It is very important to understand the diagnosis and management of pain in the temporomandibular joint and masticatory muscles, and movement disorders, which are among the adverse events and side effects that occur in oral appliance （OA） treatment for sleep apnea. Understanding these diagnoses and management strategies will lead to the continuation of OA treatment and result in successful treatment.
In this article, we explain the basic knowledge, including diagnosis and basic treatments for temporomandibular disorders, which should be known for enhancing the effectiveness of OA treatment and managing the condition.

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Objectives: The apnea-hypopnea index（AHI）is used to determine the therapeutic effect of an oral appliance（OA）on obstructive sleep apnea（OSA）. Even if the improvement in AHI is inadequate, the subjective symptoms of patients may improve. In addition to the medical judgment of the treating physician, it is important to consider the patient’s values and preferences together as the patient and the treating physician make joint decisions. Recently, studies on the values and preferences of treatment results（outcomes）of patients with various diseases have been reported, but there are still few studies on OA treatment for OSA. The aim of this prospective observational study was to investigate the values and preferences of patients for OSA treatment with OA by using a questionnaire survey.
Methods: From October 2018 to September 2019, 61 OSA patients planning to undergo OA treatment were surveyed by a questionnaire on therapeutic effects before the start of treatment. The following 11 items were scored by visual analogue scale（VAS）and evaluated: 1）health and longevity, 2）prevention of onset and exacerbation of heart disease, 3）prevention of onset and exacerbation of hypertension, 4）prevention of onset and exacerbation of diabetes, 5）improvement of apnea/hypopnea, 6）improvement of daytime sleepiness, 7）improvement of nighttime arousal, 8）improvement of snoring, 9）refreshment upon awakening, 10）improvement of thirst at night and when waking up, and 11）improvement of bed partner sleep. Statistical analysis was performed on the relationship between each score and patient information, duration of OSA, medical history, and polysomnography results.
Results: Among outcomes 1）to 11）, the highest mean scores were, in descending order, 5）improvement of apnea/hypopnea, 8）improvement of snoring, and 11）improvement of bed partner sleep, and the lowest mean scores were related to complications. Women emphasized items related to complications, especially those related to their medical history. In the group with poor sleep efficiency, the results were of high interest in 2）prevention of onset and exacerbation of heart disease and 11）improvement of bed partner sleep. In the group with severe oxygen desaturation, interest was low in 4）diabetes and 7）improvement of nighttime arousal. No significant relevance to the questionnaire results was found in any of the other items.
Conclusion: The findings of this study suggest that patients planning to undergo treatment with OA are mainly moderate and mild cases of OSA, and place more importance on improvement of subjective symptoms such as snoring than on improvement of prognosis and medical disease. On the other hand, since patients do not have sufficient medical knowledge related to OSA, there is a concern that they may have responded with a poor understanding of the intent of this questionnaire survey. Further study of this aspect is warranted.

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Due to the pandemic caused by the new coronavirus （SARS-CoV-2）, the cumulative number of infected people was 447,873, and the cumulative number of deaths due to COVID-19, the infectious disease caused by SARS-CoV-2, reached about 9,000 in Japan as of March 14, 2021. The staff of Kindai University Hospital are treating patients with severe COVID-19. Due to this pandemic, Japan faced a collapse of the medical system, declared a state of emergency, and suffered socio-economic damage. Vaccinations will be started with priority given to medical staff and society is expected to return to normal, but there are some concerns about its limitations.

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On March 11, 2020, the World Health Organization declared a pandemic caused by coronavirus disease 2019 （COVID-19）, which is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 （SARS-CoV-2）. Due to its highly contagious nature, the pandemic has changed lives drastically all over the world. Since mid-March 2020, dentists in many countries were recommended to postpone all but urgent and/or emergency treatment and care in order to reduce the risk of COVID-19 spreading and to save personal protective equipment. Oral appliance （OA） therapy for patients with obstructive sleep apnea （OSA） had also been postponed.
Epidemiological studies have shown that patients with OSA are at high risk of developing severe complications of COVID-19. Sleep physicians/dentists should continue to manage both patients with and without COVID-19 during the pandemic. However, continuous positive airway pressure （CPAP） is considered to be an aerosol-generating procedure and could transmit the virus to household members as well as healthcare workers if the patient is infected by the virus. The decision of whether to continue or stop CPAP therapy should be based on a risk-benefit analysis. In turn, oral appliance therapy could be the first-line treatment for patients with OSA during the COVID-19 pandemic, because OAs do not generate aerosols, can be easily disinfected, and feature better adherence than CPAP. Sleep physicians should take account of the predictors of OA treatment and obtain informed consent from patients with respect to the merits and demerits of switching the use of CPAP to OAs.
In the course of OA therapy during the COVID-19 pandemic, most face-to-face consultations, device delivery, titration, short-term and long-term follow-up appointments, and part of the management of side effects or problems with appliances could be replaced by teledentistry. When face-to-face treatment is implemented in the dental clinic, dentists and staff members should follow appropriate local guidance to mitigate SARS-CoV-2 transmission.

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