Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015

The Success of Oral Appliance Therapy Based on Symptom-Driven Titration

STUDY OBJECTIVE

Obstructive sleep apnea (OSA) is a chronic condition that could lead to debilitating and sometimes life-threatening consequences. Oral appliance therapy (OAT) is effective in providing a conservative, nonsurgical treatment option for patients diagnosed with mild-to-moderate OSA. The primary goal of this study is to describe a symptom-based titration protocol and determine if the patients can be effectively managed with oral appliances (OAs).

METHOD

A retrospective chart review of patients who were treated with OAs was analyzed for the management of OSA. Patients were self-titrated for symptomatic improvement before posttreatment titration sleep studies were conducted.

RESULTS

Our study has found that 87.5% of the test population was successfully managed with OAs after overnight titration. Seventy-five percentage of the patients were titrated to Apnea-Hypopnea Index (AHI) < 5 with an average of 79.6% reduction from the baseline. Statistical studies showed that patients' body mass index and age at baseline polysomnogram studies significantly influenced the reduction in AHI achieved, whereas the baseline AHI did not show any significant correlation.

CONCLUSION

Oral appliance therapy (OAT) can be a reliable treatment modality to treat OSA, and performing a separate overnight posttreatment titration study further ensures its effectiveness. Furthermore, OAT can be an effective treatment modality even for moderate-to-severe OSA with posttreatment titration.

Patient-Reported Outcomes of Maxillomandibular Surgery for Obstructive Sleep Apnea Treatment: A Scoping Review

(1) Background: The present scoping review aims to scrutinize all existing patient-reported outcomes and assess the perspectives of obstructive sleep apnea patients after maxillomandibular surgery. (2) Methods: The review was carried out according to the extensions for scoping reviews using the PRISMA-ScR guidelines. Several databases were used to carry out the initial search. This study included randomized controlled trials, cohort studies, cross-sectional and case-control studies. The included studies considered patients with obstructive sleep apnea who were submitted to orthognathic surgery as the main subjects, and the patient's perception of quality of life, satisfaction, treatment experience and side effects were assessed. (3) Results: From 1407 examined articles, a total of 16 were included. Most of the included studies used more than one questionnaire to assess quality of life, except for five articles. The most commonly referred instruments were the Epworth Sleepiness Scale, SF-36, the Functional Outcomes of Sleep and Ottawa Sleep Apnea. The most commonly assessed outcomes were sleep quality, daytime function, facial aesthetics, dental function and emotional health. (4) Conclusions: The number of variables that can be evaluated from a patient's perspective are endless, as are the tools available to assess them. Not all of these tools, which are generally questionnaires, assess all the various outcomes, and some do not compare the pre- and post-surgical situations. Most of them are generic and lack specificity for obstructive sleep apnea.

Modifications in Upper Airway Collapsibility during Sleep Endoscopy with a Mandibular Positioner: Study in Snorers and Obstructive Sleep Apnea Patients

BACKGROUND

Mandibular advancement devices (MADs) are an effective treatment for patients with sleep-related breathing disorders, with variable response. Increasingly more research points to the predictive value of Drug-Induced Sleep Endoscopy (DISE) in patient selection. This study aims to analyze the changes in upper airway collapsibility using a titratable MAD simulator during DISE.

METHODS

This study included 104 patients with simple snoring and obstructive sleep apnea (OSA). The VOTE scale was used to assess the presence of collapses during the DISE both without and with the MAD simulator.

RESULTS

In snorers, there was a decrease in collapses at the level of the soft palate and oropharynx when the advancement was achieved. Patients with mild OSA also showed a decrease in collapses at the base of the tongue. Patients with moderate/severe OSA exhibited significant amelioration at all levels. The levels at which there were residual collapses despite the maneuver were, in order, the velopharynx, oropharynx, epiglottis, and tongue.

CONCLUSIONS

The MAD simulator reduces collapsibility at all levels and in all severity groups. Residual collapses suitable for combined treatments were able to be identified. This highlights the need for individualized patient selection, as upper airway collapsibility exhibits variable improvement or worsening with the MAD simulator regardless of the severity of the condition.

Recommended assessment and management of sleep disordered breathing in patients with atrial fibrillation, hypertension and heart failure: Taiwan Society of Cardiology/Taiwan Society of sleep Medicine/Taiwan Society of pulmonary and Critical Care Medicine joint consensus statement

Sleep disordered breathing (SDB) is highly prevalent and may be linked to cardiovascular disease in a bidirectional manner. The Taiwan Society of Cardiology, Taiwan Society of Sleep Medicine and Taiwan Society of Pulmonary and Critical Care Medicine established a task force of experts to evaluate the evidence regarding the assessment and management of SDB in patients with atrial fibrillation (AF), hypertension and heart failure with reduced ejection fraction (HFrEF). The GRADE process was used to assess the evidence associated with 15 formulated questions. The task force developed recommendations and determined strength (Strong, Weak) and direction (For, Against) based on the quality of evidence, balance of benefits and harms, patient values and preferences, and resource use. The resulting 11 recommendations are intended to guide clinicians in determining which the specific patient-care strategy should be utilized by clinicians based on the needs of individual patients.

Evaluation of condylar and mandibular movements on the upper airway during the use of mandibular advancement device for obstructive sleep apnea treatment

OBJECTIVES

To evaluate the temporomandibular joint (TMJ), condylar and mandibular movements in obstructive sleep apnea (OSA) patients treated with mandibular advancement device (MAD) and to identify the influence of these anatomic factors on upper airway (UA) volume and polysomnographic outcomes after treatment.

MATERIALS AND METHODS

Twenty OSA patients were prospectively treated with MAD. Clinical examinations, cone-beam computed tomography, and polysomnography were performed before MAD treatment and after achieving therapeutic protrusion. Polysomnographic variables and three-dimensional measurements of the TMJ, mandible, and upper airway were statistically analyzed.

RESULTS

Condylar rotation, anterior translation, and anterior mandibular displacement were directly correlated with total UA volume, while vertical mandibular translation was inversely correlated with the volume of the inferior oropharynx. MAD treatment resulted in an increase in the volume and area of the superior oropharynx. There was no statistically significant correlation between condylar rotation and translation and polysomnographic variables. With MAD, there was a significant increase in vertical dimension, changes in condylar position (rotation and translation), and mandibular displacement. The central and medial lengths of the articular eminence were inversely correlated with condylar rotation and translation, respectively. The lateral length of the eminence was directly correlated with condylar translation, and the lateral height was directly correlated with condylar rotation and translation.

CONCLUSION

Condylar and mandibular movements influenced UA volume. The articular eminence played a role in the amount of condylar rotation and translation.

CLINICAL RELEVANCE

Individualized anatomical evaluation of the TMJ proves to be important in the therapy of OSA with MAD.

Self-reported oral moistening disorders in obstructive sleep apnoea: A scoping review

BACKGROUND

Obstructive sleep apnoea (OSA) is a highly prevalent problem with significant consequences. Continuous positive airway pressure (CPAP) and oral mandibular advancement device (MAD) are considered the standard treatments for OSA. Patients may experience self-reported oral moistening disorders (OMDs) (i.e. xerostomia or drooling) at the beginning, throughout and after treatment. This affects oral health, quality of life and treatment effectiveness. The exact nature of the associations between OSA and self-reported OMD is still unknown. We aimed to provide an overview of the associations between self-reported OMD on the one hand and OSA and its treatment (namely CPAP and MAD) on the other hand. In addition, we sought to determine whether OMD affects treatment adherence.

MATERIALS AND METHODS

A literature search in PubMed was performed up to 27 September 2022. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 48 studies were included. Thirteen papers investigated the association between OSA and self-reported OMD. They all suggested an association between OSA and xerostomia but not between OSA and drooling. The association between CPAP and OMD was addressed in 20 articles. The majority of studies have indicated xerostomia as a CPAP side effect; however, some have observed that xerostomia diminishes with CPAP therapy. In 15 papers, the association between MAD and OMD was investigated. In most publications, both xerostomia and drooling have been described as common side effects of MADs. These side effects are often mild and transient, and they improve as patients continue to use their appliance. Most studies found that these OMDs do not cause or are not a strong predictor of non-compliance.

CONCLUSION

Xerostomia is a common side effect of CPAP and MAD, as well as a significant symptom of OSA. It may be regarded as one of the indicators of sleep apnoea. Moreover, MAD therapy can be associated with OMD. However, it seems that OMD may be mitigated by being adherent to the therapy.

Sleep bruxism in children and adolescents-A scoping review

BACKGROUND AND OBJECTIVE

This review paper focuses on sleep bruxism (SB) in children and adolescents. It aims to assess the landscape of knowledge published in the last 20 years.

METHODS

A total of 144 relevant publications from 386 previously identified through Medline were included, of which 83 were on possible SB, 37 on probable SB, 20 on definite SB and 4 were non-applicable. The review places emphasis on the recent evidence on prevalence, pathophysiology, diagnosis and management of SB in children and adolescents, with special focus on probable and definitive SB.

RESULTS

The prevalence ranges from 5% to 50% depending on the age range and on the SB diagnosis (possible, probable or definitive). The pathophysiology is multifactorial, arousal associated and with behavioural problems and sleep disorders (obstructive sleep apnoea, snoring, nightmares) as risk factors, as well as respiratory conditions (allergies, oral breathing). Screening should include questionnaires and dental assessment. Instrumental recording is helpful to confirm diagnosis although more studies are needed to validate this approach in children. SB management includes controlling orofacial and dental consequences and assessing for any other comorbidity. Management options include occlusal splints, oral appliances (advancement mandibular), rapid maxillary expansion and some medications, although this last option is supported by limited evidences in children.

CONCLUSION

Suggestions of future topics in research are delivered to better understand comorbidities, diagnosis and management with improved outcomes compared to what is currently available.

Endorsement of "European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea" by World Sleep Society

Guidelines for management of sleep disorders from national or regional societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society's (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Task Force reviewed the European Respiratory Society's guideline on non-CPAP therapies for obstructive sleep apnea (OSA) with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. The task force and the WSS guidelines committee endorsed the European Respiratory Society's guideline with respect to the utilization of bariatric surgery, mandibular advancement devices, positioning devices, myofunctional therapy, hypoglossal neurostimulation, maxilo-mandibular surgery, and carbonic anhydrase inhibitors for the treatment of OSA. The task force and the WSS guidelines committee noted that there is substantial new evidence for the role of soft tissue, upper airway surgery, not included in the guidelines paper.

Gauging the knowledge, attitude and practice of interns and dentists about obstructive sleep apnoea-A cross-sectional study

CONTEXT

Obstructive sleep apnoea is less known and lesser practised in dentistry. Dentists often struggle to educate, diagnose or offer treatment to the patient. Hence, the disorder of the patient and the opportunity for the dentist both go unnoticed.

AIM

To assess the knowledge, attitude and practice regarding aspects of obstructive sleep apnoea among dental practitioners, faculty and interns in India.

METHODS AND MATERIAL

A self-constructed validated questionnaire was prepared and circulated online among dental interns and professionals in India. Responses received from 237 participants were evaluated and statistically analysed.

RESULTS

Only questions about diagnosis and symptoms of OSA were correctly answered by more than 50% of the participants. In all other questions, the knowledge was poor. Only 11.4% of respondents felt that they are well equipped to diagnose OSA. The general attitude of the participants was favourable but with poor practice. Only 5.1% of participants were ever involved in the treatment of OSA.

CONCLUSIONS

Given the high prevalence of OSA among the population, along with widespread ignorance among dentists for the same as found in our study, there is an urgent need to spotlight OSA in the dental curriculum at an undergraduate level. To complement this, extensive training and motivation must also be provided so that dental graduates can identify, refer and participate in the treatment of OSA.

Effectiveness of mandibular advancement devices in the treatment of obstructive sleep apnea and the impact of different body positions on treatment： A systematic review and meta-analysis

OBJECTIVE

The meta-analysis aimed to evaluate the efficacy of mandibular advancement device (MAD) for the treatment of obstructive sleep apnea (OSA) and explore the effect of different positions on MAD for OSA.

METHODS

The Embase, PubMed, Medline, and Cochrane Library databases were searched for relevant studies evaluating the effect of MAD on the treatment of OSA from database inception to November 2022. The Bayesian random-effects mode was used to calculate the pooled outcome. Subgroup analysis and sensitivity analysis were applied to investigate the heterogeneity.

RESULTS

A total of 6 studies enrolling 643 patients were eligible for further analysis. MAD treatment led to improvements in total apnea-hypopnea index (AHI) for both positional OSA(POSA) and Non-POSA groups, but there was no significant difference in the effect of MAD on Non-POSA and POSA (MD = -1.46,95%CI [-4.89,1.97], P = 0.40). In the supine position, AHI improvement after MAD treatment in POSA group was more than that in Non-POSA group by 15 events/hour in average (MD = 14.82, 95%CI [11.43,18.22], P＜0.00001), while in the non-supine position, the change of AHI in Non-POSA group was significantly better than that in POSA group by approximately 8 events/hour (MD = -7.55,95%CI[-10.73,-4.38],p < 0.00001).

CONCLUSION

MAD is more suitable for POSA compared to Non-POSA in patients with habitual sleep in the supine or supine predominant position. While for patients with habitual sleep in the non-supine position, MAD is an effective treatment option for Non-POSA.

Efficacy of titratable mandibular advancement device versus continuous positive airway pressure therapy in the treatment of obstructive sleep apnea: A clinical crossover trial

Background

To compare efficacy of continuous positive airway pressure (CPAP) and oral appliance (OA) in management of various grades of obstructive sleep apnea (OSA).

Methods

Thirty polysomnography diagnosed cases of OSA were divided into three groups based on baseline apnea hypopnea index (AHI) as follows: group 1: mild OSA (AHI = 5-14.9), group 2: moderate OSA (AHI = 15-29.9), and group 3: severe OSA (AHI >30) with 10 patients in each group. Half of the patients in each group were randomly allocated to CPAP or OA therapy, and crossover of therapy was performed after two months. AHI, Epworth's Sleepiness Scale (ESS), and mean oxygen saturation (SPO2) were measured at baseline, after each arm of treatment and after the crossover. A questionnaire survey including information regarding pretreatment sleep symptoms and improvement after therapy was performed at above time frames. At the end of therapy, the patients were surveyed regarding satisfaction and perceived effectiveness with both modalities.

Results

CPAP was more efficacious in reducing AHI and SPO2 as compared with OA across the three study groups. The improvement in most sleep-related symptoms was higher with CPAP. The satisfaction and perception on effectiveness of treatment were higher with OA than CPAP across three study groups (P-value<0.05 for all).

Conclusions

OA is an effective alternative to CPAP across all grades of OSA in selected cases, which is more preferred owing to higher effectiveness and satisfaction among the patients.

Factors associated with treatment adherence to mandibular advancement devices: a scoping review

PURPOSE

Obstructive sleep apnea (OSA) is frequently treated with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs). For various reasons, both treatment options are often affected by low adherence. While factors associated with low CPAP adherence are described in the literature extensively, less is known about adherence to MAD therapy. This scoping review aimed to synthesize the body of literature on the factors associated with adherence to MAD treatment.

METHODS

A systematic literature search was conducted using bibliographic databases PubMed, Embase.com , Web of Science, and the Cochrane Library (Wiley) to identify relevant studies that described factors associated with adherence to MAD in the treatment of OSA or snoring combined with OSA in adults.

RESULTS

The literature search yielded a total of 694 references. Forty studies were found eligible for inclusion. The literature showed that factors with a possible negative influence on the adherence to MAD treatment are personality aspects; failing effectiveness of MAD; side effects during MAD therapy; using a thermoplastic MAD; dental treatments during MAD therapy; and a poor first experience with the MAD with inadequate guidance by professionals. Factors that may have a positive effect on MAD adherence include effectiveness of therapy, custom-made MAD, good communication skills of the practitioner, early recognition of side effects, stepwise titration of the MAD, and positive first experience with MAD.

CONCLUSIONS

The knowledge of factors associated with MAD adherence can be used to provide further insight into individual adherence to OSA treatments.

Occurrence of Temporomandibular Disorders among patients undergoing treatment for Obstructive Sleep Apnoea Syndrome (OSAS) using Mandibular Advancement Device (MAD): A Systematic Review conducted according to PRISMA guidelines and the Cochrane handbook for systematic reviews of interventions

BACKGROUND

Patients undergoing mandibular advancement device (MAD) therapy for obstructive sleep apnea (OSA) may experience changes in jaw position and altered occlusion. This could potentially contribute to the development or exacerbation of TMD symptoms. The literature on the long-term impact of MAD treated for OSA on TMD is scarce. Hence, this review was undertaken to ascertain the occurrence of TMD in MAD users.

METHODS

A comprehensive search protocol was implemented across several online databases using MeSH keywords and Boolean operators. A standardised data extraction form was developed specifically for this review. Two reviewers independently extracted the data. RoB-2 was used to evaluate the methodological quality of the included studies.

RESULTS

A total of 13 clinical studies were selected for this review. Some studies reported a significant reduction in the severity and frequency of TMD symptoms following MAD treatment. However, other studies did not observe significant changes in TMD symptoms or TMJ-related parameters from baseline to follow-up intervals. Temporary increases in TMJ-related pain or symptoms at the beginning of the follow-up period, which later subsided, were reported in some studies. Overall, MAD was not discontinued in any OSA patient due to TMDs.

CONCLUSION

The findings reveal that different outcomes associated with TMD are affected differently by MAD treatment for OSAS. According to a few studies, MAD therapy significantly reduced the severity and frequency of TMD symptoms. Other research, however, found no appreciable modifications in TMD symptoms or TMJ-related indicators. Although the overall results point to no significant effect of MAD treatment on TMD symptoms, the disparity in results between studies highlights the need for additional studies using standardised approaches.

Does orthognathic surgery have an incidentally beneficial effect on mild or asymptomatic sleep apnoea?

A prospective study was performed to assess the effect of orthognathic surgery on mild obstructive sleep apnoea (OSA) in patients with an underlying dentofacial deformity treated for occlusal and/or aesthetic reasons. As the main outcome variables, changes in upper airway volume and apnoea-hypopnoea index (AHI) were evaluated at 1 and 12 months of follow-up, in patients undergoing orthognathic surgery with widening movements of the maxillomandibular complex. Descriptive, bivariate, and correlation analyses were performed; significance was set at P < 0.05. Eighteen patients diagnosed with mild OSA were enroled (mean age 39.8 ± 10.0 years). An overall upper airway volume widening of 46.7% after orthognathic surgery was observed at 12 months of follow-up. The AHI decreased significantly from a median 7.7 events/hour preoperatively to 5.0 events/h at 12 months postoperative (P = 0.045), and the Epworth Sleepiness Scale score decreased from a median 9.5 preoperatively to 7 at 12 months postoperative (P = 0.009). A cure rate of 50% was obtained at 12 months of follow-up (P = 0.009). Despite the limited sample size, this study provides evidence that in patients with an underlying retrusive dentofacial deformity and mild OSA, a slight decrease in AHI is obtained after orthognathic surgery due to upper airway enlargement, which could be added as a beneficial effect of orthognathic surgery.

Effects of CPAP and Mandibular Advancement Devices on depressive symptoms in patients with obstructive sleep apnea: a meta-analysis of randomized controlled trials

PURPOSE

Studies show that patients with obstructive sleep apnea (OSA) are more likely than the general population to have psychological disorders such as depression. However, it is less clear how OSA treatment affects this association. This meta-analysis aimed to assess whether or not continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) reduce depression symptoms in patients with OSA.

METHODS

We searched Pubmed, Embase, Web of Science, and Cochrane Library from creating the databases until November 2022. Our analysis included RCTs that examined CPAP and MAD treatment effectiveness for depression in patients with OSA.

RESULTS

We identified 17 CPAP studies comprising 1,931 patients for inclusion in the meta-analysis. The results of the meta-analysis using a fixed effects model found that CPAP improved depressed mood in patients with OSA relative to controls (SMD = 0.27;95% CI:0.18,0.36), with small heterogeneity among trials (I2 = 8.1% < 50%, P = 0.359). We performed subgroup analyses on three factors: the length of trial follow-up, patient adherence data, and depression assessment scales. The meta-analysis also identified six MAD studies involving 315 patients. According to this analysis, there was no heterogeneity between studies (I2 = 0%, P = 0.748). MADs did not significantly improve depression symptoms compared to controls, indicating a combined effect of SMD = 0.07 (95% CI: - 0.15,0.29), P > 0.05.

CONCLUSION

The present findings confirm that CPAP may improve depressive symptoms in patients with OSA. However, the review results suggest that MADs have no significant effect on depressive symptoms in patients with OSA, a finding that is different from the results of previous meta-analyses.

Truck collisions attributed to falling asleep at the wheel in two commercial drivers prescribed oral appliance therapy for obstructive sleep apnea

Falling asleep at the wheel is attributed to sleepiness, and obstructive sleep apnea is a significant cause of sleepiness that increases the risk of motor vehicle collisions due to falling asleep at the wheel. Although continuous positive airway pressure therapy for obstructive sleep apnea reduces the risk of motor vehicle collisions, similar evidence for alternatives such as oral appliance therapy is lacking. We discuss two truck collisions attributed to microsleep confirmed with dashcam video footage of commercial drivers with obstructive sleep apnea. Our results highlight the current situation where there is insufficient evidence for the prevention and reduction of the risk of motor vehicle collisions by oral appliance therapy, objective adherence monitoring of oral appliance therapy, and effectiveness confirmation tests. Therefore, it is suggested that for commercial truck drivers who require a high level of driving safety, careful selection for oral appliance therapy, systematic follow-up, and monitoring of the driver and truck status with dashcam video footage are crucial.

CITATION

Kumagai H, Tsuda H, Kawaguchi K, et al. Truck collisions attributed to falling asleep at the wheel in two commercial drivers prescribed oral appliance therapy for obstructive sleep apnea. J Clin Sleep Med. 2023;19(12):2117-2122.

Obstructive Sleep Apnea and Hypertensive Heart Disease: From Pathophysiology to Therapeutics

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of complete or partial obstruction of the upper airway that lead to intermittent hypoxemia, negative intrathoracic pressure, hypercapnia, and sleep disturbances. While OSA is recognized as a significant risk factor for cardiovascular disease, it's relationship with hypertensive heart disease (HHD) remains underappreciated. HHD is a condition characterized by the pathological hypertrophy of the left ventricle, a consequence of elevated arterial hypertension. Interestingly, both OSA and HHD share similar underlying mechanisms including hypertension, left ventricular hypertrophy, myocardial fibrosis, oxidative stress, and inflammation, which ultimately contribute to the progression of HHD. This review aims to shed light on the potential role of OSA in HHD pathogenesis, summarizing current OSA treatment options. It is hoped that this review will encourage a renewed clinical focus on HHD and underscore the need for further OSA research, particularly in the context of screening and treating HHD patients.

Long-term efficacy of mandibular advancement devices in the treatment of adult obstructive sleep apnea: A systematic review and meta-analysis

This study aims to review the long-term subjective and objective efficacy of mandibular advancement devices (MAD) in the treatment of adult obstructive sleep apnea (OSA). Electronic databases such as PubMed, Embase, and Cochrane Library were searched. Randomized controlled trials (RCTs) and non-randomized self-controlled trials with a treatment duration of at least 1 year with MAD were included. The quality assessment and data extraction of the included studies were conducted in the meta-analysis. A total of 22 studies were included in this study, of which 20 (546 patients) were included in the meta-analysis. All the studies had some shortcomings, such as small sample sizes, unbalanced sex, and high dropout rates. The results suggested that long-term treatment of MAD can significantly reduce the Epworth sleepiness scale (ESS) by -3.99 (95%CI -5.93 to -2.04, p<0.0001, I2 = 84%), and the apnea-hypopnea index (AHI) -16.77 (95%CI -20.80 to -12.74) events/h (p<0.00001, I2 = 97%). The efficacy remained statistically different in the severity (AHI<30 or >30 events/h) and treatment duration (duration <5y or >5y) subgroups. Long-term use of MAD could also significantly decrease blood pressure and improve the score of functional outcomes of sleep questionnaire (FOSQ). Moderate evidence suggested that the subjective and objective effect of MAD on adult OSA has long-term stability. Limited evidence suggests long-term use of MAD might improve comorbidities and healthcare. In clinical practice, regular follow-up is recommended.

Association between knowledge and attitudes towards pediatric obstructive sleep apnea and dental specialty

OBJECTIVE

To associate the knowledge and attitudes about Pediatric Obstructive Sleep Apnea (POSA) with the specialty of dentists in Metropolitan Lima, Peru.

METHODS

A cross-sectional, analytical observational study was carried out during 2021-2022. Two hundred and ten orthodontists and pediatric dentists were surveyed using the adapted and validated Spanish translation of the OSAKA-KIDS questionnaire and additional sociodemographic questions.

RESULTS

The data indicated an association between dental specialty and the professional's knowledge about POSA. Orthodontists were 59% less likely to have acceptable knowledge, compared to pediatric dentists (p = .013, IC 95% 0.21-0.83). The study revealed an association between the professional's attitudes and three intervening variables: age (p = .025), clinical experience (p = .049) and sector of practice (p = .020).

CONCLUSION

Knowledge was associated with the dental specialty of professionals in the sample included, whilst attitudes were not.

Evaluation and treatment approaches for neurological post-acute sequelae of COVID-19: A consensus statement and scoping review from the global COVID-19 neuro research coalition

Post-acute neurological sequelae of COVID-19 affect millions of people worldwide, yet little data is available to guide treatment strategies for the most common symptoms. We conducted a scoping review of PubMed/Medline from 1/1/2020-4/1/2023 to identify studies addressing diagnosis and treatment of the most common post-acute neurological sequelae of COVID-19 including: cognitive impairment, sleep disorders, headache, dizziness/lightheadedness, fatigue, weakness, numbness/pain, anxiety, depression and post-traumatic stress disorder. Utilizing the available literature and international disease-specific society guidelines, we constructed symptom-based differential diagnoses, evaluation and management paradigms. This pragmatic, evidence-based consensus document may serve as a guide for a holistic approach to post-COVID neurological care and will complement future clinical trials by outlining best practices in the evaluation and treatment of post-acute neurological signs/symptoms.

Oral appliance influence on jaw function in obstructive sleep apnea

INTRODUCTION

Oral appliance (OA) therapy in obstructive sleep apnea (OSA) could be a risk factor for normal jaw function, given the prolonged effect of an OA in keeping the mandible in a protruded position away from a normal position. This study aimed to assess changes in symptoms and clinical findings related to jaw function after 1 year of treating OSA with an OA.

METHODS

In this follow-up clinical trial, 302 patients with OSA were assigned to treatment with either monobloc or bibloc OA. Baseline and 1-year follow-up assessment included using the Jaw Functional Limitation Scale, self-reported symptoms and signs related to jaw function. The clinical examination of jaw function included mandibular mobility, dental occlusion, and tenderness in the temporomandibular joints and masticatory muscles. Descriptive analyses of variables are presented for the per-protocol population. To evaluate differences between the baseline and the 1-year follow-up, paired Student t tests and the McNemar change test was used.

RESULTS

One-hundred and ninety-two patients completed the 1-year follow-up (male 73%, mean aged 55 ± 11 years). There was no change in the Jaw Functional Limitation Scale score at the follow-up (nonsignificant). The patients described no change in symptoms at the follow-up, except for improvements in morning headache (P <0.001) and increased frequency of difficulties in opening the mouth or chewing on awakening (P = 0.002). Subjectively reported changes in dental occlusion during biting/chewing increased significantly at the follow-up (P = 0.009).

CONCLUSIONS

No changes in measurements of jaw mobility, dental occlusion, or pain on palpation of the temporomandibular joints or masticatory muscles were seen at the follow-up. Thus, using an OA in treating OSA had limited influence on jaw functions and related symptoms. Moreover, the risk of developing pain and functional impairment in the masticatory system was infrequent, indicating that this treatment is safe and can be recommended.

A Multicenter Prospective Study on the Use of a Mandibular Advancement Device in the Treatment of Obstructive Sleep Apnea

The main objective of this prospective study was the evaluation of 1 mm step titration of mandible advancement in the success of treating obstructive sleep apnea (OSA). For that, a multicenter prospective study was designed to recruit patients with OSA who were eligible to receive a mandibular advancement device. Gradual titration of mandibular advancement (steps of 1 mm) from maximum intercuspidation was performed to determine the optimal mandibular advancement (highest reduction in the apnea-hypopnea index (AHI)). The principal variable was the percentage of patients where a reduction ≥50% of the AHI was achieved at the end of the titration phase. A total of 102 patients participated in this study. Fifty-six percent of the participants were males and 67% had a BMI ≥ 25 kg/m2. Most of the patients (79%) had an age ≥ 50 years and the majority (74%) were either non-smokers or ex-smokers. Excessive daytime sleepiness was reported by 40% of the patients. The mean AHI at baseline was 20.6 ± 12.7 events/h. The mean advancement of the mandible was 3.1 ± 1.6 mm. The device achieved a reduction in the AHI in 93% of the patients and success (≥50% reduction in the AHI) in 69% of the patients. Success was achieved in 50%, 81.6%, and 73.3% of the patients with mild, moderate, and severe OSA, respectively. Decreasing the magnitude of mandibular advancement could be possible by controlling the vertical mouth opening and step-by-step titration.

Research trends and hotspots regarding treatment of obstructive sleep apnea

Background

Obstructive sleep apnea (OSA) is a type of sleep-disordered breathing disease, with high prevalence and multiple complications. It seriously affects patients' quality of life and even threatens their lives. Early and effective treatment can significantly improve patients' health conditions.

Objective

In this study, the main treatment methods, research hotspots and trends of OSA were summarized through bibliometric and visualization analysis.

Methods

From the Web of Science Core Collection database, articles on the treatment of OSA from 1999 to 2022 were obtained. CiteSpace and VOSviewer were comprehensively used to visualization of journals, co-authorship of countries, institutions and authors, co-citation of references, keywords cluster and burst.

Results

A total of 2,874 publications were obtained, of which 2,584 were concerned adults and 290 about children. In adults' research, Sleep and Breathing is the most published journal (280, 10.84%), the largest number of publications come from the United States (636,24.61%) and the University of Sydney (88, 3.41%), and Pepin JL is the most published author (48, 18.58%). In children's studies, International Journal of Pediatric Otorhinolaryngology is the most published journal (41, 14.14%), the maximum number of publications were also from the United States (123, 42.41%), with the University of Pennsylvania (20, 6.90%) and Marcus CL (15, 5.17%) being the most published institutions and authors. High-frequency keywords for adults' researches include positive airway pressure, oral appliance, surgery and positional therapy. On these basis, children's studies also focus on myofunctional therapy, rapid maxillary expansion and hypoglossal nerve Stimulation.

Conclusion

Over the past two decades, research in the field of OSA therapeutics has experienced significant growth in depth and breadth. The author cooperation network has already established a solid foundation, while there is potential for further strengthening the cooperation network between countries and institutions. Currently, positive airway pressure and surgery are the primary treatments for OSA in adults and children. Future research will focus on multidisciplinary combination targeted therapy, which presents a key area of interest and challenge.

Oscillation of Sympathetic Activity in Patients with Obstructive Sleep Apnea during the First Hour of Sleep

(1) Background: Snoring is a cardinal symptom of obstructive sleep apnea (OSA) and has been suggested to potentially increase sympathetic activity. On the other hand, sleep itself usually leads to a decrease in sympathetic activity. Heart rate variability (HRV) analysis is a non-invasive technique used to assess autonomic nervous system function. However, there is limited research on the combined impact of sleep and snoring on sympathetic activity in individuals with OSA, particularly during the first hour of sleep (non-rapid eye movement sleep). The current study aims to investigate the net effect of sleep and snoring on sympathetic activity and explore factors that might contribute to increased sympathetic activity in individuals with OSA during the first hour of sleep. (2) Methods: The participants were referred from the outpatient department for OSA diagnosis and underwent whole-night polysomnography (PSG). Electrocardiogram (EKG) data from the PSG were downloaded for HRV analysis. HRV measurements were conducted in both the time and frequency domain, including the root mean square of successive differences between normal heartbeats (RMSSD) and the ratio of the absolute power of the low-frequency (LF) band (0.04-0.15 Hz) to the absolute power of the high-frequency (HF) band (0.15-0.4 Hz) (LF/HF ratio), respectively. (3) Results: A total of 45 participants (38 men and 7 women) were included in the analysis. The RMSSD gradually increased from 0-5 min to 50-60 min (p = 0.024), while the LF/HF ratio decreased (p < 0.001) during the first hour of sleep (non-rapid eye movement sleep). The LF/HF ratios of the "S" (snoring) episodes were compared with those of the pre-S episodes. An elevated LF/HF ratio during the S episode was associated with the first snoring episode occurring more than 20 min after lying down to sleep (Odds ratio, OR = 10.9, p = 0.004) and with patients diagnosed with severe OSA (OR = 5.01, p = 0.045), as determined by logistic regression. (4) Conclusions: The study observed an increase in the value of RMSSD and a decrease in the value of the LF/HF ratio during the first hour of sleep for patients with OSA. Higher LF/HF ratios were associated with the first occurrence of snoring while lying down for more than 20 min and with patients with severe OSA.

The impact of obstructive sleep apnea on nonalcoholic fatty liver disease

Obstructive sleep apnea (OSA) is characterized by episodic sleep state-dependent collapse of the upper airway, with consequent hypoxia, hypercapnia, and arousal from sleep. OSA contributes to multisystem damage; in severe cases, sudden cardiac death might occur. In addition to causing respiratory, cardiovascular and endocrine metabolic diseases, OSA is also closely associated with nonalcoholic fatty liver disease (NAFLD). As the prevalence of OSA and NAFLD increases rapidly, they significantly exert adverse effects on the health of human beings. The authors retrieved relevant documents on OSA and NAFLD from PubMed and Medline. This narrative review elaborates on the current knowledge of OSA and NAFLD, demonstrates the impact of OSA on NAFLD, and clarifies the underlying mechanisms of OSA in the progression of NAFLD. Although there is a lack of sufficient high-quality clinical studies to prove the causal or concomitant relationship between OSA and NAFLD, existing evidence has confirmed the effect of OSA on NAFLD. Elucidating the underlying mechanisms through which OSA impacts NAFLD would hold considerable importance in terms of both prevention and the identification of potential therapeutic targets for NAFLD.

A clinical review of obstructive sleep apnea

ABSTRACT

Symptoms of obstructive sleep apnea (OSA) often are overlooked or misinterpreted, but without treatment, patients are at increased risk for potentially life-threatening conditions including stroke and heart failure. Clinician awareness of the risk factors for and treatment of OSA can prevent the development or progression of these complications in patients.

Computed Tomography versus Sleep Endoscopy (DISE) to Predict the Effectiveness of Mandibular Advancement Devices in Adult Patients with Obstructive Sleep Apnea: A Protocol for Systematic Review

Obstructive sleep apnea is a sleep disorder with a high prevalence in the world population. The mandibular advancement device is one of the options for treating obstructive sleep apnea. Neck computed tomography and drug-induced sleep endoscopy are complementary diagnostic tests that may help predict the effectiveness of mandibular advancement devices. This study aims to analyze the best method for predicting the effectiveness of mandibular advancement devices in the therapeutic approach to obstructive sleep apnea. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science Core Collection databases will be comprehensively searched. We will include randomized clinical trials, non-randomized prospective or retrospective clinical studies, case controls, cohort studies, and case series. Two authors will independently conduct data extraction and assess the literature quality of the studies. The analysis of the included literature will be conducted by Revman 5.3 software. The outcomes that will be analyzed are craniofacial characteristics, cephalometric assessments, site and type of obstruction of the upper airway, mean values of the apnea-hypopnea index, and SaO2 verified in the initial and follow-up polysomnography. This study will provide reliable, evidence-based support for the clinical application of mandibular advancement devices for obstructive sleep apnea.

Salivary Biomarker Levels in Children with Sleep Problems Before and After Twin Block Therapy

BACKGROUND

Disturbances in sleep have a wide-ranging effect on a child's life profoundly impacting the standard of living. The aim of this study was to investigate levels of Salivary Tumor Necrosis Factor-Alpha (TNF-α) and Malondialdehyde (MDA) in a group of children with class II malocclusion and sleep problems before and after twin block appliance therapy.

MATERIALS AND METHODS

Eleven children aged 8-12 years with skeletal class II malocclusion and at least one sleep disorder participated in the study. All children were subjected to a recording of their sleep history and a clinical and radiographic examination. Pre-treatment levels of salivary TNF-α and MDA were recorded. A twin block appliance was custom made and delivered to every child. After a minimum follow-up period of 9 months, all children were recalled for a re-evaluation of salivary biomarker levels.

RESULTS

Levels of salivary biomarkers TNF-α and MDA significantly decreased in children following myofunctional therapy using a twin block appliance.

CONCLUSION

The measurement of TNF-α and MDA could be used as an alternative and noninvasive method to evaluate prognosis of twin block therapy for children with sleep-disordered breathing (SDB).

Conservative Treatment Using Chiropractic Care and Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Case Report

Objective

The purpose of this case study was to describe the use of chiropractic care in the treatment of obstructive sleep apnea (OSA).

Clinical Features

A 42-year-old man with obesity presented for chiropractic care. He had OSA and was seeking a way to reduce snoring. The patient had a previous diagnosis of OSA and had been using a continuous positive airway pressure machine for over 5 years. The patient was a mouth breather, exhibiting poor oral and spinal posture.

Intervention and Outcome

The patient was treated for 90 days, which included chiropractic manipulation, orofacial myofunctional therapy exercises, nutritional modification, postural/ergonomic correction, and regular exercise. After a course of care, there was a drop in his apnea-hypopnea index from 55.4 events per hour to 3.4 events per hour. The patient lost 40 pounds, with an 8% reduction in body fat and an 8-point drop in his body mass index.

Conclusion

This patient's sleep apnea and other health outcomes improved under a course of a combination of chiropractic adjustments, orofacial myofunctional therapy, nutritional modification, postural/ergonomic correction, and exercise.

Effects of mandibular advancement devices on upper airway dimensions in obstructive sleep apnea: responders versus non-responders

STUDY OBJECTIVES

To compare the effects of mandibular advancement device (MAD) therapy on upper airway dimensions between responders and non-responders with mild to moderate obstructive sleep apnea (OSA).

METHODS

Thirty-one participants (21 men and 10 women) with a mean ± SD apnea-hypopnea index (AHI) of 16.6 ± 6.7 events/h, and aged 48.5 ± 13.9 years, were included in this study. Polysomnographic recordings and cone beam computed tomography (CBCT) scans in supine position were performed for every participant at baseline and at 3-month follow-up with their MAD in situ. Responders were defined as having ≥ 50% reduction in baseline AHI with a residual AHI < 10 events/h. The primary outcome variable was the minimal cross-sectional area of the upper airway (CSAmin).

RESULTS

No significant differences were found between responders (n = 15) and non-responders (n = 16) in age, gender distribution, body mass index, and neck circumference (P = 0.06-0.93), nor in AHI and CSAmin (P = 0.40 and 0.65, respectively) at baseline. The changes of the CSAmin with MAD in situ in the responder group were not significantly different compared to those in the non-responder group (P = 0.06).

CONCLUSION

Within the limitations of this study, we conclude that the changes of the upper airway dimensions induced by MADs are not significantly different between responders and non-responders with mild to moderate OSA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02724865. https://clinicaltrials.gov/ct2/show/NCT02724865.

Obstructive Sleep Apnea Treatment with Oral Appliance in a Myotonic Dystrophy Type I Subject: A Case Report

Objective  to report a myotonic dystrophy type 1 (MD1) subject with obstructive sleep apnea syndrome treated with oral appliance. Methods  A review of individual's history and records, associated with a photographic register of all diagnostic methods and literature research about the topic were done. Final Statements  This case depicts the therapeutical choices disposable to treat subjects with obstructive sleep apnea and DM1. Although considered an uncommon treatment, the oral appliances, if well indicated in adequately selected cases, can satisfactorily improve respiratory parameters, symptoms and quality of life.

A New Lighting System for Surgical Vision Optimization in Barbed Pharyngoplasty for OSA

Obstructive sleep apnea (OSA) surgery is now a viable solution in selected patients and the "remodeling" palatopharyngeal surgery is the most common one. Recently, it has become less invasive with the introduction of barbed sutures (BS). An optimization of surgical techniques is represented by barbed pharyngoplasty (BP), which requires surgical precision and needs efficient and precise oropharyngeal visualization. Consequently, the lighting system is of pivotal importance in BP. The aim of this work is to describe the first experience on the use of a new lighting system, called KLAROTM in BP for OSA. We evaluated the KLARO™ system in 15 consecutives BP for OSA in comparison with conventional headlamp illumination. The visualization of palatopharyngeal muscle in the bottom of the tonsillar fossa, entry and exit needle, such as needle tip, were statistically better with KLAROTM than headlamp illumination for both the surgeon and resident (p < 0.05). No significant differences for the visualization of the posterior pharyngeal wall and uvula were reported. The KLAROTM lighting system allows a satisfied illumination of oral cavity and oropharynx in the majority of cases. We encourage the use of KLAROTM not only in BP for OSA, but in all oral and pharyngeal surgeries, including tonsillectomy and oncological surgery.

Translation of obstructive sleep apnea pathophysiology and phenotypes to personalized treatment: a narrative review

Obstructive Sleep Apnea (OSA) arises due to periodic blockage of the upper airway (UA) during sleep, as negative pressure generated during inspiration overcomes the force exerted by the UA dilator muscles to maintain patency. This imbalance is primarily seen in individuals with a narrowed UA, attributable to factors such as inherent craniofacial anatomy, neck fat accumulation, and rostral fluid shifts in the supine posture. Sleep-induced attenuation of UA dilating muscle responsiveness, respiratory instability, and high loop gain further exacerbate UA obstruction. The widespread comorbidity profile of OSA, encompassing cardiovascular, metabolic, and neuropsychiatric domains, suggests complex bidirectional relationships with conditions like heart failure, stroke, and metabolic syndrome. Recent advances have delineated distinct OSA phenotypes beyond mere obstruction frequency, showing links with specific symptomatic manifestations. It is vital to bridge the gap between measurable patient characteristics, phenotypes, and underlying pathophysiological traits to enhance our understanding of OSA and its interplay with related outcomes. This knowledge could stimulate the development of tailored therapies targeting specific phenotypic and pathophysiological endotypes. This review aims to elucidate the multifaceted pathophysiology of OSA, focusing on the relationships between UA anatomy, functional traits, clinical manifestations, and comorbidities. The ultimate objective is to pave the way for a more personalized treatment paradigm in OSA, offering alternatives to continuous positive airway pressure therapy for selected patients and thereby optimizing treatment efficacy and adherence. There is an urgent need for personalized treatment strategies in the ever-evolving field of sleep medicine, as we progress from a 'one-size-fits-all' to a 'tailored-therapy' approach.

An Update on Obstructive Sleep Apnea Syndrome-A Literature Review

Obstructive sleep apnea syndrome (OSAS) is the most common breathing-related sleep disorder. It is characterized by recurrent episodes of partial or complete airway obstruction during sleep, resulting in a reduction in or the total cessation of airflow, despite ongoing respiratory efforts, leading to oxygen desaturation and arousal. The purpose of this literature review is to evaluate the most common characteristics of this pathology, as well as to investigate the most effective treatment options, providing an update on the management of OSA patients.

Comparative efficacy of mandibular advancement devices in obstructive sleep apnea: a network meta-analysis

PURPOSE

To analyze relative efficacies of mandibular advancement devices (MAD) in sleep apnea treatment.

METHODS

From eligible randomized controlled trials (RCT), MADs were classified based on their mechanistic designs. Data on apnea-hypopnea index (AHI), Epworth sleepiness scale (ESS), nadir oxygen saturation (minSaO2), and sleep efficiency (SE%) from RCTs were then analyzed in network meta-analyses, and relative ranking of different MADs was computed based on P scores (a method of ranking similar to SUCRA). Similar analyses were conducted based on the different brands of MADs.

RESULTS

There were no statistically significant differences between MADs in any of the outcomes analyzed. However, the P-scores, based on the point estimates and standard errors of the network estimates, ranked some MADs higher than others in some of the outcomes. Of the different mechanistic designs, the highest P scores were achieved for attached midline traction (P score = 0.84) and unattached bilateral interlocking (P score = 0.78) devices for AHI reduction, attached bilateral traction (P score = 0.78) and unattached bilateral interlocking (P score = 0.76) for ESS, monobloc (P score = 0.91) and unattached bilateral interlocking (P score = 0.64) for minSaO2, and unattached bilateral interlocking (P score = 0.82) and attached bilateral traction (P score = 0.77) for SE%. Notable findings in the network meta-analyses based on MAD brands, of the limited number of studies that specified them were the effects of SomnoDent Flex™, TAP™, and IST® in their effects on AHI reduction, with P scores of 0.94, 0.83, and 0.82, respectively. Monobloc decreased supine-AHI the most (- 44.46 [- 62.55; - 26.36], P score = 0.99), and unattached bilateral interlocking had the greatest effect on REM-AHI (- 11.10 [- 17.10; - 5.10], P score = 0.87).

CONCLUSIONS

Findings from this study show clinically (but not statistically) significant differences between MADs in terms of their relative efficacy when analyzed for different sleep apnea treatment outcomes and sleep apnea phenotypes.

Development and initial validation of a questionnaire to measure patient experience with oral appliance therapy

STUDY OBJECTIVES

To develop and validate a questionnaire to measure patient experience with oral appliance therapy.

METHODS

The AMEE Guide No. 87 was followed in the development and validation of a patient questionnaire to assess patient experience with oral appliance therapy.

RESULTS

Our search identified 522 articles; 5 of these articles described the use and/or validation of questionnaires to measure changes in symptoms and patient-reported outcomes in the treatment of obstructive sleep apnea. A total of 27 questions were developed. Five patients participated in pilot testing. A final review of the questionnaire was conducted by an expert panel.

CONCLUSIONS

The creation and validation of a questionnaire to assess patient experience with oral appliance therapy may provide new methods for advancing research in the field of dental sleep medicine.

CITATION

Ng ET, Perez-Garcia A, Lagravère-Vich MO. Development and initial validation of a questionnaire to measure patient experience with oral appliance therapy. J Clin Sleep Med. 2023;19(8):1437-1445.

Preoperative risk evaluation and perioperative management of patients with obstructive sleep apnea: a narrative review

Obstructive sleep apnea (OSA) is a common sleep-breathing disorder associated with significant comorbidities and perioperative complications. This narrative review is aimed at comprehensively overviewing preoperative risk evaluation and perioperative management strategies for patients with OSA. OSA is characterized by recurrent episodes of upper airway obstruction during sleep leading to hypoxemia and arousal. Anatomical features, such as upper airway narrowing and obesity, contribute to the development of OSA. OSA can be diagnosed based on polysomnography findings, and positive airway pressure therapy is the mainstay of treatment. However, alternative therapies, such as oral appliances or upper airway surgery, can be considered for patients with intolerance. Patients with OSA face perioperative challenges due to difficult airway management, comorbidities, and effects of sedatives and analgesics. Anatomical changes, reduced upper airway muscle tone, and obesity increase the risks of airway obstruction, and difficulties in intubation and mask ventilation. OSA-related comorbidities, such as cardiovascular and respiratory disorders, further increase perioperative risks. Sedatives and opioids can exacerbate respiratory depression and compromise airway patency. Therefore, careful consideration of alternative pain management options is necessary. Although the association between OSA and postoperative mortality remains controversial, concerns exist regarding adverse outcomes in patients with OSA. Understanding the pathophysiology of OSA, implementing appropriate preoperative evaluations, and tailoring perioperative management strategies are vital to ensure patient safety and optimize surgical outcomes.

[The current status and expectation of pediatric total facial management]

The pediatric total facial management refers to a series of diagnosis and treatment processes to achieve the healthy development of the face through reasonable medical intervention. The main reason for the poor treatment effect is that the first contact doctor is limited to his own disciplinary analysis and treatment. The importance of multidisciplinary cooperation in the diagnosis and treatment of facial dysplasia in children has become increasingly prominent. it is necessary to comprehensively analyze and find the pathogenic factors of patients and formulate a comprehensive treatment plan to restore normal upper airway structure and nasal breathing, and then reshape the healthy craniomaxillofacial tissue structure, and the monitoring of the results of medical intervention should accompany the whole process of children's growth and development. This paper summarizes the current situation of the treatment of children with facial dysplasia and puts forward the concept of orderly individualized multi-disciplinary diagnosis and treatment of pediatric oral maxillofacial management.

Self-reported improvement in obstructive sleep apnea symptoms compared to treatment response with mandibular advancement device therapy: a retrospective study

PURPOSE

Mandibular advancement device (MAD) is recognized as the treatment option for management of obstructive sleep apnea (OSA) in mild-moderate cases or those unable to tolerate positive airway pressure therapy. Post-treatment sleep study is recommended to establish MAD efficacy when maximal therapeutic benefit is achieved based on OSA symptom improvement or maximum anatomical protrusion. The aim of this study was to investigate the difference between responders and non-responders in OSA symptom improvement and predictors of treatment success.

METHODS

Medical charts of patients referred to the Orofacial Pain Clinic between 2016 and 2021 for management of OSA with MAD were retrospectively evaluated. Participants with post-treatment sleep study with MAD in situ were included. Participants were categorized as responders according to different criteria: 50% reduction in apnea-hypopnea index (AHI) compared to baseline; post-treatment AHI ≤ 10 with ≥ 50% reduction from baseline; AHI ≤ 5 with ≥ 50% reduction. OSA symptoms included snoring, apneas, sleep quality, tiredness upon awakening, daytime sleepiness, and subjective improvement. Differences in pre- and post-treatment variables within/between groups and predictors were analyzed with t test and logistic regression.

RESULTS

Among 53 participants (30 females), mean age was 64.2 ± 10.7 and pre-treatment was AHI 23.3 ± 17.2. Depending upon the criteria, responders ranged between 26 and 57%. At first follow-up after MAD delivery, non-responders reported less tiredness upon awakening (p = 0.003), better sleep quality (p = 0.005), and greater subjective improvement (p = 0.012) than responders. Among significant OSA symptoms, tiredness upon awakening, poorer sleep quality, and less subjective improvement were consistently found as predictors of treatment response.

CONCLUSION

Subjective improvement, sleep quality, and tiredness upon awakening significantly improved in non-responders at first follow-up compared to responders, according to the strictest definition of treatment response. Therefore, a post-treatment sleep study is crucial to confirm proper management of OSA with MAD.

Salivary biomarker C-reactive protein levels in children with sleep problems and Class II malocclusion before and after twin-block therapy

Context

Disturbances in sleep affects the overall quality of a child's life, with several short- and long-lasting consequences. Hence, early diagnosis and monitoring is crucial in the management of sleep disorders in children.

Aims

The aim of this study was to evaluate salivary C-reactive protein (CRP) levels in a group of children with Class II malocclusion and sleep problems before and after twin-block appliance therapy.

Settings and Design

The study was a prospective clinical study with a 9-month follow-up period.

Subjects and Methods

Eleven children aged 8-12 years with skeletal Class II malocclusion and at least one sleep disorder were enrolled in the study. All children were subjected to a recording of their sleep history and a clinical as well as radiographic examination. Pretreatment levels of salivary CRP were recorded. A twin-block appliance was custom made and delivered to every child. At the end of 9-month follow-up, all children were recalled for a re-evaluation of salivary biomarker levels.

Statistical Analysis

Pretreatment and posttreatment changes in biomarker levels were assessed statistically using the students paired t-test.

Results

Levels of salivary biomarker CRP were significantly decreased in children following myofunctional therapy using a twin-block appliance (P < 0.001). There was a considerable improvement in the clinical symptoms such as a decrease in snoring and noisy breathing in most children post-twin-block therapy.

Conclusion

The measurement of salivary biomarker CRP could be used as an alternative and noninvasive method to evaluate prognosis of oral myofunctional therapy for children with sleep disordered breathing.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Knowledge, attitude, and practice regarding different domains of pediatric obstructive sleep apnea among pediatric dentists from Kerala: A cross-sectional study

Background

Pediatric dentists should play an essential role in obstructive sleep apnea (OSA) screening, referral, and management of their child patients. However, few studies have investigated pediatric dentists' knowledge, attitude, and practice aspects regarding different domains of pediatric OSA.

Aim of the Study

This cross-sectional survey aimed to assess the knowledge, attitude, and practice aspects of different domains of pediatric OSA among pediatric dentists from Kerala.

Methods

This cross-sectional study was conducted in Kerala. The sample frame consisted of 163 dentists, and the minimum required was 115. Ethical approval was obtained before starting the study.

Settings and Design

An invitation E-mail explaining the purpose of the study with a survey link was sent to the pediatric dentists from Kerala (n = 163). Nonrespondents were contacted at timely intervals.

Statistical Analysis

Categorical and quantitative variables were expressed as frequency (percentage) and mean ± standard deviation, respectively. Chi-square test was used to find an association between categorical variables. Statistical analysis was performed using a statistical software package, SPSS, version 20.0.

Results and Conclusion

This cross-sectional study showed that pediatric dentists in Kerala have a moderate-to-good level of knowledge, along with a positive attitude toward different domains of pediatric OSA, but lag behind in the practice aspects. Hence, they are required to direct themselves toward continuing dental education programs in order to boost their routine practice. For this, steps must be taken to ensure proper networking of the practitioners and amendments in the dental billing system similar to the medical counterpart.

The role of oral appliance therapy in obstructive sleep apnoea

There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the "gold standard" in nonsurgical OSA management, OAT remains the recognised alternative treatment.This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.

Positive correlation between snoring and dyslipidemia in adults: results from NHANES

BACKGROUND

A few studies have shown that snoring, in certain populations, is associated with dyslipidemia. However, there are currently no large-scale national studies available that explore this association. Thus, for further clarification, studies using a large sample of the general population need to be conducted. This study aimed to explore this association using the National Health and Nutrition Examination Survey (NHANES) database.

METHODS

A cross-sectional survey was conducted using data from the NHANES database; 2005 to 2008 and 2015 to 2018 datasets were used (weighted to be representative of United States adults aged ≥ 20 years). Information on snoring status, lipid levels, and confounding factors were included. Logistic regression of the generalized linear model was used to analyze the relationship between snoring and dyslipidemia, and hierarchical analysis, interaction analysis, and sensitivity analysis were used to explore the stability of the results.

RESULTS

Data from 28,687 participants were analyzed, and 67% of the participants had some degree of snoring. The fully adjusted multivariate logistic regression results demonstrated that snoring frequency was significantly positively associated with dyslipidemia (P < 0.001 for linear trend). Adjusted odds ratios (aORs) of dyslipidemia among those who snored rarely, occasionally, and frequently were 1.1 (95% confidence interval [CI], 1.02-1.18), 1.23 (95% CI, 1.10-1.38), and 1.43 (95% CI, 1.29-1.58), respectively, compared with that among those who never snored. In addition, age and snoring frequency showed a correlation (P = 0.02). Sensitivity analysis demonstrated that frequent snoring was significantly associated with lipid levels (all P ≤ 0.01 for linear trend), including increased low-density lipoprotein cholesterol (LDL-C) (β = 0.09 mmol/L; 95% CI, 0.02-0.16), triglyceride (TG) (β = 0.18 mmol/L; 95% CI, 0.10-0.26), total cholesterol (TC) (β = 0.11 mmol/L; 95% CI, 0.05-0.16), and decreased high-density lipoprotein cholesterol (HDL-C) (β=-0.04 mmol/L; 95% CI, -0.06--0.03).

CONCLUSIONS

A statistically significant positive association was identified between sleep snoring and dyslipidemia. It was suggested that sleep snoring interventions may reduce the risk of dyslipidemia.

Examining the feasibility of adult quality-of-life measurement for obstructive sleep apnea in clinical settings: what is the path forward for sleep centers?

Quality of life (QoL) is one of the outcomes that can be measured as a component of the required standards for sleep facility accreditation by the American Academy of Sleep Medicine. Utilization of a psychometrically robust QoL instrument is recommended; however, clinicians face a challenge balancing psychometric properties with questionnaire completion and scoring characteristics. This article provides an overview of common QoL instruments as a reference for clinicians when selecting a QoL tool for use in the clinical setting for adult patients with obstructive sleep apnea.

CITATION

Colvin L, Collop N, Lorenz R, Morgenthaler T, Weaver TE. Examining the feasibility of adult quality-of-life measurement for obstructive sleep apnea in clinical settings: what is the path forward for sleep centers? J Clin Sleep Med. 2023;19(6):1145-1155.

Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.

Provider Perspectives on Sleep as a Determinant of Health and Housing Outcomes among Veterans Experiencing Homelessness: An Exploratory, Social-Ecological Study

Sleep problems are common among United States (U.S.) veterans and are associated with poor health, mental health, and functioning. Yet, little is known about insufficient sleep and factors contributing to sleep disparities among veterans experiencing homelessness. We conducted semi-structured interviews to better understand the clinical, environmental, and structural factors contributing to insufficient sleep among veterans and to improve care for this population. Interviews were conducted with 13 providers caring for veterans experiencing homelessness, including physicians, psychologists, nurses, social workers, and peer support specialists. Providers worked at a West Coast VA institution serving a large population of veterans experiencing homelessness. Interviews were analyzed for themes pertaining to sleep using the social-ecological model as a framework. On an individual level, factors influencing sleep included psychiatric disorders and use of substances. On an interpersonal level, factors included safety concerns while sleeping. On an environmental level, factors included noise and proximity to others as barriers to sleep. On the organizational level, logistical issues scheduling sleep clinic appointments and lack of transportation to attend sleep clinic appointments were identified as treatment barriers. These findings can inform future research studying the impact of sleep on health and housing outcomes and interventions addressing sleep among veterans experiencing homelessness.

Treatment of Severe Obstructive Sleep Apnea Using Mandibular Advancement Device: A Case Report

Obstructive Sleep Apnea (OSA) is one of the most common sleep disorders. A mandibular advancement device (MAD) can be used to manage primary snoring and OSA cases. It is mostly indicated in cases with mild to moderate OSA. This case reports shows the successful management of severe OSA using MAD. A 34-year-old male presented to the orthodontic clinic with a diagnosis of severe OSA, apnea-hypopnea index (AHI) of 71 events per hour with symptoms of loud snoring, witnessed gasping, morning headache, and excessive daytime sleepiness. The case was managed using MAD to position the lower jaw in a forward position during sleep with 7 mm advancement. Progress sleep study results showed that the AHI reached normal levels, with only two hypopnea events per hour and a complete resolution of apnea episodes. The patient's symptoms subsided after using MADs. This case report documents that severe OSA can be managed with MAD in suitable cases.

Comparisons of the effects of two types of titratable mandibular advancement devices on respiratory parameters and upper airway dimensions in patients with obstructive sleep apnea: a randomized controlled trial

OBJECTIVES

To compare the effects of two types of titratable mandibular advancement devices (MADs), namely MAD-H (allowing limited vertical opening) and MAD-S (allowing free vertical opening), on respiratory parameters and upper airway dimensions in patients with mild to moderate obstructive sleep apnea (OSA).

MATERIALS AND METHODS

Patients with mild to moderate OSA (5 ≤ apnea-hypopnea index (AHI) < 30 /h) were randomly assigned to two parallel MAD groups. All MADs were subjectively titrated according to a standardized protocol during a 3-month follow-up. Every patient underwent two polysomnographic recordings, and two cone beam computed tomography scans in supine position: one at baseline and another one after 3 months with the MAD in situ. The primary outcome variables were the AHI in supine position (AHI-supine) and the minimal cross-sectional area of the upper airway in supine position (CSAmin-supine).

RESULTS

A total of 49 patients were recruited, and 31 patients (21 men and 10 women) with a mean (± SD) age of 48.5 (± 13.9) years and a mean AHI of 16.6 (± 6.7) /h completed the study. In the per-protocol analysis, there was no significant difference between MAD-H (n = 16) and MAD-S (n = 15) in their effects on AHI-supine (P = 0.14) and CSAmin-supine (P = 0.59). Similar results were found in the intention-to-treat analysis (P = 0.47 and 0.57, respectively).

CONCLUSIONS

Within the limitations of this study, we conclude that there is no significant difference in the effects of an MAD allowing limited vertical opening and an MAD allowing free vertical opening on respiratory parameters and upper airway dimensions in patients with mild to moderate OSA.

CLINICAL RELEVANCE

MADs allowing limited vertical opening and allowing free vertical opening have similar effects on respiratory parameters and upper airway dimensions in patients with mild to moderate OSA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02724865. https://clinicaltrials.gov/ct2/show/NCT02724865.