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

A computed tomographic evaluation of effect of mandibular advancement device at two different horizontal jaw positions in patients with obstructive sleep apnea

Statement of problem

Studies pertaining to the objective assessments of the efficacy of mandibular advancement device in patients with obstructive sleep apnea are scarce.

Purpose

The purpose of this clinical study was to evaluate the effect of MAD at two different horizontal positions of mandible on upper airway dimensions through computed tomography.

Material and methods

Twenty-nine consenting participants satisfying predetermined inclusion and exclusion criteria were enrolled and an adjustable two-piece MAD was fabricated at 50% maximum mandibular protrusion and after 4 weeks was adjusted to 70% protrusion. CT scans were obtained at baseline, 4 weeks after delivering MAD with 50% mandibular protrusion, and then after 4 weeks with 70% mandibular protrusion. Cross sectional area with diameters (lateral and anteroposterior) of upper airway was measured at three specific anatomic levels (retropalatal-RP, retroglossal-RG, and epiglottal-EG). Data were analyzed using the Student t-test for parametric analysis.

Results

Intragroup comparison revealed a statistically significant increase in lateral & anteroposterior dimensions as well as cross sectional area at all three anatomical levels at 4 weeks after MAD with 50% mandibular protrusion compared with baseline and 4 weeks after MAD with 70% mandibular protrusion compared with baseline. However, the difference between lateral and anteroposterior dimensions with MAD at 70% protrusion compared with MAD at 50% protrusion was not statistically significant. The difference between cross-sectional area was found to be statistically significant.

Conclusion

Mandibular advancement device at 70% mandibular protrusion is more effective compared with the device at 50% protrusion in relieving oropharyngeal obstruction seen in OSA.

An Integrated Interdisciplinary Sleep Care Model-The Ultimate Dream Team

This Viewpoint discusses the need for diverse physicians to manage sleep health.

Role of craniofacial phenotypes in the response to oral appliance therapy for obstructive sleep apnea

BACKGROUND

Mandibular advancement device (MAD) is a good alternative for patients with obstructive sleep apnea (OSA). However, the treatment response varies amongst individuals.

OBJECTIVE

This study aimed to explore the role of craniofacial features in the response to MADs to improve prognostication and patient selection.

METHODS

The retrospective trial contained 42 males aged 41.5 ± 9.0 years, and with an apnea-hypopnea index (AHI) of 21.5 ± 13.8 events/h. According to the mandibular plane angle, participants were divided into three groups: low angle (n = 13), average angle (n = 14) and high angle (n = 15). Under the monitoring of home sleep testing, adjustable MADs were used to titrate the mandible forward from 0 mm with an increment of 0.5 mm every day. The polysomnography outcomes, mandibular protrusion amounts, changes in upper airway MRI measurements and nasal resistance were compared amongst the three groups.

RESULTS

The normalisation rate (AHI <5 /h) was 92.3%, 57.1% and 46.7%, respectively, in the low-, average- and high-angle groups (p = .027). The effective protrusion where AHI was reduced by half was 20 (11.3 ~ 37.5) %, 31.3 (23.6 ~ 50) % and 50 (36.9 ~ 64.9) % of the maximal mandibular protrusion, in the low-, average- and high-angle groups (p = .004). Multivariate logistic regression revealed that increased gonion angle (OR = 0.878) and baseline AHI(OR = 0.868) can reduce the probability of normalisation.

CONCLUSION

The high mandibular plane angle might be an unfavourable factor to MAD treatment and more protrusion was needed to achieve a 50% reduction in AHI. Vertical craniofacial pattern (gonion angle) and baseline AHI constituted the model for predicting the effect of MADs.

Oral Appliances for OSA Treatment: Meeting the Quadruple Aim

INTRODUCTION

In order to better treat obstructive sleep apnea (OSA) in a more efficient and cost-effective way, a joint program between dental clinics and the sleep medicine clinic was piloted at Fort Hood, Texas. Obstructive sleep apnea negatively affects soldier readiness and deployability, leading to the need to establish a successful and proven workflow to treat these patients with oral appliance therapy (OAT).

MATERIALS AND METHODS

We performed a retrospective review of a de-identified data set which included 288 patients from July 2016 to July 2020. Projected cost data were obtained from routinely collected sleep clinic positive airway pressure (PAP) data. Data were analyzed to determine treatment success and potential cost savings using OAT versus continuous positive airway pressure (CPAP). Patient workflow including successes and challenges with the program is summarized.

RESULTS

About 85.5% of patients met criteria for successful control of their OSA using OAT as treatment. Five patients did not tolerate OAT and switched back to CPAP. A higher (less severe) O2 nadir on diagnostic polysomnography is moderately correlated with OAT success. Diagnostic Apnea-Hypopnea Index was inversely and weakly correlated with success. Two of the major challenges noted in the program were (1) loss of follow-up and (2) the length of time from oral appliance referral to fitting the oral appliance. If this program was successfully implemented at other Defense Health Agency (DHA) medical treatment facility (MTF) markets nationwide, a potential cost savings of over $500,000/year/MTF could be achieved.

CONCLUSIONS

Oral appliance therapy has the potential to increase both readiness and deployability for active duty soldiers. Using baseline O2 nadir can help predict success with OAT patients, determining which patients will benefit from this joint program between the dental and medical sleep clinics. Future studies can aim to establish an evidence-based pathway for clinic testing and follow-up. If this patient workflow is implemented properly, there can be significant cost savings army-wide. This all helps The United States Medical Command (MEDCOM) align with the DHA's Quadruple Aim of increased readiness, better health, better care, and lower cost.

Online information on mandibular advancement device for the treatment of obstructive sleep apnea: A content, quality and readability analysis

BACKGROUND

Despite increasing scientific interest in the effectiveness of mandibular advancement device (MAD) for the treatment of obstructive sleep apnoea (OSA), laypeople lack knowledge about this treatment option.

OBJECTIVES

To investigate content, quality and readability of the online information regarding MAD.

METHODS

Google, Yahoo and Bing were searched for 'sleep apnea', 'mandibular advancement device' and 'oral appliance'. Websites were analysed for content (multidisciplinary care team, qualified dentist, treatment contraindications and side effects), as well as for quality (DISCERN instrument, HONcode) and readability scores (Flesch Reading Ease, FRE and Flesch-Kincaid Reading Grade, FKG).

RESULTS

Totally, 155 websites were included: 53% from health professionals, 20% commercial, 17% academic and 10% from non-health professionals. Content was incomplete, especially for commercial ones. 71.61% websites failed to acknowledge treatment contraindications, approximately 40.00% did not mention side effects and the need for a multidisciplinary care team, while 22.58% did not address the need to consult a qualified dentist. Quality and reliability were poor. Mean DISCERN score was 39.93 (95% CI 37.90-41.96), with lower scores for commercial websites compared with others. Only nine websites displayed HONcode certification. Readability was quite difficult, with mean FRE score of 59.50 (95% CI 57.58-61.42) and mean FKG level of 6.92 (95% CI 6.64-7.21).

CONCLUSION

Health care professionals should be aware that currently available online information do not fulfil the most important aspects of MAD therapy and may be difficult to understand by laypeople. This could contribute to cause delays in appropriate OSA care and unrealistic treatment expectations, increasing the risk of treatment discontinuation.

Obstructive Sleep Apnea Awareness Among Dentists in Saudi Arabia: A Cross-Sectional Study

OBJECTIVES

This study aims to assess the knowledge and clinical practices among dentists in Saudi Arabia regarding obstructive sleep apnea (OSA).

MATERIAL AND METHODS

This cross-sectional study was conducted over a period of 8 months across the whole country. A self-administered questionnaire was used to assess the OSA knowledge and practices. The developed questionnaire was closed-ended questions and consisted of three parts: (1) demographic information such as age, gender, work experience, workplace, and specialty; (2) knowledge of OSA; and (3) OSA management practice. The knowledge score was calculated based on six questions, each of which gives one point when answered correctly.

RESULTS

A total of 450 dentists from all over the country were surveyed, with a predominance of females (55.6%) and Saudis (59%). About 56% learned about OSA in their undergraduate study, with theoretical lectures being the main source of information. The overall knowledge score was 3.09, with specialists having a higher score than general practitioners (GPs) (p<0.001) and those who learned about OSA in their post-graduate study having higher scores (p<0.001). Despite this, 58.89% never asked their patients about sleep history, and only 19.11% diagnosed patients with OSA before. Only 7.56% used oral appliances to treat OSA, and only one-quarter referred patients to a physician for a sleep-disordered diagnosis. However, 79.33% were willing to attend a continuing education course on managing OSA patients.

CONCLUSION

Our study shows that dentists in Saudi Arabia lack fundamental understanding regarding OSA and their role in screening, diagnosing, and treating patients with OSA, highlighting the need to educate the dental fraternity. Dental GPs and specialists, including orthodontists, must be actively involved in diagnosing and treating this life-threatening health issue.

Antero-Posterior Mandibular Excursion in Obstructive Sleep Apnea Patients Treated with Mandibular Advancement Device: A Retrospective Cohort Study

Since obstructive sleep apnea (OSA) management with a mandibular advancement device (MAD) is likely to be life-long, potential changes in mandibular movements during therapy should be investigated. The purpose of this study was to use a method that has already been shown to be reliable in order to determine whether the range of antero-posterior mandibular excursion, the procedure upon which MAD titration is based, varies between baseline (T0) and at least 1 year of treatment (T1). The distance between maximal voluntary protrusion and maximal voluntary retrusion determined using the millimetric scale of the George Gauge was retrospectively collected from the medical records of 59 OSA patients treated with the MAD and compared between T0 and T1. A regression analysis was performed to evaluate the influence of treatment time, MAD therapeutic advancement and the patient's initial characteristics in excursion range variation. A statistically significant increase of 0.80 ± 1.52 mm (mean ± standard deviation, p < 0.001) was found for antero-posterior mandibular excursion. The longer the treatment time (p = 0.044) and the smaller the patient's mandibular excursion at T0 (p = 0.002), the greater the increase was. These findings could be explained by a muscle-tendon unit adaptation to the forward mandibular repositioning induced by the MAD. During MAD therapy, patients can develop a wider range of antero-posterior mandibular excursion, especially those with a smaller initial excursion capacity.

Australasian Sleep Association position statement on consensus and evidence based treatment for primary snoring

Primary snoring impacts a significant portion of the adult population and has the potential to significantly impair quality of life. The purpose of these guidelines is to provide evidence-based recommendations to assist Australasian practitioners in the management of adult patients who present with primary snoring without significant obstructive sleep apnoea. The Timetable, Methodology and Standards by which this Position Statement has been established is outlined in the Appendix S1. The main recommendations are: Weight loss, and reduced alcohol consumption should be recommended, where appropriate If clinical judgement dictates, benzodiazepine and opioid reduction or avoidance may be advised Positional therapy should be considered in supine dominant snorers In dentate patients, Mandibular advancement devices (MAD) should be recommended as a first line treatment following assessment by both an appropriate Dentist and Sleep physician Continuous positive airway pressure (CPAP) devices may be recommended in patients with primary snoring in those already committed to their use or willing to try Surgical treatment of primary snoring by an appropriately credentialled surgeon may be advised and includes nasal (adjunctive), palatal and other interventions This position statement has been designed based on the best available current evidence and our combined expert clinical experience to facilitate the management of patients who present with primary snoring. It provides clinicians with a series of both non-surgical and surgical options with the aim of achieving optimal symptom control and patient outcomes. This is the first such set of recommendations to be established within Australasia and has also been reviewed and endorsed by the Australasian Sleep Association.

Prediction of obstructive sleep apnea using deep learning in 3D craniofacial reconstruction

Background

Obstructive sleep apnea (OSA) is a common sleep disorder. However, current diagnostic methods are labor-intensive and require professionally trained personnel. We aimed to develop a deep learning model using upper airway computed tomography (CT) to predict OSA and to warn the medical technician if a patient has OSA while the patient is undergoing any head and neck CT scan, even for other diseases.

Methods

A total of 219 patients with OSA [apnea-hypopnea index (AHI) ≥10/h] and 81 controls (AHI <10/h) were enrolled. We reconstructed each patient's CT into 3 types (skeletal structures, external skin structures, and airway structures) and captured reconstructed models in 6 directions (front, back, top, bottom, left profile, and right profile). The 6 images from each patient were imported into the ResNet-18 network to extract features and output the probability of OSA using two fusion methods: Add and Concat. Five-fold cross-validation was used to reduce bias. Finally, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated.

Results

All 18 views with Add as the feature fusion performed better than did the other reconstruction and fusion methods. This gave the best performance for this prediction method with an AUC of 0.882.

Conclusions

We present a model for predicting OSA using upper airway CT and deep learning. The model has satisfactory performance and enables CT to accurately identify patients with moderate to severe OSA.

Obstructive sleep apnea: a review for the orthodontist

INTRODUCTION

Obstructive sleep apnea (OSA) affects an important part of the population and is characterized by recurrent total or partial obstruction of the upper airway (UA) during sleep, negatively affecting the quality of life of patients in the short and long terms, and constituting an important public health problem for the society. The field of expertise of orthodontists is closely related to the UA, placing them in a strategic position to diagnose air passage failures and intervene when necessary. Orthodontists, as health professionals, must know how to recognize respiratory problems and manage them appropriately, when indicated.

OBJECTIVE

Thus, this paper aims to review and critically evaluate the related literature, to provide orthodontists with updated knowledge on the diagnosis and therapy related to OSA. Science and technology are constantly evolving; thus, the literature was also reviewed considering new technologies available in consumer-targeted applications and devices for the diagnosis, monitoring, and treatment of sleep-disordered breathing.

Short-term positive effects of a mandibular advancement device in a selected phenotype of patients with moderate obstructive sleep apnea: a prospective study

STUDY OBJECTIVES

To evaluate (determinants of) treatment success of mandibular advancement device application in a selected phenotype of patients with obstructive sleep apnea (OSA).

METHODS

Ninety nonobese patients with moderate OSA (obstructive apnea-hypopnea index [OAHI] ≥ 15 and < 30 events/h) without comorbidities were prospectively included. Polysomnography was performed at baseline and with a mandibular advancement device. A drug-induced sleep endoscopy with jaw thrust was performed in 83%.

RESULTS

OAHI reduction ≥ 50% was observed in 73%, OAHI reduction ≥ 50% with OAHI < 10 events/h in 70%, and complete OSA resolution (OAHI < 5 events/h) in 40%. Patients with nonpositional OSA showed a significantly higher rate of complete OSA resolution: Posttest probability increased to 67%. In patients with total disappearance of collapse at velum level and at all levels during drug-induced sleep endoscopy with jaw thrust, the drop in OAHI was impressive with an infinitively high positive likelihood ratio. However, the proportion of patients having nonpositional OSA or the drug-induced sleep endoscopy characteristics as described above was < 20%. The change in snoring disturbance based on a visual analog scale was 76% (interquartile range 40-89%, P < .001) and a statistically significant amelioration in Epworth Sleepiness Scale (especially in somnolent subjects) was observed. High adherence was reported.

CONCLUSIONS

In this predefined OSA phenotype, a mandibular advancement device was effective in reduction of OAHI and in amelioration of symptoms. Stratification by nonpositional OSA and findings on drug-induced sleep endoscopy with jaw thrust increased treatment success defined as reduction in OAHI. However, the clinical relevance can be questioned because only a small number of patients demonstrated these characteristics.

CITATION

Buyse B, Nguyen PAH, Leemans J, et al. Short-term positive effects of a mandibular advancement device in a selected phenotype of patients with moderate obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2023;19(1):5-16.

Etiology of Pneumoparotid: A Systematic Review

Pneumoparotid describes retrogradely insufflated air within the Stensen's duct and/or parotid gland. It is a rare condition with variable causative factors. This study aimed to elucidate the clinical characteristics of pneumoparotid. Reports in all languages were evaluated following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2020. A literature search was conducted using electronic medical databases (PubMed, Scopus, Web of Science, EBSCO, Ovid, Google Scholar, SciElo, LILIACS, and others) from 1890 to 30 June 2022. One hundred and seventy patients (mean age; 28.4 years) from 126 studies were reviewed. Common symptoms included swelling (84.7%) and pain (35.9%). Characteristic findings were crepitus in the parotid region (40%) and frothy saliva from the orifice (39.4%). The common etiologies included abnormal habits such as blowing out the cheeks (23.5%), idiopathic (20%), self-induced (15.9%), playing wind instruments such as trumpets or flutes (8.8%), and diseases inducing coughing or sneezing (8.2%). The treatments included antibiotic therapy (30%), behavioral therapy to avoid continuing causative habits (25.9%), psychiatric therapy (8.2%), and surgical procedures (8.2%). Treatment should be individualized and etiology-based. However, the etiology was not identified in 20% of patients. Further detailed data from larger samples are required to clarify and improve the recognition of this entity.

Daytime Sleepiness and Quality of Life in Obstructive Sleep Apnoea Patients before and after Long-Term Mandibular Advancement Device Treatment

This study compared daytime sleepiness and quality of life in OSA patients with healthy controls and compared sleepiness and quality of life in OSA patients before and after long-term treatment with a mandibular advancement device (MAD). A total of 27 OSA patients (18 men, 9 women, mean age 52.3 years) and 32 healthy age- and sex-matched controls (20 men, 12 women, mean age 51.1 years) were included. At baseline and after MAD treatment, daytime sleepiness and quality of life were recorded by the Epworth Sleepiness Scale (ESS) and Short Form-36 questionnaires (SF-36). Daytime sleepiness occurred significantly more often in OSA patients compared to controls at baseline (p = 0.01). The quality of life domains Energy and vitality (p < 0.0001), General perception of health (p = 0.0002), Mental health (p = 0.0031), Social functioning (p = 0.0119), Role limitations due to emotional problems (p = 0.0173) and Physical functioning (p = 0.0226) were significantly poorer in OSA patients compared to controls at baseline. After long-term MAD treatment, daytime sleepiness decreased (p < 0.01) and the quality of life domain Energy and Vitality increased (p < 0.01) in OSA patients compared to baseline. The results of the present study support the relevance of MAD treatment as an effective tool for decreasing daytime sleepiness and increasing the quality of life in OSA patients—also in the long term.

OMS residents’ obstructive sleep apnea‐related education, knowledge, and professional behavior: A national survey

OBJECTIVES

Oral and maxillofacial surgeons (OMS) treat adult and pediatric patients with obstructive sleep apnea (OSA). Objective 1 assessed sleep apnea-related education, knowledge, and professional behavior of OMS residents in the United States. Objective 2 was to compare the responses of junior versus senior residents and residents in single- versus dual-degree programs.

METHODS

OMS residents in the United States received a recruitment email with a link to an anonymous online survey; 81 residents responded. The survey included 20 questions to assess respondents' OSA-related education, knowledge, attitudes, and professional behavior.

RESULTS

Respondents generally agreed that they had received OSA-related didactic-based education (5-point scale with "5" = agree strongly: mean = 3.62) and clinical training (mean = 3.75). Clinical and classroom educational gaps were identified in relation to treatment with oral appliances and hypoglossal nerve stimulation. The residents scored on average 10.38 out of 18 (58%) possible correct answer points for the knowledge questions. Findings about pediatric OSA suggest that only 43.8% of residents understand diagnostic criteria for pediatric OSA, with only 26.6% screening pediatric patients for OSA. A case analysis showed that only 1.5% of residents correctly identified an apnea-hypopnea index of 17 as moderate sleep apnea.

CONCLUSION(S)

This survey found knowledge gaps in several areas that can be improved upon. It identifies deficiency in objective knowledge about OSA among OMS residents and a specific lack of clinical training and confidence with hypoglossal nerve stimulation and management of pediatric patients with OSA. Junior and senior residents and single- and dual-degree residents showed no statistically significant differences in any category except senior residents in regard to surgical management of OSA, particularly with maxillomandibular advancement.

Maxillomandibular Advancement and Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea: A Systematic Review

This systematic review aimed to comparatively evaluate the efficacy and safety of maxillomandibular advancement (MMA) and upper airway stimulation (UAS) in obstructive sleep apnea (OSA) treatment. A MEDLINE and Embase database search of articles on MMA and/or UAS for OSA was conducted. Twenty-one MMA studies and nine UAS studies were included. All the MMA studies demonstrated a reduction in apnea hypopnea index (AHI) postoperatively, and success rates ranged from 41.1% to 100%. Ten MMA studies reported pre- and postoperative Epworth sleepiness scale (ESS), and all but one study demonstrated a reduction in ESS. In the UAS studies, all but one demonstrated a reduction in AHI, and success rates ranged from 26.7% to 77.8%. In the eight UAS studies reporting pre- and postoperative ESS, an ESS reduction was demonstrated. No studies reported any deaths related to MMA or UAS. The most common postoperative complications after MMA and UAS were facial paresthesia in the mandibular area and discomfort due to electrical stimulation, respectively. This systematic review suggests that both MMA and UAS are effective and generally safe therapies for OSA. However, due to the limitations of the included studies, there is no evidence yet to directly compare these two procedures in OSA treatment.

Treatment of Obstructive Sleep Apnea Using Oral Appliances in Saudi Arabia: Are We following the Guidelines?

BACKGROUND

This study aimed to assess sleep medicine physicians' knowledge and attitudes toward the role of oral appliances (OAs) in managing obstructive sleep apnea (OSA) in Saudi Arabia.

METHODS

An online questionnaire was administered to the registered physicians practicing sleep medicine (otolaryngology, internal medicine, pulmonology, and family medicine) in Saudi Arabia. The questionnaire included 26 questions under five domains. All the collected data were analyzed using descriptive statistics and Chi-square tests.

RESULTS

One hundred sleep physicians (43% Saudi, 75% male) from Saudi Arabia participated in this study. Almost 43% of participants reported inadequate knowledge of the treatment of OSA patients using OAs. Half of the participants were unaware of how OAs work in managing OSA. Most physicians (62%) never referred the patient for treatment of OSA using OAs, whereas 4% referred at least one patient every month. The majority (60%) believed that there are barriers to referring a case for OA treatment, mainly the lack of knowledge of the suitable cases (60%) and the lack of qualified dentists in this area (43%).

CONCLUSION

Most sleep physicians reported poor knowledge of OA indications and mechanism of use, with most never referring a case for OA therapy.

Obstructive Sleep Apnoea and Lipid Metabolism: The Summary of Evidence and Future Perspectives in the Pathophysiology of OSA-Associated Dyslipidaemia

Obstructive sleep apnoea (OSA) is associated with cardiovascular and metabolic comorbidities, including hypertension, dyslipidaemia, insulin resistance and atherosclerosis. Strong evidence suggests that OSA is associated with an altered lipid profile including elevated levels of triglyceride-rich lipoproteins and decreased levels of high-density lipoprotein (HDL). Intermittent hypoxia; sleep fragmentation; and consequential surges in the sympathetic activity, enhanced oxidative stress and systemic inflammation are the postulated mechanisms leading to metabolic alterations in OSA. Although the exact mechanisms of OSA-associated dyslipidaemia have not been fully elucidated, three main points have been found to be impaired: activated lipolysis in the adipose tissue, decreased lipid clearance from the circulation and accelerated de novo lipid synthesis. This is further complicated by the oxidisation of atherogenic lipoproteins, adipose tissue dysfunction, hormonal changes, and the reduced function of HDL particles in OSA. In this comprehensive review, we summarise and critically evaluate the current evidence about the possible mechanisms involved in OSA-associated dyslipidaemia.

Practice recommendations for the role of physiotherapy in the management of sleep disorders: the 2022 Brazilian Sleep Association Guidelines

This clinical guideline supported by the Brazilian Sleep Association comprises a brief history of the development of Brazilian sleep physiotherapy, outlines the role of the physiotherapist as part of a sleep health team, and describes the clinical guidelines in respect of the management of some sleep disorders by the physiotherapist (including sleep breathing disorders, i.e., obstructive sleep apnea, central sleep apnea, upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, and pediatric sleep breathing disorders; sleep bruxism; circadian rhythms disturbances; insomnia; and Willis-Ekbom disease/periodic limb movement disorder. This clinical practice guideline reflects the state of the art at the time of publication and will be reviewed and updated as new information becomes available.

Etiology and Management of Treatment-Resistant Hypertension in African American Adults ≥18 Years: A Literature Review

Treatment-resistant hypertension (TRH) is defined as blood pressure levels that remain above the therapeutic goal despite concurrent use of three or more antihypertensive medications taken at maximally tolerated doses, one of which should be a diuretic. Additionally, individuals on four or more antihypertensive agents regardless of blood pressure are also considered to have TRH. Amongst people diagnosed with TRH, African American adults face a huge management gap, resulting in increased cardiovascular disease risk. The primary objective of this review was to identify the commonly encountered etiologies and extensively discuss the current management strategies of TRH with a particular focus on African Americans. Relevant studies were identified by analyzing scientific databases and journals such as PubMed, Cochrane, MEDLINE, Cureus, and American Heart Association (AHA). The studies identified and examined common causes of TRH, describing their pathophysiology and highlighting different treatment options for the respective etiologies. The most prevalent etiologies of TRH amongst African Americans were chronic kidney disease (CKD), renal artery stenosis (RAS), fibromuscular dysplasia, obstructive sleep apnea (OSA), endocrine causes (Conn syndrome, Cushing syndrome, etc.), sympathetic nervous system overactivity, lifestyle factors, inaccurate blood pressure measurement, and inappropriate treatment. Of the etiologies reviewed, OSA, lifestyle factors, and CKD exhibited a striking prevalence among the subpopulation studied. Unfortunately, there was a paucity of articles addressing this topic amongst African Americans, and therefore there was not a substantial appreciation of the prevalence of some of the identified etiologies in the population of interest. Thorough diagnostic testing for associated or underlying conditions provides a basis for successful management. This review brought to the fore the need for doctors and patients to collaborate in order to improve TRH management and help patients lead healthier lives.

Equal effect of a noncustom vs a custom mandibular advancement device in treatment of obstructive sleep apnea

STUDY OBJECTIVES

Numerous types of mandibular advancement devices (MADs) are available to treat patients with obstructive sleep apnea, varying from noncustom to custom devices. Only a limited number of studies have been performed to determine whether a noncustom MAD could be used to predict treatment success of a custom MAD. In this study, we investigated the potential of a new-generation noncustom MAD, by comparing its effectiveness with a custom MAD. We hypothesized that the effectiveness of the devices is similar with regard to both objective (polysomnography) and self-reported (questionnaires, adherence, and patient satisfaction) outcomes.

METHODS

This was a single-center prospective randomized crossover study including a consecutive series of patients with obstructive sleep apnea. Patients were randomized to start either with the noncustom or custom MAD. Both MADs were applied for 12 weeks, followed by polysomnography with MAD in situ and questionnaires. After the first 12 weeks of follow-up, a washout period of 1 week was applied. Equal effectiveness was defined as no significant differences in both objective and self-reported outcomes between both devices.

RESULTS

Fifty-eight patients were included; 40 completed the full follow-up. The median apnea-hypopnea index significantly decreased from 16.3 (7.7, 24.8) events/h to 10.7 (5.6, 16.6) events/h with the custom MAD (P = .010) and to 7.8 (2.9, 16.1) events/h with the noncustom MAD (P < .001). Self-reported outcomes significantly improved in both groups. No significant differences were found between both devices.

CONCLUSIONS

The effectiveness of a noncustom and custom MAD is comparable, which suggests that a noncustom MAD can be used as a selection tool for MAD treatment eligibility to improve MAD treatment outcome.

CLINICAL TRIAL REGISTRATION

Registry: Netherlands Trial Register; Name: The Use of a Boil and Bite Mandibular Advancement Device vs a Custom Mandibular Advancement Device in Obstructive Sleep Apnea Management; URL: https://www.trialregister.nl/trial/7249; Identifier: NL64738.100.18.

CITATION

Bosschieter PFN, Uniken Venema JAM, Vonk PE, et al. Equal effect of a noncustom vs a custom mandibular advancement device in treatment of obstructive sleep apnea. J Clin Sleep Med. 2022;18(9):2155-2165.

Non-CPAP therapy for obstructive sleep apnoea

Treatment of obstructive sleep apnoea in adults is evolving, from a "one treatment fits all" to a more individualised approach. The spectrum of treatment options is broad and heterogeneous, including conservative, technological and pharmaceutical modalities. This raises the questions of which patients these modalities might be useful for, and if there are specific criteria for single or combined treatment. The most commonly used non-CPAP treatment is a mandibular advancement device. Furthermore, it appears from the available evidence that upper airway surgery, bariatric surgery, and maxillomandibular advancement can be effective in particular patient groups and should be indicated more readily in clinical practice. Technically, a tracheotomy is the most effective surgical treatment, but is not socially acceptable and is associated with major side-effects. Other treatment options are emerging, like positional therapy, hypoglossal nerve stimulation, and myofunctional exercises. Drug therapy is also promising when pathophysiological traits are considered. The range of currently available treatment options will be discussed in this review, with emphasis on the selection of appropriate patients, therapeutic efficacy and compliance, and reference to recent guidelines. In the selection process, routine application of drug-induced sleep endoscopy to assess the site(s) of collapse during sleep can increase the success rate of both surgical interventions and oral appliance therapy.

Educational aims

To outline recommendations concerning the proper management of obstructive sleep apnoea (OSA) patients that cannot be treated adequately with continuous positive airway pressure (CPAP) due to intolerance, poor adherence or compliance, or CPAP refusal.To provide information about the selection of appropriate patients for alternative non-CPAP treatment options.To better understand the different aspects of OSA treatment with noninvasive approaches, such as oral appliances, positional therapy, drug treatment and myofunctional therapy, including indications, contraindications, and expected short- and long-term results.To discuss the different surgical options for the treatment of OSA and to provide information on the important issue of proper patient selection for surgery, as most OSA surgical outcomes are associated with the pre-operative assessment of the level(s) of upper airway collapse.

Effects of oral appliances on serum cytokines in adults with obstructive sleep apnea: a systematic review

PURPOSE

This review aimed to evaluate the effects of oral appliance (OA) therapy on serum inflammatory cytokines in adults diagnosed with obstructive sleep apnea (OSA).

METHODS

Seven electronic databases and partial gray literature were searched without restrictions through March 2021. Articles evaluating the levels of serum inflammatory cytokines in patients with OSA after OA treatment were included. The risk of bias (RoB) was assessed using the before-and-after tool or RoB 2.0. The level of certainty was assessed using the GRADE tool.

RESULTS

Five studies met the eligibility criteria. One was a randomized clinical trial (RCT), while four were non-randomized clinical trials (NRCTs). Among the studies, C-reactive protein (CRP), IL-6, IL-10, IL-1β, and tumor necrosis factor α (TNF-α) were investigated. The RCT reported no significant differences in marker levels after 2 months of OA therapy, while the NRCTs showed improvement on CRP, TNF-α, and IL-1β levels after longer follow-up periods. The RoB was evaluated as showing some concern in the RCT. Three NRCTs presented good RoB, and one showed a fair RoB. The level of certainty was graded as moderate quality for inflammatory marker levels assessed in the RCT The levels of certainty evaluated in NRCTs were classified as very low.

CONCLUSIONS

Although limited, existing scientific evidence showed that OA therapy may improve serum cytokine levels in adults with OSA. However, short treatment periods are not effective in reducing markers of systemic inflammation which may require extended time and a decrease of in apneic events to improve.

Effectiveness of Titratable Oral Appliance in Management of Moderate to Severe Obstructive Sleep Apnea-A Prospective Clinical Study with Acoustic Pharyngometry

To assess effectiveness of titratable Oral Appliance (OA) in management of moderate to severe cases of Obstructive Sleep Apnea (OSA). Thirty Polysomnography (PSG) diagnosed cases of moderate to severe OSA were subjected to a thorough cranio-facial-dental evaluation, a detailed sleep history and three dimensional assessment of upper airway geometry utilising Acoustic Pharyngometry (AP) (Eccovision, sleep group solutions). A titratable OA was delivered to all patients for mandibular advancement. Apnea Hypopnea Index (AHI), Oxygen Saturation (SPO2), Epworth's Sleepiness Scale (ESS), Mean area and volume of upper airway were recorded at Baseline (T0) and after 08 weeks of appliance delivery (T1). The mean AHI & ESS scores were significantly lower and SPO2 was significantly higher at T1 compared to T0 (P-value < 0.05 for all). The mean area and volume of upper airway at T1 were significantly higher compared to values at T0 (P-value < 0.05 for both). The mean area showed 19.51% increase at T1 whereas mean volume increased by 18.55%. OA therapy is highly efficacious in cases with moderate to severe OSA, especially, in those with retrognathic mandible. This modality should be considered as an effective alternate to Continuous Positive Airway Pressure (CPAP) therapy in non-compliant patients rather than no treatment. AP is an effective modality to predict airway changes after advancement with OA, to ascertain follow up changes and is highly recommended in routine clinical practice. Large scale, multicenter studies are recommended to elaborate the findings of the present study and to add better quality evidence in this regard.

Reliability of STOP-Bang questionnaire and pulse oximetry as predictors of OSA - a retrospective study

OBJECTIVE

To verify the reliability of a STOP-Bang questionnaire and objective blood oxygen concentration (SpO2) estimation by pulse oximetry as an indicator of patients' vulnerability to OSA, by correlating data of these two tests with that of the "gold standard" all-night polysomnography.

METHODS

STOP-Bang score and pulse oximetry value (SpO2) for each patient were tabulated against the total sleep AHI score (obtained from subsequent all-night polysomnography) and analyzed to evaluate the diagnostic accuracy of the STOP-Bang questionnaire and pulse oximetry.

RESULTS

With sensitivity and specificity scores of 91.2% and 88.6%, respectively, positive predictive value 90.5%, negative predictive value 40.2%, the twin diagnostic test (STOP-Bang and pulse oximetry) was found to be highly congruent with the polysomnography (PSG), achieving a diagnostic accuracy of 85%.

CONCLUSION

Dental chairside screening by STOP-Bang questionnaire and pulse oximetry would be a good option, especially where logistic and economic constraints impede all-night polysomnography.

Mandibular Advancement Device Therapy in Japanese Rugby Athletes with Poor Sleep Quality and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) may contribute to poor sleep quality. This study assessed subjective sleep quality, the Respiratory Event Index (REI), reaction times, and the therapeutic effects of a custom-made mandibular advancement device (MAD) in male Japanese elite rugby athletes. The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and level III sleep test (REI and minimum oxygen saturation [SpO2 min]) were used to evaluate sleep quality. MAD therapy was used daily for 3 weeks. A telephone-based reaction time test of kinetic vision (the ability to identify moving objects) was recorded within 15 min of waking and over 5 days of pre- and post-MAD therapy. Differences in variables were evaluated using paired t-tests. Of the 42 players (mean age, 26.3 ± 3.7 years; mean body mass index, 28.7 ± 3.2 kg/m2) included in this study, 29 (69.0%) had poor sleep quality (PSQI > 5.5), and 27 were diagnosed with OSA (64.3%) (mild = 16/moderate = 9/severe = 2). Six were treated with MAD therapy, which significantly improved the REI (p < 0.01), SpO2 min (p < 0.001), ESS score (p < 0.001), reaction times (p < 0.01), and sleep quality. A significant reduction in reaction times suggests that OSA treatment can improve kinetic vision. Future studies should systematically evaluate the impact of sleep-disordered breathing on kinetic vision in athletes.

The comparison of two different mandibular positions for oral appliance therapy in patients with obstructive sleep apnea

BACKGROUND

An oral appliance (OA) can alleviate upper airway obstruction by pulling the mandible forward during sleep. While a large mandibular advancement with an OA decreases the number of apnea and hypopnea events, long-term use may cause side effects, such as toothache, stiffness, and pain in the temporomandibular joint.

OBJETIVES

This study aimed to evaluate the effectiveness of different mandibular positions for obstructive sleep apnea (OSA) and determine the optimal therapeutic mandibular position.

METHODS

Thirty-two patients (17 males and 15 females) with mild to moderate OSA participated in this prospective study. All patients were randomly allocated to receive a 50% mandibular advancement or a 75% mandibular advancement with an OA. The pre- and posttreatment apnea-hypopnea index (AHI), apnea index (AI), and Epworth Sleepiness Scale (ESS) were compared. Treatment effectiveness and treatment success were compared between groups.

RESULTS

AHI improved significantly in both groups, and AI improved significantly in the group with 50% mandibular advancement. No significant improvements in the ESS were observed in either group. There was no significant difference in treatment effectiveness between groups. In the proportion of females and males whose treatment was effective in the two groups, females were significantly greater than males.

CONCLUSIONS

For patients with mild to moderate OSA, 50% mandibular advancement is recommended as the initial therapeutic mandibular position. It was suggested that gender differences also affect treatment effectiveness.

Obstructive sleep apnea: personalizing CPAP alternative therapies to individual physiology

Introduction The recent continuous positive airway pressure (CPAP) crisis has highlighted the need for alternative obstructive sleep apnea (OSA) therapies. This article serves to review OSA pathophysiology and how sleep apnea mechanisms may be utilized to individualize alternative treatment options.Areas covered: The research highlighted below focuses on 1) mechanisms of OSA pathogenesis and 2) CPAP alternative therapies based on mechanism of disease. We reviewed PubMed from inception to July 2022 for relevant articles pertaining to OSA pathogenesis, sleep apnea surgery, as well as sleep apnea alternative therapies.Expert opinion: Although the field of individualized OSA treatment is still in its infancy, much has been learned about OSA traits and how they may be targeted based on a patient's physiology and preferences. While CPAP remains the gold-standard for OSA management, several novel alternatives are emerging. CPAP is a universal treatment approach for all severities of OSA. We believe that a personalized approach to OSA treatment beyond CPAP lies ahead. Additional research is needed with respect to implementation and combination of therapies longitudinally, but we are enthusiastic about the future of OSA treatment based on the data presented here.

The effects of obstructive sleep apnea-hypopnea syndrome (OSAHS) on learn and memory function of 6-12 years old children

BACKGROUND

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a sleep disorder causing cognitive impairments.

AIMS

We use the auditory verbal learning test (AVLT), clock drawing test (CDT), Wechsler intelligence scale for children (WISC) and Montreal cognitive assessment (MoCA) to evaluate the memory and spatial impairments of OSHAS in 6-12 years old children patients with different severity.

MATERIAL AND METHODS

A total of 137 children of snoring were enrolled following the inclusion criteria of this study. According to the apnea-hypopnea indices (AHI), they were divided into three groups. The AVLT, CDT, WISC and MoCA tests were executed by physicians. The self-rating depression scale (SDS) test was performed for depression screening.

RESULTS

Compared with the children in the primary snoring group, the other two groups had higher body mass index (BMI), longer periods of snoring and older age. The AHI, oxygen desaturation index (ODI) and 90% oxygen saturation (TS90%) showed increasing trends whereas the lowest blood oxygen saturation (LSaO₂) showed a decreasing trend. Besides, compared with the primary snoring group, the two groups had lower immediate recall scores in AVLT.

CONCLUSION

AVLT had clinical values for evaluation of impaired memory function in OSAHS children, suggesting a correlation between cognitive impairments and nocturnal hypoxia.

Sleep apnea predicts cardiovascular death in patients with Marfan syndrome: a cohort study

Background

Surgical replacement of the aortic root is the only intervention that can prevent aortic dissection and cardiovascular death in Marfan syndrome (MFS). However, in some individuals, MFS also causes sleep apnea. If sleep apnea predicts cardiovascular death, a new target for predictive, preventive, and personalized medicine (PPPM) may emerge for those individuals with MFS who have sleep apnea.

Methods

This is an investigator-initiated study with long-term follow-up data of 105 individuals with MFS. All individuals were screened for sleep apnea regardless of symptoms. Cardiovascular death served as a primary endpoint, and aortic events as a secondary outcome.

Results

Sleep apnea with an apnea–hypopnea index (AHI) > 5/h was observed in 21.0% (22/105) with mild sleep apnea in 13% (14/105) and moderate to severe sleep apnea in 7.6% (8/105). After a median follow-up of 7.76 years (interquartile range: 6.84, 8.41), 10% (10/105) had died, with cardiovascular cause of death in 80% (8/10). After adjusting for age and body mass index (BMI), the AHI score emerged as an independent risk factor for cardiovascular death (hazard ratio 1.712, 95% confidence interval [1.061–2.761], p = 0.0276). The secondary outcome of aortic events occurred in 33% (35/105). There was no effect of the AHI score on aortic events after adjusting for age and BMI (hazard ratio 0.965, 95% confidence interval [0.617–1.509]), possibly due to a high number of patients with prior aortic surgery.

Interpretation

Sleep apnea is emerging as an independent predictor of cardiovascular death in MFS. It seems mandatory to screen all individuals with MFS for sleep apnea and to include these individuals, with both MFS and sleep apnea, in further studies to evaluate the impact of preventive measures with regard to cardiovascular death.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00291-4.

Craniofacial Morphologic Predictors for Passive Myofunctional Therapy of Pediatric Obstructive Sleep Apnea Using an Oral Appliance with a Tongue Bead

We conducted this retrospective study to identify potential clinical, polysomnographic, and cephalometric predictors for the treatment outcomes of a tongue-beaded oral appliance (OA) in children with obstructive sleep apnea syndrome (OSAS). In total, 63 patients—50 boys and 13 girls ranging in age from 4 to 16 years—underwent OA treatment nightly for at least 6 months. A baseline digital lateral cephalometric radiograph was obtained for each patient. Multivariate logistic regression analysis was performed to examine predictors for the treatment outcome based on the clinical and cephalometric measurements. Overall, 28 patients responded to the treatment (post-treatment improvement > 50% or apnea−hypopnea index (AHI) < 1/h), and 35 did not (post-treatment improvement < 50% and AHI ≥ 1/h). Significantly larger cranial base angle (SNBa), smaller lower gonial angle (LGo Angle), and shorter length of anterior cranial base (SN) were found in responders. Smaller lower gonial angle (LGo Angle) and smaller anterior cranial base (SN) predict a favorable outcome for pediatric OSAS using a tongue-beaded OA. This finding will equip practitioners with additional insights when selecting suitable candidates for OA therapy in pediatric patients.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Effectiveness of a Uniquely Designed Oral Appliance on Obstructive Sleep Apnea Control: A Pilot Study

OBJECTIVES

 Obstructive sleep apnea is an inflammatory, chronic, and evolutive disease often needing adequate treatment and follow-up. The oral appliance (OA) is an accepted alternative therapy for obstructive sleep apnea (OSA) control. Due to greater adherence, OA with mandibular advancement (OAm) is being recommended treatment for patients who refuse or do not tolerate continuous positive airway pressure. The mode of action of OAm is to promote the advancement of the mandible or tongue with a subsequent increase in the tone of the pharyngeal muscles and the permeability of the upper airway, but most OAm use conventional models as reference, analogic, or digital, dissociating dental arches of the skull structures.

MATERIALS AND METHODS

 A retrospective longitudinal study of 33 OSA patient treated with a different OAm, that use Camper plane as reference with skull structures for dental arches disocclusion, where polysomnographic, cephalometric measures, and subjective data from questionnaires pre- and post-treatment were assessed and correlated. Descriptive analysis, correlated Chi-square tests, and basic statistics were used. Generalized linear mixed model for repeated measure and post hoc Tukey-Kramer test compares the variables pre- and post-treatment. Shapiro-Wilk test and Pearson's correlation coefficients were used. All statistical tests were set in 5% level of significance.

RESULTS

 Regarding polysomnography data, there was a significant association between apnea hypopnea index (AHI) with oxygen saturation, arousal index (AI) and the maximum heartbeats, and sleep improvement and health risk reduction. Additionally, from cephalometric data, it was found a significant association between the tongue posture with the soft palate, hioyd-C3 and, lower and posterior airway. When both parameters are correlated, there are a significant dependent association with hyoid bone position with AHI and AI. The limitation of this study was the two-dimensional image used without provide volumetric measurements, but this limitation was reduced with the follow-up polysomnography parameters.

CONCLUSION

 In this pilot study, DIORS OAm as an uniquely designed device using Camper plane as a reference for disocclusion was effective in the control of OSA.

[Obstructive Sleep Apnea]

Obstructive sleep apnea (OSA) is defined as the presence of an apnea-hyponea index (AHI)>15/h, predominantly obstructive or AHI greater than 5 with symptoms, the classic symptoms are observed apneas, daytime sleepiness and snoring, however, there are many other associated symptoms. To assess the severity of OSA, classically, only the AHI value was considered, but there is increasing evidence to implicate other factors. The predisposition to develop OSA is determined by anatomical and functional features. Having OSA increases the risk of accidents, high blood pressure (HBP) and is associated with cardiovascular risk, diabetes mellitus (DM), cardiac arrhythmia and neoplasms. To assess the probability of OSA, questionnaires and scales have been developed to assess symptoms, the certain diagnosis is obtained by polysomnography (PSG), which is the gold standard test, or polygraphy, which is a simpler and more accessible diagnostic test for diagnosis validated, the use of one or the other will depend on the suspicion and the associated comorbidities. Treatments for sleep apnea increasingly tend to be more individualized based on the characteristics of the patient and all are complementary. Hygienic-dietary measures should be applied in all patients, continuous positive airway pressure (CPAP) is the most effective treatment and with the most evidence, but other treatments are also available such as mandibular advancement devices (MAD), postural therapy and surgical options among others. Telemedicine is advancing in the follow-up of patients with OSA, both from non-face-to-face consultations and control of equipment via Wi-Fi to assess adherence, efficacy and correct control of therapy.

The relationship between mandibular advancement, tongue movement, and treatment outcome in obstructive sleep apnea

Study Objectives

To characterize how mandibular advancement enlarges the upper airway via posterior tongue advancement in people with obstructive sleep apnea (OSA) and whether this is associated with mandibular advancement splint (MAS) treatment outcome.

Methods

One-hundred and one untreated people with OSA underwent a 3T magnetic resonance (MRI) scan. Dynamic mid-sagittal posterior tongue and mandible movements during passive jaw advancement were measured with tagged MRI. Upper airway cross-sectional areas were measured with the mandible in a neutral position and advanced to 70% of maximum advancement. Treatment outcome was determined after a minimum of 9 weeks of therapy.

Results

Seventy-one participants completed the study: 33 were responders (AHI&lt;5 or AHI≤10 events/hr with &gt;50% AHI reduction), 11 were partial responders (&gt;50% AHI reduction but AHI&gt;10 events/hr), and 27 nonresponders (AHI reduction&lt;50% and AHI≥10 events/hr). Responders had the greatest naso- and oropharyngeal tongue anterior movement (0.40 ± 0.08 and 0.47 ± 0.13 mm, respectively) and oropharyngeal cross-sectional area enlargement (6.41 ± 2.12%) per millimeter of mandibular advancement. A multivariate model that included tongue movement and percentage of airway enlargement per millimeter of mandibular advancement along with baseline AHI correctly classified 69.2% (5-fold cross-validated 62.5%, n = 39) of participants in response categories when the jaw was advanced in the range that would usually be regarded as sufficient for clinical efficacy (&gt; 4 mm). In comparison, a model using only baseline AHI correctly classified 50.0% of patients (5-fold cross-validated 52.5%, n = 40).

Conclusions

Tongue advancement and upper airway enlargement with mandibular advancement in conjunction with baseline AHI improve treatment response categorization to a satisfactory level (69.2%, 5-fold cross-validated 62.5%).

Treatment options in obstructive sleep apnea

Treatment of OSA with CPAP is currently the recommended treatment and has the greatest evidence of efficacy on AHI, symptoms and comorbidities. Symptomatic patients with moderate-severe OSA generally have good adherence to CPAP therapy, while those with mild OSA, female, young and generally paucisymptomatic, have lower CPAP adherence, especially in the medium and long term. The recent identification of different clinical and pathophysiological phenotypes of OSA has paved the way for alternative treatments to CPAP, leading to an increasingly personalized therapy. Weight loss and lifestyle modifications are highly recommended in all obese or overweight patients. Mandibular advancement devices (MAD), positional therapy (PT) and hypoglossal nerve stimulation (HSN) are recent and personalized alternative therapies on which there is promising and encouraging data but with still little strong scientific evidence. The purpose of this review is to compare the efficacy, adherence and costs of various therapeutic options for OSA patients in the light of recent evidence and to provide useful guidance for specialists.

Obstructive sleep apnea: transition from pathophysiology to an integrative disease model

Obstructive sleep apnea (OSA) is characterised by recurring episodes of upper airway obstruction during sleep and the fundamental abnormality reflects the inability of the upper airway dilating muscles to withstand the negative forces generated within the upper airway during inspiration. Factors that result in narrowing of the oropharynx such as abnormal craniofacial anatomy, soft tissue accumulation in the neck, and rostral fluid shift in the recumbent position increase the collapsing forces within the airway. The counteracting forces of upper airway dilating muscles, especially the genioglossus, are negatively influenced by sleep onset, inadequacy of the genioglossus responsiveness, ventilatory instability, especially post arousal, and loop gain. OSA is frequently associated with comorbidities that include metabolic, cardiovascular, renal, pulmonary, and neuropsychiatric, and there is growing evidence of bidirectional relationships between OSA and comorbidity, especially for heart failure, metabolic syndrome, and stroke. A detailed understanding of the complex pathophysiology of OSA encourages the development of therapies targeted at pathophysiological endotypes and facilitates a move towards precision medicine as a potential alternative to continuous positive airway pressure therapy in selected patients.

Pneumoparotid related to obstructive sleep apnea syndrome treated by oral appliance with anterior opening to reduce intraoral pressure

Pneumoparotid is associated with retrograde air insufflation in Stensen's duct and the parotid gland. A 57‐year‐old man experienced swelling and pain in the right parotid region after sleeping during a flight. Pneumoparotid and obstructive sleep apnea syndrome were diagnosed. Pneumoparotid was suspected as caused by increased intraoral pressure during sleep; thus, an oral appliance to reduce intraoral pressure was effective. After 9 years, the symptoms recurred on the left side. The appliance was reinserted and helped substantially. This is the first case report of obstructive sleep apnea syndrome accompanying pneumoparotid, treated effectively with an oral appliance, with a 10‐year follow‐up.

Prediction of Mandibular Advancement Device Response Using CPAP Pressure in Different Polysomnographic Phenotypes

Objective

Both continuous positive airway pressure (CPAP) pressure and polysomnographic phenotypes have been associated with mandibular advancement device (MAD) treatment response, but the precise relationship has not been fully elucidated. We hypothesized that utilizing CPAP pressure would predict the MAD response in treatment-naïve patients with moderate-severe obstructive sleep apnea (OSA), and the MAD response would be associated with two polysomnographic phenotypes, including sleep stage dependency and positional dependency.

Methods

OSA treatment-naïve patients with an apnea-hypopnea index (AHI) ≥15/h who declined CPAP treatment and received MAD treatment for 3-6 months were enrolled. The MAD treatment response was defined as 1) residual AHI under MAD (AHIMAD) <5/h and 2) AHIMAD <10/h. Logistic regression was applied to identify the association between CPAP pressure and MAD treatment responders. The predictability of the MAD responder status utilizing CPAP pressure was assessed with the area under the receiver operating characteristic (AUROC).

Results

A total of 128 enrolled patients (AHI ≥30/h in 74.2%) were recruited, of whom 119 patients and 80 patients were included for analysis of sleep stage and positional dependency, respectively. REM-predominant OSA had lower AHI than stage-independent OSA, while the supine-predominant phenotype had lower anthropometrics than the nonpositional-dependent phenotype. The response rates for AHIMAD <5/h and AHIMAD <10/h were 25.8% and 48.4%, respectively. Lower anthropometrics, baseline AHI, and supine predominance were associated with the responder status, while CPAP pressure was an independent predictor. The AUROCs for the prediction of AHIMAD <5/h and AHIMAD <10/h responders were 0.635 and 0.664, respectively. Utilizing a CPAP level >14 cmH2O as the cutoff to predict criterion 1 and 2 nonresponders, the sensitivity was 93.9% and 95.2%, respectively.

Conclusion

In treatment-naïve patients with moderate-severe OSA, the supine-predominant phenotype and lower CPAP pressure were associated with the MAD response, while the sleep stage dependency phenotype was not. Utilization of a CPAP level >14 cmH2O could be a sensitive measure to identify nonresponders.

Dental and Skeletal Side Effects of Oral Appliances Used for the Treatment of Obstructive Sleep Apnea and Snoring in Adult Patients—A Systematic Review and Meta-Analysis

Background: Mandibular advancement devices for obstructive sleep apnea treatment are becoming increasingly popular among patients who do not prefer CPAP devices or surgery. Our study aims to evaluate the literature regarding potential dental and skeletal side effects caused by mandibular advancement appliances used for adult OSA treatment. Methods: Electronic databases were searched for published and unpublished literature along with the reference lists of the eligible studies. Randomized clinical trials and non-randomized trials assessing dental and skeletal changes by comparing cephalometric radiographs were selected. Study selection, data extraction, and risk of bias assessment were performed individually and in duplicate. Fourteen articles were finally selected (two randomized clinical trials and 12 non-randomized trials). Results: The results suggest that mandibular advancement devices used for OSA treatment increase the lower incisor proclination by 1.54 ± 0.16°, decrease overjet by 0.89 ± 0.04 mm and overbite by 0.68 ± 0.04 mm, rotate the mandible downward and forward, and increase the SNA angle by to 0.06 ± 0.03°. The meta-analysis revealed high statistical heterogeneity. Conclusions: The MADs affect the lower incisor proclination, overjet, overbite, the rotation of the mandible and the SNA angle. More randomized clinical trials providing high-quality evidence are needed to support those findings.

Long-term benefits of a new oral appliance on adult snoring: a trend analysis

Background: Snoring constitutes a worldwide public health concern that may be associated with daytime fatigue, endothelial dysfunction, vascular injury, stroke, cardiovascular diseases, and diabetes among female patients. This study explored the effects of the so-called Lin Oral Appliance (LOA) on Taiwanese adults’ snoring rates.Methods: A time series analysis was conducted to examine the associations between LOAs’ tongue compressors of different lengths, and snoring rates were calculated using the SnoreClock app. The LOA comprises 2 components: custom-made dental braces and tongue compressors of adjustable lengths; different versions had different-length compressors.Results: Our multiple linear regression time-series model revealed the effects of the LOA on snoring rates. The results indicated the following: i) LOA tongue compressor lengths of 1 and 2.5 cm (LOA-1 and LOA-2.5, respectively) were associated with reduced snoring rates; ii) sleep durations of 5.5-7.5 h and daytime sleepiness were associated with increased snoring rates; and iii) among participants with snoring rates above 10%, the snoring rates observed 1-7 days before a given day constituted a significant factor influencing snoring rates on the given day.Conclusions: We discovered that the LOA could reduce snoring rates and that the 2.5-cm compressor length in the LOA produced the best results.

Disparities in oxygen saturation and hypoxic burden levels in obstructive sleep apnea patient's response to oral appliance treatment

Background

Oxygen saturation indices show a strong correlation with long‐term health outcomes. Nonetheless, evidence on the relationship between reduction in respiratory events and increase in oxygenation levels following oral appliance (OA) treatment is scarce.

Objectives

To verify the relationship between reduction in the apnoea‐hypopnoea index (AHI) and oxygen saturation levels following OA treatment, we have conducted an evaluation of polysomnography (PSG) and clinical parameters associated with the improvement of oxygen desaturation.

Methods

OSA patients (n = 48) who received an OA and had pre‐ and post‐treatment PSG were classified into three responder groups according to the change in AHI and min O₂ post‐treatment: responder_AHIonly (decrease in AHI of ≥50% but increase in min O₂ level of <4% or decrease); responder_MinO2only (increase in min O₂ level of ≥4% but decrease in AHI <50% or increase) and responder_Congruous (decrease in AHI of ≥50% and increase in min O₂ level of ≥4%). Various demographic and PSG variables were statistically compared among groups.

Results

There were 26 (54.17%) responder_AHIonly, 9 (18.75%) responder_MinO2only and 13 (27.08%) responder_Congruous. Pre‐treatment min O₂ was significantly lower in responder_MinO2only. A higher pre‐treatment min O₂ showed a significant correlation with a smaller amount of change in mean O₂ (r = −.486) and min O₂ (r = −.764) with treatment. Pre‐treatment min O₂ showed the strongest ability to predict those who would show a ≥4% min O₂ increase following treatment.

Conclusion

Certain patients do not show sufficient decrease in hypoxaemia in spite of the improvement in AHI. Pre‐treatment min O₂ should be considered in OA treatment planning regarding its close relation to improvements in oxygenation levels with treatment.

Mouth Closing to Improve the Efficacy of Mandibular Advancement Devices in Sleep Apnea

RATIONALE

Mouth breathing increases upper airway collapsibility, leading to decreased efficacy of obstructive sleep apnea (OSA) treatments. We hypothesized that the use of mandibular advancement devices (MAD) increases mouth breathing and, thus, using an adhesive mouthpiece (AMT), to prevent mouth breathing, in combination with MAD can improve the treatment efficacy.

OBJECTIVES

To evaluate the efficacy of MAD + AMT in comparison to MAD alone.

METHODS

A prospective crossover pilot study was designed to test this hypothesis. Briefly, adult participants with an apnea-hypopnea index (AHI) between 10-50 events/h at the screening visit were randomized to no treatment (baseline), MAD treatment, AMT treatment, and MAD+AMT treatment. As a primary analysis, absolute AHI was compared between MAD and MAD + AMT arms. Secondary analyses included quantifying the percent change in AHI, percentage of complete (AHI < 5 events/h) and incomplete (AHI 5 - 10 events/h) responders, and the efficacy of AMT alone in comparison with other treatment arms.

RESULTS

A total 21 of participants were included. (Baseline AHI= 24.3±9.9 event/h) The median AHI (Interquartile [IQR]) in the MAD and MAD+AMT arms were 10.5 [5.4-19.6] events/h and 5.6 [2.2-11.7] events/h (p-value= 0.02), respectively. A total of 76% of individuals achieved an AHI < 10 events/h in the MAD + AMT arm vs. 43% in the MAD arm (p-value<0.01). Finally, the observed effect was similar in moderate to severe OSA (AHI ≥15 events/h) in terms of absolute reduction and treatment responders, and AMT alone did not significantly reduce the AHI compared to baseline.

CONCLUSION

Combination of an adhesive mouthpiece and MAD is a more effective therapy than MAD alone. These findings may help improve clinical decision-making in sleep apnea.