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Essick G. Combination Therapies with an Oral Appliance in the Management of Obstructive Sleep Apnea. Dent Clin North Am 2024; 68:517-531. [PMID: 38879284 DOI: 10.1016/j.cden.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Combination therapy (CT) with a mandibular advancement device (MAD) and positive airway pressure (PAP) has been advocated for patients for whom neither MAD nor PAP alone provides an efficacious and tolerated therapy. This article reviews the small and limited, but growing body of evidence in support of CT and highlights details in its implementation. In most studies, CT was found to be preferred by many, but not all PAP-intolerant patients. CT can be more efficacious than either MAD or PAP alone.
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Affiliation(s)
- Greg Essick
- Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7450, USA.
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2
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Parthasarathy S, Ayas NT, Bogan R, Hwang D, Kushida C, Lown JS, Ojile JM, Patel I, Prasad B, Rapoport DM, Strollo P, Vanderveken OM, Viviano J. Oral appliance therapy and hypoglossal nerve stimulation as non-positive airway pressure treatment alternatives for obstructive sleep apnea: a narrative expert review. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2024; 5:zpae035. [PMID: 38966620 PMCID: PMC11223066 DOI: 10.1093/sleepadvances/zpae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/13/2024] [Indexed: 07/06/2024]
Abstract
This perspective on alternatives to positive airway pressure (PAP) therapy for the treatment of obstructive sleep apnea (OSA) summarizes the proceedings of a focus group that was conducted by the Sleep Research Society Foundation. This perspective is from a multidisciplinary panel of experts from sleep medicine, dental sleep medicine, and otolaryngology that aims to identify the current role of oral appliance therapy and hypoglossal nerve stimulation for the treatment of OSA with emphasis on the US practice arena. A secondary aim is to identify-from an implementation science standpoint-the various barriers and facilitators for adoption of non-PAP treatment that includes access to care, multidisciplinary expertise, reimbursement, regulatory aspects, current treatment guidelines, health policies, and other factors related to the delivery of care. The panel has contextualized the review with recent events-such as a large-scale PAP device recall compounded by supply chain woes of the pandemic-and emerging science in the field of OSA and offers solutions for multidisciplinary approaches while identifying knowledge gaps and future research opportunities.
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Affiliation(s)
- Sairam Parthasarathy
- Department of Medicine, University of Arizona Health Sciences Center for Sleep and Circadian Sciences, University of Arizona, Tucson, AZ, USA
| | - Najib T Ayas
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Richard Bogan
- Department of Psychaiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Dennis Hwang
- Division of Sleep Medicine, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Clete Kushida
- Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | | | | | - Imran Patel
- Department of Medicine, University of Arizona Health Sciences Center for Sleep and Circadian Sciences, University of Arizona, Tucson, AZ, USA
- Dental Sleep Service Line, Banner University Medical Center - Tucson, Tucson, AZ, USA
| | - Bharati Prasad
- Department of Medicine, University of Illinois at Chicago and Jesse Brown VA Medical Center, Chicago, IL, USA
| | - David M Rapoport
- Mount Sinai Health System Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick Strollo
- Division of Pulmonary, Allergy, and Critical Care Medicine University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Oliver M Vanderveken
- Department of ENT-HNS, Antwerp University Hospital, Edegem, Belgium and Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - John Viviano
- Sleep Disorders Dentistry Research and Learning Center, Mississauga, ON, Canada
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3
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Fernández-Sanjuán P, Alcaraz M, Bosco G, Pérez-Martín N, Morato M, Lugo R, Arrieta JJ, Sanabria J, Ríos-Lago M, Plaza G. Modifications in Upper Airway Collapsibility during Sleep Endoscopy with a Mandibular Positioner: Study in Snorers and Obstructive Sleep Apnea Patients. J Clin Med 2024; 13:1184. [PMID: 38592035 PMCID: PMC10932289 DOI: 10.3390/jcm13051184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Patricia Fernández-Sanjuán
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Universidad Rey Juan Carlos, 28002 Madrid, Spain
| | - Marta Alcaraz
- Department of Otolaryngology, Hospital Universitario La Moraleja, 28050 Madrid, Spain;
| | - Gabriela Bosco
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, 28942 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario La Zarzuela, 28023 Madrid, Spain
| | - Nuria Pérez-Martín
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, 28942 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario La Zarzuela, 28023 Madrid, Spain
| | - Marta Morato
- Department of Otolaryngology, Hospital Quirónsalud San José, 28002 Madrid, Spain;
| | - Rodolfo Lugo
- Department of Otolaryngology Head and Neck Surgery, Hospital San José, Monterrey 64718, Mexico;
| | - Juan José Arrieta
- Department of Stomatology, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Jaime Sanabria
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Marcos Ríos-Lago
- Department of Basic Psychology II, Faculty of Psychology, UNED—Universidad Nacional de Educación a Distancia, 28040 Madrid, Spain;
| | - Guillermo Plaza
- Sleep Respiratory Disorders Unit, Hospital Universitario La Zarzuela, 28023 Madrid, Spain; (P.F.-S.); (G.B.); (N.P.-M.)
- Universidad Rey Juan Carlos, 28002 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, 28942 Madrid, Spain
- Department of Otolaryngology, Hospital Universitario La Zarzuela, 28023 Madrid, Spain
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4
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Kattimani V, Panneerselvam E, Tiwari R, Panga GSK, Sreeram RR. An Overview of Systematic Reviews on the Surgical Management of Obstructive Sleep Apnoea. J Maxillofac Oral Surg 2023; 22:781-793. [PMID: 38105854 PMCID: PMC10719205 DOI: 10.1007/s12663-023-02051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/21/2023] [Indexed: 12/19/2023] Open
Abstract
Background Obstructive Sleep Apnoea (OSA) is a common sleep disorder marked by partial or total obstruction of the upper airway while a person is asleep leading to breathing difficulty, reduced oxygenation and frequent awakenings. This condition affects the general health significantly compromising quality of life. The objective of this overview is to thoroughly assess the systematic reviews on current surgical therapies for the management of OSA in terms of patient outcomes. Methods A thorough literature search was performed from inception till 31st December 2022 using PubMed, and Cochrane databases. Studies evaluating the effectiveness and safety of different surgical techniques for the management of OSA were considered. The quality of articles was assessed using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and Glenny et al. checklist. Results Out of eighteen studies, only seven studies met the inclusion and exclusion criteria. Results showed that the majority of studies were in the pediatric age group except one systematic review which assessed the adult age group. Conclusion None of the published articles had compared all surgical procedures based on the standard evaluating procedure nor followed all reporting guidelines in the primary studies. For better implementation, further multi center studies are warranted with unique reporting criteria and guidelines about pre- as well as post-operative phases. Future research should concentrate on contrasting strategies, combination therapies, and evaluating long-term effects. Supplementary Information The online version contains supplementary material available at 10.1007/s12663-023-02051-x.
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Affiliation(s)
- Vivekanand Kattimani
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
| | | | - Rahul Tiwari
- Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat India
| | | | - Roopa Rani Sreeram
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
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5
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Johal A, Hamoda MM, Almeida FR, Marklund M, Tallamraju H. The role of oral appliance therapy in obstructive sleep apnoea. Eur Respir Rev 2023; 32:220257. [PMID: 37343962 DOI: 10.1183/16000617.0257-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2023] [Indexed: 06/23/2023] Open
Abstract
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.
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Affiliation(s)
- Ama Johal
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
| | - Mona M Hamoda
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Fernanda R Almeida
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Marie Marklund
- Department of Otontology, Medical Faculty, Umea University, Umea, Sweden
| | - Harishri Tallamraju
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
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6
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Vimal J, Dutt P, Singh N, Singh BP, Chand P, Jurel S. To compare different non-surgical treatment modalities on treatment of obstructive sleep apnea: A systematic review and meta-analysis. J Indian Prosthodont Soc 2022; 22:314-327. [PMID: 36511065 PMCID: PMC9709867 DOI: 10.4103/jips.jips_261_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/07/2022] Open
Abstract
The study aimed to assess the effect of mandibular advancement device (MAD) in patients with obstructive sleep apnea for reduction in 24-h mean blood pressure, sleep quality, Apnea Hypopnea Index (AHI), and patient compliance, compared to continuous positive airway pressure (CPAP), other interventions, or no treatment. Three different databases such as PubMed, EMBASE, and CENTRAL were searched using different search terms till July 2021 as per the inclusion and exclusion criteria. After inclusion of studies, data extraction including risk of bias assessment was done. For each study, we used odds ratio, mean difference, and 95% confidence interval to assess and synthesize the outcomes. The quality of evidence was evaluated as per the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Twenty-one randomized controlled trials were included: 497 patients in the MAD group, 239 patients in the CPAP group, and 274 patients in the sham group. In MAD-CPAP comparison, the results favored CPAP in the reduction of AHI of 3.48 (1.76-5.19). However, unclear results were found for sleep quality measured as Epworth Sleepiness Scale (ESS), patient compliance, and 24-h mean blood pressure. In MAD-sham comparison, the results favored MAD in the reduction of AHI of - 8.39 (-10.90--5.88] and ESS of - 0.91 (-1.70--0.12) and favored sham in terms of patient compliance while, unclear results for 24-h mean blood pressure. The GRADE score indicated that the quality of evidence is very low, low, and moderate for different outcomes. CPAP in comparison to MAD and MAD in comparison to sham showed a significant AHI reduction. However, patient compliance and 24-h mean blood pressure were not significantly different in MAD-CPAP or MAD-sham. Quality of evidence is very low and low when MAD was compared with CPAP and sham, respectively, for AHI.
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Affiliation(s)
- Jyotsna Vimal
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Pranjali Dutt
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Nishi Singh
- Department of Conservative Dentistry and Endodontics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Balendra P. Singh
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Pooran Chand
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sunit Jurel
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
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7
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Alansari RA. The role of orthodontics in management of obstructive sleep apnea. Saudi Dent J 2022; 34:194-201. [PMID: 35935723 PMCID: PMC9346943 DOI: 10.1016/j.sdentj.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/30/2022] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
Abstract
Dental sleep medicine is the field of dental practice that deals with the management of sleep-related breathing disorders, which includes obstructive sleep apnea (OSA) in adults and children. Depending on the developmental age of the patient and the cause of the apnea dental treatment options may vary. For adult patients, treatment modalities may include oral appliance therapy (OAT), orthognathic surgery and surgical or miniscrew supported palatal expansion. While for children, treatment may include non-surgical maxillary expansion and orthodontic functional appliances. Many physicians and dentists are unaware of the role dentistry, particularly orthodontics, may play in the interdisciplinary management of these disorders. This review article is an attempt to compile evidence-based relevant information on the role of orthodontists/sleep dentists in the screening, diagnosis, and management of sleep apnea. Oral sleep appliance mechanisms of action, selective efficacy, and the medical physiological outcomes are discussed. The purpose of this review is to provide a comprehensive understanding of how orthodontists and sleep physicians can work in tandem to maximize the benefits and minimize the side effects while treating patients with OSA.
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8
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Randerath W, Verbraecken J, de Raaff CAL, Hedner J, Herkenrath S, Hohenhorst W, Jakob T, Marrone O, Marklund M, McNicholas WT, Morgan RL, Pepin JL, Schiza S, Skoetz N, Smyth D, Steier J, Tonia T, Trzepizur W, van Mechelen PH, Wijkstra P. European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea. Eur Respir Rev 2021; 30:30/162/210200. [PMID: 34853097 PMCID: PMC9489103 DOI: 10.1183/16000617.0200-2021] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 12/12/2022] Open
Abstract
Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes. OSA-patients who refuse/don't adhere to CPAP can profit from established/emerging treatment options. High scientific evidence is lacking. Patients’ values/preference may weigh heavy in the decision for non-CPAP options, while health inequity is a concern.https://bit.ly/3o0tJeP
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Affiliation(s)
- Winfried Randerath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany .,Co-shared first authorship
| | - Johan Verbraecken
- Antwerp University Hospital and University of Antwerp, Edegem (Antwerp), Belgium.,Co-shared first authorship
| | | | - Jan Hedner
- Dept of Sleep Medicine, Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Simon Herkenrath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany
| | | | - Tina Jakob
- Evidence-based Oncology, Dept I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Oreste Marrone
- National Research Council of Italy, Institute for Biomedical Research and Innovation, Palermo, Italy
| | - Marie Marklund
- Dept of Odontology, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Walter T McNicholas
- School of Medicine, University College Dublin, Dublin, Ireland.,Dept of Respiratory and Sleep Medicine, St Vincent's Hospital Group, Dublin, Ireland
| | - Rebecca L Morgan
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Sofia Schiza
- Sleep Disorders Unit, Dept of Respiratory Medicine, Medical School, University of Crete, Greece
| | - Nicole Skoetz
- Evidence-based Oncology, Dept I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dan Smyth
- European Lung Foundation, Sheffield, UK.,Sleep Disorder Support Foundation, Dublin, Ireland
| | - Jörg Steier
- Lane Fox Unit and Sleep Disorders Centre at Guy's & St Thomas' NHS Foundation Trust, Centre for Human & Applied Physiological Sciences, King's College London, London, UK
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Wojciech Trzepizur
- Dept of Respiratory and Sleep Medicine, Angers University hospital, Angers, France
| | | | - Peter Wijkstra
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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9
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Abstract
Undiagnosed and untreated obstructive sleep apnea (OSA) is associated with health comorbidities and negatively affects quality of life. Alternative treatments should be considered in patients who are unable to tolerate or benefit from positive airway pressure treatment. When properly indicated, positional devices, oral appliances, airway surgery, and hypoglossal nerve stimulation have been shown to be effective in treating OSA. Hypoglossal nerve stimulation is a successful second-line treatment with low associated morbidity and complication rate.
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10
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Premaraj TS, Stadiem J, Premaraj SA, Davies CR, Dennis M, Harrington JJ. Continuous Positive Airway Pressure-Mandibular Advancement Device Combination Therapy for Moderate-to-Severe Obstructive Sleep Apnea: A Preliminary Study. Eur J Dent 2021; 16:749-755. [PMID: 33412609 PMCID: PMC9683874 DOI: 10.1055/s-0040-1719220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives
The purpose of this pilot study was to determine whether compliance to auto-adjusting positive airway pressure (APAP) improves with the addition of a mandibular advancement device (MAD). Secondary outcome measures included were APAP pressure, subjective daytime sleepiness, apnea–hypopnea index (AHI), and mask leaks.
Setting and Sample Population
Participants included were diagnosed with moderate-to-severe obstructive sleep apnea (OSA) and became noncompliant to prescribed APAP. Thirteen participants with a mean age of 61.6 years were recruited for this study.
Materials and Methods
All participants were given a MAD to use with their APAP. Parameters measured included APAP pressure, AHI, mask leak reported via ResMed AirViewTM software, and self-reported daytime sleepiness (Epworth Sleepiness Scale [ESS]). A paired two-sample for mean
t
-test was performed to determine significance.
Results
The mean difference of pre- and postintervention APAP compliance was 23.1%, which was statistically significant (
p
= 0.015). The mean APAP air pressures were unchanged. The difference between pre- and postintervention mean ESS scores was 1.4 and was statistically significant (
p
= 0.027). The mean difference between pre- and postintervention AHI values and mask leak showed no significant difference.
Conclusion
This study showed that combination of APAP-MAD therapy, for patients with moderate-to-severe OSA who were noncompliant to APAP use, significantly increased compliance with APAP therapy, and significantly decreased the daytime sleepiness of participants.
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Affiliation(s)
- Thyagaseely Sheela Premaraj
- Department of Orthodontics, College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska, United States
| | - Jacob Stadiem
- Department of Orthodontics, University of Nebraska Medical Center, Lincoln, Nebraska, United States
| | - Shyamaly Arya Premaraj
- College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska, United States
| | - Charles R Davies
- Carle Neuroscience Institute, Carle Physician Group, University of Illinois at Urbana, Illinois, United States
| | - Matthew Dennis
- Division of Pediatric Pulmonology & Sleep Medicine, University of Nebraska Medical Center, Children's Hospital & Medical Center, Omaha, Nebraska, United States
| | - John J Harrington
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States
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11
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Francis CE, Quinnell T. Mandibular Advancement Devices for OSA: An Alternative to CPAP? Pulm Ther 2020; 7:25-36. [PMID: 33170490 PMCID: PMC8137783 DOI: 10.1007/s41030-020-00137-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/19/2020] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a prevalent condition causing unrefreshing sleep and excessive daytime sleepiness. It has individual socioeconomic impacts and, through association with increased risk of road traffic accidents, diabetes, and cardiovascular disease, OSA is a public health issue. Continuous positive airway pressure (CPAP) is the first-line treatment for moderate-to-severe OSA. It is effective in improving excessive daytime sleepiness and quality of life. There is also evidence that CPAP therapy has cardiovascular benefits although nature and extent remain uncertain. Despite its benefits, a significant proportion of patients are unable to tolerate CPAP. There are also patients with mild but symptomatic disease, for whom CPAP is usually not available or appropriate, so there is a need for other treatment options. Mandibular advancement devices (MADs) offer an effective alternative to CPAP and can improve daytime symptoms and quality of life. There are many devices available, representing a range of complexity and cost. It is challenging to properly evaluate the effectiveness of this ever-evolving range. The more basic MADs are cheaper and more accessible but are less well tolerated. More complex devices are better tolerated and may be more effective. However, they are more expensive and often require dental expertise, so access is more limited. Efforts continue to try to improve accessibility to effective MAD therapy. Alongside increasing awareness, this may be facilitated by developing and refining devices that could be fitted by non-dental clinicians, and potentially by patients themselves. Research efforts need to focus on determining how to efficiently identify patients who are likely to respond to MAD therapy, so as to improve clinical and cost-effectiveness of OSA therapy overall.
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Affiliation(s)
| | - Tim Quinnell
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
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12
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Tong BK, Tran C, Ricciardiello A, Donegan M, Chiang AKI, Szollosi I, Amatoury J, Carberry JC, Eckert DJ. CPAP combined with oral appliance therapy reduces CPAP requirements and pharyngeal pressure swings in obstructive sleep apnea. J Appl Physiol (1985) 2020; 129:1085-1091. [PMID: 32909921 DOI: 10.1152/japplphysiol.00393.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Oral appliance (OA) therapy is the leading alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA). It is well tolerated compared with CPAP. However, ≥50% of patients using OA therapy have incomplete resolution of their OSA. Combination therapy with CPAP and oral appliance (CPAP + OA) is a potential alternative for incomplete responders to OA therapy. This study aimed to determine the extent to which combination therapy reduces therapeutic CPAP requirements using gold-standard physiological methodology in those who have an incomplete response to OA therapy alone. Sixteen incomplete responders [residual apnea/hypopnea index (AHI) > 10 events/h] to a novel OA with a built-in oral airway were recruited (3 women:13 men, aged 31-65 yr, body mass index: 22-38 kg/m2, residual AHI range: 13-63 events/h). Participants were fitted with a nasal mask, pneumotachograph, epiglottic pressure catheter, and standard polysomnography equipment. CPAP titrations were performed during non-rapid eye movement (NREM) supine sleep in each participant during three conditions (order randomized): CPAP only, CPAP + OA (oral airway open), and CPAP + OA (oral airway closed). OSA was resolved at pressures of 4 ± 2 and 5 ± 2 cmH2O during CPAP + OA (oral airway open) and CPAP + OA (oral airway closed) conditions versus 8 ± 2 cmH2O during CPAP only (P < 0.01). Negative epiglottic pressure swings in oral airway open and closed conditions were normalized to CPAP only levels [-2.5(-3.7, -2.6) vs. -2.3(-3.2, -2.4) vs. -2.1(-2.7, -2.3) cmH2O]. Combined CPAP and OA therapy reduces therapeutic CPAP requirements by 35%-45% and minimizes epiglottic pressure swings. This combination may be a therapeutic alternative for patients with incomplete responses to OA therapy alone and those who cannot tolerate high CPAP levels.NEW & NOTEWORTHY Combined CPAP and oral appliance therapy has been suggested as an alternative for incomplete responders to oral appliance therapy. We used a novel oral appliance incorporating an oral airway together with CPAP to show that pharyngeal pressure swings were normalized at reduced CPAP levels. Our findings demonstrate that using CPAP and oral appliance together may be a beneficial alternative for incomplete responders to oral appliance therapy and intolerant CPAP users due to high-pressure requirements.
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Affiliation(s)
- Benjamin K Tong
- Neuroscience Research Australia (NeuRA), Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Carolin Tran
- Adelaide Institute for Sleep Health (AISH) and Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, Australia
| | | | | | | | | | - Jason Amatoury
- Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture, American University of Beirut, Beirut, Lebanon
| | - Jayne C Carberry
- Neuroscience Research Australia (NeuRA), Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia.,Adelaide Institute for Sleep Health (AISH) and Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia.,Adelaide Institute for Sleep Health (AISH) and Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, Australia
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Abstract
Obstructive sleep apnea (OSA) is a multifactorial condition, and an interdisciplinary approach to diagnosis forms the basis for effective treatment planning. Craniofacial structure and attached soft tissues and muscles play a central role in OSA. Evidence-based studies demonstrate the effectiveness of oral appliances for mandibular advancement and tongue stabilization in managing OSA, and current clinical standards of practice recommend the use of oral appliances to treat OSA when patients cannot tolerate continuous positive airway pressure (CPAP). Although effective, oral appliances are less predictable in managing OSA compared with CPAP therapy. Measures can be taken to improve predictability of oral appliance treatment.
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Affiliation(s)
- Jing Hao Ng
- Department of Orthodontics, National Dental Centre Singapore, 5 Second Hospital Avenue, Singapore 168938, Singapore.
| | - Mimi Yow
- Department of Orthodontics, National Dental Centre Singapore, 5 Second Hospital Avenue, Singapore 168938, Singapore
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14
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Sutherland K, Cistulli PA. Oral Appliance Therapy for Obstructive Sleep Apnoea: State of the Art. J Clin Med 2019; 8:jcm8122121. [PMID: 31810332 PMCID: PMC6947472 DOI: 10.3390/jcm8122121] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/17/2022] Open
Abstract
Obstructive sleep apnoea (OSA) represents a significant global health burden, with impact on cardiometabolic health, chronic disease, productivity loss and accident risk. Oral appliances (OA) are an effective therapy for OSA and work by enlarging and stabilising the pharyngeal airway to prevent breathing obstructions during sleep. Although recommended in clinical guidelines for OSA therapy, they are often considered only as second-line therapy following positive airway pressure (PAP) therapy failure. There has been a long-standing barrier to selecting OA over PAP therapy due to the inability to be certain about the level of efficacy in individual OSA patients. A range of methods to select OSA patients for OA therapy, based on the outcome of a single sleep study night, have been proposed, although none has been widely validated for clinical use. Emergent health outcome data suggest that equivalent apnoea–hypopnea index reduction may not be necessary to produce the same health benefits of PAP. This may be related to the more favourable adherence to OA therapy, which can now be objectively verified. Data on longer term health outcomes are needed, and there are additional opportunities for device improvement and combination therapy approaches. OAs have an important role in precision care of OSA as a chronic disorder through a multi-disciplinary care team. Future studies on real-world health outcomes following OA therapy are needed.
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Affiliation(s)
- Kate Sutherland
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia;
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Correspondence:
| | - Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia;
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW 2065, Australia
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15
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Foellner S, Guth P, Jorde I, Lücke E, Ganzert C, Stegemann-Koniszewski S, Schreiber J. Prevention of leakage due to mouth opening through applying an oral shield device (Sominpax™) during nasal CPAP therapy of patients with obstructive sleep apnea. Sleep Med 2019; 66:168-173. [PMID: 31884409 DOI: 10.1016/j.sleep.2019.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND/OBJECTIVE The first line treatment for obstructive sleep apnea (OSA) is nasal continuous positive airway pressure (nCPAP), for which a variety of masks are available. While nasal masks (NM) are the first choice; oronasal masks (ONM) are also frequently used to prevent mouth dryness resulting from mouth opening. Our cross-sectional, prospective, randomized, un-blinded study addressed the efficacy of wearing an oral shield in addition to NM in preventing mouth leakage METHODS: Patients with OSA and established therapy using NM and complaining about mouth dryness (n = 29) underwent three polysomnographies (PSGs) using NM, ONM or a nose mask in combination with an oral shield (NMS). Mask leakage was continuously documented and objective sleep quality was assessed. RESULTS There were significant differences in the apnea-hypopnea-index (AHI) between ONM (8.5/h; SD 6,7) and NM/nasal mask combined with oral shield device (NMS) (2.6/h; SD 2,3; 2.7/h; SD 2,6) (p < 0,05) as well as in leakage [ONM (39.7 l/min SD 12,4); NM (34.6 l/min SD 9,4); NMS (33.1 l/min SD 9,6)] (p = 0.011). Furthermore, analysis of sleep quality (NREM3) favored NM and NMS over ONM (p = 0.02). There were no significant differences between NM and NMS in any objective outcome. CONCLUSIONS Our data consistently confirmed the NM as the first choice for continuous positive airway pressure (CPAP) therapy of OSA. Notably, we demonstrated a high potential of the oral shield for patients with mouth opening to achieve additional comfort and thereby possibly compliance, without affecting nCPAP therapy effectiveness.
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Affiliation(s)
- Sebastian Foellner
- Otto - von - Guericke University Magdeburg, Dept. of Pneumonology, Centre for Sleep Medicine, Magdeburg, Germany.
| | - Patricia Guth
- Otto - von - Guericke University Magdeburg, Dept. of Pneumonology, Centre for Sleep Medicine, Magdeburg, Germany
| | - Ilka Jorde
- Otto - von - Guericke University Magdeburg, Dept. of Pneumonology, Centre for Sleep Medicine, Magdeburg, Germany
| | - Eva Lücke
- Otto - von - Guericke University Magdeburg, Dept. of Pneumonology, Centre for Sleep Medicine, Magdeburg, Germany
| | - Christine Ganzert
- Otto - von - Guericke University Magdeburg, Dept. of Pneumonology, Centre for Sleep Medicine, Magdeburg, Germany
| | - Sabine Stegemann-Koniszewski
- Otto - von - Guericke University Magdeburg, Dept. of Pneumonology, Centre for Sleep Medicine, Magdeburg, Germany
| | - Jens Schreiber
- Otto - von - Guericke University Magdeburg, Dept. of Pneumonology, Centre for Sleep Medicine, Magdeburg, Germany
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16
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Cistulli PA, Sutherland K. Phenotyping obstructive sleep apnoea—Bringing precision to oral appliance therapy. J Oral Rehabil 2019; 46:1185-1191. [DOI: 10.1111/joor.12857] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine Royal North Shore Hospital Sydney New South Wales Australia
| | - Kate Sutherland
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine Royal North Shore Hospital Sydney New South Wales Australia
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17
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Lai V, Tong BK, Tran C, Ricciardiello A, Donegan M, Murray NP, Carberry JC, Eckert DJ. Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces obstructive sleep apnea severity. Sleep 2019; 42:5513371. [DOI: 10.1093/sleep/zsz119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/07/2019] [Indexed: 12/21/2022] Open
Abstract
AbstractStudy ObjectivesMandibular advancement splint (MAS) therapy is a well-tolerated alternative to continuous positive airway pressure for obstructive sleep apnea (OSA). Other therapies, including nasal expiratory positive airway pressure (EPAP) valves, can also reduce OSA severity. However, >50% of patients have an incomplete or no therapeutic response with either therapy alone and thus remain at risk of adverse health outcomes. Combining these therapies may yield greater efficacy to provide a therapeutic solution for many incomplete/nonresponders to MAS therapy. Thus, this study evaluated the efficacy of combination therapy with MAS plus EPAP in incomplete/nonresponders to MAS alone.MethodsTwenty-two people with OSA (apnea–hypopnea index [AHI] = 22 [13, 42] events/hr), who were incomplete/nonresponders (residual AHI > 5 events/hr) on an initial split-night polysomnography with a novel MAS device containing an oral airway, completed an additional split-night polysomnography with MAS + oral EPAP valve and MAS + oral and nasal EPAP valves (order randomized).ResultsCompared with MAS alone, MAS + oral EPAP significantly reduced the median total AHI, with further reductions with the MAS + oral/nasal EPAP combination (15 [10, 34] vs. 10 [7, 21] vs. 7 [3, 13] events/hr, p < 0.01). Larger reductions occurred in supine nonrapid eye movement AHI with MAS + oral/nasal EPAP combination therapy (ΔAHI = 23 events/hr, p < 0.01). OSA resolved (AHI < 5 events/hr) with MAS + oral/nasal EPAP in nine individuals and 13 had ≥50% reduction in AHI from no MAS. However, sleep efficiency was lower with MAS + oral/nasal EPAP versus MAS alone or MAS + oral EPAP (78 ± 19 vs. 87 ± 10 and 88 ± 10% respectively, p < 0.05).ConclusionsCombination therapy with a novel MAS device and simple oral or oro-nasal EPAP valves reduces OSA severity to therapeutic levels for a substantial proportion of incomplete/nonresponders to MAS therapy alone.Clinical TrialsName: Targeted combination therapy: Physiological mechanistic studies to inform treatment for obstructive sleep apnea (OSA)URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372279 Registration: ACTRN12617000492358 (Part C)
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Affiliation(s)
- Victor Lai
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin K Tong
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Carolin Tran
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
| | | | | | | | - Jayne C Carberry
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
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18
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Abstract
Obstructive sleep apnea (OSA) is a multifactorial condition, and an interdisciplinary approach to diagnosis forms the basis for effective treatment planning. Craniofacial structure and attached soft tissues and muscles play a central role in OSA. Evidence-based studies demonstrate the effectiveness of oral appliances for mandibular advancement and tongue stabilization in managing OSA, and current clinical standards of practice recommend the use of oral appliances to treat OSA when patients cannot tolerate continuous positive airway pressure (CPAP). Although effective, oral appliances are less predictable in managing OSA compared with CPAP therapy. Measures can be taken to improve predictability of oral appliance treatment.
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19
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Léotard A, Lesgoirres M, Daabek N, Lebret M, Bailly S, Verain A, Series F, Pépin JL, Borel JC. Adherence to CPAP with a nasal mask combined with mandibular advancement device versus an oronasal mask: a randomized crossover trial. Sleep Breath 2019; 23:885-888. [PMID: 30689098 DOI: 10.1007/s11325-018-01772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/05/2018] [Accepted: 12/14/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Evidence for the management of CPAP-treated obstructive sleep apnea suggests that oronasal masks reduce mouth leaks at the expense of higher pressures and poorer adherence. Some authors have proposed the use of mandibular advancement devices in combination with nasal masks to address this. The aim of this study was to assess adherence to CPAP after 1 month's use of a nasal mask with a mandibular advancement device and to compare adherence with an oronasal mask. METHODS A randomized crossover trial design to assess whether a mandibular advancement device combined with a nasal mask would improve CPAP adherence compared to an oronasal mask. RESULTS There was no improvement in CPAP adherence and self-reported interface-related pain was significantly higher with the combined treatment. CONCLUSIONS Although the combined treatment reduced pressures, likely by improving upper airway patency, it may only be appropriate for a small number of patients due to associated discomfort. TRIAL REGISTRATION NCT01889472.
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Affiliation(s)
- Antoine Léotard
- HP2, INSERM U1042, University Grenoble Alpes, F-38000, Grenoble, France
- Sleep and Exercise Laboratory, Thorax-Vaisseaux Department, Grenoble-Alpes University Hospital, Saint-Martin-d'Hères, France
| | | | - Najeh Daabek
- HP2, INSERM U1042, University Grenoble Alpes, F-38000, Grenoble, France
- AGIR à dom. Association, 36 bd du Vieux Chêne, F-38240, Meylan, France
| | - Marius Lebret
- HP2, INSERM U1042, University Grenoble Alpes, F-38000, Grenoble, France.
- AGIR à dom. Association, 36 bd du Vieux Chêne, F-38240, Meylan, France.
| | - Sebastien Bailly
- HP2, INSERM U1042, University Grenoble Alpes, F-38000, Grenoble, France
- Sleep and Exercise Laboratory, Thorax-Vaisseaux Department, Grenoble-Alpes University Hospital, Saint-Martin-d'Hères, France
| | - Alain Verain
- Sleep and Exercise Laboratory, Thorax-Vaisseaux Department, Grenoble-Alpes University Hospital, Saint-Martin-d'Hères, France
| | - Fréderic Series
- Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ) Université Laval, Québec, QC, G1V4G5, Canada
| | - Jean-Louis Pépin
- HP2, INSERM U1042, University Grenoble Alpes, F-38000, Grenoble, France
- Sleep and Exercise Laboratory, Thorax-Vaisseaux Department, Grenoble-Alpes University Hospital, Saint-Martin-d'Hères, France
| | - Jean-Christian Borel
- HP2, INSERM U1042, University Grenoble Alpes, F-38000, Grenoble, France
- AGIR à dom. Association, 36 bd du Vieux Chêne, F-38240, Meylan, France
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20
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Luzzi V, Brunori M, Terranova S, Di Paolo C, Ierardo G, Vozza I, Polimeni A. Difficult-to-treat OSAS: Combined continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) therapy. A case report. Cranio 2018; 38:196-200. [PMID: 30048222 DOI: 10.1080/08869634.2018.1496628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Obstructive sleep apnea syndrome and is characterized by recurrent episodes of partial or complete upper airway collapse during sleep with consequent oxygen desaturations and cardiovascular, neurological, and metabolic impairment. Clinical presentation: The authors report the case of a 66-year-old male presenting "metabolic syndrome" (obesity, impaired glucose tolerance, dyslipidemia, multi-drug treated arterial hypertension), atopy, mouth breathing due to turbinate hypertrophy, and pathological daytime sleepiness. As patient's compliance to standard continuous positive airway pressure (CPAP) therapy was poor, he was treated using low-pressure CPAP combined with a mandibular advancement device (MAD). Conclusion: In selected patients, a treatment combining CPAP and MAD might be a more tolerable alternative to CPAP alone. The improved pharyngeal patency, promoted by mandibular advancement and stretching of the pharyngeal muscles, allows operating the CPAP at lower pressures when the MAD alone is not sufficient to induce a safe sleep profile.
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Affiliation(s)
- Valeria Luzzi
- Department of Oral and Maxillo-facial Sciences, Head and Neck Integrated Activities Department, Policlinico "Umberto I", Sapienza University of Rome, Rome, Italy
| | - Marco Brunori
- Respiratory Pathophysiology and Rehabilitation Unit, Policlinico Umberto I, Rome, Italy
| | | | - Carlo Di Paolo
- Department of Oral and Maxillo-facial Sciences, Head and Neck Integrated Activities Department, Policlinico "Umberto I", Sapienza University of Rome, Rome, Italy
| | - Gaetano Ierardo
- Department of Oral and Maxillo-facial Sciences, Head and Neck Integrated Activities Department, Policlinico "Umberto I", Sapienza University of Rome, Rome, Italy
| | - Iole Vozza
- Department of Oral and Maxillo-facial Sciences, Head and Neck Integrated Activities Department, Policlinico "Umberto I", Sapienza University of Rome, Rome, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillo-facial Sciences, Head and Neck Integrated Activities Department, Policlinico "Umberto I", Sapienza University of Rome, Rome, Italy
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21
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Laryngeale Obstruktion bei therapieresistenter obstruktiver Schlafapnoe. SOMNOLOGIE 2018. [DOI: 10.1007/s11818-017-0131-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Tsuda H, Wada N, Ando SI. Practical considerations for effective oral appliance use in the treatment of obstructive sleep apnea: a clinical review. SLEEP SCIENCE AND PRACTICE 2017. [DOI: 10.1186/s41606-017-0013-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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23
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Liu HW, Chen YJ, Lai YC, Huang CY, Huang YL, Lin MT, Han SY, Chen CL, Yu CJ, Lee PL. Combining MAD and CPAP as an effective strategy for treating patients with severe sleep apnea intolerant to high-pressure PAP and unresponsive to MAD. PLoS One 2017; 12:e0187032. [PMID: 29073254 PMCID: PMC5658160 DOI: 10.1371/journal.pone.0187032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 10/12/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction This study aimed to determine the effect of combining positive airway pressure (PAP) therapy and mandibular advancement device (MAD) in patients with severe obstructive sleep apnea (OSA) who were pressure intolerant for PAP and were unresponsive to MAD. Methods This retrospective study reviewed the medical records of severe OSA patients with apnea-hypopnea index (AHI) ≥ 30/hr who were diagnosed between October 1, 2008 and June 30, 2014. Patients were initially treated with 2 weeks of PAP, and those who were intolerant to high-pressure PAP (≥15 cm H2O) were switched to 12 weeks of MAD, which is a monobloc designed at 75% of maximum protrusion. Patients who had high residual AHI (≥15/hr) on MAD underwent 12 weeks of combination therapy (CT) with MAD and CPAP and were enrolled in the present study. Enrolled subjects who completed the 12-week CT were followed-up until June 30, 2016. Results A total of 14 male patients were included. All three treatments effectively reduced AHI, oxygen desaturation index (ODI), and total sleep time with SpO2 <90% (% TST-SpO2<90%) compared to pretreatment values. The residual AHI and ODI on CT was lower than that on MAD or PAP. The residual % TST-SpO2<90% was lower than that on MAD and similar to that on PAP. The therapeutic pressure on CT was on average 9.2 cm H2O lower than that on PAP. For the 11 patients who completed CT, only CT reduced ESS compared to pretreatment value. No treatment had significant impact on % slow wave sleep or overnight change of blood pressure. For patients who completed CT, the average usage was 5.9±1.7 hr/night at 12th week and 6.4±1.5 hr/night at a median follow-up of 36.5-months. Conclusions Combining MAD and CPAP showed additive effects on reducing AHI and ODI, and lowered the therapeutic pressures.
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Affiliation(s)
- Hsiang-Wen Liu
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, Taipei, Taiwan
| | - Yunn-Jy Chen
- Department of Dentistry, School of Dentistry, Graduate Institute of Clinical Dentistry, Taipei, Taiwan
| | - Yi-Chun Lai
- Department of Internal Medicine, National Yang-Ming University Hospital, I-Lan, Taiwan
| | - Ching-Yi Huang
- Department of Dentistry, School of Dentistry, Graduate Institute of Clinical Dentistry, Taipei, Taiwan
| | - Ya-Ling Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tzer Lin
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, Taipei, Taiwan
- Department of Internal Medicine, Hsiao Chung-Cheng Hospital, New Taipei, Taiwan
| | - Sung-Ying Han
- Department of Dentistry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chi-Ling Chen
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Lin Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Center of Sleep Disorder, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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24
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Abstract
Purpose of Review The majority of the adult population is affected by obstructive sleep apnea (OSA), according to recent epidemiological research. Oral appliance (OA) therapy is increasingly recommended, particularly for patients with milder OSA. This review updates the evidence in favor of OA therapy. Recent Findings A high level of evidence shows that OA is effective in the treatment of OSA, but continuous positive airway pressure (CPAP) is more efficient. Higher adherence with OAs may compensate for this difference. Daytime sleepiness is better treated with CPAP than with OA in patients with severe OSA. In patients with milder OSA, it is unclear whether sleepiness is significantly reduced. The long-term effectiveness of OAs is uncertain because of side-effects and the risk of OSA deterioration. Summary OAs are effective, but their efficacy is more variable than that of CPAP. More research is needed about the mechanism of action of OA, subjective effects and long-term health outcomes.
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Affiliation(s)
- M Marklund
- Department of Odontology, Medical Faculty, Umeå University, SE-906 87 Umeå, Sweden
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25
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Abstract
Oral appliances (OAs) are becoming increasingly recognized not only as an alternative to but also possibly as an adjunct treatment modality for OSA. Compared with CPAP, the gold standard therapy, OAs are less efficacious but are more accepted and tolerated by patients, which, in turn, may lead to a comparable level of therapeutic effectiveness. Different OA designs currently exist, and more are constantly emerging. Additionally, state-of-the-art technologies are being used in the fabrication of many; however, all the currently available OAs employ the same mechanism of action by targeting the anatomical component involved in the pathogenesis of the disease. Furthermore, the scope of use of OAs is expanding to include patients who are edentulous. For patients with OAs, the dentist is a member of an interdisciplinary team managing OSA, and constant communication and follow-up with the sleep physician and other team members is necessary for disease management.
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26
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Abstract
Sleep-related breathing disorders include obstructive sleep apnea (OSA), central sleep apnea, sleep-related hypoventilation, and sleep-related hypoxemia. Excessive daytime sleepiness (EDS) is frequently reported by patients with OSA but is not invariably present. The efficacy of positive airway pressure therapy in improving EDS is well established for OSA, but effectiveness is limited by suboptimal adherence. Non-OSA causes of sleepiness should be identified and treated before initiating pharmacotherapy for persistent sleepiness despite adequately treated OSA. Further research on the identification of factors that promote EDS in the setting of OSA is needed to aid in the development of better treatment options.
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Affiliation(s)
- Ken He
- Division of General Internal Medicine, University of Washington, Seattle, WA 98195, USA; Hospital and Sleep Medicine Sections, VA Puget Sound Health Care System, S-111-Pulm, 1660 South Columbian Way, Seattle, WA 98108, USA
| | - Vishesh K Kapur
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA 98104, USA
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27
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Abstract
Screening for obstructive sleep apnea (OSA) with in-laboratory polysomnography is recommended for children with sleep disordered breathing. Adenotonsillectomy is the first-line therapy for pediatric OSA, although intranasal steroids and montelukast can be considered for those with mild OSA and continuous positive airway pressure for those with moderate to severe OSA awaiting surgery, poor surgical candidates or persistent OSA. Bony or soft tissue upper airway surgery is reasonable for children failing medical management or those with persistent OSA following adenotonsillectomy. Weight loss and oral appliance therapy are also useful. A multi-modality approach to diagnosis and treatment is preferred.
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Affiliation(s)
- Zarmina Ehsan
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA
| | - Stacey L Ishman
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA; Division of Pediatric Otolaryngology - Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229, USA; University of Cincinnati School of Medicine, Department of Otolaryngology - Head & Neck Surgery, 231 Albert Sabin Way, MSB 6503, Cincinnati, Ohio 45267-0528, USA.
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Cao MT, Sternbach JM, Guilleminault C. Continuous positive airway pressure therapy in obstuctive sleep apnea: benefits and alternatives. Expert Rev Respir Med 2017; 11:259-272. [PMID: 28287009 DOI: 10.1080/17476348.2017.1305893] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a highly prevalent condition affecting persons of all age with an increasing public health burden. It is implicated in cardiovascular disease, metabolic syndrome, neurocognitive impairment, reductions in quality of life, and increased motor vehicle accidents. The goals of OSA treatment are to improve sleep and daytime symptoms, and minimize cardiovascular risks.Areas covered: Continuous positive airway pressure (CPAP) is considered the gold standard therapy that delivers pressurized air into the upper airway to relieve obstruction during sleep. Although CPAP is an effective modality of treatment for OSA, adherence to therapy is highly variable. This article highlights the benefits of CPAP therapy, along with alternative treatment options including oral appliance, implantable and wearable devices, and surgery. Expert commentary: CPAP therapy is the gold standard treatment option and should continue to be offered to those who suffer from OSA. Alternative options are available for those who are unable to adhere to CPAP or choose an alternative treatment modality. The most interesting advances have been incorporating orthodontic procedures in conjunction with myofunctional therapy in prepubertal children, raising the possibility of OSA prevention by initiating treatment early in life.
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Affiliation(s)
- Michelle T Cao
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
| | - Joshua M Sternbach
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
| | - C Guilleminault
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
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Abstract
BACKGROUND Obstructive sleep apnoea is common in children and, if untreated, can lead to multiple medical sequelae. The Childhood Adenotonsillectomy Trial demonstrated benefit from early surgical intervention, but rapid access to such treatment is not always available. AIMS To examine the recent literature on non-surgical aspects of the management of paediatric obstructive sleep apnoea (OSA). METHODS The English language literature was searched for articles on the conservative management of OSA. RESULTS In mild cases of OSA, intra-nasal steroids and other anti-inflammatory medications may give relief in mild cases of OSA, but the long-term safety of these treatments has not been established. Weight loss in obese children has been shown to be effective in selected patients but is limited in practice. Non-invasive ventilation may be effective but compliance can be a major obstacle. Oral appliances are effective by stenting the pharyngeal airway, but research in this area is limited. CONCLUSIONS There are number of potential, if not proven, alternative management strategies for children with OSA, which could be considered in the absence of early surgical intervention.
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Key Words
- American Academy of Pediatrics, AAP
- Childhood Adenotonsillectomy Trial, CHAT
- Intranasal steroid
- Non-invasive ventilation
- Non-surgical management
- Obstructive sleep apnoea
- Obstructive sleep apnoea, OSA
- Oral appliances
- Review
- apnoea-hypoxia index, AHI
- bi-level positive airway pressure, BPAP
- continuous positive airway pressure, CPAP
- high-flow nasal cannulae, HFNC
- non-invasive ventilation, NIV
- rapid maxillary expansion, RME
- sleep-disordered breathing, SDB
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Affiliation(s)
- Laura Whitla
- a Department of Paediatrics , University Hospital Waterford , Waterford , Ireland
| | - Paul Lennon
- b Otolaryngology, Head and Neck Surgery , University Hospital Waterford , Ireland
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Abstract
Oral appliance therapy (OAT) has become an increasingly popular nonsurgical option for the treatment of obstructive sleep disorders. Recent research supports its efficacy and high levels of compliance for patients with obstructive sleep disorders. Common side effects of OAT include temporomandibular joint-related symptoms, bite changes, and tooth movement. These side effects can be minimized by the use of exercises. The American Academy of Dental Sleep Medicine and the American Academy of Sleep Medicine have released joint clinical practice guidelines for the treatment of obstructive sleep apnea and snoring with OAT.
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Kılınç DD, Didinen S. An algorithm of dental/dentofacial-based options for managing patients with obstructive sleep apnoea referred to a dentist/dental specialist by a physician. Br Dent J 2016; 221:37-40. [DOI: 10.1038/sj.bdj.2016.498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 12/20/2022]
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Oral Appliances for Sleep Breathing Disorders. CURRENT SLEEP MEDICINE REPORTS 2016. [DOI: 10.1007/s40675-016-0041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bettega G, Breton P, Goudot P, Saint-Pierre F. Place de l’orthèse d’avancée mandibulaire (OAM) dans le traitement du syndrome d’apnées hypopnées obstructives du sommeil de l’adulte (SAHOS). Juillet 2014. Rev Mal Respir 2016; 33:526-54. [DOI: 10.1016/j.rmr.2015.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
In the last several years, a variety of novel approaches to the treatment of sleep-disordered breathing have emerged. This new technology holds promise in serving to re-engage with patients who have previously been lost to follow-up due to continuous positive airway pressure intolerance. With more tools at our disposal, in turn more options can be offered to patients' growing demand for alternatives that are tailored to their individual needs. The key to proper deployment of alternative therapies will often depend on identification of certain phenotypic traits that trend toward a reasonable response to a given therapy.
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Donovan LM, Boeder S, Malhotra A, Patel SR. New developments in the use of positive airway pressure for obstructive sleep apnea. J Thorac Dis 2015; 7:1323-42. [PMID: 26380760 DOI: 10.3978/j.issn.2072-1439.2015.07.30] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 07/03/2015] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea (OSA) is a disorder which afflicts a large number of individuals around the world. OSA causes sleepiness and is a major cardiovascular risk factor. Since its inception in the early 1980's, continuous positive airway pressure (CPAP) has emerged as the major treatment of OSA, and it has been shown to improve sleepiness, hypertension, and a number of cardiovascular indices. Despite its successes, adherence with treatment remains a major limitation. Herein we will review the evidence behind the use of positive airway pressure (PAP) therapy, its various modes, and the methods employed to improve adherence. We will also discuss the future of PAP therapy in OSA and personalization of care.
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Affiliation(s)
- Lucas M Donovan
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Schafer Boeder
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Atul Malhotra
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sanjay R Patel
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Garg H. Mutifaceted care of OSA: The role of mandibular advancement splints. Lung India 2015; 32:182-3. [PMID: 25814809 PMCID: PMC4372878 DOI: 10.4103/0970-2113.152649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Himanshu Garg
- Head, Respiratory, Critical Care and Sleep Medicine, Artemis Hospitals, Gurgaon, Haryana, India. E-mail:
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Tsuda H, Moritsuchi Y, Higuchi Y, Tsuda T. Oral health under use of continuous positive airway pressure and interest in alternative therapy in patients with obstructive sleep apnoea: a questionnaire-based survey. Gerodontology 2015; 33:416-20. [PMID: 25677191 DOI: 10.1111/ger.12184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is associated with a variety of adverse health outcomes. Continuous positive airway pressure (CPAP) is considered first-line treatment for sleep apnoea patients, but there are few studies on oral health in patients with OSA who are using CPAP. OBJECTIVE This study aimed to estimate the prevalence of oral symptoms and interest in alternative treatments such as oral appliance (OA) therapy in CPAP users. METHODS A questionnaire was used to ascertain oral health including denture use, oral symptoms at present and since the start of CPAP, and interest in OA therapy. Relevant demographic and clinical data were collected from medical records. RESULTS The 744 participants who completed the questionnaire had following characteristics (mean ± standard deviation): age (55.1 ± 12.9 years); apnoea-hypopnoea index (40.9 ± 23.2/h); body mass index (27.9 ± 5.2 kg/m(2) ) and length of CPAP usage (49.1 ± 30.7 months); halitosis (30.4%); and gingival bleeding (27.5%). Nearly half (44.6%) complained of dry mouth since beginning CPAP therapy. Patients with diabetes were older (57.8 ± 11.9 vs. 54.2 ± 12.8 years), had a higher rate of denture use (28.3 vs. 19.0%), more dental clinic visits (71.4 vs. 58.7%) and more oral symptoms (50.0 vs. 38.2%) than non-diabetes patients (p < 0.05). Thirty-eight per cent of subjects were interested in OA therapy. CONCLUSIONS This study exhibited that almost 40% of CPAP users had oral symptoms. In particular, OSA patients with diabetes may be at high risk of oral disease.
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Affiliation(s)
- Hiroko Tsuda
- General Dentistry, Kyushu University Hospital, Fukuoka, Japan
| | | | | | - Toru Tsuda
- Sleep Center, Kirigaoka Tsuda Hospital, Kitakyushu, Japan
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Nazarali N, Altalibi M, Nazarali S, Major MP, Flores-Mir C, Major PW. Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review. Eur J Orthod 2015; 37:618-26. [PMID: 25681125 DOI: 10.1093/ejo/cju101] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 12/22/2014] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of mandibular advancement appliances (MAAs) for treatment of pediatric obstructive sleep apnea (OSA). METHODS Several electronic databases (The Cochrane Database, EMBASE, Healthstar, MEDLINE, PubMed) were systematically searched, as well as a limited grey literature (Google Scholar) and manual searches. A health sciences librarian helped with the selection of Medical Subject Headings (MeSH), key words, and combinations of key words with truncations to account for any differences in controlled terminology in the different databases. Only studies that evaluated the effects of MAAs in children with OSA were pursued. RESULTS Only 4 articles satisfied all inclusion criteria. Selected studies were retrospective except one study that was a quasi-randomized clinical trial. High risk of bias (Cochrane Risk of Bias assessment) was judged in all included studies. Based on the limited available evidence use of MAAs in a POSA population may result in improvements in Apnea Hypopnea Index (AHI) scores. However complete normalization of AHI scores was not demonstrated. Heterogeneity in study designs and collected information precluded meta-analysis. LIMITATIONS There are significant weaknesses in the existing evidence due primarily to absence of control groups, small sample sizes, lack of randomization and short-term results. Determination of AHI scores with MAAs still in the mouth should be avoided. CONCLUSIONS The current limited evidence may be suggestive that MAAs result in short-term improvements in AHI scores, but it is not possible to conclude that MMAs are effective to treat pediatric OSA. Medium- and long-term assessments are still required.
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Affiliation(s)
- Natasha Nazarali
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Mostafa Altalibi
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Samir Nazarali
- Health Sciences (Hons) Programme, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael P Major
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Carlos Flores-Mir
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Paul W Major
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
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Bettega G, Breton P, Goudot P, Saint-Pierre F. [Mandibular advancement device for obstructive sleep apnea treatment in adults. July 2014]. ACTA ACUST UNITED AC 2015; 116:28-57. [PMID: 25593082 DOI: 10.1016/j.revsto.2014.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- G Bettega
- Service de chirurgie maxillo-faciale et chirurgie plastique, hôpital A.-Michallon, BP 217, 38043 Grenoble cedex 9, France.
| | - P Breton
- Service de stomatologie, chirurgie maxillofaciale et chirurgie plastique de la face, centre hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - P Goudot
- Service de stomatologie et chirurgie maxillo-faciale, hôpital Pitié-Salpêtrière (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
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Arya D, Singh SV, Tripathi A, Tripathi SK. A pilot study to compare patient perception of obstructive sleep apnea treatment with CPAP or appliance therapy. J Prosthet Dent 2014; 112:1188-93. [PMID: 24969408 DOI: 10.1016/j.prosdent.2014.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 05/18/2014] [Accepted: 05/19/2014] [Indexed: 11/26/2022]
Abstract
STATEMENT OF PROBLEM The continuous positive airway pressure (CPAP) device yields optimum results in treating mild to moderate obstructive sleep apnea (OSA). However it may be bulky, noisy, and difficult to sleep with for the patient. Mandibular advancement devices (MAD) have shown better compliance but at the expense of lesser efficiency. PURPOSE The purpose of this study was to evaluate the patient's posttreatment subjective perception of the effectiveness of 2 common treatments of OSA. MATERIAL AND METHODS Thirty-two patients diagnosed with OSA filled out the Epworth Sleepiness Scale and Berlin Sleep Quality Questionnaire before treatment and again at 4 to 6 weeks after treatment. Two groups were formed (n=16 each); one group was treated with MAD and the other with CPAP. The data obtained were recorded and compared with the Mann Whitney U test (between groups) and the Wilcoxon signed rank test (within groups) (α=.05). RESULTS The analysis showed that the participants perceived significant posttreatment improvement (P<.05) for all variables of the Berlin Sleep Quality Questionnaire and the Epworth Sleepiness Scale for both the MAD and CPAP groups. CONCLUSIONS According to the questionnaires, participants perceived significant improvement in OSA symptoms after treatment in both the MAD and CPAP groups. The study was inconclusive as to whether improvement of perceived symptoms was higher with MAD or CPAP.
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Affiliation(s)
- Deeksha Arya
- Assistant Professor, Department of Prosthodontics, Faculty of Dental Sciences, KG Medical University, Lucknow, India.
| | - Saumyendra Vikram Singh
- Associate Professor, Department of Prosthodontics, Faculty of Dental Sciences, KG Medical University, Lucknow, India
| | - Arvind Tripathi
- Professor and Head, Saraswati Institute of Dental Sciences and Hospital, Lucknow, India
| | - Surya Kant Tripathi
- Professor and Head, Department of Pulmonary Medicine, Faculty of Medicine, KG Medical University, Lucknow, India
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Abstract
Divergent approaches to treatment of hypocapnic central sleep apnea syndromes reflect the difficulties in taming a hyperactive respiratory chemoreflex. As both sleep fragmentation and a narrow CO2 reserve or increased loop gain drive the disease, sedatives (to induce longer periods of stable non-rapid eye movement (NREM) sleep and reduce the destabilizing effects of arousals in NREM sleep) and CO2-based stabilization approaches are logical. Adaptive ventilation reduces mean hyperventilation yet can induce ventilator-patient dyssynchrony, while enhanced expiratory rebreathing space (EERS, dead space during positive pressure therapy) and CO2 manipulation directly stabilize respiratory control by moving CO2 above the apnea threshold. Carbonic anhydrase inhibition can provide further adjunctive benefits. Provent and Winx may be less likely to trigger central apneas or periodic breathing in those with a narrow CO2 reserve. An oral appliance can meaningfully reduce positive pressure requirements and thus enable treatment of complex apnea. Novel pharmacological approaches may target mediators of carotid body glomus cell excitation, such as the balance between gas neurotransmitters. In complex apnea patients, single mode therapy is not always successful, and multi-modality therapy might need to be considered. Phenotyping of sleep apnea beyond conventional scoring approaches is the key to optimal management.
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Sutherland K, Vanderveken OM, Tsuda H, Marklund M, Gagnadoux F, Kushida CA, Cistulli PA. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014; 10:215-27. [PMID: 24533007 PMCID: PMC3899326 DOI: 10.5664/jcsm.3460] [Citation(s) in RCA: 259] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Oral appliances (OA) have emerged as an alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) treatment. The most commonly used OA reduces upper airway collapse by advancing the mandible (OAm). There is a strong evidence base demonstrating OAm improve OSA in the majority of patients, including some with more severe disease. However OAm are not efficacious for all, with approximately one-third of patients experiencing no therapeutic benefit. OAm are generally well tolerated, although short-term adverse effects during acclimatization are common. Long-term dental changes do occur, but these are for the most part subclinical and do not preclude continued use. Patients often prefer OAm to gold-standard CPAP treatment. Head-to-head trials confirm CPAP is superior in reducing OSA parameters on polysomnography; however, this greater efficacy does not necessarily translate into better health outcomes in clinical practice. Comparable effectiveness of OAm and CPAP has been attributed to higher reported nightly use of OAm, suggesting that inferiority in reducing apneic events may be counteracted by greater treatment adherence. Recently, significant advances in commercially available OAm technologies have been made. Remotely controlled mandibular positioners have the potential to identify treatment responders and the level of therapeutic advancement required in single night titration polysomnography. Objective monitoring of OAm adherence using small embedded temperature sensing data loggers is now available and will enhance clinical practice and research. These technologies will further enhance efficacy and effectiveness of OAm treatment for OSA.
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Affiliation(s)
- Kate Sutherland
- Centre for Sleep Health and Research, Department of Respiratory Medicine, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), University of Sydney and Woolcock Institute of Medical Research, Sydney, Australia
| | - Olivier M. Vanderveken
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Hiroko Tsuda
- General Oral Care, Kyushu University Hospital, Fukuoka, Japan
| | - Marie Marklund
- Department of Orthodontics, Faculty of Medicine, Umea University, Umea Sweden
| | - Frederic Gagnadoux
- LUNAM University, Angers, France
- Department of Respiratory Diseases, Angers University Hospital, Angers, France
- INSERM U1063, Angers, France
| | | | - Peter A. Cistulli
- Centre for Sleep Health and Research, Department of Respiratory Medicine, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), University of Sydney and Woolcock Institute of Medical Research, Sydney, Australia
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Abstract
OPINION STATEMENT Complex sleep apnea currently refers to the emergence and persistence of central apneas and hypopneas following the application of positive airway pressure therapy in patients with obstructive sleep apnea. However, this narrow definition is an "outcome" and does not capture the spectrum of pathological activation of the respiratory chemoreflex in sleep apnea. The International Classification of Sleep Disorders - 3rd edition recognizes the phenomenon of Treatment-Related Central Sleep Apnea, but the phenotype is usually evident prior to onset of therapy. The key polysomnographic characteristics of chemoreflex modulated and mediated sleep apnea are nonrapid eye movement (NREM) dominance of respiratory events, short (<30 seconds) or long (>60 seconds) cycle time with a self-similar metronomic timing, and spontaneous improvement during rapid eye movement (REM) sleep. Thus, the majority of chemoreflex effects go unrecognized due to the bias toward obstructive sleep apnea's current scoring criteria. Any treatment of apparently obstructive sleep apnea, including surgery and oral appliances, can expose chemoreflex-driven instabilities. As both sleep fragmentation and a narrow CO2 reserve or increased loop gain drive the disease, sedatives (to induce longer periods of stable NREM sleep and reduce the destabilizing effects of arousals in NREM sleep) and CO2-based stabilization approaches are logical. Adaptive ventilation reduces mean hyperventilation yet can induce ventilator-patient desynchrony, while enhanced expiratory rebreathing space (EERS, dead space during positive pressure therapy) and CO2 manipulation directly stabilize respiratory control by moving CO2 above the apnea threshold. Carbonic anhydrase inhibition can provide further adjunctive benefits. Novel pharmacological approaches may target mediators of carotid body hypoxic sensitization, such as the balance between gas neurotransmitters. In complex apnea patients, single mode therapy is unlikely to be successful, and the power of multi-modality therapy should be harnessed for optimal outcomes.
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46
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Sharma S, Essick G, Schwartz D, Aronsky AJ. Sleep medicine care under one roof: a proposed model for integrating dentistry and medicine. J Clin Sleep Med 2013; 9:827-33. [PMID: 23946715 DOI: 10.5664/jcsm.2934] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Integrating oral appliance therapy into the delivery of care for sleeprelated breathing disorders has been a challenge for dental and medical professionals alike. We review the difficulties that have been faced and propose a multidisciplinary care delivery model that integrates dental sleep medicine and sleep medicine under the same roof with educational and research components. The model promises to offer distinct advantages to improved patient care, continuity of treatment, and the central coordination of clinical and insurance-related benefits.
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Affiliation(s)
- Sunil Sharma
- Jefferson Sleep Center, Thomas Jefferson University & Hospitals, Philadelphia, PA 19107, USA
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Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B, Grillet Y, Muir JF, Levy P, Series F, Pepin JL. Type of mask may impact on continuous positive airway pressure adherence in apneic patients. PLoS One 2013; 8:e64382. [PMID: 23691209 PMCID: PMC3654912 DOI: 10.1371/journal.pone.0064382] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 04/12/2013] [Indexed: 11/19/2022] Open
Abstract
RATIONALE In obstructive sleep apnea patients (OSA), continuous positive airway pressure (CPAP) adherence is crucial to improve symptoms and cardiometabolic outcomes. The choice of mask may influence CPAP adherence but this issue has never been addressed properly. OBJECTIVE To evaluate the impact of nasal pillows, nasal and oronasal masks on CPAP adherence in a cohort of OSA. METHODS Newly CPAP treated OSA participating in "Observatoire Sommeil de la Fédération de Pneumologie", a French national prospective cohort, were included between March 2009 and December 2011. Anthropometric data, medical history, OSA severity, sleepiness, depressive status, treatment modalities (auto-CPAP versus fixed pressure, pressure level, interface type, use of humidifiers) and CPAP-related side effects were included in multivariate analysis to determine independent variables associated with CPAP adherence. RESULTS 2311 OSA (age = 57(12) years, apnea+hypopnea index = 41(21)/h, 29% female) were included. Nasal masks, oronasal masks and nasal pillows were used by 62.4, 26.2 and 11.4% of the patients, respectively. In univariate analysis, oronasal masks and nasal pillows were associated with higher risk of CPAP non-adherence. CPAP non-adherence was also associated with younger age, female gender, mild OSA, gastroesophageal reflux, depression status, low effective pressure and CPAP-related side effects. In multivariate analysis, CPAP non-adherence was associated with the use of oronasal masks (OR = 2.0; 95%CI = 1.6; 2.5), depression, low effective pressure, and side effects. CONCLUSION As oronasal masks negatively impact on CPAP adherence, a nasal mask should be preferred as the first option. Patients on oronasal masks should be carefully followed.
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Affiliation(s)
| | - Renaud Tamisier
- HP2 Laboratory INSERM U 1042, University Grenoble Alpes, Grenoble, France
- Pôle Locomotion, Rééducation et Physiologie, Hôpital Albert Michallon, Grenoble, France
| | - Sonia Dias-Domingos
- HP2 Laboratory INSERM U 1042, University Grenoble Alpes, Grenoble, France
- Pôle Locomotion, Rééducation et Physiologie, Hôpital Albert Michallon, Grenoble, France
| | - Marc Sapene
- Unité Sommeil et Vigilance, Polyclinique Bordeaux Cauderan, Bordeaux, France
| | - Francis Martin
- Unité des pathologies du sommeil, Centre hospitalier de Compiègne, Compiègne, France
| | - Bruno Stach
- Pneumologie, Cabinet Médical Saint Michel, Valenciennes, France
| | | | - Jean François Muir
- Pneumology and Respiratory Intensive Care U, Rouen University Hospital, Rouen, France
| | - Patrick Levy
- HP2 Laboratory INSERM U 1042, University Grenoble Alpes, Grenoble, France
- Pôle Locomotion, Rééducation et Physiologie, Hôpital Albert Michallon, Grenoble, France
| | - Frederic Series
- Institut Universitaire de Pneumologie et Cardiologie de Québec, Université Laval, Québec, Canada
| | - Jean-Louis Pepin
- HP2 Laboratory INSERM U 1042, University Grenoble Alpes, Grenoble, France
- Pôle Locomotion, Rééducation et Physiologie, Hôpital Albert Michallon, Grenoble, France
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Amini F, Borzabadi-Farahani A, Behnam-Roudsari G, Jafari A, Shahidinejad F. Assessment of the uvulo-glossopharyngeal dimensions in patients with β-thalassemia major. Sleep Breath 2012; 17:943-9. [PMID: 23114728 DOI: 10.1007/s11325-012-0782-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 10/10/2012] [Accepted: 10/22/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Thalassemia patients present varying degrees of craniofacial characteristics, while the morphology of the upper airway is less studied. The purpose of this study was to compare the uvula-glossopharyngeal dimensions (UGDs) of patients with β-thalassemia major (BTM) with non-thalassemic subjects who had similarities in the maxillo-mandibular skeletal pattern. SUBJECTS AND METHODS The material for this cross-sectional retrospective study consisted of lateral cephalograms of 40 BTM patients (23 males, 17 females, aged 9.5 ± 0.97 years). These were compared with lateral cephalograms of a control group of 40 non-thalassemic subjects (23 males, 17 females, aged 11.0 ± 0.87 years). The control group was chosen so that they had similarities with the BTM patients in the following cephalometric variables: SNA (in degree), SNB (in degree), ANB (in degree), and anterior facial height (N-Me). RESULTS The following UGDs in thalassemic subjects were significantly shorter in patients with BTM: tongue length (P < 0.05), the distance between the hyoid bone and the mandibular plane (P < 0.01), and the vertical distance between hyoid bone and the C3-RGN line (line connecting third vertebra and retrognathion) (P < 0.05). The middle airway space in BTM patients was significantly wider (P < 0.05), and a trend was observed for the wider inferior airway space (P = 0.07). CONCLUSIONS Based on this study, some UGDs in BTM patients were significantly different, compared to non-thalassemic subjects who had a similar maxillo-mandibular skeletal pattern. These findings may have implications for the long-term treatment of BTM patients; however, since groups were not exactly age-matched, the observed differences between groups could be attributed to either BTM, age, or both. Additional studies with age-matched subjects are needed to investigate the relationship between BTM and UGDs.
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Affiliation(s)
- Fariborz Amini
- Department of Orthodontics and Dentofacial Orthopedics, Dental Branch, Islamic Azad University, Tehran, Iran
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Evaluation and management of pediatric obstructive sleep apnea beyond tonsillectomy and adenoidectomy. Curr Opin Otolaryngol Head Neck Surg 2012; 19:449-54. [PMID: 22052530 DOI: 10.1097/moo.0b013e32834c1728] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW There is an increasing percentage of children with persistent obstructive sleep apnea (OSA) after removal of the tonsils and adenoids (T&A). Although sleep apnea has been an active area of research and treatment in the adult population, our awareness of this problem in children is still in its initial stages. In addition, therapies to successfully treat this residual OSA are still not fully established. It is important to develop evaluation and management protocols for these children. RECENT FINDINGS This review will discuss risk factors associated with persistent OSA after T&A and techniques to evaluate the pediatric airway in order to identify the site, or sites, of obstruction. Various medical and surgical options are presented. SUMMARY Clinicians need to be aware of the potential for persistent sleep disordered breathing and OSA in children, despite previous T&A. Evaluation protocols and techniques will differ in children, due to limitations in their cooperation during the physical examination. Alternative methods, such as airway endoscopy and cine MRI, are presented. Medical and surgical options are presented. Outcomes data for pediatric populations are rare. Multilevel, single stage surgery has a higher risk for oropharyngeal stenosis in children compared with adults and conservative, multistage approaches may be more appropriate.
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Cohen-Levy J, Pételle B, Pinguet J, Limerat E, Fleury B. Forces created by mandibular advancement devices in OSAS patients. Sleep Breath 2012; 17:781-9. [DOI: 10.1007/s11325-012-0765-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 08/11/2012] [Accepted: 08/20/2012] [Indexed: 11/28/2022]
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