Predictors of success in the treatment of obstructive sleep apnea syndrome with mandibular repositioning appliance: a systematic review

The Effect of Bite Raise on AHI Values in Adult Patients Affected by OSA: A Systematic Review with Meta-Regression

Obstructive sleep apnea (OSA) is a highly prevalent sleep breathing disorder characterized by the collapse of the pharyngeal walls that entails recurrent episodes of cessation of breathing or decrease in airflow while sleeping. This results in sleep fragmentation, decreased oxygen saturation and an increase in the partial pressure of carbon dioxide, causing excessive daytime sleepiness, hypertension and increased prevalence of cardiovascular morbidity and mortality. Mandibular advancement devices (MAD) represent a valid alternative therapy to Continuous Positive Airway Pressure, thrusting the mandible forward, increasing the lateral diameter of the pharynx and reducing the collapsibility of the airway. Several investigations have focused on the detection of the best mandibular advancement amount in terms of effectiveness and tolerance, but few and contrasting data are available on the role of occlusal bite raise in reducing the apnea/hypopnea index (AHI). The aim of this systematic review with meta-regression analysis was to investigate the effect of the bite raise of MAD on AHI values in adult patients affected by OSA. An electronic search was performed in MEDLINE, the Cochrane Database, Scopus, Web of Science and LILACS. Randomized controlled trials (RCT) investigating the effectiveness of MAD in OSA patients were included. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias with the Cochrane risk-of-bias tool for randomized trials (RoB2). Six RCT were included. The success rate of each study was computed: (mean baseline AHI - mean post treatment AHI)/mean baseline AHI. The GRADE scores indicated that the quality of evidence was very low. The meta-regression analysis showed that there was no correlation between the occlusal bite raise and the AHI improvement.

Effect of a Mandibular Advancement Device on the Upper Airway in a Patient With Obstructive Sleep Apnea

The authors present a case of a 33-year-old male patient with obstructive sleep apnea syndrome who was treated with a mandibular advancement device with excellent results. The aim of this study is to underline the importance of new instruments that allow evaluating the upper airway with greater precision, such as cone beam tomography. Given the diagnosis and treatment, the upper airway was assessed using cone beam tomography; an increase in UA volume of 22% was observed (initial volume 22,962 mm), along with a 28% increase in area (initial area 971 mm). The evaluation of the UA using teleradiography also showed an increase in the points evaluated, with the midpoint of the soft palate presenting the greatest increase.

Friedman Score in Relation to Compliance and Treatment Response in Nonsevere Obstructive Sleep Apnea

Nonsevere obstructive sleep apnea (OSA) is most often treated with a continuous positive airway pressure (CPAP) device or a mandibular advancement splint (MAS). However, patient compliance with these treatments is difficult to predict. Improvement in apnea-hypopnea index (AHI) is also somewhat unpredictable in MAS treatment. In this study, we investigated the association between Friedman tongue position score (Friedman score) and both treatment compliance and AHI improvement in patients with nonsevere OSA receiving CPAP or MAS treatment. 104 patients with nonsevere OSA were randomly allocated to CPAP or MAS treatment and followed for 12 months. Data were collected through a medical examination, questionnaires, sleep recordings from ambulatory type 3 polygraphic sleep recording devices, and CPAP recordings. Associations between Friedman score, treatment compliance, and AHI improvement were analysed with logistic regression analyses. Friedman score was not associated with treatment compliance (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.59-1.23), or AHI improvement (OR: 1.05, 95% CI: 0.62-1.76) in the overall study sample, the CPAP treatment group, or the MAS treatment group. Adjustment for socioeconomic factors, body mass index, and tonsil size did not significantly impact the results. Although Friedman score may predict OSA severity and contribute to the prediction of success in uvulopalatopharyngoplasty, we found no association between Friedman score and treatment compliance in patients with nonsevere OSA receiving CPAP or MAS treatment, nor did we find any association between Friedman score and AHI improvement. Factors other than Friedman score should be considered when deciding whether a patient with nonsevere OSA should be treated with CPAP or MAS.

Prevalence of interstitial and other lung diseases on Aruba

Background: Health care management has to be based on the local prevalence of diseases and the local diagnostic and therapeutic needs. So far, no systematic registration system for various lung diseases exists on Aruba. Questions that need to be answered are: what specific lung disorders occur on Aruba, and what are the specific needs there? The aim of this study was to assess the prevalence of lung disorders and the diversity of the patient population. Methods: Retrospectively, all records (n=2352) of patients of the Department of Respiratory Diseases of the Dr. Horatio E. Oduber Hospital, Aruba, who were seen at the clinic at least once in the period between January 2010 and October 2014 were reviewed. Results: Asthma (22%) and sleeping disorders (20%) were the most prevalent diagnoses. The mean body mass index (BMI) of the overall lung patient population was 31.6 kg/m². Obstructive sleep apnea syndrome (OSAS) was the most frequently diagnosed sleeping disorder (78.4%). A diagnosis of interstitial lung diseases (ILD) was established in 4.4% of the cases. Among the ILDs, non-specific interstitial pneumonia (NSIP: 28%), sarcoidosis (18%) and idiopathic pulmonary fibrosis (IPF: 16%) were the most frequent. Conclusion: Obesity and OSAS appeared to be major problems on Aruba. Increased awareness, education, and diagnostic facilities are required to prevent and diagnose obesity and OSAS in an early stage. NSIP, sarcoidosis and IPF are the most frequently diagnosed ILDs on Aruba, and optimization of ILD management is warranted, considering new treatment options available for ILD, especially for IPF.(Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 217-225)

Review of systematic reviews on mandibular advancement oral appliance for obstructive sleep apnea: The importance of long-term follow-up

The purpose of this review was to present the currently available information on oral appliance (OA) therapy for dentists, especially clinic-based dentists, to aid them in performing this treatment for the management of symptoms of obstructive sleep apnea (OSA). The clinical research evidence comprised of systematic reviews concerned with the mandibular advancement oral appliance (OAm). Continuous positive airway pressure (CPAP) is superior to OA therapy in improving OSA symptoms. It is necessary to survey the adherence of patients who stopped CPAP therapy to OAm therapy. There is little evidence supporting the theory that OAm therapy prevents cardiovascular disease or improves prognosis. There is still room to investigate the types of OAm. OAm therapy has clear dental and skeletal side effects with long-term use, and these are important for dentists. However, a certain percentage of patients discontinue consultations. Regarding consultation rate for follow-up and repair/adjustments of OAm, there are advantages for the clinic-based dentists treating OSA with OAm. We believe that enhancing under-graduate and post-graduate education on sleep medicine, and establishing a specialist system could be the strategies for enabling the dentists to handle OAm therapy in dental clinics.

Prediction of MAS Therapy Response in Obstructive Sleep Apnoea Patients using Clinical Data

Mandibular Advancement Splint (MAS) is an oral appliance based treatment to Obstructive Sleep Apnoea (OSA) patients that is only effective for some patients. We present an investigation to predict MAS treatment response in OSA patients. A unique dataset in a large number (n=543 patients) consisting of convenient measurement such as demographic, anthropometric and Polysomnography (PSG) variables was utilised. Treatment Responders were defined as those with ≥50% reduction in Apnoea Hypopnoea Index (AHI) resulting in an AHI of less than 10 after the treatment process. Leaveone-out cross validation results using a Quadratic Neural Network showed an overall accuracy of 63%, with 63% sensitivity and 63% specificity for correctly predicting treatment response which is an improvement on previously published results.

Challenges and perspectives in obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is a major challenge for physicians and healthcare systems throughout the world. The high prevalence and the impact on daily life of OSA oblige clinicians to offer effective and acceptable treatment options. However, recent evidence has raised questions about the benefits of positive airway pressure therapy in ameliorating comorbidities.

An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field, and proposed topics for future research on epidemiology, phenotyping, underlying mechanisms, prognostic implications and optimal treatment of patients with OSA.

The group concluded that a revision to the diagnostic criteria for OSA is required to include factors that reflect different clinical and pathophysiological phenotypes and relevant comorbidities (e.g.nondipping nocturnal blood pressure). Furthermore, current severity thresholds require revision to reflect factors such as the disparity in the apnoea–hypopnoea index (AHI) between polysomnography and sleep studies that do not include sleep stage measurements, in addition to the poor correlation between AHI and daytime symptoms such as sleepiness. Management decisions should be linked to the underlying phenotype and consider outcomes beyond AHI.

The effectiveness of different mandibular advancement amounts in OSA patients: a systematic review and meta-regression analysis

PURPOSE

The therapy with mandibular advancement devices (MADs) represents a treatment option for patients with obstructive sleep apnea (OSA). The literature does not provide evidence regarding the most effective mandibular advancement; therefore, the aim of this systematic review with meta-regression was to investigate the effectiveness of different mandibular advancement amounts in reducing apnea-hypopnea index (AHI) in OSA patients.

METHODS

An electronic search was performed in MEDLINE, Cochrane Database, Google Scholar Beta, ISI Web of Knowledge, Scopus, and LILACS to select randomized controlled trials (RCTs) investigating the efficacy of MADs in reducing AHI in adult OSA patients. Inclusion criteria were the diagnosis of OSA and success evaluation performed with a polysomnography, follow-up of maximum 12 months, and protrusion amount reported as a percentage of the maximum mandibular advancement. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The success rate of each study was computed: [(mean AHI at baseline-mean AHI after treatment)/mean AHI at baseline].

RESULTS

Thirteen RCTs performing advancements from 50 to 89 % of maximum mandibular protrusion were included. The meta-regression analysis showed that advancement amounts higher than 50 % do not significantly influence the success rate (Q = 0.373, p = 0.541). According to the GRADE score system, the quality of evidence resulted to be moderate.

CONCLUSION

The AHI improvement resulted to be not proportional to the mandibular advancement increase. It is plausible that the success of the therapy is influenced by a combination of variables that need closer study.

Cephalometric predictors of treatment outcome with mandibular advancement devices in adult patients with obstructive sleep apnea: a systematic review

Objective

The efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA) ranges between 42% and 65%. However, it is still unclear which predictive factors can be used to select suitable patients for MAD treatment. This study aimed to systematically review the literature on the predictive value of cephalometric analysis for MAD treatment outcomes in adult OSA patients.

Methods

The MEDLINE, Google Scholar, Scopus, and Cochrane Library databases were searched through December 2014. Reference lists from the retrieved publications were also examined. English language studies published in international peer-reviewed journals concerning the predictive value of cephalometric analysis for MAD treatment outcome were considered for inclusion. Two review authors independently assessed eligibility, extracted data, and ascertained the quality of the studies.

Results

Fifteen eligible studies were identified. Most of the skeletal, dental, and soft tissue cephalometric measurements examined were widely recognized as not prognostic for MAD treatment outcome; however, controversial and limited data were found on the predictive role of certain cephalometric measurements including cranial base angle, mandibular plane angle, hyoid to mandibular plane distance, posterior nasal spine to soft-palate tip distance, anterior nasal spine to epiglottis base distance, and tongue/oral cross sectional area ratio thus justifying additional studies on these parameters.

Conclusions

Currently available evidence is inadequate for identification of cephalometric parameters capable of reliably discriminating between poor and good responders to MAD treatment. To guide further research, methodological weaknesses of the currently available studies were highlighted and possible reasons for their discordant results were analyzed.