The overall improvement in moderate OSA: 91.3%.

 

3. Mild OSA: N = 40: Mean DX-AHI was 8.3, DX-AHI range was 5-14.9, and the 1 Std. dev. was 4.0. Mean DX-LSAT was 86.1%, DX-LSAT range was 73% - 90%. Mean RX-AHI was 1.1, RX-AHI range was 0 – 5 with 1 Std. Dev of 1.5. Mean RX-LSAT was 93.1%, RX-LSAT range was 90% - 98%. DX-Hypoxic Burden (<90%) averaged 21% and RX-hypoxic burden (<90%) was 0.0%. The overall improvement in mild OSA: 87%.

 
Conclusion: AIO Breathe® successfully treated severe OSA (mean RX AHI 2.4, LSAT 91.1%), moderate OSA (mean RX-AHI 2.0, mean RX-LSAT 91.2%) and mild OSA (mean RX-AHI 1.1, mean RX-LSAT 93.1%). Residual Hypoxic burden (<90%) was 0%. A single prescription strength (RAP 2 mm + TT 2.7 mm and Mandibular Plateau) was used. AHI was brought down below 5 in all participants. Improvement in clinical symptoms of OSA was observed and AIO Breathe® MB comfort was well tolerated. TMJ dysfunction was not observed. Adaptive Antero-Vertical Open Airway Therapy appears to produce superior results in treatment of severe OSA in comparison with published data on anterior advancement Gen1 devices that have historically shown 30-50% improvement in severe OSA and decrease in hypoxic burden (<90%) to 60%. Adaptive airflow proved to be effective (AHI < 5, LSAT >90%) with AI-predictive modeling of AIO BREATHE geometry. Planned Design geometry using AIOMEGA®’s AI-Predictive Algorithm reduced therapeutic uncertainty, minimized side effects like TMJ or dental movement and built dentist/physician/patient trust.
 
Support: AIOMEGA® LLC
 
ABSTRACT #002
THE CRISIS OF OBSTRUCTIVE SLEEP APNEA: ARE DENTISTS THE KEY TO ACCESS THAT PATIENTS NEED?
Lucy Hovanisyan, DDS, MBA¹; Aaron Soeprono, DDS¹; Rushi Patel, DDS^1
1New York University College of Dentistry
 
Introduction: Despite increased awareness, Obstructive Sleep Apnea (OSA) continues to be underdiagnosed due to limited access to sleep specialists and low rates of primary care screening. Many at-risk individuals regularly visit dentists for preventive care, creating an overlooked point of entry for detection. The STOP-BANG questionnaire offers a simple, evidence-based method for identifying OSA risk within a general dental setting.
 
Methods: A meta-analysis was conducted to evaluate the effectiveness of STOP-BANG when utilized by general dentists. Studies were included if they were published within the last ten years, trained general dentists in STOP-BANG administration, and reported new OSA detections initiated from dental screenings.
 
Results: Dentist-led screening using STOP-BANG significantly increased the rate of OSA identification among undiagnosed patients. Across studies, dental practices demonstrated consistent success in recognizing high-risk individuals and facilitating appropriate referrals for sleep testing.
 
Conclusion: The integration of STOP-BANG screening into general dental practice may represent a scalable public health solution to address undiagnosed OSA. By leveraging their routine patient contact, dentists can expand access to screening and reduce barriers to care for a condition that often goes unnoticed.
 
Support: This analysis underscores the potential of interprofessional collaboration and targeted training to position dentistry as a first-line resource in OSA detection. No financial support.
 
ABSTRACT #003
PREDICTORS OF SHORT-TERM ADHERENCE TO MANDIBULAR ADVANCEMENT DEVICE THERAPY IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA
Zhengfei Huang, DMD, MSc, PhD¹; Joey Chung, DDS, MSc¹; Frank Lobbezoo, DDS, PhD^1,2; Ghizlane Aarab, DDS, PhD^1
1Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
²Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Malmö, Sweden
 
Introduction: Adherence is a key determinant of the effectiveness of mandibular advancement device (MAD) therapy in patients with obstructive sleep apnea (OSA). Understanding the factors that influence adherence can guide patient selection and improve treatment success. Previous research has been limited by small sample sizes and a primary focus on objective measures such as the apnea-hypopnea index (AHI) when examining adherence. Yet, patients’ subjective experiences, such as perceived symptom improvement and MAD-related side effects, may exert an even greater influence on adherence than objective outcomes, but have rarely been investigated. Consequently, the determinants of adherence remain insufficiently understood. This study aimed to identify predictors of short-term MAD adherence, using a comprehensive set of patient- and treatment-related variables in a large OSA cohort.
 
Methods: This prospective longitudinal study included adult patients who were referred for  MAD therapy for OSA between April 2017 and August 2024. Data were collected both at baseline and at follow-up. At baseline, self-reported data were collected on demographics, OSA-related symptoms, lifestyle variables, dental sleep-related conditions, psychological conditions, and systemic comorbidities. At follow-up, self-reported data on OSA-related symptoms, MAD-related side effects, and adherence were recorded. Complete adherence was defined as using MAD ≥80% of sleeping hours during ≥5 nights per week. Logistic regression was used to identify predictors of adherence. In addition, network analysis was performed to investigate direct and indirect interrelations among variables included in the multivariable logistic regression model.
 
Results: Of the 726 patients who had an intake for MAD treatment between April 2017 and August 2024, 442 were excluded for the following reasons: no permission to use their data for research purposes (n = 172), missing follow-up data (n=167), no MAD applied after intake (n = 51), AHI<5 events/hour (n = 43), and missing baseline data (n=9). Therefore, a total of 284 participants (195 [68.7%] males; median [interquartile range] age: 51 [39-59] years; body mass index: 26.7 [24.6-29.1] kg/m²; AHI: 14.7 [9.5-21.7] events/hour) were included in the analyses. The mean follow-up duration was 3 months. Of the participants, 228 (80.3%) met the criterion for complete adherence. Logistic regression showed that persistent snoring (OR=0.41 [0.20-0.83]; P=0.01), persistent breathing stops at night (OR=0.32 [0.14-0.71]; P=0.01), difficulty swallowing with the MAD (OR=0.27 [0.08-0.88]; P=0.03), difficulty retaining the MAD in the mouth (OR=0.17 [0.07-0.42]; P<0.01), smoking (OR=0.27 [0.11-0.64]; P<0.01), and painful temporomandibular disorder at baseline (OR=0.80 [0.65-0.99]; P=0.04) were negatively associated with adherence, while perceived change in occlusion was positively associated with adherence (OR=3.18 [1.29-7.83], P=0.01). Network analysis confirmed the negative associations between adherence and MAD-related side effects, including difficulty swallowing with the MAD and difficulty retaining the MAD in the mouth.
 
Conclusion: Persistent symptoms, smoking, baseline temporomandibular pain complaints, and device-related side effects were negatively associated with adherence. These findings suggest the importance of managing pain-related complaints prior to treatment initiation, addressing residual symptoms and discomfort throughout follow-up, and recognizing smoking as a behavioral factor that may require targeted counseling to optimize adherence and improve treatment outcomes.
 
Support: None
 
ABSTRACT #004
SEX-RELATED DIFFERENCES IN PATIENT-REPORTED OUTCOMES OF MANDIBULAR ADVANCEMENT DEVICE TREATMENT IN ADULTS WITH OBSTRUCTIVE SLEEP APNEA
Joey Chung, DDS, MSc¹; Zhengfei Huang, DDS, PhD¹; Frank Lobbezoo, DDS, PhD^{1, 2}; Jean-Pierre T.F. Ho, MD, DDS, PhD^{3, 4}; Ning Zhou, DDS, PhD³; Marjolein A.J. van Looij, MD, PhD^5,6; J. Peter van Maanen, MD, PhD^5,6; Jerryll Asin, MD⁷; Ghizlane Aarab, DDS, PhD^1
1Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
²Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Malmö, Sweden
³Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centers (Amsterdam UMC), Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
⁴Department of Oral and Maxillofacial Surgery, Northwest Clinics, Alkmaar, The Netherlands ⁵Department of Otolaryngology, Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
⁶Department of Sleep Medicine, OLVG, Amsterdam, The Netherlands
⁷Department of Pulmonology, Center for Sleep Medicine, Amphia Hospital, Breda, The Netherlands
 
Introduction: Sex-related differences in obstructive sleep apnea (OSA) are well documented, particularly in terms of prevalence and pathophysiology. However, it is unclear whether these differences also affect treatment with mandibular advancement devices (MADs), especially regarding patients’ subjective experiences. Such experiences may influence treatment adherence and, ultimately, overall effectiveness. A better understanding of sex-related differences in response to MAD treatment could support clinicians in patient selection and treatment decisions, thereby improving outcomes. This study therefore aimed to assess sex-related differences in patient-reported outcomes of MAD treatment, including improvement in OSA-related symptoms, MAD-related side effects, and adherence.
 
Methods: This prospective longitudinal cohort study enrolled all patients with OSA referred for MAD treatment at an academic dental clinic between April 2017 and August 2024. Data were collected as part of routine care. Baseline information included age, sex, body mass index (BMI), apnea–hypopnea index (AHI), and patient-reported OSA-related symptoms (snoring, daytime sleepiness, fatigue, non-restorative sleep, frequent awakenings, breathing pauses during sleep, and lack of concentration). MAD treatment was provided according to a standardized titration protocol, using a custom-made, titratable device. Follow-up assessments documented patient- reported OSA-related symptoms, treatment adherence, and side effects. Sex-related differences were analyzed using the Mann–Whitney U test, Chi-square test, and repeated logistic regression models.
 
Results: Of the 726 patients referred for MAD treatment, 266 were excluded for the following reasons: no consent for research use of data (n = 172), no MAD fitted after intake (n = 51), and AHI < 5 events/hour (n = 43). The final study sample comprised 460 participants (317 [68.9%] males; median age [IQR] = 50 [38–59] years; BMI = 26.3 [24.2–29.0] kg/m²; AHI = 14.9 [9.4–21.5] events/hour). At baseline, females were older than males, while BMI and AHI did not differ significantly between sexes. Snoring and daytime fatigue were the most frequently reported symptoms in both sexes, but females reported daytime fatigue (P = .05) and breathing pauses during sleep (P = .04) more often than males. At follow-up, 133 participants were excluded due to missing data, leaving 327 participants with a mean follow-up of 3.0 months. Compared to baseline, participants were significantly less likely to report all OSA-related symptoms (odds ratios < 1; P < .01), with no sex-related differences after adjustment for age, sex, BMI, and AHI. Adherence to MAD treatment was similar in both sexes (P = .36). Reports of difficulty keeping the MAD in the mouth during sleep (P < .01) and dry mouth (P = .01) were significantly more frequent among females.
 
Conclusion: Although MAD treatment showed no significant sex-related differences in overall effectiveness, females reported more fatigue and breathing pauses at baseline, as well as more side effects at follow-up. These findings underscore the importance of considering sex-related differences when planning and delivering MAD treatment to provide more personalized care and improve patient outcomes.
 
Support: No funding or non-monetary support was received for this study.
 
ABSTRACT #005
MINIMAL TITRATION APPROACH FOR MANDIBULAR ADVANCEMENT DEVICE TREATMENT IN OBSTRUCTIVE SLEEP APNEA: A RETROSPECTIVE MULTICENTER COHORT STUDY IN 182 PATIENTS ACROSS SIX GENERAL HOSPITALS – PRELIMINARY RESULTS
Ellen Collier, MD, DDS^1-6; Marc Braem, DDS, PhD^{1, 7}; Marijke Dieltjens, PhD^{1, 7
1}Oral Appliance Clinic (Dept. ENT), Antwerp University Hospital (UZA), Edegem, Belgium
²Department of Maxillofacial Surgery, AZ Voorkempen, Malle, Belgium
³Department of Dental Sleep Medicine, AZ Monica, Antwerp, Belgium
⁴Department of Dental Sleep Medicine, Heilig Hart Ziekenhuis, Lier, Belgium
⁵Department of Dental Sleep Medicine, ZAS, Antwerp, Belgium
⁶Department of Pulmonology, VITAZ, Sint-Niklaas, Belgium
⁷Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
 
Introduction: Mandibular advancement device (MAD) treatment is an established non-invasive therapy for treating obstructive sleep apnea (OSA). To date, there is no evidence-based guideline however, for where to initiate mandibular protrusion at the start of treatment. This leaves clinicians to rely on e.g. arbitrary percentages of maximal mandibular protrusion (MMP) to start with. Such an approach lacks personalization and may lead to inefficient titration, discomfort, and an extended time-to-effect.
 
This study evaluated the start of MAD-therapy at maximal comfortable protrusion (MCP) minus 2 mm (MCP-2), a patient-specific and clinically reproducible position. We examined whether MCP-2 results in effective improvements in apnea-hypopnea index (AHI), OSA severity category, and snoring (visual analogue scale – VAS), and how much of additional titration was required.
 
Methods: The retrospective multicenter cohort study included 182 adults with moderate to severe OSA (AHI ≥15 events/h) diagnosed by Level 1 polysomnography, across six Belgian general hospitals. All patients demonstrated improved upper-airway patency during drug-induced-sleep-endoscopy at MCP-2.
 
Digital dental imprints and a standardized bite registration (The BiteFix, Scheu-Dental, Iserlohn, Germany) were used to define MMP and MCP. MAD therapy was initiated at MCP-2 (EVO, ProSomnus Sleep Technologies, Pleasanton, CA, USA). Patients performed symptom-driven titration until snoring resolution or upon reaching physiological limits. Follow-up included a 1-month telephone check and a type-3 home polygraphy after 3–5 months of therapy.
 
Results: 182 patients (137 men; median age 50.0 years) were included in this study with 81.9% suffering from moderate OSA and 18.1% suffering from severe OSA. Overall, the mean AHI decreased from 24.4 (SD 9.6)events /h. to mean AHI of 7.1 (SD 5.1) events/h after median 126.0 (102.0-148.3) days of MAD therapy (p<0.0001).
 
More in particular, OSA category improved markedly: 45% of cases achieved no OSA (AHI <5/h), 47% achieved mild OSA (5 ≤ AHI < 15/h), 8% remained moderate (15 ≤ AHI < 30/h), and 0% remained severe (AHI ≥30/h).
 
Additional titration was not required in 47% of cases that remained at MCP-2). 32% required 1–2 mm additional protrusion.  Only 1 patient required less protrusion due to discomfort. The remaining patients (20%) required ≥3 mm of additional advancement.
 
Median starting position was 73% of MMP, increasing to 82% at therapeutic position. No correlation was found between the amount of protrusion and percentagewise improvement in AHI (R² <0.01). VAS for snoring improved substantially, with nearly 80% of patients reaching socially acceptable snoring levels (VAS .≤ 3)
 
Conclusion: Initiating MAD therapy at the personalized MCP-2 position provides rapid and effective improvement in OSA severity and snoring, while requiring no additional titration in almost half of patients. The absence of correlation between protrusion amount and therapeutic effect highlights the inappropriateness of arbitrary percentage-of-MMP-wise approaches.
 
The described minimal titration protocol is clinically feasible, reproducible, and well-tolerated as demonstrated in real-world settings. Further research should assess generalizability across other MAD designs and long-term outcomes.
 
Support: Marc Braem reports research support from ProSomnus and royalties from Scheu Dental related to the bite-registration device used. Ellen Collier and Marijke Dieltjens declare no financial support.
 
ABSTRACT #006
TEMPOROMANDIBULAR JOINT OUTCOMES FOLLOWING HYPOGLOSSAL NERVE STIMULATION IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA
Sarah Alnemrat, BDS¹; Ryan Greenway DDS²; Erin Gurski APRN,FNP-C³; Rizwana Sultana MD⁴; Hisham Marwan DDS MBA FACS^5
1Department of Pharmacology and Toxicology, University of Texas Medical Branch.
²Resident, Department of Surgery, Division of Oral and Maxillofacial Surgery, University of Texas Medical Branch
³Nurse Practitioner, Division of Pulmonary Critical Care and Sleep Medicine, University of Texas Medical Branch
⁴Associate Professor, Department of Internal Medicine, Division of Sleep Medicine, University of Texas Medical Branch
⁵Associate Professor and Division Chief, Department of Surgery, Division of Oral and Maxillofacial Surgery, University of Texas Medical Branch, Faculty at King Abdulaziz University, Jeddah, Saudi Arabia
 
Introduction: Hypoglossal nerve stimulation (HNS) is an increasingly utilized surgical therapy for obstructive sleep apnea (OSA) in patients who cannot tolerate continuous positive airway pressure (CPAP). While its efficacy for airway patency is well documented, musculoskeletal and craniofacial sequelae, particularly temporomandibular joint (TMJ) discomfort and headache, have received little attention. This study examined the association between HNS implantation and the development or worsening of TMJ pain and headache.
 
Methods: We conducted a retrospective cohort analysis of patients who underwent HNS implantation for OSA between January 2021 and June 2025 and subsequently reported TMJ pain or headache. Preoperative and postoperative TMJ symptom status was recorded, along with age and sex. Clinical significance was evaluated using a smallest-effect-size-of-interest framework, with 0.41 defined as the minimal clinically important effect, 1.15 as moderate, and 2.70 as strong.

Results: Eighteen patients experienced TMJ-related symptoms following hypoglossal nerve stimulator implantation. Among these patients, ten were female and eight were male. Six of the eighteen patients (33.3%) had TMJ symptoms prior to surgery, while twelve patients (66.7%) developed new TMJ pain after HNS placement.
 
Conclusion: Patients with pre-existing TMJ dysfunction appear to be at increased risk for worsening TMJ symptoms after hypoglossal nerve stimulator implantation.
 
Support: None
 
ABSTRACT #007
FIVE YEAR EFFICACY DATA FOR NOVEL EPAP ENHANCED ORAL APPLIANCE TO TREAT OSA
Sat Sharma, MD, FRCPC, FCCM¹; Hilary Reiter, DDS¹; Cecilia Fonesca, BSc.², Antonella Conflitti, PA, CCPA¹; George Abraham, MDS^3
1Centre for Sleep and Chronobiology, Toronto, ON, Canada
²Waterloo Sleep Institute, Waterloo, ON, Canada ³DentCare, Cochin, Kerala, India
 
Introduction: O2Vent Optima, a next generation oral appliance launched in Australia in 2019 has seen successful worldwide adoption for treatment of obstructive sleep apnea.  The novel oral appliance incorporates both mandibular advancement to reduce pharyngeal collapsibility and an air channel that allows airflow through the device to circumvent nasopharyngeal obstruction. The ExVent accessory to the novel mandibular advancement device (MAD) provides oral Expiratory Positive Airway Pressure (EPAP). Oral EPAP with the accessory is designed to provide upper airway support via similar mechanisms of action of nasal EPAP devices in commercial distribution, e.g., passive dilatation of the airway, which reduces flow limitation.    
 
Most of the oral appliance efficacy studies have relatively small number of participants. Therefore, studies with larger population of patients are required. The purpose of our study was to assess efficacy of the novel combination therapy in a large cohort of patients treated for OSA. Change in polysomnographic variables compared to baseline was assessed as primary outcome measure.

Methods: The retrospective data analysis of all patients who received O2Vent Optima MAD and ExVent since 2019 worldwide was performed. Data collected included: demographics, Total AHI, REM AHI, non-REM, mean SpO2, lowest SpO2, and arousal index were analyzed.
 
Results: The O2Vent repository had complete data set including in laboratory polysomnographic studies at baseline and on therapy for 2874 patients. Average age was 52.21±13.45, average was BMI 30.19±4.28 and 68% were male. With novel oral appliance, improvement in the following variables were observed. Total AHI from 28.62±7.82 to 11.32±3.21 (p<0.001); REM AHI 35.21±13.82 to 13.27±5.87(p<0.001); non-REM AHI from 18.22±8.43(p<0.001); mean SpO2 from 90.21±1.27% to 94.73±1.27%(p<0.001); nadir SpO2 from 81±2.63% to 90.54% (p<0.001); and arousal index from 22.79±6.85 to 9.43±3.45 (p<0.001).
 
Conclusions: In this large cohort of OSA patients, the novel oral appliance and oral EPAP accessory demonstrated a remarkable improvement in sleep apnea polysomnographic variables. The study establishes efficacy of incorporating mandibular advancement with device air channel to circumvent nasopharyngeal obstruction with concurrent use of EPAP accessory.
 
Support: Centre for Sleep and Chronobiology, Toronto, ON, Canada
 
ABSTRACT #008
EFFECTIVENESS OF HYPOGLOSSAL NERVE STIMULATION WITH MANDIBULAR ADVANCEMENT DEVICES AS A COMBINATION THERAPY
Zain Moin, BS¹; Gautam Chiang, BS²; Acquin Kulkarni, BS³; Aaron Glick, DDS^4
1Texas A&M University School of Engineering Medicine
²University of Virginia School of Medicine
³University of Texas
⁴University of Texas Health Science Center Houston School of Dentistry
 
Introduction: Hypoglossal nerve stimulation (HGNS) and mandibular advancement devices (MAD) are both well-established therapies for obstructive sleep apnea (OSA), each demonstrating effectiveness and advantages over conventional continuous positive airway pressure (CPAP) therapy such as improved patient comfort, and greater compliance. HGNS senses inspiratory effort and stimulates the genioglossus muscle, advancing the tongue to increase airway patency and reduce apneic events. MADs function by repositioning the mandible forward. Given the differences in MAD and HGNS mechanism of action, it is likely that an additive or synergistic benefit could improve outcomes. The current review investigated the current evidence of effectiveness for dual use of MAD and HGNS.
 
Methods: A structured PubMed review was performed to identify articles involving the combined use of HGNS and MADs, using the following key terms: “hypoglossal nerve stimulation” AND “mandibular advancement devices” OR “oral appliance therapy” as well as “hypoglossal nerve stimulation with mandibular combination therapy.” A supplemental manual search of Google Scholar was conducted using the previously defined keywords to ensure a comprehensive literature search. Articles were excluded if not addressing combination therapy (MAD and HGNS) or if were not published in English.
 
Results: Across all searches, four articles and abstracts describing combination therapy were identified. These articles consisted of retrospective case reports or case series. All published cases showed additional reduction of AHI with combination therapy. In the case reports there was an average of baseline AHI of 42.6 and combination therapy AHI of 2.7. All published cases attempted monotherapy initially. The reasons for prescription of MAD were due to patient discomfort of HGNS at therapeutic level, persistent snoring, abrasion of the tongue, and residual AHI. Additional elements were highlighted showing success in edentulous patients, allowing for reductions in HGNS parameters, improved symptom management, and optimization of personalized care and patient preferences.
 
Conclusion: Current evidence consisting of case report/series, suggest that combination therapy with hypoglossal nerve stimulation and mandibular advancement devices may offer clinical benefit for select patients with obstructive sleep apnea who demonstrate incomplete response to monotherapy. Although high-quality prospective studies are currently lacking, existing clinical experience supports further investigation into this combined approach and the development of criteria to identify patients most likely to benefit.
 
Support: None
 
ABSTRACT #009
APNEA-HYPOPNEA INDEX AT THE US / MEXICO BORDER: SOCIODEMOGRAPHIC AND HEALTH CORRELATES   
Nadia Sardjev, BS¹; Michael Amadei, MD¹; Dorothy Tung, MD¹; Michael Grandner, PhD, MTR, DBSM^1
1Sleep and Health Research Program, Department of Psychiatry, University of Arizona College of Medicine – Tucson, Tucson, AZ
 
Introduction: Little is known about how sleep-disordered breathing is experienced in border communities. This study examines how Apnea-Hypopnea Index (AHI) in this community is related to demographic and health characteristics.
 
Methods: Data were collected from 992 working-age adults (age 25-60) living at the US-Mexico Border. AHI was determined from Embletta home sleep tests scored by certified polysomnographic technicians, using the 3% hypopnea criterion. To identify a parsimonious set of predictors of AHI, we first applied least absolute shrinkage and selection operator (LASSO) regression using a linear model with AHI as the outcome and a broad set of demographic, clinical, behavioral, psychosocial, and sleep-related variables as candidate predictors. Model tuning was performed using 10-fold cross-validation, with the optimal penalty parameter (λ) selected based on minimization of out-of-sample prediction error. Predictors with nonzero coefficients at the selected λ were retained for subsequent analysis. These LASSO-selected variables were then entered into a conventional multivariable linear regression model to obtain unpenalized coefficient estimates, standard errors, and inferential statistics.
 
Results: The mean AHI in the sample was 3.6 (SD=9.7, Range 0.0-89.2, IQR 1.4-7.3). Frequent snoring was reported in 22.3%. Using LASSO regression with 10-fold cross-validation, 13 predictors of apnea–hypopnea index (AHI) were selected and subsequently entered into a multivariable linear regression model. The final model was statistically significant (F(14,849)=13.0, p<.001) and explained 17.6% of the variance in AHI. Greater apnea severity was independently associated with older age (b=0.09, p=.009), higher body mass index (b=0.27, p<.001), hypertension (b=2.37, p=.006), and male sex (b=−2.98, p<.001). Snoring frequency showed the strongest symptom-based associations, with frequent and very frequent snoring associated with increases of 5.33 and 3.35 AHI events per hour, respectively (both p<.01). Among physiologic sleep metrics, Mexican acculturation was inversely associated with AHI (b=−1.33, p=.023). Caffeine consumption was also inversely related to apnea severity (b=−0.49, p=.025). Psychosocial factors, including bicultural identity and family social support, demonstrated smaller effects, with family support showing a trend toward lower AHI (p=.085). 
 
Conclusion: Together, these findings indicate that apnea severity reflects a convergence of demographic, cardiometabolic, symptomatic, physiologic, and contextual social factors.
 
Support: NIH/NIMHD R01MD011600, NIH/NIMH R01MH135978 R01MD011600 is funded by the National Institute on Minority Health and Health Disparities (NIMHD), and R01MH135978 is funded by the National Institute of Mental Health (NIMH). Both are NIH grants with Dr. Michael A. Grandner as the Principal Investigator.
 
ABSTRACT #010
DO WE REFER WHO WE SCREEN?
Stephanie Andrade, DMD Candidate¹; Tanya Al-Talib, DDS, MSc.O^1
1UNLV School of Dental Medicine
 
Introduction: Obstructive sleep apnea (OSA) is a disorder characterized by airway collapse during sleep and may be associated with snoring and excessive daytime sleepiness. This condition can significantly impact the quality of life, increase accident risk, and contribute to cardiovascular and psychological complications. Early detection and referral for diagnosis are critical to prevent long term health consequences.
 
This study aimed to determine the prevalence of referrals made for patients at intermediate and high risk for OSA and excessive daytime sleepiness at UNLV School of Dental Medicine.
 
Methods: A retrospective review was conducted of patient records from July 1, 2017 to December 31, 2021. Adult patients aged 18 years and older who completed a comprehensive exam and a sleep form containing both the STOP-BANG questionnaire and the Epworth Sleepiness Scale (ESS) were included. Patients with a STOP-BANG score of 3–8 and/or an ESS score > 11 were identified as requiring referral to their primary care provider or a sleep specialist. Data extracted from the electronic health records included demographics, STOP-BANG and ESS scores, BMI, anatomical findings, health conditions, referral documentation, follow-up status, and confirmed diagnoses if available.
 
Results: Nine hundred and ninety-eight high and intermediate risk patients out of 2,456 records were included in the study. Records indicated that 18.4% and 62.8% of overall patients were high and intermediate risk respectively on the STOP Bang screening tool. Females constitutes 36.5% of the high and intermediate risk groups. Among the intermediate and high-risk patients only 1.1% were referred for further assessment.
 
Conclusion: Within the limitation of this study, males are at risk more than females. In addition, there seems to be a need to calibrate faculty for risk assessment and referral to increase the referral of patients at risk for OSA.
 
Support: No financial support received for this study.
 
CASE REPORT #011
RESOLUTION OF SEVERE OBSTRUCTIVE SLEEP APNEA USING A MANDIBULAR REPOSITIONING NIGHTTIME APPLIANCE: A CASE REPORT
¹Sarah Pitarra, BS, DDS
¹Sarah Pitarra, DDS, PLLC
 
Introduction: This case report describes a patient with severe obstructive sleep apnea (OSA) who demonstrated substantial improvement following treatment with a mandibular repositioning nighttime appliance. Therapy resulted in a reduction in apnea–hypopnea index (AHI) from 51 events/hour to 4 events/hour after completion of guided airway expansion. This case highlights the potential role of mandibular repositioning nighttime appliance therapy as a non-CPAP, non-surgical intervention for severe OSA in appropriately selected adult patients.
 
Obstructive sleep apnea is a chronic condition characterized by recurrent upper-airway collapse during sleep. Although continuous positive airway pressure (CPAP) remains the gold standard, adherence challenges often prompt interest in alternative therapies. The mandibular repositioning nighttime appliance is designed to promote maxillary expansion, mandibular repositioning, and neuromuscular airway remodeling over time to improve upper-airway dimensions.

 This report presents a case in which mandibular repositioning nighttime appliance therapy resulted in near-resolution of severe OSA.
 
Report of Case:
 
Patient Profile

• Age: 44
• Sex: Female
• Chief Complaint: Loud snoring, bruxism, headaches, non-restorative sleep, nocturnal gasping, and excessive daytime sleepiness
• Medical History: Unremarkable
• Previous OSA Therapy: None

 Diagnostics

• Baseline HSAT revealed:
• AHI: 51 events/hour (severe OSA
• Respiratory Disturbance Index: 56
• Oxygen Nadir: 74%
• Anatomical Findings: Upper-airway constriction

 Intervention Mandibular Repositioning Nighttime Appliance Therapy
 
Treatment Protocol
The patient was treated with a mandibular repositioning nighttime appliance worn nightly and titrated per protocol. Key components included digital airway measurements, CBCT imaging, custom appliance design, and a 13-month expansion and remodeling phase with scheduled adjustments to promote maxillary expansion, mandibular remodeling, and improved tongue posture. The patient was monitored for changes in airway volume, symptoms, and sleep quality.
 
Symptom Reporting During Treatment

• Reduced snoring
• Fewer nighttime awakenings
• Increased daytime alertness
• Improved Epworth Sleepiness Scale scores

 Follow-Up Sleep Study
Post-treatment outcomes included:

• AHI: 4 events/hour (92% reduction)
• Oxygen Nadir: Improved to 88%

 Subjective Results
The patient and bed partner reported elimination of snoring, normalization of daytime function, and resolution of gasping episodes. These findings demonstrate near-complete resolution of severe OSA without CPAP, surgery, or mandibular advancement.
 
Discussion: This case demonstrates the potential effectiveness of mandibular repositioning nighttime appliance therapy for adult patients with severe OSA when craniofacial and airway structural factors contribute to airflow limitation. Unlike mandibular advancement devices, this therapy aims to produce structural and functional airway improvements intended to persist after treatment completion.
 
Conclusion: The patient experienced a marked reduction in OSA severity, with AHI decreasing from 51 to 4 following mandibular repositioning nighttime appliance therapy. This result demonstrates the potential efficacy of a nonsurgical jaw expansion approach in carefully selected cases of severe OSA and highlights the importance of interdisciplinary evaluation in managing sleep-disordered breathing.
 
Support: None
 
CASE REPORT #012
A CASE STUDY IN UTILIZING CBCT (NON-INVASIVE AIRWAY ANALYSIS) FOR REAL-TIME DISPLAY OF INCREMENTAL INCREASE IN AIRWAY DIMENSIONS AND HYOID LIFT USING AI-PREDICTIVE ORAL APPLIANCE GEOMETRY BUILT IN A TAVMLRD (TOTAL ANTERO-VERTICAL MANDIBULARLINGUAL REPOSITIONING DEVICE) TO DELIVER ADAPTIVE ON-DEMAND AIRFLOW DURING SLEEP/WAKE
Raghavendra V Ghuge, MD, DABSM, FAASM, MBA¹; Advait R Ghuge, BS^1
1Sleep Medicine Institute of Texas
 
Introduction: Multi-level airway collapse phenotype in OSA introduces uncertainty in pre-treatment decision-making. Multi-level airway collapse is a probable explanation for partial success with PAP, COAT/OAT Gen1 custom oral devices or with surgical approach like HNS and Hyoid lift. CBCT airway analysis is capable of demonstrating multi-level narrowing. Average normal adult male and female airway SMCA’s (smallest Cross-Sectional Area) are 272 mm2 and 194 mm2 respectively by CBCT (noted by multiple other authors). AIO-AI predictive algorithm designed device-characteristics in a TAVMLR (Total Antero-Vertical Mandibular-Lingual Repositioning) device such as AIO Breathe® has demonstrable success in OSA control (SLEEP2025).
 
Report of Case: CBCT airway analysis of 61 YO male with severe OSA DXCO (without treatment), with oral placement of TAVMLR®1 device CO RX20% and TAVMLR®2 device MO RX50%. HST and Remote Patient Monitoring with AIOMEGA APP were performed. Pre-treatment CBCT reported (DXCO) SMCA at C3 (hypopharynx) was 135.95 mm2. SMCA’s with TAVMLR®1 (RX20%) and TAVMLR®2 (RX50% MO) were 325.04 mm2 and 516.64 mm2 respectively which were 239% and 386% greater than SMCA DXCO without device.  CBCT DXCO data: RPCSA (Retro-Palatal Cross-sectional Area) 404.36 mm2, RPTD (Transverse) 29.48 mm, RPAPD (Antero-Posterior) 16.37mm, RGCSA (Retro Glossal) 302.95 mm2, RGAPD 7.91 mm, RGTD 23.39 mm, HPCSA (Hypopharynx SMCA) 135.95 mm2, HPTD 21.57 mm, HPAPD 7.22 mm, HMPD (Hyoid to Mandibular Plane Distance) 26.03 mm, TDLCSA (Longitudinal) 1917.38 mm2, Condyle to mandibular Fossa 1.3 mm (Articular Disc). CBCT RX50% dimensions: RPCSA 556.64 mm2 (138%), RPTD 40.65 mm (138%), RPAPD 19 mm (116%), RGCSA 582.76 mm2 (192%), HPCSA 516.64 mm2 (386%), HPTD 40.74 mm (189%), HPAD 17.58 mm (243%), HMPD 3.52 mm (Vertical lift 10.9 mm and anterior lift 0.35 mm), TDLCSA 2257.48 (115%), Condyle -Mandibular Fossa 2.2 mm. HST (WatchPat) DX: pAHI (3%) 62.5/hr., pAHI (4%) 59.1/hr., ODI4% 57.2, LSAT 79%, mean O2 desaturation 89%, O2< 90% 43.6 min (12.2% TST), HB90% (burden<90%) 110, HB90/hr. 19 min/hr. HST (WatchPat) RX: pAHI (3%) 3.5, pAHI (4%) 1.5, ODI4% 1.3, LSAT 91%, Mean O2 Desaturation 92%, HB90% (burden<90%) 0 min, HB90/hr. 0 min, O2<90% 0 min (0% TST). Self-reported compliance 100%. AIOMEGA APP analysis showed significant improvement in TST (15%), Sleep Efficiency increased 20%, increased Deep and REM sleep. Improvement in ESS and Ghuge Fatigue Scale.
 
Discussion: Pre-treatment CBCT precisely captures baseline multi-level obstructive phenotype of OSA. With TAVMLR®, CBCT displays airway enlargement, hyoid lift and incremental airway enlargement with degrees of mandibular translation and rotation. CBCT can be an independent reliable predictor of successful OSA treatment with TAVMLR® type oral appliances like AIO Breathe.
 
Support: AIOMEGA (non-financial)
 
CASE REPORT #013
TWO-NIGHT BREAKTHROUGH IN TREATMENT-RESISTANT OSA: IMMEDIATE EFFECTIVE OUTCOMES BY COMBINING CHAIRSIDE OA WITH MOUTH SHIELD
Jason Hui, DDS, MAGD, D. ABDSM¹; Alan G. McDavid, DDS, MAGD, D. ABDSM^2
1Texas A&M College of Dentistry
²Texas Sleep and TMJ Solutions
 
Introduction: Obstructive sleep apnea (OSA) affects 2-4% of middle-aged adults, including healthcare professionals, yet symptom denial delays diagnosis, exacerbating risks like cardiovascular disease and neurocognitive decline. Characterized by pharyngeal collapse causing hypoxemia and sympathetic activation, OSA management includes CPAP, surgery, and oral appliances (OAs). Titratable OAs offer customizable, immediate therapy, addressing adherence barriers.
This report details a 45-year-old female respiratory therapist denying sleep-related breathing disorder (SRBD) symptoms despite partner-noted snoring and bed-sharing avoidance. Using myTAP—a chair-side titratable OA—with a mouth shield, we achieved near-complete resolution, emphasizing nasal breathing's synergy with minimal protrusion. This challenges assumptions of equivalent nasal/oral airflow in therapies like full-face CPAP, advocating screening in high-risk groups.
 
Report of Case:
 
Patient History and Baseline Assessment
A 45-year-old female respiratory therapist with no comorbidities denied SRBD symptoms, despite occupational expertise. Partner reports confirmed loud snoring and relational strain.
 
Baseline polysomnography (PSG) diagnosed moderate-severe OSA: apnea-hypopnea index (AHI) 25.4 events/hour; 4% oxygen desaturation index (ODI) 39.3; 3% ODI 30.1; T90 (SpO2 <90%) 23.9 min; REM sleep 15.15%; mean pulse rate (PR) 365/35 (sympathetic dominance); autonomic nervous system (ANS) ratio 1:9:1; unquantified hypoxic burden.
 
Intervention
Immediate treatment used myTAP OA, fitted chair-side for day-1 therapy. Night 1: ~3 mm advancement to edge-to-edge (below 40-60% therapeutic zone). Night 2: Added mouth shield for nasal patency, no further titration.
 
Outcomes
Night 1 PSG (myTAP alone): AHI 13.8 (46% improvement); 4% ODI 17.1; 3% ODI 10.5; T90 5.16 min; REM 4.54%; PR 51/49; ANS 1:0:1.0. Residual events noted.
 
Night 2 (myTAP + shield): AHI 3.6 (86% overall); 4% ODI 8.9 (77%); 3% ODI 3.9 (87%); T90 1.81 min (92%); REM 8.34% (+3% from night 1); PR 95.3/47 (10% stabilization); ANS 1:1:1; hypoxic burden 0.17 (47% reduction). Snoring ceased; bed-sharing resumed; alertness improved.
 
Discussion: This case demonstrates myTAP's efficacy—via chair-side titration—for rapid OSA relief in denial-prone patients, with mouth shielding amplifying benefits at minimal advancement. Step-wise PSG at fixed edge-to-edge position shows nasal enforcement resolving residual apneas, desaturations, and sympathetic overdrive beyond protrusion alone, highlighting TAP appliances' market advantage.
 
Findings refute nasal/oral airflow equivalence, as in full-face CPAP. Nasal receptors maintain rhythmicity; anesthesia quadruples apneas, mimicking obstruction. Variable obstruction disrupts more than fixed, correlating with AHI via flow limitation and pharyngeal instability. Nasal breathing boosts nitric oxide, reduces resistance, and balances ANS/vagal tone.
 
Limitations
Single case; short-term data. Future trials should assess long-term efficacy and overjet. Integrated nasal-OA protocols suit mild-moderate OSA; stigma-free screening prevents sequelae.
 
Support: None
 
CASE REPORT #014
 Withdrawn by the Author
 
CASE REPORT #015
A PAINFUL BITE: RESOLUTION OF REFRACTORY TRIGEMINAL NEURALGIA THROUGH IDENTIFICATION AND TREATMENT OF SLEEP BRUXISM
Ching Xie¹, Inshya Desai^2
1Brooklyn Unity Medical Care PC
²Jefferson Einstein Montgomery
 
Introduction: Sleep bruxism is a common sleep-related movement disorder characterized by repetitive jaw clenching or grinding during sleep. While often considered benign or limited to dental wear and temporomandibular joint (TMJ) symptoms, sleep bruxism can have broader neurologic consequences. Trigeminal neuralgia is a chronic neuropathic pain condition characterized by paroxysmal, severe facial pain in the distribution of the trigeminal nerve. Typical etiologies include neurovascular compression, demyelinating disease, or structural lesions; however, secondary causes related to peripheral nerve irritation are less commonly recognized. We present a unique case of chronic, treatment-refractory trigeminal neuralgia caused by undiagnosed sleep bruxism, which resolved following targeted oral appliance therapy. This case highlights the importance of considering sleep-related oral parafunctions in patients with unexplained craniofacial pain.
 
Report of Case: A 52-year-old woman presented with a 3-year history of episodic right-sided facial pain localized to the maxillary and mandibular distributions of the trigeminal nerve. She described the pain as electric, stabbing, painful, intermittent, occurring more frequently in the mornings. She was diagnosed with trigeminal neuralgia by neurology and treated with carbamazepine, gabapentin, and later baclofen, with only partial and transient relief. MRI of the brain did not show any evidence of neurovascular compression or intracranial pathology.
Additionally, the patient reported chronic morning jaw soreness and frequent headaches upon awakening, though she denied awareness of nocturnal grinding or any history of sleep apnea. She had no prior sleep evaluation. Referral to a dentist revealed significant masseter hypertrophy and tenderness along the trigeminal nerve distribution. Overnight home sleep testing was negative for obstructive sleep apnea but notable for frequent jaw muscle activity consistent with sleep bruxism.
 
A custom-made hard acrylic maxillary night guard was prescribed. After four weeks of nightly use, the patient reported marked reduction in facial pain frequency and intensity. By three months, she experienced near-complete resolution of her symptoms and was able to taper off all neuropathic pain medications.
 
Discussion: This case illustrates an uncommon but clinically significant link between sleep bruxism and secondary trigeminal neuralgia. Repetitive nocturnal jaw clenching likely caused chronic peripheral irritation or sensitization of the trigeminal nerve branches, perpetuating neuropathic pain.
 
Clinicians treating chronic facial pain should consider sleep-related movement disorders in the differential diagnosis, particularly when standard neurologic evaluations are unrevealing. Collaboration between sleep medicine specialists, neurologists, and dental sleep medicine providers can uncover treatable contributors and significantly improve patient outcomes.
 
Support: None
 
CASE REPORT #016
SURGICAL-ORTHODONTIC MANAGEMENT OF A PATIENT WITH PIERRE ROBIN SEQUENCE, ECTRODACTYLY, AND SEVERE PEDIATRIC OBSTRUCTIVE SLEEP APNEA: A CASE REPORT
Fonthip Tatiyanupanwong, DDS, MS¹; Sukkarn Themkumkwan, DDS¹; Kiatanant Boonsiriseth DDS, MD¹; Supakit Peanchitlertkajorn, DDS, MDS^1
1Faculty of Dentistry, Mahidol University, Bangkok, Thailand
Introduction: Pierre Robin Sequence (PRS) is characterized by a clinical triad of micrognathia, glossoptosis, and upper airway obstruction, leading to severe obstructive sleep apnea (OSA). PRS has an incidence of 1:8,500 to 1:14,000 live births, with cleft palate occurring in 66-90% of cases. Ectrodactyly, also known as split hand/foot malformation, is a limb abnormality involving deficiency or hypoplasia of phalanges and metacarpals with deep median clefts. This condition can occur in isolation or as a component of over 75 syndromes. The co-occurrence of PRS with ectrodactyly is extremely rare, with only one previous case report describing PRS in a patient with ectrodactyly-ectodermal dysplasia-clefting syndrome. This report presents a unique case of PRS with isolated ectrodactyly and discusses the multidisciplinary clinical management approach.
 
Report of Case: A 14-year-6-month Thai female presented with chief complaints of dental crowding and difficulty cleaning her teeth. Medical history revealed cleft palate repair at 11 months of age with bilateral hearing loss requiring a hearing aid and cochlear implant, and severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 26.6. Genetic testing revealed an abnormal 46, XX female karyotype with abnormal banding of the long arm of chromosome 7 (7q). Extraoral examination found down-slanting eyes, severely retrognathic mandible and chin, and bilateral ectrodactyly of the hands. Intraoral findings included severe crowding, deep overbite, congenitally missing second premolars (#13, 20). Cephalometric analysis confirmed severe skeletal Class II relationship (ANB = 9) with retrognathic maxilla and mandible, posterior mandibular rotation, and hyperdivergent pattern. Drug-induced sleep endoscopy identified hypopharyngeal obstruction. The treatment plan included pre-surgical orthodontics with extraction the lower right bicuspid (#28), followed by Le Fort I advancement with counterclockwise rotation, bilateral sagittal split ramus osteotomy with 8 mm mandibular advancement, and genioplasty with 10 mm chin advancement. Post-treatment evaluations demonstrated successful resolution of dental crowding, improved facial profile, and significant improvement in OSA with AHI reduced to 1.4. Speech was maintained without worsening hypernasality despite a maxillary advancement.
 
Discussion: This case represents the first reported instance of PRS with isolated ectrodactyly in the literature. The patient's chromosomal abnormality involving 7q aligns with previous reports linking ectrodactyly to aberrations in bands 7q21-7q22. The presence of both conditions in this patient raises the question of whether this represents a novel syndrome or co-occurrence of multiple anomalies, warranting further genetic investigation. Surgical-orthodontic management of OSA in PRS patients with cleft palate presents unique challenges, as maxillomandibular advancement may worsen velopharyngeal insufficiency and hypernasality. Drug-induced sleep endoscopy proved valuable in identifying the obstruction level and guiding surgical planning. The extraction of # 28 was performed to resolve the lower anterior crowding and create additional overjet for larger mandibular advancement. The successful outcome demonstrates that careful multidisciplinary treatment planning between an orthodontist and a maxillofacial surgeon can achieve significant improvement in airway, facial aesthetics, and function.
 
Support: None.
 
CASE REPORT #017
MULTIMODAL, PHENOTYPE-DRIVEN MANAGEMENT OF SEVERE OSA: A CASE REPORT DEMONSTRATING SYNERGISTIC HYPOGLOSSAL NERVE STIMULATION AND ORAL APPLIANCE THERAPY
Harmeet Chiang, DDS,MS¹; Aaron Glick DDS²; Gautam Chiang, Medical Student³; Ryan Nord MD⁴; Elsa Mathew, MD^5
1,4Virginia Commonwealth University
²University of Texas School of Dentistry
³University of Virginia School of Medicine
⁵Veteran Affairs Medical Center
 
Introduction: Obstructive sleep apnea (OSA) affects nearly 30 million adults in the United States, yet achieving durable, effective therapy remains challenging. Although Continuous Positive Airway Pressure (CPAP) is the gold standard, long-term adherence limitations necessitate alternative strategies. Hypoglossal Nerve Stimulation (HNS) and Oral Appliance Therapy(OAT) are well-established non-CPAP therapies with distinct mechanisms of action. However, incomplete response to either modality alone remains common. Emerging evidence and clinical experience support a combination approach integrating HNS and OAT to achieve multilevel airway stabilization by addressing phenotype-specific collapse patterns. Respiratory-synchronized stimulation of distal hypoglossal nerve branches primarily improves anterior–posterior (AP) airway patency at the tongue base and velum. However, HNS efficacy diminishes in patients with lateral pharyngeal wall collapse, particularly at the velum, an anatomic feature strongly associated with non-response. In contrast, OAT has demonstrated greater effectiveness in patients with lateral wall involvement. This case report illustrates a phenotype-driven combination therapy leveraging complementary actions of HNS (AP stability) and OAT (lateral stability) to optimize airway patency in a patient with refractory OSA.
 
Report of Case: A patient with severe OSA presented after failing CPAP therapy. Prior to HNS implantation in 2020, the patient underwent uvulopalatopharyngoplasty (UPPP) and septoplasty. Despite surgery, baseline polysomnography demonstrated persistent severe disease with an apnea–hypopnea index (AHI) of 79.3 events/hour (supine: 80.1/hr; non-supine: 77.1/hr). Drug-Induced Sleep Endoscopy (DISE) was performed to characterize airway collapse and revealed multilevel obstruction, including AP collapse at the tongue base and partial lateral wall collapse at the velum.
 
Following HNS implantation, post-titration sleep testing at 3.2 volts in 2022 demonstrated only a partial therapeutic response, with a residual AHI of 49.9/hr. Given the DISE-documented lateral velum collapse, an anatomical phenotype that is insufficiently addressed by tongue-based HNS stimulation alone, a combination treatment approach was pursued. A mandibular advancement device was introduced in 2024, resulting in a reduction of AHI to 38.5/hr. Further optimization in 2025 included maximal tolerable mandibular advancement combined with positional therapy. This multimodal strategy yielded a final AHI of 22.5/hr. Notably, non-supine AHI improved dramatically from 77.1/hr at baseline to 9.4/hr, representing a total AHI reduction of 72.5%.
 
Discussion: This case highlights the limitations of a single-therapy paradigm in OSA management and supports a phenotype-driven treatment framework. The patient’s partial response to HNS was predictable based on DISE findings demonstrating lateral wall collapse, a key anatomic determinant of HNS non-response. Rather than treating lateral collapse as a contraindication, this report demonstrates how it can be effectively managed through adjunctive OAT. By combining modalities with complementary mechanisms, HNS addressing AP tongue-base collapse and OAT stabilizing lateral pharyngeal walls, multilevel airway patency was achieved. These findings reinforce the importance of incorporating lateral wall assessment into preoperative decision-making and DISE-based algorithms. Precision sleep medicine increasingly depends on strategic sequencing and integration of therapies to optimize outcomes in patients with complex airway phenotypes.
 
Support: None.
 
CASE REPORT #018
FROM SURGERY TO MAD: WHEN SURGERY DOESN’T CUT IT
Clayton Blackwell, DDS¹; Roopali Kulkarni, DMD, MPH^1
1University of Pennsylvania School of Dental Medicine, Philadelphia, PA
 
Introduction: Obstructive sleep apnea (OSA) is a disease that impacts an estimated 936 million people worldwide. The typical patient at presentation is an older adult male with increased body mass index; however, race plays a role in the development of OSA. Black Americans younger than 35 years old are impacted at a higher rate than White Americans of the same age group, independent of body weight. This leads to the consideration of advanced therapies in younger patients with more severe OSA.
 
Report of Case: A 30-year-old Black American male with a significant medical history of asthma, bronchitis, depression, anxiety, and a history of tuberculosis presents to our oral medicine clinic for evaluation of oral appliance therapy for his OSA on the recommendation of his sleep physician. After completing his initial sleep study, the patient was found to have an apnea-hypopnea index (AHI) of 30.5. It was recommended to attempt a trial of CPAP therapy. The patient tried and failed this line of therapy. Given the severity of the sleep apnea at such a young age, the patient was interested in surgical options.
 
Four months after his initial visit, the patient underwent uvulopalatopharyngoplasty (UPPP) and rhinoplasty. He had healing without issue and after a sufficient healing period underwent a repeat sleep study with an AHI of 18.3. The patient was then given a referral to our clinic. After delivery of a mandibular advancement device, the patient was titrated at a rate of 1 mm per week. At the 1 month follow up, the patient reports a noted reduction in snoring and improvement in sleep quality. At the second follow up 6 weeks later, the patient continues to note significant benefit, with mild myalgia on occasion in the mornings. A repeat HST to ensure quality of the MAD therapy was conducted and revealed an AHI of 6.9.
 
Discussion: UPPP is the most common surgical procedure of the upper airway. It is understood that it reduces AHI but does not normalize it. One study of 63 patients undergoing the UPPP surgery found that only 24% achieved a post-surgical AHI of less than 5. It is recommended that patients who do not achieve optimal surgical outcomes continue with CPAP. In patients who decided to pursue surgery after failing CPAP, it is important that dental sleep medicine can be consulted and provide therapy to patients who have not yet achieved a therapeutic treatment to manage their OSA.
 
Support: There is no financial support for this Case Report.
 
CASE REPORT #019
MANAGING TRIAD OF OBSTRUCTIVE SLEEP APNEA, TEMPOROMANDIBULAR DISORDERS AND FATIGUE: A CASE REPORT
Anamaria-Mirabela Korman, DMD¹; Mayank Shrivastava, BDS, MDS, MS^1
1Orofacial Pain and Dental Sleep Medicine, Adams School of Dentistry, University of North Carolina, Chapel Hill, USA
 
Introduction: Obstructive sleep apnea (OSA) is a potentially life-threatening condition that commonly co-occur with Temporomandibular Disorders (TMD) leading to a combined prevalence of OSA in TMD reported as 28-37%. Patients with TMD and OSA often experience wide range of symptoms varying from chronic pain, jaw functional limitation, headaches, fatigue, excessive daytime sleepiness, snoring, pauses in breathing, and disturbed sleep.  Assessment of fatigue is clinically important because it is self-perpetuating and can be used as a marker to identify poor sleep, high pain sensitivity and depression which can negatively affect daily functioning, and other aspects of well being.  Some studies have found improvement in fatigue after treating sleep disturbances, but research on comorbid OSA and TMD is still growing. Therefore, this case report explores how management of comorbid OSA and TMD improves fatigue and quality of life. It also highlights the improvements in self-reported OSA related symptoms and emphasizes the importance of integrating multidimensional outcomes when managing such cases.
 
Report of Case: A 65-year-old-female came to the orofacial pain and sleep clinic with one-year history of constant dull pain in the bilateral masseter, and temporalis muscles. The sleep complaints included frequent loud snoring that worsens in supine position, grogginess upon awakening, daily nap cravings, and fatigue. She sleeps 5-6 hr/night on average with latency of 20 minutes and no difficulties in falling asleep when awake. The medical history was significant for GERD and depression (managed with medications). The initial screening scores were ESS 16, STOP BANG 3, Fatigue Severity Scale (FSS) 48, Sleep Apnea Quality of Life Index (SAQLI) moderate-severe impairment across domains of daily functioning, social interactions, emotional functioning, and symptoms. The diagnosis was chronic masticatory myalgia and untreated moderate OSA (AHI 18/hr min SaO2 85%), with stressors, poor sleep and fatigue as contributing factors. Primary treatment for chronic masticatory myalgia included patient education and self care, pharmacotherapy (short course of muscle relaxants), physical therapy, biobehavioral therapy and strict lateral positional therapy for OSA. After achieving 90% pain reduction and slight improvement in OSA symptoms with positional therapy, MAD was delivered at 55% MAP. Upon 60% MAP, patient experienced significant improvement in fatigue and OSA related symptoms. At six-month follow up, outcome measures were ESS 8, STOP BANG 1, FSS 16, SAQLI (none-mild impairment). Patient currently noted significant improvement in sleep quality, sleeping well through out the night without any pain flare ups and feeling energetic during daytime.
 
Discussion: Integrative care effectively improves patient symptoms and outcomes. The case report emphasizes the importance of including fatigue assessment and quality of life measures in addition to symptom-based assessment alone to identify potential underlying disorders. Clinicians should recognize that complaints of fatigue or lack of energy in the absence of TMD and OSA do not exclude the presence of other underlying conditions as depression. We believe that recognizing this phenotype is of clinical utility, and addressing each condition independently is critical to improving fatigue. Therefore, a comprehensive history, clinical examination, and targeted treatment are essential to optimize overall patient quality of life.
 
Support: None.
 
CASE REPORT #020
RESOLUTION OF SEVERE OBSTRUCTIVE SLEEP APNEA WITH MANDIBULAR ADVANCEMENT DEVICE FOLLOWING PARTIAL IMPROVEMENT WITH TIRZEPATIDE-ASSOCIATED WEIGHT LOSS IN A PAP-INTOLERANT PATIENT
Venugopal Komakula, MD, MPH^1
1Assistant Professor Clinical, Sleep Medicine, University of Cincinnati, Cincinnati, OH
 
Introduction: Severe obstructive sleep apnea (OSA) often requires higher positive airway pressure (PAP) settings for adequate control; however, intolerance frequently limits long-term adherence, even with bilevel PAP (BPAP) therapy. Mandibular advancement device (MAD) is typically recommended for mild to moderate OSA, though selected patients with severe disease may benefit. This case report describes a patient with chronic severe OSA requiring higher PAP settings who achieved normalization of OSA using MAD, confirmed by repeat objective testing.
 
Report of Case: A 51-year-old female with severe OSA was evaluated approximately three and a half years ago. She was treated with auto-adjusting CPAP of 9–17 cm HâO. Examination demonstrated Mallampati class IV airway, retrognathia, macroglossia, and adequate dentition.
 
Home sleep apnea test (HSAT) performed approximately one year prior, at a body weight of 204 lbs (BMI 35) and with adequate total monitoring time (TMT), demonstrated severe OSA with a pAHI of 47 events/hour (3% desaturation), oxygen desaturation index (ODI) of 42/hour (3%), 32/hour (4%), and oxyhemoglobin saturation (SpO2) nadir of 87%.
 
Approximately two months after evaluation, in-laboratory titration polysomnography at a weight of 215 lbs demonstrated need for BPAP therapy and at IPAP 21 and EPAP 15 cm HâO, supine REM sleep was adequately captured with effective control of OSA. BPAP therapy was recommended with EPAP minimum 16, pressure support 4, and IPAP maximum 25 cm HâO. Although sleep quality improved, long-term intolerance persisted due to discomfort and aerophagia.
 
Approximately one year later, patient initiated pharmacologic weight-loss therapy with tirzepatide for insulin resistance, achieving 30 lbs weight loss compared to her initial HSAT. Despite this, repeat HSAT demonstrated persistent severe OSA, though partially improved, with REI 31.4/hour (3%), 27.2/hour (4%), ODI 30.2/hour (3%) and SpO2 nadir 79%. TMT was adequate, with supine time comprising 27% of TMT. Marked positional worsening was observed (supine AHI 53.4/hour vs non-supine AHI 22.5/hour).
 
Due to ongoing intolerance of high-pressure PAP therapy, patient elected treatment with a MAD. HSAT performed two months later at similar body weight demonstrated complete resolution of OSA, with pAHI 1.2/hour (3%) and 0.1/hour (4%), and SpO2 nadir of 93%. A confirmatory HSAT several weeks later, after further weight reduction to 160 lbs, demonstrated sustained normalization with REI 2.4/hour (3%) and 1.4/hour (4%), SpO2 nadir 90%, and adequate supine time comprising 51% of TMT. Both studies had adequate TMT.
 
Discussion: This case demonstrates normalization of severe OSA requiring higher PAP pressure settings using MAD in a PAP intolerant patient. Pharmacologic weight loss alone resulted in partial improvement but did not normalize disease severity. Repeat objective follow-up testing with adequate supine sleep time confirmed that therapeutic success was attributable to MAD. This case underscores MAD as a viable option in carefully selected severe OSA cases. 
 
Support: No external funding or non-monetary support was received.
 
PDF