Complications causing patients to discontinue using oral appliances for treatment of obstructive sleep apnea

Factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea: a systematic review and meta-analysis

STUDY OBJECTIVES

The review aimed to identify the factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea.

METHODS

The protocol was initially registered with the International Register of Systematic Reviews (Prospero: CRD42019122615) prior to undertaking a comprehensive electronic search of databases and references without language and date restrictions. Quality assessment was undertaken using the Cochrane Collaboration's risk of bias tool and Quality in Prognosis Studies (QUIPS) tool.

RESULTS

Studies exhibited low or unclear risk of bias for the domains assessed by the respective quality assessment tools. The influence of independent variables such as disease characteristics, patient characteristics, appliance features, and psychological and social factors on adherence levels was also assessed. There was a total of 31 included studies, which consisted of 8 randomized controlled trials, 2 controlled clinical trial, 7 prospective cohorts, 11 retrospective cohorts, and the remaining 3 studies were a case-series, case-control, and a mixed-methods. All 31 included studies were subject to qualitative analysis, with only 4 studies included in the quantitative analysis. Results of the meta-analysis demonstrated increased adherence with custom-made appliances, with a pooled mean difference of -1.34 (-2.02 to -0.66) and low levels of heterogeneity (I² = 0%).

CONCLUSIONS

A weak relationship was observed between objective adherence and patient and disease characteristics, such as age, sex, obesity, apnea-hypopnea index, and daytime sleepiness, to oral appliance therapy. Nonadherent patients reported more side effects with oral appliance therapy than users and tended to discontinue the treatment within the first 3 months. Custom-made oral appliances were preferred and increased adherence reported in comparison to ready-made appliances. Further research is imperative to examine the relationship between psychosocial factors and adherence to oral appliance therapy.

What Do We Know About Adherence to Oral Appliances?

Long-term effective therapy is essential for obstructive sleep apnea (OSA) control and preventing comorbidity. OSA patients are often reported to be more receptive to oral appliance therapy over positive airway pressure (PAP). Oral appliance usage can now be objectively recorded by temperature microsensors. Studies using commercially available microsensor chips have reported data out to 1 year, with high rates of adherence (>80%), albeit in small samples. There is opportunity to further use this technology to understand individual adherence factors and patterns and in obtaining objective measures of treatment effectiveness, particularly for longer-term health outcomes and allowing comparison to PAP.

Use of mandibular advancement devices for the treatment of primary snoring with or without obstructive sleep apnea (OSA): A systematic review

The aim of this review was to systematically evaluate the available scientific evidence on the benefit of mandibular advancement devices (MADs) in the treatment of primary snoring (PS). From 905 initially identified articles, 18 were selected. Papers that provided indirect information regarding obstructive sleep apnea syndrome (OSAS) and/or sleep breathing disorders (SBD) were included. Information was obtained on monoblock and duoblock appliances from the selected studies. The devices were most commonly able to achieve 50%-70% of the maximum mandibular protrusion. The frequently used outcome measurements were the apnea-hypopnea index, Epworth sleepiness scale, and oxygen desaturation index, which all yielded positive post-treatment results. The most common side effects were temporomandibular joint pain and excessive salivation, which improved with time. Our findings indicated that the use of MADs, even with varying designs, improved outcomes in all the reported patient populations (PS, OSAS, and SBD). Despite the lack of studies on PS, the available evidence supports the use of MADs for treatment of PS. Snoring should be treated from a preventive and psychosocial perspective to avoid progression to more severe diseases that could have a significant medical and economic impact.

Treatment of snoring disorder with a non-ablactive Er:YAG laser dual mode protocol. An interventional study

Background

Snoring disorder is a common problem among world population. Treatment modalities may involve surgical and non-surgical procedures. As main objective we proposed to evaluate the efficacy of non-ablative Er:YAG laser in the treatment of snoring disorder.

Material and Methods

We performed an interventional study in 30 patients with snoring disorders. Three sessions were performed with Er:YAG laser 2940nm in long pulse mode (2J/cm2) and smooth mode (10-8J/cm2) in oropharynx region. We analyzed the efficacy of this protocol using questionnaires for snoring intensity, snoring related characteristics of quality of life (including the Epworth sleepness scale and OHIP-14), the satisfaction of the patients and existence of adverse effects comparing the results before and after the treatment using Wilcoxon Signed Rank test.

Results

There was a 96.7% satisfaction rate after one month of treatment, and 96.4% after 6 months. A reduction of the severity of snoring from 8±1.9 before the treatment to 1.6±1.1 one month after treatment was observed (p<0.001). Decrease in mean values of Epworth sleepness scale (9.97±5.3 to 6.54±4.3) (p=0.002), and OHIP-14 score (10.9±6.2 to 5.9±5) (p<0.001) were also noted. A significant decrease in the Mallampatti and Friedman classification scores were observed (p=0.001 and p<0.001, respectively). No anesthesia was required, nor adverse effects were observed.

Conclusions

Non-ablative Er:YAG laser treatment is a safe, painless, and can be an effective treatment option to reduce snoring and is well accepted by the patient. However, further controlled studies with longer follow-up are required.

Key words:Er:YAG laser, snoring, sleep disorders, epworth sleepiness scale, OHIP-14.

Outpatient erbium:YAG (2940 nm) laser treatment for snoring: a prospective study on 40 patients

Snoring is a sleep phenomenon due to the partial upper airway obstruction during sleep which causes vibration of the tissues of the rhino-oro-hypopharynx and less frequently the larynx. This study evaluated the use and effectiveness of the erbium:YAG 2940-nm laser as an adjunctive in providing treatment for patients suffering from chronic snoring-related sleep disorders. A prospective study of 40 consecutive patients with snoring and sleep disorders was performed, assessing data before and after three Er:YAG laser treatment sessions. During laser treatment, the pain was almost absent. There were no side effects, except a very mild sore throat in 1 out of 40 patients. The patient's evaluation of satisfaction of the results obtained after the treatments showed that 85% of cases were very satisfied, 5 patients (12.5%) reported being fairly satisfied with the treatment and only 1 subject (2.5%) was not satisfied. Mallampati, Friedman Tongue Position, and degree of O (oropharynx) at nose oropharynx hypopharynx and larynx classification were significantly decreased after the laser sessions. The decrease of Epworth Sleepiness Scale and Visual Analogue Scale for loudness of snoring, waking up during sleep because of snoring, dry mouth on waking, and choking was all statistically significant. The incidence of dreaming during the night also raised significantly; 30/40 (75%) of cases perceived less tightness in their throat and better breathing after treatment. These results were stable at 20 months follow-up (14-24 q) in 72% of cases. Nonsurgical and non-invasive Er:YAG laser treatment demonstrated to be a valid procedure in reducing the loudness of snoring.

Update on Oral Appliance Therapy for OSA

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.