Subjective versus objective dental side effects from oral sleep apnea appliances

Treatment of obstructive sleep apnea syndrome (OSAS) with mandibular advancement devices-A statement of the Portuguese society of pulmonology, the Portuguese society of stomatology and dental medicine, the Portuguese dental association, and the Portuguese society of temporomandibular disorders, orofacial pain and sleep

With the purpose of establishing a consensus around clinical orientations for professionals involved in managing patients with sleep breathing disorders (SBD), an interdisciplinary group of scientific societies involved in this field discussed and reviewed all the published international guidelines from the American Dental Association, American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and the European counterparts. Treatment of SBD is multidisciplinary and should be made in concert with the patient, the sleep physician, and the qualified dentist to solve the individual, social, and economic burden of the disease,. This consensus document represents the current thinking of a team of Portuguese experts on managing patients with SBD based on the available evidence.

Correlation between craniocervical posture and upper airway dimension in patients with bilateral anterior disc displacement

OBJECTIVE

To investigate the relationship between upper airway dimension and craniocervical posture in adult patients with bilateral anterior disc displacement and to provide some references for clinical diagnosis and plan formulation in orthodontics.

METHODS

Based on RDC/TMD (Research Diagnostic Criteria for Temporomandibular Disorder), 98 Patients were divided into three groups by two experienced TMJ (Temporomandibular Joint) specialists: bilateral disc normal position group (BN), bilateral anterior disc displacement with reduction group (ADDWR) and bilateral anterior disc displacement without reduction group (ADDWoR). Inter-group comparison and correlation analysis were performed after 11 craniocervical posture and 15 upper airway dimension measurements finished with Dolphin and Uceph software in Two or Three-dimensional.

RESULTS

Anterior disc displacement often accompanied with extension of craniocervical posture, as ADDWR and ADDWoR groups have significantly higher cervical curvature and inclination than BN group (P < 0.05). Simultaneously anterior disc displacement often associated with constrained upper airway dimension for the total and each segment upper airway volume were significantly smaller in ADDWR and ADDWoR than BN group (P < 0.05). Correlation analysis revealed that C0-C1 (the distance from the base of the occipital bone (C0) to the posterior arch of the atlas (C1)) is significantly related to the total and each segment upper airway volume reduction (P < 0.05).

CONCLUSION

There exists markedly close correlation between anterior disc displacement and craniocervical posture forward extension, which may be physiologically adaptive cervical extension to keep oropharyngeal airway unobstructed as upper airway dimension constrained by anterior disc displacement.

CLINICAL RELEVANCE

These findings allow us to infer the potential consequences if the treatment of anterior disc displacement would result in an improvement of intervertebral relationships and upper airway constraint.

Starting Mandibular Advancement Device Therapy in Patients with Good Protrusive Capacity: A Randomized Pilot Study

Objective

Discomfort has been related to the poor acceptance of a mandibular advancement device (MAD) in patients with obstructive sleep apnea. The present study compared severe initial side effects between a smaller and a larger degree of mandibular advancement in patients with a good protrusive capacity.

Methods

Consecutive patients with obstructive sleep apnea and a good protrusive capacity (≥8 mm) were randomized to start treatment with the mandible advanced by either 70% of maximum protrusion (Adv70%) or by 4 mm (Adv4mm) in a pilot study with a parallel design. The main outcome was tenderness or pain in the teeth or jaws using a 0-10 visual analogue scale (VAS) (from "not at all" to "very extensive") or excluded use because of side effects during the first week of treatment. Secondary outcomes included salivation problems and bite changes.

Results

Eighteen patients were randomly selected and 17 patients fulfilled the study protocol. Four patients in the Adv70% group and none in the Adv4mm group reported severe tenderness or pain (VAS ≥7) on five or more of the seven days (p=0.03). The degree of mandibular advancement measured in millimeters correlated with the number of days with severe side effects, r=0.64 (p=0.006). The secondary side effects were minor.

Conclusion

Starting MAD treatment with 70% mandibular advancement was related to more severe side effects during the first week of treatment compared with a smaller fixed millimeter value in patients with a good protrusive capacity in this pilot study.

Oral appliance-generated malocclusion traits during the long-term management of obstructive sleep apnea in adults

OBJECTIVES

To identify malocclusion characteristics generated after using oral appliances (OAs) for at least 5 years for the management of snoring and obstructive sleep apnea (OSA) in adults.

MATERIALS AND METHODS

PubMed, MEDLINE (Ovid), Scopus, CINAHL, and Informit were searched without language restrictions through January 20, 2021. Unpublished literature was searched on ClinicalTrials.gov, the National Research Register, and the Pro-Quest Dissertation Abstracts and Thesis database. Authors were contacted when necessary, and reference lists of the included studies were screened. Risk of bias was assessed through the revised Cochrane Risk of Bias tool for randomized controlled trials (RoB2) and Non-Randomized Studies of Interventions for non-RCTs and uncontrolled before-after studies (ROBINS-I). A random-effects meta-analysis was conducted only on studies that used the same OAs to exclude biomechanical differences. Risk of bias across studies was assessed with the Grading of Recommendations, Assessment, Development and Evaluation tool.

RESULTS

A total of 12 studies were included in the final qualitative synthesis. Eight included studies had high, one had moderate, and three had low risks of bias. Significant progressive decreases of overjet (OJ; -1.43 mm; 95% confidence interval [CI], -1.66 to -1.20) and overbite (OB; -1.94 mm; 95% CI, -2.14 to -1.74) associated with maxillary incisor retroclination and mandibular incisor proclination were reported long term. Although most studies showed no sagittal skeletal changes, some degree of vertical skeletal changes were noted.

CONCLUSIONS

Based on a very low evidence level, inevitable anterior teeth positional changes seem to be a common long-term adverse effect of OAs. The magnitude of those changes could be considered clinically irrelevant for most pretreatment occlusions, but in occlusions with limited OJ and OB, it may be worth clinical consideration.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The Scientific Investigation Committee of the American Academy of Restorative Dentistry offers this review of the 2020 professional literature in restorative dentistry to inform busy dentists regarding noteworthy scientific and clinical progress over the past year. Each member of the committee brings discipline-specific expertise to this work to cover this broad topic. Specific subject areas addressed include prosthodontics; periodontics, alveolar bone, and peri-implant tissues; implant dentistry; dental materials and therapeutics; occlusion and temporomandibular disorders (TMDs); sleep-related breathing disorders; oral medicine and oral and maxillofacial surgery; and dental caries and cariology. The authors focused their efforts on reporting information likely to influence day-to-day dental treatment decisions with a keen eye on future trends in the profession. With the tremendous volume of dentistry and related literature being published today, this review cannot possibly be comprehensive. The purpose is to update interested readers and provide important resource material for those interested in pursuing greater detail. It remains our intent to assist colleagues in navigating the extensive volume of important information being published annually. It is our hope that readers find this work useful in successfully managing the dental patients they encounter.

Partner perceptions are associated with objective sensor-measured adherence to oral appliance therapy in obstructive sleep apnea

The aims of the present prospective clinical study were to determine objective, sensor-measured adherence to a mandibular advancement device (MAD) in patients with obstructive sleep apnea (OSA) and to identify partner-specific adherence-related factors. A total of 77 eligible participants with mild, moderate, or severe OSA and who were non-adherent to continuous positive airway pressure (mean age 56.2 years) participated in the study (32.5% women). The mean (range) observation time between MAD delivery and final follow-up was 8.3 (3.4-16.5) months. The mean apnea-hypopnea index (AHI) was 26.6 events/hr at baseline and 12.5 events/hr at the 8-month follow-up (both p < 0.001). The mean sensor-measured adherence at the 8-month follow-up was 60.1% for ≥4 hr/night of appliance use for ≥5 days/week. Average usage was 6.4 hr/night, when worn. The mean reduction in the AHI was significantly greater in the "good adherence" (Δ 17.4) than the "poor adherence" group (Δ11.0; p < 0.05). From the partner's perspective, the appliance had a positive effect on sharing a bedroom in the good- (55%) compared to the poor-adherence group (25%; p < 0.05) and on their relationship (51.7% versus 17.9%, respectively; p < 0.05). Regression analyses identified the partner's snoring and apneas to be the most significant factor predicting good adherence to MAD (odds ratio 4.4, 95% confidence interval 1.4-14.0). In conclusion, social factors, like partner perceptions, were positively associated with adherence, which indicate that partner's attitudes and support may be a resource that can be utilised to improve adherence in oral appliance treatment of OSA.

The Association between Temporomandibular Disorder and Sleep Apnea-A Nationwide Population-Based Cohort Study

An increased incidence of temporomandibular disorders (TMD) among patients with sleep apnea (SA) has been reported. However, the association between TMD and SA has not been demonstrated in a large-scale study. This population-based cohort study with the Taiwan National Health Insurance (NHI) Research Database aimed to understand the association between SA and TMD. We identified adult patients with suspected SA (identified with diagnostic codes) and excluded those diagnosed with TMD prior to SA. Patients with SA diagnosis after polysomnography were also identified as probable SA patients. The index dates were the dates of their initial SA diagnosis. Ten control subjects were matched, by age and sex, to each SA patient, and were assigned the same index dates as the SA patients. In total, 10,408 suspected SA patients (including 4105 probable SA patients) matched to 104,080 control subjects (including 41,050 subjects matched to the probable SA patients) in this study. The TMD incidence rate was significantly higher in the SA patients than in the control subjects (2.8 vs. 1.0 per thousand-patient-year in probable SA patients vs. the corresponding control subjects, with an adjusted incidence rate ratio [95% confidence interval] = 2.5 [2.3–2.7], p < 0.0001). SA patients significantly showed a higher cumulative incidence of TMD than the corresponding control subjects (p < 0.0001). Multivariable Cox regression analysis revealed SA as an independent risk factor for the development of TMD (adjusted hazard ratio = 2.5 [1.7–3.7], p < 0.0001). In summary, this study confirmed an increased TMD incidence in the SA patients. While treating TMD patients, dentists should pay careful attention to the potential underlying SA.

Dental sleep medicine: Time to incorporate sleep apnoea education in the dental curriculum

Dental sleep medicine is a discipline that includes conditions such as sleep breathing disorders (eg snoring and sleep apnoea), sleep bruxism, orofacial pain and sleep-related complaints, and to some extent gastro-oesophageal reflux disorder and/or insomnia. Obstructive sleep apnoea (OSA) is a life-threatening condition that dentists need to identify and manage when indicated in order to increase patient well-being and to be taken in consideration in the dental curriculum. The main objective of this paper is to highlight the relevance of dental sleep medicine in the context of dental education, and to discuss potential educational content for integration in the dental curriculum with a focus on OSA, a condition that is not yet integrated in many dental training curricula around the world.

Oral Appliance Therapy for Obstructive Sleep Apnoea: State of the Art

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.

Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea

This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.

Update on oral appliance therapy

Oral appliances are increasingly recommended for selected patients with obstructive sleep apnoea (OSA) and those who do not tolerate nor prefer continuous positive airway pressure. The most commonly used oral appliance advances the lower jaw during sleep, the so-called mandibular advancement device (MAD). Patients seek treatment because of disturbing snoring, daytime symptoms, apnoeas that disturb sleep and the longer term consequences with regard to cardiovascular risks. MADs reduce the apnoea–hypopnoea index, although to various degrees among patients. Effects on daytime sleepiness have been observed mainly among the more severe OSA patients. Blood pressure may be reduced in MAD-treated OSA patients. There is, however, uncertainty about which patients will respond to this therapy in terms of apnoea reductions, decreased sleepiness and other symptoms, and reduced risk for future impaired health. The occurrence of side-effects also remains difficult to predict at present. The majority of sleep apnoea patients suffer from various comorbidities in terms of cardiovascular diseases, type 2 diabetes and depression. The most recent findings indicate that phenotyping of patients, considering various aspects of this multifaceted disease, will shed more light on the indications for MADs in patients with nightly sleep breathing disturbances. This review summarises the most recent knowledge about MAD treatment.