Letter 1, Issue 7.4

Considerations About Oral Appliance Therapy During the COVID-19 Pandemic


Caetano Petrella1; Milton Maluly, PhD1; Gabriel Natan Pires, PhD1,2; Monica L. Andersen, PhD1; Sergio Tufik, MD, PhD1

 1Departamento de Psicobiologia, Universidade Federal de São Paulo São Paulo, SP, Brazil; 2Department of Physiological Sciences, Santa Casa de São Paulo School of Medical Sciences São Paulo, SP, Brazil 

The recent article published by Schwartz et al. entitled “Oral appliance therapy should be prescribed as a first-line therapy for OSA during the COVID-19 pandemic”1 is opportune and welcome. We would like to endorse their statements and call attention to further aspects. 

The article adds significant information in respect of the current approach to treating obstructive sleep apnea (OSA) during the COVID-19 pandemic. This is particularly important, as we still know relatively very little about the transmission and dissemination mechanisms of COVID-19. Recent studies have suggested that there is a relationship between COVID-19 and OSA2, which reinforces the need to discuss the most suitable approach to the treatment of sleep-disordered breathing during the pandemic.

The authors stated that currently the American Academy of Dental Sleep Medicine (AASDM) has recommended oral appliance therapy (OAT) as the first-line therapy for the treatment of the OSA, especially for adult patients who prefer alternative therapies to positive airway pressure (PAP). Other Sleep Medicine societies, including the Brazilian Sleep Odontology Society (ABROS), the World Sleep Society (WSS) and the American Academy of Sleep Medicine (AASM), have also released similar guidelines, at least in respect to mild cases.

OAT devices have important benefits in comparison with PAP devices, including:

  1. They do not generate aerosol, which theoretically might increase the chance of infection
  2. They are easy to disinfect, and do not pose a risk of possible reinfection
  3. Their use is associated with higher compliance rates.

The authors of the article highlighted the warning given by the AASM that PAP therapy has the potential to expose those who are near OSA patients to an increased risk of COVID-19, if the patients are themselves infected.

Another important point to consider is that sleep medicine services were reduced by almost 80% during the first months of the COVID-19 pandemic in Europe, and many facilities may still be closed, or working under technical restrictions. This makes PAP titration in the sleep laboratory difficult, as they are often now only able to assess a limited and highly selected number of patients3. Thus, these logistical and operational issues reinforce the benefits of OAT over PAP.

We, in general, support the use of OAT, not only during the COVID-19 pandemic, but also as a first-line of treatment for mild and moderate OSA4, 5. However, we stress the need to remain aware of the criteria for the proper use of OAT, taking into consideration its indications and contraindications, the patient´s individual characteristics, and the presence of comorbidities6, and ensure that the diagnosis of OSA is made by a physician who is a registered sleep-specialist7.

To prioritize the use of OAT for the treatment of OSA during the COVID-19 pandemic, odontology professionals need to pay particular attention to patient protection and hygiene measures. These measures should be clearly explained to the patients in order to assure the safety of the procedures. It is of utmost importance that appropriate and comprehensive individual protection equipment (IPE) is used, and that strict hygiene measures in respect of the working environment are taken. All surfaces must be disinfected with alcohol with, at least a concentration of 62%, and 0.5% of hydrogen peroxide or 1,000 ppm (0.1%) of sodium hypochlorite8,9. In the waiting room, patients should keep a minimum distance of 1.5 meters from one another, and there should be an interval of at least 30 minutes between appointments to avoid overcrowding and allow enough time for the disinfection of the environment. If possible, there should be natural ventilation to avoid the use of air conditioning.

These protection and disinfection measures, and compliance with all recommendations from sanitary authorities, can help to make the patients feel safe in their search for treatment and follow-up OAT therapy. We add our support to the recommendation given by Schwartz et al., and sleep medicine societies worldwide that OAT should be the first-line of treatment of mild and moderate OSA during the COVID-19 pandemic.


Petrella C, Maluly M, Pires GN, Andersen ML, Tufik, S. Considerations about oral appliance therapy during the COVID-19 pandemic. J Dent Sleep Med. 2020;7(4)


  1. Schwartz D, Addy N, Levine M, Smith H. Oral appliance therapy should be prescribed as a first-line therapy for OSA during the COVID-19 pandemic. J Dent Sleep Med. 2020;7(3).
  2. Tufik S, Gozal D, Ishikura IA, Pires GN, Andersen ML. Does obstructive sleep apnea lead to increased risk of COVID-19 infection and severity? J Clin Sleep Med. 2020; 16(8): 1425-1426; doi: 10.5664/jcsm.8596. Online ahead of print.
  3. Grote L, McNicholas WT, Hedner J. Sleep apnoea management in Europe during the COVID-19 pandemic: data from the European Sleep Apnoea Database (ESADA). Eur Respir J 2020; 55(6):2001323. doi: 10.1183/13993003.01323-2020.
  4. Marklund M, Braem MJA, Verbraecken J. Update on oral appliance therapy. Eur Respir Rev. 2019;28(153):190083.
  5. Wojda M, Jurkowski P, Lewandowska A, Mierzwiska-Nastalska E, Kostrzewa–Janicka J. Mandibular Advancement Devices in Patients with Symptoms of Obstructive Sleep Apnea: A Review. Adv Exp Med Biol. 2019;1153:11-17. doi:10.1007/5584_2019_334.
  6. Holley, A. B., Lettieri, C. J., & Shah, A. A. Efficacy of an Adjustable Oral Appliance and Comparison with Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome. Chest. 2011;140(6), 1511–1516
  7. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. Journal of Clinical Sleep Medicine 2015. J Clin Sleep Med. 2015;11(7):773-827.
  8. Kampf G, Scheithauer S, Lemmen S, Saliou P, Suchomel M. COVID-19-associated shortage of alcohol-based hand rubs, face masks, medical gloves and gowns – proposal for a risk-adapted approach to ensure patient and healthcare worker safety. J Hosp Infect. 2020;105(3):424-427. doi:10.1016/j.jhin.2020.04.041
  9. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents. [published correction appears in J Hosp Infect. 2020 Jun 17;:]. J Hosp Infect. 2020;104(3):246-251. doi:10.1016/j.jhin.2020.01.022


Submitted in final revised form August 4, 2020
Accepted for publication September 15, 2020
Address correspondence to: Dr. Monica L. Andersen, Departamento de Psicobiologia, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros, 925, São Paulo, 04024-002, Brazil ; Phone: 55 11 21490155/55 11 5572-5092; Email: ml.andersen12@gmail.com


The authors have no conflicts of interest to disclose.