The Path of Least Invasiveness

Treating obstructive sleep apnea (OSA) is at an exciting crossroads where therapeutic advances are coming of age in the era of precision medicine. In the past, the only option was continuous positive airway pressure (CPAP) therapy. Now, there are many effective alternatives to manage sleep apnea and even more on the horizon, including pharmacological and preventive measures.

As a dentist who treats sleep apnea, I am fortunate to collaborate with multiple cross-disciplinary specialists and can direct my patients to a variety of treatment options that best suit their needs or enhance any monotherapy approach. Most healthcare providers I partner with share the same treatment goal: optimizing management of the patient’s disorder in the least invasive way with the lowest associated risks.

That’s true of most healthcare specialties in this country. Think about it—knee replacement surgery isn’t the initial treatment for knee pain.

A patient usually starts by seeing their primary care physician, who may recommend something like a knee brace or prescription NSAIDs. If the knee pain persists, the primary care physician usually refers the patient to an orthopedic specialist who might prescribe additional interventions like physical therapy, steroid injections, or a combination of multiple treatments.

It’s possible that knee replacement will end up being the necessary course of treatment—but only after less invasive alternatives have been ruled out. This stepwise approach helps to ensure that patients avoid the unnecessary potential risks and recovery time associated with surgery if the first-line treatments are effective.

A Stepwise Approach to OSA

Similarly, hypoglossal nerve stimulation (HGNS) is not the first-line treatment for OSA. The standard of care dictates that adult patients must be intolerant or unaccepting of PAP prior to surgical considerations. In 2021, the American Academy of Sleep Medicine published a clinical practice guideline for the referral of adults with OSA for surgical consultation.¹ This guideline recommends that clinicians discuss referral options with certain populations of adults with OSA who are intolerant or unaccepting of PAP as part of a “patient-oriented discussion of alternate treatment options.”

Oral appliance therapy (OAT) is also a recommended alternative treatment option for adult patients who are intolerant or unaccepting of PAP, regardless of the level of OSA severity. And it’s noninvasive.

In taking a stepwise approach to OSA treatment, I propose that an adequate trial of OAT would make more sense as the next step in the standard of care, prior to considering HGNS.

What constitutes an adequate OAT trial?

1. A qualified dentist evaluates the patient to determine if they are a suitable candidate for OAT.
2. The oral appliance is a custom-made device fabricated by a dental professional. Over-the-counter products, prefabricated appliances, entirely virtual mail order processes, or patient self-directed impression techniques are inadequate and increase the risk of inferior results.
3. The oral appliance is fitted, adjusted, and calibrated by a qualified dentist who manages the patient’s care and any emergent side effects for a minimum of 90 days—and ideally for the lifespan of the device.
4. At the conclusion of the trial, patients are referred to the treating physician to verify treatment efficacy or discuss alternative treatment options if the qualified dentist determines the patient is not a good candidate, is intolerant or unaccepting of OAT.

Why OAT Makes Sense as a Next Step

HGNS is certainly a welcomed and valued addition to the arsenal of treatment options for OSA. And like the analogy involving knee pain, surgical intervention may, in fact, end up being the best course of action for the patient.

However, it’s important not to skip over OAT as a next-line treatment before HGNS. If an adequate trial of OAT shows that it is an effective treatment option, the patient may be able to avoid some of the inherent risks involved with HGNS altogether.

Time to treatment

HGNS requires several steps, which can significantly delay treatment. For example, prior to scheduling the surgery, physicians must demonstrate that HGNS is medically necessary, which includes the completion of a drug-induced sleep endoscopy procedure. It’s not uncommon to have a six-month gap between the initial consultation and the actual surgery. Following the surgical procedure, there is about a month integration period before activation of the device and then an additional few months for titration of the device.

By comparison, OAT treatment typically begins within the month of the initial appointment, and many patients start to experience relief of symptoms almost immediately upon delivery of the appliance.

Recovery time

While recovery time will differ for each patient, in general, most patients will need several weeks to recover from the HGNS surgery and may need to take time off from work. A standard recommendation may include no strenuous activity or heavy lifting and limiting movement of the right arm and shoulder, which can prove to be problematic for certain patient occupational requirements.

By comparison, OAT has no recovery time and no restrictions at any time after delivery of the device.

Pain and complications

All surgeries, regardless of the clinical expertise of the surgeon, come with an element of risk from infection, unexpected complications, and anesthesia. Discomfort will depend on each patient’s unique pain tolerance level, but it is fair to say surgery of any type is not pain-free.

In some cases, patients may require additional surgeries for device positioning or removal, software modifications, and maintenance of an implanted device. The power supply of these implants needs periodic replacement (10-year battery life), making ongoing maintenance more invasive compared to non-surgical options like oral appliances. As with all treatments, there is also always a risk of recall on any device, and the need to recalibrate any software.

OAT, on the other hand, is reversible and does not involve surgical, anesthesia, or infection risks to the patient. The patient is readily able to begin the calibration process upon delivery of the oral appliance.

Noncompliance and relief of symptoms

As with any current treatment for OSA, patients with HGNS must comply with the treatment. Some patients may not tolerate the required amplitude to effectively treat their OSA, leading to only partial management outcomes or non-compliance. In both these instances, patients may benefit from the addition of adjunctive therapies after HGNS.  

Recently, I have treated several patients who have HGNS devices implanted and have also required combination therapy with an oral appliance to optimize management of their OSA. I am fortunate that I’ve been able to work collaboratively with the treating physician in my region and co-manage our mutual patients. However, I find myself wondering if these patients could have been effectively treated with an oral appliance if provided an OAT trial prior to surgery.

Conclusion

Given the invasiveness and increased risks associated with HGNS compared to OAT, it is surprising that an adequate OAT trial is not more commonly required before HGNS.  With medical device advertising and medical information more readily accessible to today’s patients, it’s very likely that many patients with OSA are approaching their healthcare providers to request HGNS. Undoubtedly, HGNS is absolutely the best option for some patients, just as CPAP or an oral appliance is absolutely the best option for other patients. The important thing is that patients are aware of all of their therapeutic options.

As part of standard informed consent protocols in treating OSA, we all share the responsibility to ensure our patients are aware of those options, including OAT.  While we all navigate the ever-changing landscape of our industry, I encourage all OSA treatment providers to consider a policy in your practice to discuss the benefits of OAT with your patients prior to HGNS surgery and to collaborate with a qualified dentist.

Source: SleepWorld Magazine Nov/Dec 2025

By: Becky Fox, DMD

Becky Fox, DMD, D-ABDSM, solely practices dental sleep medicine and treats sleep apnea  at Pennsylvania Dental Sleep Medicine in Harrisburg, Pa., and a member of the American Academy of Dental Sleep Medicine.

Reference

1. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(12):2499–2505.