Dental side effects of an oral device to treat snoring and obstructive sleep apnea

Patients' perceptions of the importance of improvements and side effects from mandibular advancement device therapy for obstructive sleep apnea and snoring

OBJECTIVE

To assess which improvements and side effects are considered most important by patients with OSA treated with a MAD.

METHODS

A specific questionnaire consisting of 20 questions, including 10 questions on improvements and 10 on side effects, was developed and mailed to all subjects (54).

RESULTS

42 patients, participated in the survey by answering the questionnaire. The results showed that patients placed greater importance on the positive outcomes of treatment, with the most significant being the reduction in snoring and improvement in sleep quality. On the other hand, the side effects of difficulty speaking with the device, tooth mobility, and foreign body sensation were considered important.

CONCLUSIONS

The advantages perceived by the patients appear to outweigh the disadvantages, especially the reduction of snoring, increased productivity, and improved social and intellectual life. Most significant side effects are reversible and short-term, while occlusal changes, is not considered important by patients.

Self-reported oral moistening disorders in obstructive sleep apnoea: A scoping review

BACKGROUND

Obstructive sleep apnoea (OSA) is a highly prevalent problem with significant consequences. Continuous positive airway pressure (CPAP) and oral mandibular advancement device (MAD) are considered the standard treatments for OSA. Patients may experience self-reported oral moistening disorders (OMDs) (i.e. xerostomia or drooling) at the beginning, throughout and after treatment. This affects oral health, quality of life and treatment effectiveness. The exact nature of the associations between OSA and self-reported OMD is still unknown. We aimed to provide an overview of the associations between self-reported OMD on the one hand and OSA and its treatment (namely CPAP and MAD) on the other hand. In addition, we sought to determine whether OMD affects treatment adherence.

MATERIALS AND METHODS

A literature search in PubMed was performed up to 27 September 2022. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 48 studies were included. Thirteen papers investigated the association between OSA and self-reported OMD. They all suggested an association between OSA and xerostomia but not between OSA and drooling. The association between CPAP and OMD was addressed in 20 articles. The majority of studies have indicated xerostomia as a CPAP side effect; however, some have observed that xerostomia diminishes with CPAP therapy. In 15 papers, the association between MAD and OMD was investigated. In most publications, both xerostomia and drooling have been described as common side effects of MADs. These side effects are often mild and transient, and they improve as patients continue to use their appliance. Most studies found that these OMDs do not cause or are not a strong predictor of non-compliance.

CONCLUSION

Xerostomia is a common side effect of CPAP and MAD, as well as a significant symptom of OSA. It may be regarded as one of the indicators of sleep apnoea. Moreover, MAD therapy can be associated with OMD. However, it seems that OMD may be mitigated by being adherent to the therapy.

Comparisons of the effects of two types of titratable mandibular advancement devices on respiratory parameters and upper airway dimensions in patients with obstructive sleep apnea: a randomized controlled trial

OBJECTIVES

To compare the effects of two types of titratable mandibular advancement devices (MADs), namely MAD-H (allowing limited vertical opening) and MAD-S (allowing free vertical opening), on respiratory parameters and upper airway dimensions in patients with mild to moderate obstructive sleep apnea (OSA).

MATERIALS AND METHODS

Patients with mild to moderate OSA (5 ≤ apnea-hypopnea index (AHI) < 30 /h) were randomly assigned to two parallel MAD groups. All MADs were subjectively titrated according to a standardized protocol during a 3-month follow-up. Every patient underwent two polysomnographic recordings, and two cone beam computed tomography scans in supine position: one at baseline and another one after 3 months with the MAD in situ. The primary outcome variables were the AHI in supine position (AHI-supine) and the minimal cross-sectional area of the upper airway in supine position (CSAmin-supine).

RESULTS

A total of 49 patients were recruited, and 31 patients (21 men and 10 women) with a mean (± SD) age of 48.5 (± 13.9) years and a mean AHI of 16.6 (± 6.7) /h completed the study. In the per-protocol analysis, there was no significant difference between MAD-H (n = 16) and MAD-S (n = 15) in their effects on AHI-supine (P = 0.14) and CSAmin-supine (P = 0.59). Similar results were found in the intention-to-treat analysis (P = 0.47 and 0.57, respectively).

CONCLUSIONS

Within the limitations of this study, we conclude that there is no significant difference in the effects of an MAD allowing limited vertical opening and an MAD allowing free vertical opening on respiratory parameters and upper airway dimensions in patients with mild to moderate OSA.

CLINICAL RELEVANCE

MADs allowing limited vertical opening and allowing free vertical opening have similar effects on respiratory parameters and upper airway dimensions in patients with mild to moderate OSA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02724865. https://clinicaltrials.gov/ct2/show/NCT02724865.

Dental and Occlusal Changes during Mandibular Advancement Device Therapy in Japanese Patients with Obstructive Sleep Apnea: Four Years Follow-Up

Dentoskeletal changes caused by the long-term use of mandibular advancement devices (MADs) for obstructive sleep apnea (OSA) have rarely been investigated in Japan. We assessed the long-term dentofacial morphological changes in 15 Japanese patients with OSA who used two-piece MADs for an average of 4 years. Lateral cephalography analyses were performed initially and 4 years later (T1). The dental assessment included overjet, overbite, upper anterior facial height, lower anterior facial height (LAFH), total anterior facial height (TAFH), and anterior facial height ratio. Dental casts were digitized and analyzed using a 3D scanner. Changes in the apnea hypopnea index (AHI) and other sleep-assessment indices were assessed using polysomnography and out-of-center sleep testing. Radiography revealed lingual inclination of the maxillary central incisors, labial inclination of the mandibular central incisors, clockwise rotation of the mandible, and an increase in the TAFH and LAFH at T1. In the dental cast analysis, the diameter width and palatal depth tended to decrease and increase, respectively. There was a significant decrease in the AHI and other sleep assessment indices after using the MADs for approximately 4 years. However, these findings do not provide a strong basis and should be interpreted cautiously. Future studies should have a larger sample size and should further investigate the long-term occlusal and dental changes caused by the original MADs in Japanese patients with OSA.

Proof of Concept Study of an Oral Orthotic in Reducing Tic Severity in Tourette Syndrome

The use of an oral orthotic, called an occlusal splint, has gained recognition for the potential to reduce the frequency of tics for individuals with Persistent Tic Disorders. The purpose of this study was to assess the feasibility of a fully blinded, randomized controlled trial (RCT) to assess the safety, tolerability and initial efficacy of the oral orthotic in youth with chronic tics. Thirteen youth were randomly assigned to wear an active or sham orthotic in a two week double-blind RCT, with a 4-6 week unblinded follow up period. A statistically significant difference was found for change in tic severity between participants wearing the active and sham orthotic. However, this difference was not replicated during the follow up period. The oral orthotic is a promising intervention for the reduction of tics in youth with Tourette's Syndrome and is worthy of continued study to establish intervention efficacy and mechanism of action.

The comparison of two different mandibular positions for oral appliance therapy in patients with obstructive sleep apnea

BACKGROUND

An oral appliance (OA) can alleviate upper airway obstruction by pulling the mandible forward during sleep. While a large mandibular advancement with an OA decreases the number of apnea and hypopnea events, long-term use may cause side effects, such as toothache, stiffness, and pain in the temporomandibular joint.

OBJETIVES

This study aimed to evaluate the effectiveness of different mandibular positions for obstructive sleep apnea (OSA) and determine the optimal therapeutic mandibular position.

METHODS

Thirty-two patients (17 males and 15 females) with mild to moderate OSA participated in this prospective study. All patients were randomly allocated to receive a 50% mandibular advancement or a 75% mandibular advancement with an OA. The pre- and posttreatment apnea-hypopnea index (AHI), apnea index (AI), and Epworth Sleepiness Scale (ESS) were compared. Treatment effectiveness and treatment success were compared between groups.

RESULTS

AHI improved significantly in both groups, and AI improved significantly in the group with 50% mandibular advancement. No significant improvements in the ESS were observed in either group. There was no significant difference in treatment effectiveness between groups. In the proportion of females and males whose treatment was effective in the two groups, females were significantly greater than males.

CONCLUSIONS

For patients with mild to moderate OSA, 50% mandibular advancement is recommended as the initial therapeutic mandibular position. It was suggested that gender differences also affect treatment effectiveness.

Intervention to enhance adherence to mandibular advancement appliance in patients with obstructive sleep apnoea: study protocol for a randomised clinical trial

Background

Obstructive sleep apnoea (OSA) is a sleep-related breathing disorder characterised by the repeated episodic collapse of the upper airway during sleep, resulting in sleep deprivation, giving rise to apnoeas and hypopnoeas. Based on the severity of OSA, there are two primary treatment modalities, continuous positive airway pressure (CPAP) and mandibular advancement appliances (MAA); both are adherence-dependent. MAA is offered to those with mild to moderate OSA and is prescribed as an alternative to patients intolerable to CPAP. However, adherence to MAA treatment is variable and declines over time. Hence, the current study aims to assess the effectiveness of the stage-matched intervention, the Health Action Process Approach (HAPA), on adherence to MAA in patients with OSA.

Methods

A single-centre randomised clinical trial will be undertaken at Bart’s Health NHS Trust. Fifty-six participants with newly diagnosed OSA are planned to be enrolled in the study and randomised to intervention care (IC) and standardised care (SC) groups. Participants in the SC group will receive routine care whilst participants in the IC group will receive the stage-matched intervention, developed using the HAPA model. Data indicating MAA adherence will be collected both objectively and subjectively, from micro-sensors embedded in the MAA design and sleep diaries, respectively at 3, 6, 18 and 36 months. In addition, a range of questionnaires designed to assess risk perception, outcome expectancy, and self-efficacy (SEMSA) and quality of sleep (PSQI and ESS) and life (EQ-5DL), socio-economic and social support scales will be used.

Discussion

The currently available treatments for obstructive sleep apnoea depend entirely on the patient’s acceptance and use. There are several factors that affect cooperation and wear for example patients’ awareness of their condition, social support and psychological behaviour. In addition, mood, such as anxiety, stress, and depression, may affect wear. At the same time, we know that interventions involving more education and behaviour approaches can help patients adapt more easily to some treatments. As a result, the present trial aims to explore the potential role of these factors to maximise treatment success and minimise side effects.

Trial registration

ClinicalTrials.gov NCT04092660. Registered on September 6, 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05582-1.

Force Distribution of a Novel Core-Reinforced Multilayered Mandibular Advancement Device

A mandibular advancement device (MAD) is a commonly used treatment modality for patients with mild-to-moderate obstructive sleep apnea. Although MADs have excellent therapeutic efficacy, dental side effects were observed with long-term use of MADs. The aim of this study was to analyze the force distribution on the entire dentition according to the materials and design of the MADs. Three types of MADs were applied: model 1 (single layer of polyethylene terephthalate glycol (PETG)), model 2 (double layer of PETG + thermoplastic polyurethane (TPU)), and model 3 (core-reinforced multilayer). In the maxilla, regardless of the model, the incisors showed the lowest force distribution. In most tooth positions, the force distribution was lower in models 2 and 3 than in model 1. In the mandible, the mandibular second molar showed a significantly lower force in all models. The mandibular incisors, canines, and molars showed the highest force values in model 1 and the lowest values in model 3. Depending on the material and design of the device, the biomechanical effect on the dentition varies, and the core-reinforced multilayered MAD can reduce the force delivered to the dentition more effectively than the conventional single- or double-layer devices.

Effect of mandibular advancement device on the stomatognathic system in patients with mild-to-moderate obstructive sleep apnoea-hypopnoea syndrome

Objective

This study was conducted to evaluate the changes of temporomandibular joints (TMJs) through magnetic resonance imaging (MRI) scanning and the electrical changes in mandibular movement and masticatory muscle surface of mild‐to‐moderate obstructive sleep apnoea‐hypopnoea syndrome (OSAHS) patients before and after treatment with mandibular advancement device (MAD).

Methods

This was a single‐centre, prospective study recruiting OSAHS patients undergoing treatment with MAD in Department of Stomatology, Yannan Hospital, Kunming, China. Patients were recruited from February 2015 to October 2015, and TMJ changes were observed in MRI scanning before and after 18 months of treatment with MAD in cohort 1. The second cohort of the patients were recruited from January 2014 to September 2015 and electrical changes in mandibular movement and masticatory muscle surface of patients before and after 6 months of treatment with MAD.

Results

In the cohort 1, TMJ changes analysed through MRI scanning, before and after 18‐month treatment with MAD, there was no significant deviation in the angle of joint disc position. A minor change in the position relationship between condylar process, articular disc and articular fossa but not significant was observed. There was no significant difference in the shape and magnitude of mandibular incision edge movement, percussion movement, masticatory movement and condylar central trajectory among the recruited OSAHS patients, before and after 6 months of MAD treatment as analysed through electromyography.

Conclusion

In this study, from the results it was evident that the effect of MAD on the stomatognathic system of OSAHS patients is minimal.

Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: A randomized, placebo-controlled trial on temporomandibular side-effects

Purpose

To assess the differences in the frequency of clinical signs of temporomandibular disorder (TMD) pain and mandibular function impairment between mandibular advancement device (MAD) and nasal continuous positive airway pressure (nCPAP) therapies in obstructive sleep apnea (OSA) patients at baseline and after 6 month of treatment.

Methods

This study concerns a secondary analysis of a randomized placebo‐controlled trial in which different treatment effects of an objectively titrated MAD were compared with those of nCPAP and an intra‐oral placebo appliance in a parallel design. Sixty‐four mild to severe OSA patients (52.0 ± 9.6 years) were randomly assigned to these three groups. All patients underwent a shortened functional examination of their masticatory system at baseline and after 6 months to establish the presence of clinical signs of TMD pain. Mandibular function impairment was assessed with a questionnaire.

Results

Clinical signs of TMD pain were only rarely present at baseline and therapy evaluation. No significant differences were found between the three groups in the (low) frequency of clinical signs of TMD pain at both time points (p = .401–.176). In addition, the (low) scores of mandibular function impairment did not differ between the three groups either, neither at baseline (p = .744) nor after 6 months (p = .359).

Conclusions

A low frequency of clinical signs of TMD pain in mild to severe OSA patients was found after 6 months, regardless of treatment with MAD or nCPAP. In addition, no difference in mandibular function impairment was observed between the different treatment modalities.

Oral Appliances in Obstructive Sleep Apnea

Oral appliance therapy is increasingly prescribed as a non-invasive treatment option for patients diagnosed with obstructive sleep apnea. The custom-made titratable mandibular advancement devices (MAD) are the recommended type of oral appliances. Mandibular advancement devices are efficacious in reducing the severity of obstructive sleep apnea, however, only to a lesser extent than standard therapy using continuous positive airway pressure (CPAP). Although oral appliance therapy is known to reduce the severity of obstructive sleep apnea in most of the patients, one out of three patients still show negligible improvement under MAD therapy. Therefore, the selection of the appropriate candidates for this therapy is imperative and several upfront prediction tools are described. Overall, the health outcome of mandibular advancement device therapy is similar to that of CPAP, probably due to the inferior compliance of CPAP compared to MAD therapy, resulting in similar clinical effectiveness.

Mandibular advancement splints for the treatment of obstructive sleep apnea

Introduction: Obstructive sleep apnea (OSA) is a chronic condition which requires a comprehensive chronic disease management model, rather than a device-focused approach, so as to achieve the best possible health outcomes. Oral appliances are the main alternative to continuous positive airway pressure (CPAP) for the treatment of OSA. There has been an expansion of the research evidence to support the use of oral appliances in clinical practice and the clinical use of oral appliances for the treatment of OSA has become a mainstream practice.Areas covered: This review summarizes the evidence base for the use of oral appliances for the treatment of OSA. The types of oral appliances; their mechanism of action and clinical efficacy for the treatment of OSA; adverse effects, and the impact on patient acceptability and treatment adherence; and clinical effectiveness and health outcomes are discussed.Expert opinion: Personalization of treatment is vitally important in OSA and is a pre-requisite for optimizing adherence with treatment which, in turn, is a key determinant of clinical effectiveness. Treatment of OSA with mandibular advancement splints could provide an equivalent health benefit to CPAP despite not achieving a complete normalization of polysomnographic indices, mediated by differences in adherence profiles.

Subjective versus objective dental side effects from oral sleep apnea appliances

Purpose

Occlusal changes are common during long-term treatment with oral appliances (OAs) for sleep apnea. The aim of the present study was to compare subjectively reported bite changes with objective findings.

Methods

Consecutive adherent treated patients were asked to participate in this study. The patients responded to two questionnaires using numeric visual analogue scales (VAS), ranging from 0 (not at all) to 10 (very much). The first questionnaire included open questions and the second questionnaire comprised specific questions about side effects. Measurements of overjet, overbite, and space for the teeth were made on plaster casts taken before treatment start and at follow-up.

Results

Thirty-eight (12 women) patients with a median age of 64 years (interquartile range (IQR) 57 to 69 years) and a median treatment time of 9.5 years (IQR 5.8 to 14.3 years) were included. Overjet, overbite, the molar relationship, and the irregularity of the lower front teeth had changed significantly during treatment. There were no associations between any of the patients’ responses and the objectively measured bite changes. Younger patients, those with a small baseline overjet or overbite and those who developed an anterior crossbite were more likely to report bite changes.

Conclusions

Patients who choose to continue long-term treatment with oral appliances for sleep apnea are unaware of various types of bite changes. Such changes will, however, progressively increase in magnitude and be more difficult to take care of, if needed. It is therefore important continuously to follow up patients in regard to bite changes.

Dentoskeletal effects of oral appliance wear in obstructive sleep apnoea and snoring patients

Objectives

To evaluate the dentoskeletal changes associated with long-term and continuous mandibular advancement device (MAD) use in sleep-related breathing disorder patients.

Methods

Cephalometric measurements and three-dimensional model analysis were performed at baseline and after 3.5 ± 1.1 years in 20 snoring and obstructive sleep apnoea patients treated with the Silensor® appliance. Intra-group differences were compared using paired t-test or Wilcoxon signed-rank test. A regression analysis was performed for variables that showed a statistically significant difference between time points to evaluate the influence of treatment time and patient's initial characteristics on their variations. The statistical significance was set at P < 0.05.

Results

At cephalometric assessment, the maxilla revealed a significant decrease in horizontal position (SNA: -0.4 ± 0.72 degree, P = 0.021) and a significant retroclination of the upper incisor (-1.59 ± 1.07 degree, P < 0.001), while the mandible displayed a significant downward rotation (0.88 ± 1.28 degree, P = 0.006) and a proclination of the lower incisor (2.27 ± 1.38 degree, P < 0.001). Model analysis showed a decrease in upper total space discrepancy (-0.66 ± 0.72 mm, P < 0.002), overjet (OJ; -0.34 ± 0.47 mm, P < 0.011), and overbite (-0.4 ± 0.52 mm, P < 0.004). In the regression analysis, treatment time influenced the lower incisor inclination (Beta = -0.713, P = 0.018) and OJ (Beta = -0.218, P = 0.018); patients' initial characteristics had an effect on OJ (Beta = -0.195, P = 0.011).

Limitations

A larger sample size could increase the generalizability of the findings.

Conclusion

MAD wear after a mean of 3.5 years determines statistically significant but clinically irrelevant dentoskeletal changes. Their potential occurrence should be thoroughly discussed with patients; regular follow-up visits by a specialist experienced in dental sleep medicine are also mandatory during treatment in addition to polysomnographic examinations.

Alternative technique to transfer jaw relations for custom mandibular advancement devices: A case report

Background: Oral appliance therapy for obstructive sleep apnea can be helpful in mild and moderate cases. This clinical report evaluates the efficacy of a protocol that predicts an optimal jaw position and describes the response of a young OSA patient to treatment. Clinical Presentation: A 27-year-old woman was diagnosed with moderate OSA and had an apnea-hypopnea index (AHI) of 25.8/hr. In order to fabricate a custom device, an alternative procedure to determine the optimal protrusion and vertical positioning of the jaw was applied. After a follow-up period of 14 months, her apnea-hypopnea index (AHI) significantly decreased from 25.8 to 1.0 per hr with the appliance. The total number of respiratory events decreased from 211 to 8. Conclusion: Improved polysomnographic parameters showed that the oral device was efficient in treatment. The advantages of the device in this study are that it is comfortable, economical, and simple to fabricate.

Predictors of Side Effects With Long-Term Oral Appliance Therapy for Obstructive Sleep Apnea

STUDY OBJECTIVES

The aim of this study was to investigate the predictors of dental changes associated with long-term treatment with oral appliances (OAs) in patients with obstructive sleep apnea (OSA).

METHODS

This was a retrospective study to investigate Japanese patients with OSA receiving long-term treatment with OAs. Comparisons of cephalometric analysis were carried out between the initial and follow-up assessments of dental and skeletal changes. Based on dental changes, predictors that may cause side effects were investigated.

RESULTS

A total of 64 patients (average age at start of treatment: 57.7 ± 14.2 years, 44 males) were included in this study. The average duration of treatment was 4.3 ± 2.1 years. Over the total treatment period, there was a significant reduction in overjet (OJ) (1.5 ± 1.3 mm) and overbite (0.90 ± 1.5 mm), and an increase in the lower incisor line to the mandibular plane (3.1 ± 5.4°). A larger reduction in OJ of ≥ 1 mm was associated with treatment duration, use frequency, and mandibular advancement of the OAs. In addition to these predictive factors, the number of teeth was correlated with the amount of OJ reduction.

CONCLUSIONS

For long-term treatment with OAs, the risk of dental side effects should be considered, such as a reduction in OJ. A small number of maxillary teeth, as well as the factors associated with OAs, including treatment duration, use frequency, and mandibular advancement of the OAs, was correlated with an increased rate of OJ reduction.

COMMENTARY

A commentary on this article appears in this issue on page 7.

A prospective 10-year follow-up dental cast study of patients with obstructive sleep apnoea/snoring who use a mandibular protruding device

Objectives

This 10-year prospective study aimed to measure and evaluate the teeth position and occlusion following 10-year nocturnal use of a mandibular protruding device (MPD) in subjects with obstructive sleep apnoea (OSA) or snoring.

Materials and methods

Seventy-seven consecutive patients diagnosed with OSA/snoring were treated with an MPD. Fabrication of dental casts with jaw registration indexes in the intercuspal position was carried out at baseline and at follow-up, a construction bite was made, and an MPD was fitted. At the 10-year follow-up, all subjects (n = 74) were invited to participate. The dental casts were analysed in a series of measurements.

Results

Sixty subjects were included in the follow-up examination-41 were still using the device and 19 had ceased using the MPD. The MPD users showed significant changes in all analysed variables-decrease of overjet (-1.8 mm), overbite (-1.5 mm)-except the mandibular intercanine width and the maxillary anteroposterior relationship. Subjects who had ceased using their MPD retained their initial values, with the exception of a decreased overbite. The MPD users also showed an increased number of subjects with mesio-occlusion and posterior infra-occlusion; those who had ceased using their MPD mostly retained their initial status.

Conclusions

Long-term nocturnal use of an MPD may cause both favourable and unfavourable occlusion changes, such as a decrease of the overjet and overbite or posterior infra-occlusion, and these changes may continue to develop during treatment with an MPD. Subjects with a Class III relationship may not be a suitable group for treatment with an MPD due to the mesial drift of the mandibular teeth.

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.

Decrease of respiratory events in patients with obstructive sleep apnea-hypopnea syndrome using a mandibular advancement device assessed with split night polysomnography

Introduction

Mandibular advancement device (MAD) may represent a feasible choice in the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS), in well selected patients.

Objective

The aim of this study is to assess the efficacy of MAD in patients with OSAHS, using split night polysomnography (SNP)

Method

We performed an auto controlled clinical trial to assess the efficacy of MAD in 30 patients with snoring and OSAHS. Clinical evaluation was made every 2 weeks to adjust treatment and observe changes in clinical symptoms. Three-months after placement of the MAD, a SNP was performed, using the MAD in the second half of the night, in order to compare the respiratory results.

Results

SNP show significant changes with use of MAD (p<0.05) such as: Decrease in Snore index (from 159.95 to 32.46/h) and in Apnea-hypopnea index (AHI, from 22.45 to 4.63/h), increase in oxygen saturation (SaO₂, from 89.98% to 91.39%) and somnolence improvement, using the Epworth Sleepiness Scale (from 14.4 to 4.6 points).

Conclusion

Our data supports that the use of MAD is an alternative in the management of OSAHS, in well selected patients, used in a multidisciplinary fashion, and evaluated using a SNP.

Changes in lower incisor irregularity during treatment with oral sleep apnea appliances

PURPOSE

The purpose of this study is to test the hypothesis that a flexible oral appliance without incisor coverage (OA_Flex) increases the irregularity of the front teeth compared with a rigid appliance with incisor coverage (OA_Rigid) in patients treated for obstructive sleep apnea (OSA).

METHOD AND PATIENTS

Nineteen patients (10 men) who had used OA_Rigid and 22 patients (19 men) who had used OA_Flex with a median age of 61 years (IQR of 56 to 67 years) who had been treated during a median period of 2.9 years (IQR of 2.7 to 3.1 years) were included in the study. There was no difference in age (p = 0.601) or treatment time (p = 0.432) between the two appliance groups. The patients had clinical examinations, responded to a questionnaire, and had impressions taken for plaster casts. The irregularity of the front teeth was measured by Little's Index, where the combined linear displacement of all the front teeth is assessed. Changes between baseline and follow-up were compared between the two groups.

RESULTS

The OA_Flex group increased the irregularity of their lower front teeth by 0.3 mm (p = 0.018), while the OA_Rigid group had unchanged frontal irregularity (p = 0.717). The difference between the groups was significant (p = 0.035). There were no changes in the irregularity of the upper front teeth in either group. Patient satisfaction with treatment did not differ between the two appliances.

CONCLUSIONS

The present results support the hypothesis that a flexible OA without incisor coverage increases the irregularity of the lower front teeth compared with a rigid OA with incisor coverage.

Effect of jaw-opening exercise on prevention of temporomandibular disorders pain associated with oral appliance therapy in obstructive sleep apnea patients: A randomized, double-blind, placebo-controlled trial

PURPOSE

There are no studies on the prevention of temporomandibular joint and/or masticatory muscle pain (TMD pain) associated with oral appliance (OA) therapy in patients with obstructive sleep apnea (OSA). The aim of this study was to determine the effect of jaw-opening exercise on TMD pain associated with OA therapy in OSA patients.

METHODS

Twenty-five OSA patients without pain-related TMD were consecutively enrolled into a two-arm, randomized, double-blind, placebo-controlled trial. One group performed jaw-opening exercise (JE, n=13), and the other group performed placebo exercise (PE, n=12) for 1-month, and had started 2-weeks prior to insertion of an adjustable OA. TMD sign using the Research Diagnostic Criteria for Temporomandibular Disorders and TMD pain intensity using a visual analog scale (VAS) in the morning and daytime were evaluated at baseline (pre-exercise) and at 2-weeks, 1-month, and 3-months after OA insertion.

RESULTS

Pain-related TMD was not observed in the JE-group at all evaluation periods, although one subject in the PE-group was diagnosed with arthralgia at the 1-month evaluation. The JE-group showed lower morning and daytime VAS scores than the those of the PE-group at all evaluation periods, and significant group differences were found in terms of chewing pain and jaw-opening pain in the morning at the 1-month evaluation, and of jaw-opening pain during daytime at the 3-month evaluation (P<0.05).

CONCLUSIONS

Within the limitations of the study, jaw-opening exercise prior to OA therapy reduced the risk of TMD pain associated with OA use. Therefore, jaw-opening exercise may contribute to the prevention of TMD pain.

Influence of Oral Appliances for Mandibular Advancement on Dentitions Using a Strain Gauge Analysis: A Pilot Study

Introduction. This study aimed to evaluate the influence of oral appliances (OAs) on dentition using a strain gauge analysis. Materials/Methods. Eight volunteers, who were mild snorers, participated in this study. OAs were individually constructed, and advancement was defined as two-thirds of the maximum mandibular advancement. Strain gauges were mounted on the right first molar and central incisor of both the upper and lower arches. After OA use, two measurement sessions (short- and long-term) were performed. Results. Compressive strain on the labial surface was significantly larger than the stretching strain on the lingual surface on U1. On L1, the stretching strain on the labial surface was significantly larger than the compressive strain on the lingual surface. Comparing the upper and lower teeth, the stretching strain was significantly greater on L1 than on U1 in both test sessions. Moreover, the stretching strain was significantly larger on U6 than on L6. Conclusion. OA side effects, such as forcing on the incisors, might be repeated every night. In this way, permanent occlusal changes, such as labial tipping of L1, may occur, followed by lingual tipping of U1 and buccal and lingual movements of the U6 and L6, respectively.

Assessment of oral appliance for obstructive sleep apnea patients

Although oral appliances (OAs) have become widely used for the management of obstructive sleep apnea (OSA), side effects of OAs are generally related to poor utilization. The purpose of the present study was to evaluate relationship between utilization and treatment efficacy of a boil-and-bite appliance for OSA patients. A total of 135 patients with OSA who had used an OAs were mailed a questionnaire to determine whether they were currently using the OA. If so, they were asked about OA use, improvement of signs and subjective symptoms, and utilization. Otherwise, they were asked to indicate why and when they quit using the OA. Results of overnight polysomnography (PSG) before and after treatment were reviewed. Of the 48 responding patients, 33 patients were currently using the OA. The most common complication was excessive salivation (n = 11). All indices from PSG excluding arousal index were significantly improved after treatment (p < 0.05). Thirty patients showed improved signs and subjective symptoms. Eight out of 12 subjects (66.7%) were successfully treated, achieving an apnea-hypopnea index (AHI) < 10/h and >50% reduction in apnea-hypopnea index. Of the 15 patients no longer using the OA, the primary reason for quitting was "no treatment effect" (n = 5). No indices from PSG recording differed between before and after treatment in the not-using group. These results suggest that both subjective and objective signs and symptoms improved with use of the OA in the using group. However, no signs and subjective symptoms or indices of sleep quality differed between before and after treatment in the not-using group. Device improvements are needed to achieve better treatment efficacy, and thus improve compliance. The present study evaluated relationship between utilization and treatment efficacy of a boil -and bite appliance for OSA patients. Device improvements are needed to achieve better treatment efficacy, thus improve compliance.

How has our interest in the airway changed over 100 years?

Since the beginning of our specialty, our understanding of the link between function and facial growth and development has progressively improved. Today, we know that children with sleep-related breathing problems will often develop distinctive facial characteristics. In adults, sleep apnea can result in serious morbidity and mortality. Orthodontists can ask sleep-related questions in the health history to help identify sleep breathing disorders. Treating these patients presents unique opportunities for orthodontists to collaborate with other medical specialties to improve a patient's health and treatment outcome. Research presented in our Journal in the next century may shed new light that will help us better identify the problem and aid the specialty in developing more effective evidence-based treatment. Additional efforts are needed to understand the physiology, neurology, and genetics of sleep breathing disorders.

Efficacy of custom made oral appliance for treatment of obstructive sleep apnea

INTRODUCTION

oral appliance for the treatment of OSA is considered as an effective, low-risk alternative to CPAP. Demand for oral appliance increases as an alternative for those who cannot tolerate CPAP and refuse surgery. Oral appliances uses the traditional methods to advance the mandible thus modify the posture and their by enlarge the airway or otherwise reduce the collapsibility.

AIMS AND OBJECTIVES

The main objective of this study was to evaluate the efficacy of custom made oral appliance on sleep characteristics of OSA patients.

MATERIALS AND METHODS

Polysomnography was done on 15 patients of 24-60 years of age before (T1), and after the delivery of the custom made oral appliance (T2).

STATISTICAL ANALYSIS

Paired t tests were performed to determine the significance of change in the polysomnographic and cephalometric variables. P < 0.05 was considered as significant.

RESULTS

All patients with oral appliance showed an improvement in sleep parameters with an increase in sleep efficiency, and desaturation index with the use of oral appliance. ESS and cephalometric findings showed improvement in the sleep apnea in concordance with the sleep parameters.

CONCLUSIONS

Custom made oral appliance is a useful treatment option for improving quality of sleep and can be considered as an alternative treatment modality.

Long term therapeutic efficacy of a soft monobloc mandibular advancement device in adults with obstructive sleep apnea

AIM

To evaluate the long term (48 months) therapeutic efficacy of a soft monobloc mandibular advancement device in adult patients with mild or moderate obstructive sleep apnea.

METHODS

The study population comprised 28 patients (6 female and 22 male, mean age 52.2 ± 6.8 years) affected by obstructive sleep apnea. After a baseline medical and somnographic examination, a functional examination of the stomatognathic system, and a questionnaire focused on sleep-related qualities and a daytime somnolence, each patient received an individual device. Two follow-ups were made 6 months (T1) and 48 months (T2) after soft monobloc mandibular advancement device treatment had been initiated, and all initial examinations were repeated.

RESULTS

The statistical analysis showed a significant decrease in body mass index value between T1 and T2 (ρ = 0,012), an increase of Epworth sleepiness scale value between T1 and T2 (ρ = 0,012), and a significant improvement and decrease of apnea/hypopnea index between T0 and T1 (ρ = 0,010) and between T0 and T2 (ρ = 0,013).

CONCLUSION

Treatment with the soft monobloc mandibular advancement device is a therapeutic solution with long term and stable effects (48 months) for patients suffering from mild or moderate obstructive sleep apnea.

Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment

STUDY OBJECTIVES

To evaluate the magnitude and progression of dental changes associated with long-term mandibular advancement splint (MAS) treatment of obstructive sleep apnea (OSA).

METHODS

Retrospective study of adults treated for primary snoring or mild to severe OSA with MAS for a minimum of 8 years. The series of dental casts of patients were analyzed with a digital caliper for changes in overbite, overjet, dental arch crowding and width, and inter-arch relationships. The progression of these changes over time was determined and initial patient and dental characteristics were evaluated as predictors of the observed dental side effects of treatment.

RESULTS

A total of 77 patients (average age at start of treatment: 47.5 ± 10.2 years, 62 males) were included in this study. The average treatment length was 11.1 ± 2.8 years. Over the total treatment interval evaluated there was a significant (p < 0.001) reduction in the overbite (2.3 ± 1.6 mm), overjet (1.9 ± 1.9 mm), and mandibular crowding (1.3 ± 1.8 mm). A corresponding significant (p < 0.001) increase of mandibular intercanine (0.7 ± 1.5 mm) and intermolar (1.1 ± 1.4 mm) width as well as incidence of anterior crossbite and posterior open bite was observed. Overbite and mandibular intermolar distance were observed to decrease less with time, while overjet, mandibular intercanine distance, and lower arch crowding all decreased continuously at a constant rate.

CONCLUSIONS

After an average observation period of over 11 years, clinically significant changes in occlusion were observed and were progressive in nature. Rather than reaching a discernible end-point, the dental side effects of MAS therapy continue with ongoing MAS use.

COMMENTARY

A commentary on this article appears in this issue on page 1293.

Management of snoring and obstructive sleep apnea with mandibular repositioning appliances: a prosthodontic approach

Dentists are becoming increasingly aware of the importance of the detection and management of obstructive sleep apnea. The anatomic and neuromuscular risk factors in the pathogenesis of obstructive sleep apnea are reviewed with particular emphasis on oral findings. Mandibular repositioning appliances hold an important role in the treatment of this condition; however, knowledge of indications and contraindications for treatment, potential areas of oropharyngeal obstruction, appliance design, and treatment steps are vital to ensure maximum treatment success. A review of the steps involved in treatment and management with particular emphasis on collaborative care with physicians is presented.

Evaluation of a novel device for measuring patient compliance with oral appliances in the treatment of obstructive sleep apnea

PURPOSE

The purpose of this study was to evaluate a novel intraoral monitor for measuring patient compliance of oral appliances for the treatment of obstructive sleep apnea.

MATERIALS AND METHODS

A clinical trial was conducted to compare objective recording by an intraoral compliance monitor and self-reporting by participants using a mandibular repositioning device (MRD). Ten participants were fitted with a Thornton Adjustable Positioner (TAP III) with an embedded compliance monitor. The participants were asked to wear the test appliance for seven nights and to record their usage of the appliance and any adverse effects in a treatment journal. The data were downloaded to a dedicated computer using radio-frequency identification (RFID) technology, and the information was compared to the data in the participant's journal.

RESULTS

The mean objective wearing time, as detected by the compliance monitor, was found to be 6.6 ± 1.6 hours/night. The mean subjective wearing time, as recorded by the participants, was 6.5 ± 1.5 hours/night. The correlation between subjective and objective times was 0.9985. The use of the test appliance by this sample population was 68.7% with a range of 24% to 100%. Participants reported a range of adverse outcomes related to the MRD consistent with those reported in the literature and were found to be transient in nature.

CONCLUSIONS

This study supports previously reported usage times and adverse outcomes. The compliance monitor showed a very high linear correlation between subjective and objective data, validating its use in future compliance studies.

Short-term efficacy of mandibular advancement splint in treatment of obstructive sleep apnea-hypopnea syndrome

OBJECTIVE: The aim of the present study was to determine the short-term efficacy of treatment for snoring and obstructive sleep apnea-hypopnea syndrome (OSAHS) using a mandibular advancement splint. METHODS: The sample comprised 20 patients (13 men and 7 women; mean age = 48 years; mean body mass index = 27.07) with OSAHS. Polysomnograms were performed before and 60 days after mandibular advancement splint therapy. RESULTS: There was a significant reduction in the apnea-hypopnea index (AHI) following treatment (mean pretreatment AHI = 20.89 ± 17.9 versus mean posttreatment AHI = 4.43 ± 3.09) (p < 0.05). The snoring reduced and the sleep efficiency improved, as registered by polysomnograms (p<0.05). CONCLUSIONS: The sleep quality improved in patients using mandibular advancement splint. Further studies evaluating long-term effects are needed.

Treatment of obstructive sleep apnea with oral appliances

BACKGROUND

The purpose of this study was to evaluate the effectiveness of mandibular advancement devices (MADs) for treatment of obstructive sleep apnea syndrome (OSAS) compared with the results obtained with a placebo device in accordance with the following indicators: apnea hypopnea index (AHI) per hour of sleep, apnea index (AI) per hour of sleep, mean oxyhemoglobin saturation, sleep efficiency, and percentage of rapid eye movement (REM) sleep.

METHODS

This is a controlled, prospective longitudinal study with a follow-up time of 10.5 months. Nineteen patients (8 females and 11 males) with mean age 48.6 years (SD 9.6) were selected for the study. The sample was randomized in terms of device use, and the evaluation design was double blind. A total of 57 polysomnography tests were studied (at baseline, after the use of a MAD, and after the use of placebo). The following variables were assessed: AHI, AI, mean oxyhemoglobin saturation, percentage of REM sleep, and sleep efficiency. Wilcoxon and Mann-Whitney tests were used for evaluating data (p<0.05).

RESULTS

Reductions from 16.3 to 11.7 in AHI and from 5.7 to 3.8 in AI were observed after MAD use. During the use of placebo, AHI increased from 16.3 to 19.6, and AI from 5.7 to 7.5. The other indexes showed no statistically significant differences.

CONCLUSIONS

Treatment with oral appliances, i.e., MADs, can be an effective alternative for mild and medium-to-moderate OSAS, but requires strict monitoring due to differences in individual response to this therapy.

Effect of mandibular advancement device therapy on the signs and symptoms of temporomandibular disorders

Objectives

Mandibular advancement device therapy is effectively used in the treatment of obstructive sleep apnea, but also several side effects in the masticatory system have been reported. The aim of this study was to evaluate the subjective symptoms and clinical signs of temporomandibular disorders connected to mandibular advancement device therapy.

Material and Methods

The material consisted of 15 patients (9 men and 6 women, mean age 51.1 years, range 21 to 70 years) diagnosed with obstructive sleep apnea (OSA). Subjective symptoms and clinical temporomandibular disorders (TMD) signs were recorded at the beginning of the treatment (baseline) and at 1-month, 3-month, 6-month and 24-month follow-ups. The degree of TMD was assessed using the anamnestic (Ai) and the clinical dysfunction index (Di) of Helkimo. For assessing the effect of TMD the patients were divided in discontinuing and continuing groups.

Results

According to Ai and Di, the severity of TMD remained unchanged during the follow-up in most of the patients. Temporomandibular joint (TMJ) crepitation was found more frequently in discontinuing patients at all follow-ups. The difference was statistically significant (P < 0.05) at the six-month follow-up. Masticatory muscle pain during palpation was a frequent clinical sign at the baseline and during the follow-up period but the difference between discontinuing and continuing patients was not significant.

Conclusions

It seems that signs and symptoms of temporomandibular disorders do not necessarily increase during long-term mandibular advancement device therapy. However, it seems that patients with clinically assessed temporomandibular joint crepitation may discontinue their mandibular advancement device therapy due to temporomandibular disorders.

Long-term therapeutic efficacy of oral appliances in treatment of obstructive sleep apnea-hypopnea syndrome

Objective:

To investigate the long-term efficacy and safety of oral appliances (OAs) in treating obstructive sleep apnea-hypopnea syndrome (OSAHS) by length of treatment.

Materials and Methods:

This is a retrospective study to review the usage of OAs in Chinese OSAHS patients in recent decades. Ninety-four valid questionnaires were returned by 412 patients with OSAHS receiving OA treatment. Among the wearers, 22 agreed to follow-up polysomnography, and 25 agreed to follow-up cephalograms. Tolerance and side effects of OAs were assessed by a survey. Comparisons of efficacy were carried out between the initial and follow-up polysomnography measurements. Cephalometric analysis was used to investigate skeletal and occlusal changes to determine safety of the OAs.

Results:

The longest treatment extended to 147 months, with a median of 74 months (first and third quartiles, 30 and 99 months, respectively). Among the participants, 14.9% had been treated for more than 120 months. Side effects were temporary and relatively minimal and included tooth soreness (37.2%), dry mouth (33.0%), odd bite feeling (31.9%), and excess salivation (30.8%). Polysomnography proved that OAs remained effective for the treatment of OSAHS in the long term; initial Apnea-Hypopnea Index values were reduced from a median of 24.50 (quartiles, 14.65, 54.05) without the OA to 7.40 with the OA (2.12, 10.00), and follow-up median values were 25.55 without the OA (11.71, 43.65) and 4.25 with the OA (1.38, 7.70). Cephalometric analysis indicated mild and slow changes in the skeleton and occlusion after average treatment duration of 5 years.

Conclusion:

OAs provided effective and safe long-term therapy for patients with OSAHS. Follow-up supervision is recommended since long-term alterations take place, although these appear to be minimal.

Recent Developments in the Treatment of Obstructive Sleep Apnea

Modern sleep medicine has been in existence for only 20 years and therefore has to be regarded as a comparatively recent field of specialization. For this reason it is not surprising that there are numerous new trends and developments concerning the treatment of sleep-related breathing disorders. This review focuses on developments in the treatment of obstructive sleep apnea (OSA) over the last 5 years.The review is based on a Medline bibliographic search using the key words 'treatment', 'obstructive sleep apnea' and 'sleep-related breathing disorders' and covers papers published since 1997, including references in these articles. In respect to conservative treatments the following important developments were found. Oral devices were shown to be effective in about 50-70% of patients with OSA, but at this stage it is not possible to predict in which patients successful treatment can be expected. As subjective compliance averages only about 50%, thermoplastic devices used as trial devices provide a reasonable alternative to reduce costs. Automatic continuous positive airway pressure (CPAP) units have been shown to cut costs when used for pressure titration in severe sleep apneics during the day or when used in so-called split-night procedures in appropriate cases. Nasal CPAP has proven to be effective in children, showing higher compliance rates than in adults. The development of mouth-pieces provides the possibility of using CPAP orally, e.g. after nasal surgery. Electrical stimulation of the tongue muscles shows promising preliminary results. Nevertheless, further research in this field is necessary. In the field of surgery, the most valuable development has been tissue reduction using radiofrequency energy, which has been shown to be effective and minimally invasive. Other fundamentally new surgical techniques have not been attempted within the last 5 years; instead, development in this area appears to be defined by a combination of previously known methods (so-called multilevel surgery) and optimized methods of patient selection. Such combined surgical procedures has achieved success rates of about 70%. Taking all these developments into account, CPAP therapy remains the gold standard for treatment of patients with OSA; yet the low long-term compliance rates of 60-70% have to be regarded as a major challenge warranting further effort.

Short-term change in occlusal function after using mandibular advancement appliance for snoring: a pilot study

The main aim was to evaluate the influence on occlusal contact area (OCA), maximum bite force (MBF), center of occlusal load (COL), and tooth pain after the nocturnal use of different mandibular advance appliances (MAAs) for snoring. Subjects were consisted of ten adult volunteers with mild snoring in Hiroshima University Hospital. Recordings of occlusal function were performed six times for two hours, that is, immediately and 5, 15, 30, 60, and 120 minutes after the nocturnal use of MAA. The subjects continuously scored their pain intensity on a 10 cm visual analogue scale (VAS) when MBF was measured. Comparing two MAAs, OCA and MBF were significantly larger in two-piece MAA than in one-piece MAA five minutes after removing the appliance. Significant difference in COL and VAS score compared to baseline disappeared more quickly with two-piece MAA than with one-piece MAA. In conclusion, it is shown that two-piece MAA could be superior to the one-piece one in terms of the degree side effect on occlusal function.

The surgical treatment of sleep-related upper airway obstruction

BACKGROUND

Obstructive sleep apnea (OSA) is a very common disorder among adults: the prevalence of mild OSA is 20%, and that of moderate or severe OSA is 6% to 7%. Simple snoring is even more common. Conservative treatments such as nocturnal ventilation therapy and oral appliances are successful as long as the patient actually uses them, but they do not eliminate the underlying obstruction of the upper airway.

METHOD

The relevant literature up to 2008 on the surgical treatment of OSA was selectively reviewed.

RESULTS

Five types of surgical treatment for OSA are available, each for its own indications: optimization of the nasal airway to support nasal ventilation therapy, (adeno-)tonsillectomy as first-line treatment for OSA in children, minimally invasive surgery for simple snoring and mild OSA, invasive surgery as first- and second-line treatment for mild OSA, and invasive multilevel surgery as second-line treatment of moderate to severe OSA that remains refractory to ventilation therapy.

CONCLUSION

Surgical treatment for OSA is appropriate for specific indications as a complement to the established conservative treatment methods.