We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suitable for inclusion in the evidence base, including 15 Level I to II randomized controlled trials and 5 of these trials with placebo-controlled treatment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment adherence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been compared favorably to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP.

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In patients with incomplete response to OAT, DISE with and without the appliance can identify residual anatomical locations of collapse, which may direct additional medical and surgical treatment options to augment OAT effectiveness. Further work is needed to determine if DISE affects outcomes.

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/ A strategy for management of giant sequoia groves is formulated using a conceptual framework for eco system management recently developed by Region Five of the USDA Forest Service. The framework includes physical, bio logical, and social dimensions. Environmental indicators and reference variability for key ecosystem elements are discussed in this paper. The selected ecosystem elements include: 1) attitudes, beliefs, and values; 2) economics and subsistence; 3) stream channel morphology; 4) sediment; 5) water; 6) fire; 7) organic debris; and 8) vegetation mosaic. Recommenda tions are made for the attributes of environmental indicators that characterize these elements. These elements and associ ated indicators will define and control management activities for the protection, preservation, and restoration of national forest giant sequoia ecosystems.