Patient Selection and Clinical Evaluation
What the candidate must know
Patient selection begins with a structured sleep history (snoring, witnessed apneas, gasping, unrefreshing sleep, daytime sleepiness), a validated symptom instrument such as the Epworth Sleepiness Scale, and a focused airway examination. Document comorbidities that shift risk: obesity, hypertension, atrial fibrillation, type 2 diabetes, and prior stroke. Assess nasal patency, tonsillar size, Mallampati class, retrognathia, maxillary constriction, and dentition because these both predict appliance candidacy and constrain fabrication. Screen for contraindications to oral appliance therapy (OAT): insufficient healthy teeth or poor periodontal support, active caries, severe temporomandibular joint disorder, and inability to protrude the mandible.
Traps in questions
Examinees commonly conflate a screening questionnaire with a diagnostic test. The STOP-BANG and Epworth tools stratify risk and quantify symptoms; they do not diagnose obstructive sleep apnea (OSA). Another trap is assuming a low body mass index excludes OSA - normal-weight patients, women, and those with primarily hypopneas may score low on screening tools yet have meaningful disease. Questions may also test that OAT is generally second-line to positive airway pressure for severe OSA but can be first-line for mild-to-moderate disease or PAP intolerance. Do not treat a single office measurement as diagnostic.
Worked example / rule of thumb
A 52-year-old with snoring, Epworth of 12, BMI 27, and hypertension: risk factors (hypertension, sleepiness) plus symptoms warrant referral for a sleep study before appliance fabrication. Rule of thumb: symptoms plus risk factors trigger testing; a negative screen in a high-risk patient does not exclude disease. Confirm the diagnosis and severity with a sleep physician before committing to OAT, and record baseline dentition and joint status for later comparison.