Letter 1, Issue 8.1

Treating OSA Patients Right: Commentary on Identifying the Appropriate Therapeutic Position of an Oral Appliance by Sheats et al. (2020)


Dillon A. Hambrook, PhD1; Shouresh Charkhandeh, DDS1; John E. Remmers, MD1,2

 1Zephyr Sleep Technologies, Calgary, Canada; 2University of Calgary, Calgary, Canada

View Dr. Sheats' response to this letter

We anticipated that the consensus report on identifying a therapeutic position of an oral appliance (OA) would offer leadership and vision in standardizing treatment protocols based on existing evidence. Unfortunately, the report is a disappointing departure from the stated mission of the AADSM.

Sheats and colleagues1 define the appropriate therapeutic position as one that improves “signs, symptoms, or objective indices of sleep-related breathing disorders.” This is deeply troubling. When monitoring obstructive sleep apnea (OSA), signs or symptom reports are not equivalent to objective indices of respiratory status. Snoring is a poor indicator for the resolution OSA because: snoring is only moderately correlated to respiratory indices 2 and reports of snoring are unreliable3. Questionnaires screen for sleep apnea, but no validated questionnaires that track improvement in OSA exist. Therefore, they should not be relied upon as the sole guidance for OA titration. Equivocating signs and symptoms with objective measures of OSA in determining the therapeutic position of an oral appliance is a regressive repudiation of evidence-based decision making.

Sheats and colleagues assert that, “no definition of treatment success exists, … OAT providers should … individualize treatment goals for each patient.” This assertion is incorrect for OSA patients. The task force cites many studies that used the common definitions for OAT success: reduction in AHI/REI to less than 5hr-1 or 10hr-1, with or without a 50% reduction in AHI/REI. Setting aside debates about which definition of success is most useful or whether a single index can adequately characterize a complex condition like OSA,4 definitions of success exist, are widely used, and are helpful in managing OSA treatment.

Including respiratory indices in defining treatment success enhances treatment effectiveness. Several studies1 compared using signs and symptoms alone with using objective respiratory indices (pulse oximetry or polysomnogram (PSG)) to direct OA titration. Using objective respiratory measures substantially more patients were able to reach a satisfactory treatment outcome1. Titration protocols that employ objective measurement of respiratory parameters should be recommended over titration by signs and symptoms alone. Therefore, oral appliance titration should be performed during attended PSGs, by serial HST, or by validated, objective automatic home titration systems5. Endorsing treatment protocols based on signs and symptoms alone does a disservice to OSA patients.


Hambrook DA, Charkhandeh S, Remmers JE. Treating OSA Patients Right: Commentary on Identifying the Appropriate Therapeutic Position of an Oral Appliance by Sheats et al. (2020). J Dent Sleep Med. 2021;8(1).


  1. Sheats R, Essick G, Grosdidier J, et al. Identifying the appropriate therapeutic position of an oral appliance. J Dent Sleep Med. 2020;7(4).
  2. Maimon N, Hanly PJ. Does snoring intensity correlate with the severity of obstructive sleep apnea? J Clin Sleep Med. 2010;6(5):475-478.
  3. Fischer R, Kuehnel TS, Vielsmeier V, Haubner F, Mueller S, Rohrmeier C. Snoring: is a reliable assessment possible? Eur Arch Oto-Rhino-Laryngology. 2020;277(4):1227-1233.
  4. Pevernagie DA, Gnidovec-Strazisar B, Grote L, et al. On the rise and fall of the apnea−hypopnea index: A historical review and critical appraisal. J Sleep Res. 2020;29(4):1-20.
  5. Remmers JE, Topor Z, Grosse J, et al. A feedback-controlled mandibular positioner identifies individuals with sleep apnea who will respond to oral appliance therapy. J Clin Sleep Med. 2017;13(7):871-880.


Submitted for publication November 16, 2020
Accepted for publication December 16, 2020
Address correspondence to: Dr. John Remmers, Chief Medical Officer, Zephyr Sleep Technologies Inc., #102, 701 64 Ave SE, Calgary, AB, Canada; Email: jremmers@zephyrsleep.com


DAH, SC, and JER are employees of Zephyr Sleep Technologies. SC and JER own stock in Zephyr Sleep Technologies.