Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: An updated meta-analysis

Dental pulp stem cells promote genioglossus repair and systemic amelioration in chronic intermittent hypoxia

Obstructive sleep apnea (OSA) leads to chronic intermittent hypoxia (CIH) and is not well addressed by current therapies. The genioglossus (GG) is the largest upper airway dilator controlling OSA pathology, making its repair a potential treatment. This study investigates dental pulp stem cells (DPSCs) in repairing GG injury in a CIH mouse model. We induced DPSCs to myogenic lineage cells (iDPSCs) and transplanted them into GG of CIH mice. DPSCs/iDPSCs grafts improved EMGGG and muscle type transitions while reducing tumor necrosis factor α (TNF-α), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and creatine kinase (CK) levels, improving body weight. Moreover, iDPSCs increased Pax7+/Ki67+ and human-derived STEM121 cells in the GG compared with DPSCs. DPSCs/iDPSCs enhanced Desmin+ myotube formation in myoblasts under hypoxia in vitro, with iDPSCs increased human-derived myogenic markers and nuclei in myotubes. These results indicate that iDPSCs, beyond their paracrine effects like DPSCs, directly participate in myogenic differentiation, supporting the potential use of DPSCs for OSA treatment.

Evaluating pharmacological treatments for excessive daytime sleepiness in obstructive sleep apnea: A comprehensive network meta-analysis and systematic review

Obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness (EDS). Pharmacotherapy offers a potential treatment approach for EDS in OSA patients. This systematic review and meta-analysis aimed to assess the efficacy and safety of pharmacological interventions for alleviating EDS in patients with OSA. Following PRISMA guidelines, we included randomized controlled trials investigating pharmacological treatments for EDS in adult OSA until August 2023. We conducted meta-analysis, subgroup, and meta-regression analyses using a random effects model. Finally, a network meta-analysis synthesized direct and indirect evidence, followed by a comprehensive safety analysis. We included 32 articles in the meta-analysis (n = 3357). Pharmacotherapy showed a significant improvement in the Epworth Sleepiness Scale (ESS) score (Mean Difference (MD) -2.73, (95 % Confidence Interval (CI) [-3.25, -2.20], p < 0.01) and Maintenance of Wakefulness Test (MWT) score (MD 6.00 (95 % CI [2.66, 9.33] p < 0.01). Solriamfetol, followed by Pitolisant and modafinil, exhibited the greatest ESS reduction, while Danavorexton, followed by Solriamfetol and MK-7288, had the strongest impact on MWT. MK-7288 had the most total adverse events (AEs), followed by Danavorexton and armodafinil. Pharmacological Interventions significantly alleviate EDS in OSA patients but with heterogeneity across medications. Treatment decisions should involve a personalized assessment of patient factors and desired outcomes.

CPAP Treatment Improves Quality of Life and Self-perception of Voice Impairment in Patients with OSA

OBJECTIVE

The purpose of this study is to examine vocal fatigue and impairment, gastroesophageal symptoms, dysphagia risk, and sleep-related quality of life in individuals with obstructive sleep apnea (OSA) who have been treated with continuous positive airway pressure (CPAP) compared to those who have not received treatment.

METHODS

Fifty-four participants diagnosed with OSA completed an online research form. Of these, 29 were receiving CPAP treatment, while 25 were not undergoing treatment. The following instruments were used: Vocal Fatigue Index, Voice Handicap Index, Gastroesophageal symptoms, Eating Assessment Tool, and Quebec Sleep Questionnaire.

RESULTS

The group that received CPAP treatment had significantly lower scores in the functional domain and total Voice Handicap Index. They also experienced fewer symptoms of regurgitation, reduced daytime sleepiness, fewer nocturnal symptoms, and better emotional and social interactions in their quality of life compared to the untreated group. There were no significant differences in voice fatigue and dysphagia risk between the groups.

CONCLUSION

Individuals treated with CPAP experience reduced vocal impairment, fewer regurgitation symptoms, and improvement in the emotional and social interactions domains of their quality of life compared to individuals without treatment.

The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study

STUDY OBJECTIVES

To prospectively validate drug-induced sleep endoscopy with mandibular advancement maneuvers as a prediction tool for treatment success of oral appliance treatment (OAT).

METHODS

Seventy-seven patients diagnosed with moderate obstructive sleep apnea were included and underwent drug-induced sleep endoscopy. The upper airway collapse was assessed using the VOTE classification. Additionally, three mandibular advancement maneuvers were performed to predict treatment success of OAT. If the maneuver was negative, the level and degree and configuration of the persistent collapse was described according to the VOTE classification. All patients were treated with OAT and completed a follow-up sleep study with OAT in situ without regard to their anticipated response to treatment.

RESULTS

Sixty-four patients completed 6-month follow up. A positive jaw thrust maneuver proved to be significantly associated with favorable OAT response, whereas the chin lift maneuver and the vertical chin lift maneuver were not. Additionally, a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver was significantly associated with unfavorable OAT response.

CONCLUSIONS

The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting OAT response. Patients with a positive jaw thrust maneuver should be counseled toward favorable OAT response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of unfavorable OAT response. A negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing drug-induced sleep endoscopy solely for predicting the efficacy of OAT. However, the results of the current study could be influenced by heterogeneity in the assessment of respiratory parameters, variability in the performance of the mandibular advancement maneuvers, and the instability of bolus technique sedation.

CLINICAL TRIAL REGISTRATION

Registry: Netherlands Trial Register; Name: Drug-induced Sleep Endoscopy: a prediction tool for success rate of oral appliance treatment; Identifier: NL8425; URL: https://www.onderzoekmetmensen.nl/en/trial/20741.

CITATION

Veugen CCAFM, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2024;20(3): 353-361.

A Systematic Review of Oral Modifications Caused by the Prolonged Application of Continuous Positive Airway Pressure (CPAP) and Intraoral Appliances in Patients with Obstructive Sleep Apnea (OSA)

Objective

Prolonged use of oral devices as a substitute for traditional treatments has been studied in relation to the dental and skeletal changes associated with obstructive sleep apnea syndrome (OSA), which is a sleep-breathing disorder.

Materials and Methods

A review of articles indexed in PubMed, Google Scholar, Cochrane Library, Scopus, Web of Sciences, and CINHAL databases in September 2022 based on MeSH-based keywords with "dental and skeletal" and "oral appliance" and "obstructive sleep apnea" was examined to ensure that the keywords alone or cross-linked, depending on which base of the searched data, were used. 16 articles out of 289 articles were included in the research, and 273 articles were excluded due to lack of study.

Conclusions

CPAP treatment has limited dental or skeletal effects in short-term or long-term use. OAs and MADs show significant dental changes with prolonged use. MAS and TSD are more effective in short-term goals than CPAP. OAs' increase may cause dental and skeletal changes. MPD shows notable cephalometric alterations.

Oral appliance therapy for the management of obstructive sleep apnea in adults: an umbrella review protocol

OBJECTIVE

The objective of this review is to summarize the evidence on the effectiveness of oral appliance therapy compared with other therapeutic approaches (continuous positive airway pressure, maxillomandibular and upper airway surgeries, behavioral techniques) for the management of obstructive sleep apnea in adults.

INTRODUCTION

For primary snoring, mild to moderate obstructive sleep apnea, and patients with a severe condition who are intolerant of continuous positive airway pressure therapy, an oral appliance is the treatment of choice among conservative procedures. The effectiveness of these appliances is largely determined by a variety of parameters, including the severity of sleep apnea (mild, moderate, severe), materials and methods used to fabricate the appliance, and the degree of mandibular protrusion. Thus, it is important to evaluate the effectiveness of oral appliances in the reduction of sleep apnea.

INCLUSION CRITERIA

This review will include systematic reviews of quantitative studies reporting on the effectiveness of oral appliances for the treatment of obstructive sleep apnea of any severity, confirmed using polysomnography. The primary outcome will be measured by reduction in the apnea-hypopnea index.

METHODS

A search will be conducted of MEDLINE, Cochrane Database of Systematic Reviews, Scopus, Web of Science, CINAHL, Epistemonikos, Embase, ProQuest Dissertations and Theses, and Shodhganga Dissertations and Theses from database inception until the present, with no language restrictions. Google Scholar will be searched manually. Two independent reviewers will screen titles, abstracts, and full-text articles and perform data extraction. Quality assessment will be conducted using the standard JBI critical appraisal tool. Data will be extracted from systematic reviews and a synthesis of the findings will be presented. The certainty will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

REVIEW REGISTRATION

PROSPERO CRD42021258515.

Comparative evaluation of the efficacy of customized maxillary oral appliance with mandibular advancement appliance as a treatment modality for moderate obstructive sleep apnea patients-a randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) is quite common among the adult population, according to recent epidemiological studies. The most frequently suggested alternate treatment for mild to moderate OSA is oral appliances (OA). The purpose of the present study was to assess as well as compare the effectiveness of custom-made maxillary oral appliances against mandibular advancement appliances in the care of individuals suffering from moderate obstructive sleep apnea.

METHODS

A prospective interventional research was carried out with 40 participants. Polysomnography (PSG) was done and the participants with an apnea-hypopnea index (AHI) >15-30 were involved in the research. Study participants were randomly split up into two test groups: group I was the "Control Group" (group treated with a mandibular advancement device (MAD), n=20), while group II was exposed to a "customized maxillary oral appliance" (CMOA, n=20). Both groups had reference measures for AHI, blood oxygen saturation (SpO2), oro-nasal airflow via respiratory disturbance index (RDI), and the Epworth Sleepiness Scale (ESS). Appliances were fabricated and delivered to the respective study group participants. PSG was again conducted after a period of 1 and 3 months of appliance delivery and re-evaluation was done for all the parameters and was compared with reference measurements. The facts were analyzed using descriptive and analytical statistical methods. The statistical program utilized in the study was "SPSS (Statistical Package for Social Sciences) Version 20.1." After 1 and 3 months, the statistical significance between the two study groups was assessed at P<0.05.

RESULTS

The analysis of mean AHI, SPO2, RDI, and ESS for both test groups manifested statistically significant measures (P<0.001). The study results revealed a statistically significant depletion in mean AHI scores, improvement in mean SPO2 scores, and reduction in mean RDI scores and ESS scores when compared with reference measurements to 1 month, 1 to 3 months, and between reference measurements and 3 months.

CONCLUSION

The CMOA was effective in managing moderate OSA and has great therapeutic potential. It can be an option for the MAD for treating patients suffering from moderate obstructive sleep apnea.

TRIAL REGISTRATION

The study was registered under Clinical Trials Registry-India and the registration number is CTRI/2020/07/026936 . Registered on 31 July 2020.

Comparative evaluation of the efficacy of customized maxillary oral appliance with mandibular advancement appliance as a treatment modality for moderate obstructive sleep apnea patients-protocol for a randomized controlled trial

Background

Obstructive sleep apnea (OSA) is due to the obstruction of the upper airway during sleep. This condition is often associated with multiple symptoms and co-morbidities. There are many treatment options mentioned in the literature to manage OSA, among which interventional option of continuous positive airflow (CPAP) and non-interventional option, i.e., mandibular advancement device (MAD), which is an oral appliance (OA), are the most preferred ones. This study aims to evaluate the efficacy of customized maxillary oral appliances with mandibular advancement devices in moderate OSA patients.

Methods

A prospective interventional study with a randomized controlled trial will be carried out involving 40 participants (sample size), with an apnea-hypopnea index (AHI) > 15–30, recorded on polysomnography (PSG). Study participants will be randomly divided into the following treatment groups: control group or group subjected to mandibular advancement device (MAD, n=20) and second group subjected to customized maxillary oral appliance (CMOA, n=20). Baseline assessment of apnea/hypopnea index (AHI), oxygen saturation in blood, percentage of rapid eye movement, electroencephalogram, electrocardiogram, oro-nasal airflow via a pressure transducer, and Epworth Sleepiness Scale will be done. Then both study group participants will receive their respective appliances. And after one month and three months of delivery of the appliance, all the parameters, i.e., AHI, oxygen saturation in blood, percentage of rapid eye movement, electroencephalogram, electrocardiogram, oro-nasal airflow via a pressure transducer, and Epworth Sleepiness Scale will be re-evaluated and compared with the baseline measurements. Descriptive and analytical statistics will be done. SPSS (Statistical Package for Social Sciences) Version 20.1 will be used as statistical software. The statistical significance between the two groups after one month and three months will be evaluated at p< 0.05.

Discussion

We expect, customized maxillary oral appliance to be more efficient in managing moderate OSA, in comparison with MAD. If the hypothesis of the present study is confirmed, then this customized maxillary appliance will be quoted as a “gold standard” for managing moderate OSA.

Trial registration

CTRI/2020/07/026936 Registered 31 July 2020.

Oral appliances for obstructive sleep apnea: Emerging issues, upcoming challenges, and possible solutions

Background

As per the current epidemiological studies, the prevalence of obstructive sleep apnea (OSA) among the adult population is very high. Oral appliances (OAs) have emerged as the most recommended alternative treatment option for mild to moderate OSA.

Objective

The objective of this article is to propose or develop a new design of OA named "customized maxillary oral appliance (CMOA)," for managing moderate OSA syndrome.

Methods

The design proposed in this article is first of its kind that is fabricated on the maxillary arch. CMOA is developed by combining the principles of the three most popular OAs used in OSA, namely, soft palate lifters, tongue retaining devices, and mandibular advancement devices.

Conclusions

Given the potential impact of OSA on general and mental health and the side effects of existing appliances, there is a need for a new remedy to be introduced in the field of sleep medicine. This novel design can provide a new therapeutic option for patients with moderate OSA.

Clinical and Research Solutions to Manage Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA), a common sleep disorder disease, affects millions of people. Without appropriate treatment, this disease can provoke several health-related risks including stroke and sudden death. A variety of treatments have been introduced to relieve OSA. The main present clinical treatments and undertaken research activities to improve the success rate of OSA were covered in this paper. Additionally, guidelines on choosing a suitable treatment based on scientific evidence and objective comparison were provided. This review paper specifically elaborated the clinically offered managements as well as the research activities to better treat OSA. We analyzed the methodology of each diagnostic and treatment method, the success rate, and the economic burden on the world. This review paper provided an evidence-based comparison of each treatment to guide patients and physicians, but there are some limitations that would affect the comparison result. Future research should consider the consistent follow-up period and a sufficient number of samples. With the development of implantable medical devices, hypoglossal nerve stimulation systems will be designed to be smart and miniature and one of the potential upcoming research topics. The transcutaneous electrical stimulation as a non-invasive potential treatment would be further investigated in a clinical setting. Meanwhile, no treatment can cure OSA due to the complicated etiology. To maximize the treatment success of OSA, a multidisciplinary and integrated management would be considered in the future.

Oral Appliances for Snoring and Obstructive Sleep Apnea

Obstructive sleep apnea is a common condition, caused primarily by narrowing of the nasal and pharyngeal airway, leading to partial or complete airway collapse during sleep. Treatment with positive airway pressure (PAP) is considered first-line therapy, due to an efficacy rate of approximately 95%, yet long-term compliance with PAP is less than 40%. The efficacy of a sleep oral appliance is lower than PAP, yet it may have similar effectiveness. A sleep oral appliance is a reasonable second-line therapy for patients who refuse or fail PAP and may be reasonable first-line therapy.

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.