Mandibular advancement device in patients with obstructive sleep apnea : long-term effects on apnea and sleep

Long-term efficacy of mandibular advancement devices in the treatment of adult obstructive sleep apnea: A systematic review and meta-analysis

This study aims to review the long-term subjective and objective efficacy of mandibular advancement devices (MAD) in the treatment of adult obstructive sleep apnea (OSA). Electronic databases such as PubMed, Embase, and Cochrane Library were searched. Randomized controlled trials (RCTs) and non-randomized self-controlled trials with a treatment duration of at least 1 year with MAD were included. The quality assessment and data extraction of the included studies were conducted in the meta-analysis. A total of 22 studies were included in this study, of which 20 (546 patients) were included in the meta-analysis. All the studies had some shortcomings, such as small sample sizes, unbalanced sex, and high dropout rates. The results suggested that long-term treatment of MAD can significantly reduce the Epworth sleepiness scale (ESS) by -3.99 (95%CI -5.93 to -2.04, p<0.0001, I2 = 84%), and the apnea-hypopnea index (AHI) -16.77 (95%CI -20.80 to -12.74) events/h (p<0.00001, I2 = 97%). The efficacy remained statistically different in the severity (AHI<30 or >30 events/h) and treatment duration (duration <5y or >5y) subgroups. Long-term use of MAD could also significantly decrease blood pressure and improve the score of functional outcomes of sleep questionnaire (FOSQ). Moderate evidence suggested that the subjective and objective effect of MAD on adult OSA has long-term stability. Limited evidence suggests long-term use of MAD might improve comorbidities and healthcare. In clinical practice, regular follow-up is recommended.

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.

Arch Measurement Changes upon Biomimetic Oral Appliance Therapy for Adults with Obstructive Sleep Apnea

Background:

Obstructive Sleep Apnea (OSA) is the most common form of sleep disordered breathing. Patients who arrive at the dental office with a diagnosis of OSA are often treated with a mandibular advancement device (MAD). A biomimetic oral appliance therapy (BOAT) offers an alternative nonsurgical method, which can putatively resolve OSA by combining maxilla-mandibular correction and addressing craniofacial deficiencies.

Aim:

To determine whether maxilla-mandibular correction changes induced by BOAT produce a more favorable upper airway, which might result in a reduction in the severity of OSA.

Methods:

Patients who were diagnosed with mild to moderate obstructive sleep apnea (OSA, 9 males, 8 females; age, mean (SD): 45.76(10.31), BMI mean (SD): 33.5(13.43), underwent BOAT therapy. Subjects had 2 months of follow-up visits, including examinations for progress and adjustment of the appliances. The mean apnea-hypopnea index (AHI) with no appliance in the mouth prior to BOAT and after treatment was recorded. The mid-palatal screw mechanism of the appliance was advanced once per week. The subjects were asked to wear the appliance for 10-12 hours/day and night. Paired T-Test was used to analyze the results.

Results:

The BOAT treatment enhanced upper airway function as the total AHI was significantly lower after treatment (P=0.019). Parameters that were significantly improved by the end of the treatment period included total AHI/Per hour of sleep (p=0.019), NREM-AHI (p=0.019), desaturation index (p=0.041), average SpO2 (p=0.088), and average O2 while in non-REM (p=0.043). Measurements of jaw changes were all statistically significant except lower 6-6 and lower 7-7. Additionally, a strong negative correlation between AHI and jaw changes was shown for upper 6-6 (p=-0.52), upper 7-7 (p=-0.48), and lower 3-3 (p=-0.42).

Conclusion:

The BOAT provides a useful form of therapy for the resolve of OSA. This study suggests that BOATS may be able to reduce the AHI to within normal limits. Still, long-term follow-up is needed to determine whether these subjects need a maintenance program to retain their initial upper airway improvement.

Current and Novel Treatment Options for OSA

Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy.

The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd

Berlin and Epworth Surveys to Predict Obstructive Sleep Apnea for Adults on Biomimetic Oral Appliance Therapy: A Nonrandomized Clinical Trial

Background

Two questionnaires (Berlin Questionnaire (BQ) and Epworth Sleepiness Scale (ESS)) are the widely used screening instruments for subjects suffering from sleep disorders. Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing. The biomimetic oral appliance therapy (BOAT) offers an alternative nonsurgical method, which can improve symptoms and indices of OSA on objective sleep testing.

Aim

To describe testing the ability of BQ and EES for prediction of BOAT outcomes during OSA.

Methods

Seventeen adults (9 males, 8 females; age, mean (SD): 45.76 (10.31), BMI mean (SD): 33.5(13.43)) who underwent an overnight sleep study were diagnosed by a sleep specialist physician. The BQ and EES were recorded before and after BOAT treatment. Subjects with mild-to-moderate OSA had 2 months of follow-up visits and underwent a final overnight sleep study to measure apnea-hypopnea index (AHI). The subjects were asked to wear the appliance for 10–12 hours/day and at night. Findings were analyzed statistically using paired t-tests.

Result

As per sleep test results, pre-BOAT AHI measures versus post-BOAT AHI measures showed significant improvement. Comparing the BQ before versus after treatment showed that at the pretreatment stage, 66.0% of patients had high-risk score, whereas 34% had low-risk score. After treatment, 66.0% of patient had low-risk scores, whereas 34% had high-risk scores. As for the ESS, treatment resulted in significant reduction of total score from 10.43 ± 6.32 to 5.00 ± 5.20 (P < 0.01, paired t-test). Finally, there was a mild negative correlation between AHI and each of the BQ and ESS scores that was not statistically significant (r = −0.420, N = 26, P > 0.05, and r = −0.41, N = 26, P > 0.05, respectively).

Conclusion

The BOAT device may provide a useful form of therapy to improve OSA-related PSG parameters such as AHI. Both BQ and ESS were predictive to improvements detected by the sleep study during BOAT device use.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mandibular advancement device use in obstructive sleep apnea: ORCADES study 5-year follow-up data

STUDY OBJECTIVES

Mandibular advancement devices (MADs) are an alternative to continuous positive airway pressure for the management of obstructive sleep apnea (OSA). The ORthèse d'avanCée mAndibulaire dans le traitement en DEuxième intention du SAHOS sévère (ORCADES) study is investigating the long-term effectiveness of MAD therapy in patients with OSA who refused or were intolerant of continuous positive airway pressure. Five-year follow-up data are presented.

METHODS

Data were available in 172 of 331 patients treated with a custom-made computer-aided design/computer-aided manufacturing biblock MAD (Narval CC; ResMed, Saint-Priest, France). The primary end point was treatment success (≥50% decrease in apnea-hypopnea index from baseline).

RESULTS

Five-year treatment success rates were 52% overall and 25%, 52%, and 63%, respectively, in patients with mild, moderate, or severe OSA. This reflects a decline over time vs 3-6 months (79% overall) and 2 years (68%). Rates declined in all patient subgroups but to the greatest extent in patients with mild OSA. The slight worsening of respiratory parameters over time was not associated with any relevant changes in sleepiness and symptoms. Moderate or severe OSA at baseline, treatment success at 3-6 months, and no previous continuous positive airway pressure use were significant independent predictors of 5-year treatment success on multivariate analysis. No new safety signals emerged during long-term follow-up. The proportion of patients using their MAD for ≥4 h/night on ≥4 days/wk was 93.3%; 91.3% of patients reported device use of ≥6 h/night at 5 years. At 5-year follow-up, 96.5% of patients reported that they wanted to continue MAD therapy.

CONCLUSIONS

Long-term MAD therapy remained effective after 5 years in >50% of patients, with good levels of patient satisfaction and adherence.

CITATION

Vecchierini MF, Attali V, Collet JM, et al. Mandibular advancement device use in obstructive sleep apnea: ORCADES study 5-year follow-up data. J Clin Sleep Med. 2021;17(8):1695-1705.

Avoiding and Managing Oral Appliance Therapy Side Effects

There is a serious need to consider all potential side effects thoughtfully before commencing individual treatment with oral appliance therapy. Although many of these side effects are self-limiting, easily corrected, or innocuous, others are difficult or impossible to correct and can affect the patient in serious ways. As this field evolves, new information is discovered, and new products are introduced at a rather rapid pace, continuing education and prudent practice are critical to ethical care in the practice of dental sleep medicine.

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.

Long-term obstructive sleep apnea therapy: a 10-year follow-up of mandibular advancement device and continuous positive airway pressure

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder, commonly managed by either continuous positive airway pressure (CPAP) or a mandibular advancement device (MAD). Long-term follow-up and comparison regarding efficacy of these therapies is scarce. In this study the results of treatment, patient adherence, and satisfaction over a 10-year follow-up of these therapies are reported.

METHODS

This is a longitudinal follow-up study taken from a subset of patients initially enrolled in a randomized controlled clinical trial of 103 patients with OSA (51 and 52 patients randomized for MAD and CPAP, respectively). After a 10-year follow-up period, 14 patients using MAD and 17 patients using CPAP could be evaluated for this longitudinal follow-up study. Data were analyzed at baseline, after 3 months and at 1-, 2-, and 10-year follow-up. All 31 patients with OSA underwent polysomnography and self-reported measurements.

RESULTS

Polysomnography results showed a favorable outcome of both therapies at 10-year follow-up. At baseline, included patients in both groups did not significantly differ in apnea-hypopnea index (AHI) values. At 10-year follow-up, both the MAD and CPAP groups showed a significant reduction in AHI. At baseline the mean AHI in the MAD group was 31.7 ± 20.6 events/h whereas in the CPAP group it was 49.2 ± 26.1 events/h. At 10-year follow-up the mean AHI in the MAD group was 9.9 ± 10.3 events/h and in the CPAP group it was 3.4 ± 5.4 events/h. Both therapies resulted in a substantial improvement in self-reported neurobehavioral outcomes at 10-year follow-up.

CONCLUSIONS

Both CPAP and MAD therapy demonstrate good and stable treatment effects after a 10-year follow-up period. Therefore, when indicated, both therapies are appropriate modalities for the long-term management of OSA.

CLINICAL TRIAL REGISTRATION

Registry: Netherlands Trial Register; Name: Management of the Obstructive Sleep Apnea-Hypopnea Syndrome: Oral Appliance versus Continuous Positive Airway Pressure Therapy; Identifier: NL75; URL: https://www.trialregister.nl/trial/75.

Efficacy and tolerability of a custom-made Narval mandibular repositioning device for the treatment of obstructive sleep apnea: ORCADES study 2-year follow-up data

OBJECTIVE/BACKGROUND

Mandibular repositioning device (MRD) therapy is an alternative to continuous positive airway pressure (CPAP). The Orkney Complex Disease Study-ORCADES study is assessing the long-term efficacy and tolerability of MRD therapy in obstructive sleep apnoea syndrome (OSAS); two-year follow-up data are presented.

PATIENTS/METHODS

OSAS patients who refused or were noncompliant with CPAP were fitted with a custom-made computer-aided design/computer-aided manufacturing (CAD/CAM) bi-block MRD (ResMed, Narval CC™); mandibular advancement was individually titrated. Sleep and respiratory parameters were determined at baseline, 3-6 months, and two years. The primary endpoint was treatment success (percentage of patients achieving a ≥50% reduction in the apnoea-hypopnoea index [AHI]).

RESULTS

Of 315 enrolled patients, 237 remained on MRD treatment at two years, and 197 had follow-up data. The treatment success rate at two years was 67%; AHI <5/h, <10/h and <15/h was achieved in 30%, 56% and 72% of patients, respectively. On multivariate analysis, ≥50% decrease in AHI at 3-6 months and absence of nocturia at 3-6 months were significant predictors of MRD treatment continuation. Adverse events were generally mild, and the majority occurred in the first year of treatment.

CONCLUSIONS

Two years' treatment with an MRD was effective and well tolerated in patients with mild to severe OSAS who refused or were intolerant of CPAP.

Avoiding and Managing Oral Appliance Therapy Side Effects

There is a serious need to consider all potential side effects thoughtfully before commencing individual treatment with oral appliance therapy. Although many of these side effects are self-limiting, easily corrected, or innocuous, others are difficult or impossible to correct and can affect the patient in serious ways. As this field evolves, new information is discovered, and new products are introduced at a rather rapid pace, continuing education and prudent practice are critical to ethical care in the practice of dental sleep medicine.

Oral appliance therapy in obstructive sleep apnea: Long-term adherence and patients experiences

BACKGROUND

Despite the advances in the treatment of obstructive sleep apnea (OSA) with mandibular advancement appliances (MAA), their effectiveness is dependent on the patients compliance. Our aims were to evaluate the long-term adherence to MAA therapy and patients experiences of the treatment in OSA.

MATERIAL AND METHODS

Sixty-nine patients (52 males, 17 females; Mean age: 54.4±10.8 years) were included in the study. The subjects were mild (56%) and moderate (44%) OSA patients who had been treated using MAA at least 4 years prior to the study. A phone survey was used to determine the demographic characteristics of the patients, as well as to assess self-reported adherence to therapy, subjective long-term effectiveness, and patient experiences with the appliance. Descriptive statistics, Pearson Chi-square test, and independent samples t-test were used for data analysis.

RESULTS

Only 22 (32%) patients reported using the appliance regularly. Most of the non-adherent patients had stopped using their appliances in the first year (55%). The mean duration of appliance use was 33.5 months (Median: 12 months). No significant differences in appliance type, OSA severity, educational level, gender, marital status, income status, employment status or place of residence existed between adherent and non-adherent subjects. Adherent subjects were significantly younger than non-adherent subjects (Age: 50.6 ± 11.9 versus 56.1 ± 9.9, p < 0.05). The most common reasons reported by patients were inability to adapt to the appliance (62%) and pain in the temporomandibular joint (38%). The most common factors associated with continued usage were effectiveness (100%) and ease of use (64%).

CONCLUSIONS

The overall long-term nonadherence to MAA therapy in mild-to moderate OSA patients was high suggesting that barriers to MAA therapy adherence should be prevented to increase the efficiency of oral appliance treatment in OSA and achieve better outcomes for this disease.

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.

Long-term side effects on the temporomandibular joints and oro-facial function in patients with obstructive sleep apnoea treated with a mandibular advancement device

Patients with obstructive sleep apnoea (OSA) in long-term treatment with a mandibular advancement device (MAD) to increase the upper airway space may develop changes in the temporomandibular joint (TMJ) and the oro-facial function due to the protruded jaw position during sleep. The aim was to investigate the influence of long-term MAD treatment on the TMJs, oro-facial function and occlusion. This prospective study included 30 men and 13 women (median age 54) with OSA [Apnoea-Hypopnoea Index (AHI): 7-57]. They were examined with the Nordic Orofacial Test Screening (NOT-S), the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and cone beam computed tomography (CBCT) of the TMJs. The examination was performed before MAD treatment (T0), and 3-6 months (T1, no CBCT), 1 year (T2) and 3 years (T3) after treatment start. The results were analysed as long term (T0-T3, n = 14) and short term (T0-T2, n = 24) by t-test, Fisher's exact test and anova. Both long- and short-term analyses revealed a reduction in AHI (P < 0·002). Significant long term were increased scores in the NOT-S Interview (P < 0·045), reduced vertical overbite (P < 0·031) and increased jaw protrusive movement (P < 0·027). TMJ changes were found as joint sounds in terms of reciprocal clicking and crepitus, short term as a decrease and subsequent recurrence (P < 0·053; P < 0·037). No significant radiological changes were found. In conclusion, MAD treatment is beneficial to some OSA patients, but might induce changes in the TMJs, the oro-facial function and the occlusion. However, these changes seemed to be less harmful than previously reported with careful adaptation, control and follow-ups.

Lip muscle training improves obstructive sleep apnea and objective sleep: a case report

The present study assessed the potential of lip muscle training for improving sleep. A patient with heavy snoring, daytime sleepiness and dry mouth underwent lip muscle training. Lip closure force LCFmax increased by 67.3% and LCFmin by 152% post-training. AHI decreased from 12.2 to 3.9 events/h by reducing hypopneic episodes. TST, sleep stage N3 and REM sleep increased, and WASO, sleep stage N1, and AI decreased. The patient switched from mouth to nose breathing during sleep and stopped snoring. Improved LCF, by moving the tongue into the anterior-superior oral cavity, may increase upper airway space and reduce the hypopnea index.

Effectiveness of Oral Appliances in Obstructive Sleep Apnea with Respiratory Arousals

STUDY OBJECTIVES

To compare adherence and treatment effects with an oral appliance (OA) in patients with different types of obstructive sleep apnea (OSA): those with mainly respiratory arousals ("arousers"), and those with oxygen desaturations ("desaturaters") at polysomnography (PSG).

METHODS

A prospective intervention study on 72 "tired snorers" with "normal" home sleep study (HSS), but later diagnosed as OSA with PSG, who accepted OA treatment. They were offered evaluation with a follow-up PSG and questionnaires, including the Epworth Sleepiness Scale (ESS), general health (GH), satisfaction, and side effects.

RESULTS

Sixty-six patients, 33 arousers and 33 desaturaters, were adapted to OA. The 1-year adherence rate was significantly higher among arousers (85%) than desaturaters (55%) (p = 0.034). Thirty-six of 66 patients underwent follow-up PSG; the apnea-hypopnea index was significantly reduced in 22 arousers from a median of 14 to 3 (p < 0.001), and in 14 desaturaters from 18 to 7 (p = 0.002; no significant group difference). ESS and GH showed no significant improvements in either group, although sleepy "arousers" (ESS ≥ 10) significantly improved their ESS. In total, 77% reported side effects, while 63% were still satisfied with the OA treatment. Gender analysis showed a significant dominance of females classified as "arousers" (p = 0.025).

CONCLUSIONS

OSA patients with mainly arousals at PSG showed higher adherence to OA treatment, compared to patients with desaturations. Both groups responded similarly to treatment: improved nocturnal respiration, but only a small reduction of symptoms. We suggest that "tired snorers" with "normal HSS" should be offered PSG, and if OSA, also OA treatment.

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.

Long-term efficacy of an oral appliance in early treated patients with obstructive sleep apnea

PURPOSE

The purpose of the present study was to evaluate the long-term efficacy of oral appliances (OAs) in early treated patients with obstructive sleep apnea (OSA).

METHOD AND PATIENTS

Polysomnographic sleep recordings without and with an OA were performed at treatment start and in patients who had been continuously treated with OAs for at least 15 years.

RESULTS

Nine patients (eight men) with a median age of 68.1 years (interquartile range (IQR) 60.0 to 76.3 years) and a median treatment time of 16.5 years (IQR 16.3 to 18.0 years) were included. The apnea-hypopnea index decreased from a median of 17.3 (IQR 9.7 to 26.5) to 7.2 (IQR 4.0 to 9.6; p = 0.03) at the short-term follow-up. After long-term use, the apnea-hypopnea index was 32.4 (IQR 22.2 to 58.8) without the device and 35.1 (IQR 13.6 to 46.2) with it (p = 0.08). There were increases in the apnea-hypopnea index, both without the device (p = 0.02) and with it (p = 0.008). The degree of mandibular advancement did not differ between the two study occasions (p = 1.0).

CONCLUSIONS

Patients treated with oral appliances may experience deteriorations in disease severity and treatment efficacy during continuous long-term OA treatment. Regular follow-up schedules with renewed sleep apnea recordings should be considered for these patients in order to avoid suboptimal or a total loss of effects on sleep apneas.

Obstructive sleep apnoea syndrome and its management

Obstructive sleep apnoea (OSA) is a common disorder characterized by repetitive episodes of nocturnal breathing cessation due to upper airway collapse. OSA causes severe symptoms, such as excessive daytime somnolence, and is associated with a significant cardiovascular morbidity and mortality. Different treatment options are now available for an effective management of this disease. After more than three decades from its first use, continuous positive airway pressure (CPAP) is still recognized as the gold standard treatment. Nasal CPAP (nCPAP) is highly effective in controlling symptoms, improving quality of life and reducing the clinical sequelae of sleep apnoea. Other positive airway pressure modalities are available for patients intolerant to CPAP or requiring high levels of positive pressure. Mandibular advancement devices, particularly if custom made, are effective in mild to moderate OSA and provide a viable alternative for patients intolerant to CPAP therapy. The role of surgery remains controversial. Uvulopalatopharyngoplasty is a well established procedure and can be considered when treatment with CPAP has failed, whereas maxillar-mandibular surgery can be suggested to patients with a craniofacial malformation. A number of minimally invasive procedures to treat snoring are currently under evaluation. Weight loss improves symptoms and morbidity in all patients with obesity and bariatric surgery is an option in severe obesity. A multidisciplinary approach is necessary for an accurate management of the disease.

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.

Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review

OBJECTIVE

To evaluate the effectiveness of mandibular advancement appliances (MAAs) for treatment of pediatric obstructive sleep apnea (OSA).

METHODS

Several electronic databases (The Cochrane Database, EMBASE, Healthstar, MEDLINE, PubMed) were systematically searched, as well as a limited grey literature (Google Scholar) and manual searches. A health sciences librarian helped with the selection of Medical Subject Headings (MeSH), key words, and combinations of key words with truncations to account for any differences in controlled terminology in the different databases. Only studies that evaluated the effects of MAAs in children with OSA were pursued.

RESULTS

Only 4 articles satisfied all inclusion criteria. Selected studies were retrospective except one study that was a quasi-randomized clinical trial. High risk of bias (Cochrane Risk of Bias assessment) was judged in all included studies. Based on the limited available evidence use of MAAs in a POSA population may result in improvements in Apnea Hypopnea Index (AHI) scores. However complete normalization of AHI scores was not demonstrated. Heterogeneity in study designs and collected information precluded meta-analysis.

LIMITATIONS

There are significant weaknesses in the existing evidence due primarily to absence of control groups, small sample sizes, lack of randomization and short-term results. Determination of AHI scores with MAAs still in the mouth should be avoided.

CONCLUSIONS

The current limited evidence may be suggestive that MAAs result in short-term improvements in AHI scores, but it is not possible to conclude that MMAs are effective to treat pediatric OSA. Medium- and long-term assessments are still required.

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.

Clinical guidelines for oral appliance therapy in the treatment of snoring and obstructive sleep apnoea

The purpose of this review is to provide guidelines for the use of oral appliances (OAs) for the treatment of snoring and obstructive sleep apnoea (OSA) in Australia. A review of the scientific literature up to June 2012 regarding the clinical use of OAs in the treatment of snoring and OSA was undertaken by a dental and medical sleep specialists team consisting of respiratory sleep physicians, an otolaryngologist, orthodontist, oral and maxillofacial surgeon and an oral medicine specialist. The recommendations are based on the most recent evidence from studies obtained from peer reviewed literature. Oral appliances can be an effective therapeutic option for the treatment of snoring and OSA across a broad range of disease severity. However, the response to therapy is variable. While a significant proportion of subjects have a near complete control of the apnoea and snoring when using an OA, a significant proportion do not respond, and others show a partial response. Measurements of baseline and treatment success should ideally be undertaken. A coordinated team approach between medical practitioner and dentist should be fostered to enhance treatment outcomes. Ongoing patient follow-up to monitor treatment efficacy, OA comfort and side effects are cardinal to long-term treatment success and OA compliance.

Assessing Orthotic Normalization of Pharyngeal Dynamics

Airway orthotic therapy, considered mainstream in the treatment of sleep-disordered breathing, has been demonstrated to normalize both structure and function of the pathological airway through manipulation of mandibular posture. Although effective, the literature reports a variable rate of success and no validated candidacy selection protocol. Acoustic reflection has been used to evaluate and document the upper airway and its dynamics with and without an orthotic in place. This paper will discuss the use of acoustic reflection to assess the level of airway normalization resulting from protrusive and vertical repositioning of the mandible and its utility to establish orthotic candidacy, construction, titration, and maintenance parameters. This protocol has potential for use in both medical and dental facilities that treat patients with sleep-disordered breathing.

Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up

STUDY OBJECTIVES

Oral appliance therapy has emerged as an important alternative to continuous positive airway pressure (CPAP) in treating patients with obstructive sleep apnea syndrome (OSAS). In this study we report about the subjective and objective treatment outcome of oral appliance therapy and CPAP in patients with OSAS.

DESIGN

Cohort study of a previously conducted randomized clinical trial.

SETTING

University Medical Center, Groningen, The Netherlands.

PATIENTS OR PARTICIPANTS

One hundred three patients with OSAS.

INTERVENTIONS

CPAP and oral appliance therapy (Thornton Adjustable Positioner type-1, Airway Management, Inc., Dallas, TX, USA).

MEASUREMENTS AND RESULTS

Objective (polysomnography) and subjective (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, Medical Outcomes Study 36-item Short Form Health Survey [SF-36]) parameters were assessed after 1 and 2 years of treatment. Treatment was considered successful when the apnea-hypopnea index (AHI) was < 5 or showed substantial reduction, defined as reduction in the index of at least 50% from the baseline value to a value of < 20 in a patient without OSAS symptoms while undergoing therapy. Regarding the proportions of successful treatments, no significant difference was found between oral appliance therapy and CPAP in treating mild to severe OSAS in a 2-year follow-up. More patients (not significant) dropped out under oral appliance therapy (47%) compared with CPAP (33%). Both therapies showed substantial improvements in polysomnographic and neurobehavioral outcomes. However, CPAP was more effective in lowering the AHI and showed higher oxyhemoglobin saturation levels compared to oral appliance therapy (P < 0.05).

CONCLUSIONS

Oral appliance therapy should be considered as a viable treatment alternative to continuous positive airway pressure (CPAP) in patients with mild to moderate obstructive sleep apnea syndrome (OSAS). In patients with severe OSAS, CPAP remains the treatment of first choice.

CLINICAL TRIAL INFORMATION

The original randomized clinical trial, of which this study is a 2-year follow-up, is registered at ISRCTN.org; identifier: ISRCTN18174167; trial name: Management of the obstructive sleep apnea-hypopnea syndrome: oral appliance versus continuous positive airway pressure therapy; URL: http://www.controlled-trials.com/ISRCTN18174167.

Efficacy and compliance in treatment of sleep apnea with Herbst mandibular advancement splints (OHA version)

The benefits of the Herbst thermoformed advancement splint in the treatment of obstructive breathing disorders during sleep have been assessed in numerous studies. Unfortunately, like all other mandibular advancement devices, patients fail to wear it regularly in the long-term. Injuries, discomfort or pain caused by errors in manufacture or adjustment are generally blamed for this. After a critical review of the literature, some solutions are proposed to improve production of the orthesis and patient management.

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.

Formoterol

Inhaled formoterol is a long-acting selective beta2-adrenoceptor agonist, with an onset of action of 5 minutes postdose and a bronchodilator effect that lasts for at least 12 hours. Statistically significant and clinically relevant (>120 ml) improvements in lung function [assessed using standardized/normalized area under the forced expiratory volume in 1 second (FEV1) versus time curve (AUC FEV1)] were observed with inhaled formoterol 12 microg twice daily (the approved dosage in the US) compared with placebo in 12-week and 12-month, randomized, double-blind trials in patients with chronic obstructive pulmonary disease (COPD). The bronchodilator efficacy of formoterol 12 microg twice daily was greater than that of oral slow-release theophylline (individualized dosages) in a 12-month trial or inhaled ipratropium bromide 40 microg four times daily in a 12-week trial. Improvement in AUC FEV1 with formoterol, but not theophylline, compared with placebo was observed in patients with irreversible or poorly-reversible airflow obstruction. Formoterol also significantly improved health-related quality of life compared with ipratropium bromide or placebo and significantly reduced symptoms compared with placebo. Combination therapy with formoterol 12 microg twice daily plus ipratropium bromide 40 microg four times daily was significantly more effective than albuterol (salbutamol) 200 microg four times daily plus the same dosage of ipratropium bromide in a 3-week, randomized, double-blind, double-dummy, crossover trial. Inhaled formoterol was well tolerated in clinical trials. The incidence of investigator-determined drug-related adverse events with inhaled formoterol 12 microg twice daily was similar to that with placebo and inhaled ipratropium bromide 40 microg four times daily but lower than that with oral slow-release theophylline (individualized dosages). Importantly, there were no significant differences between formoterol and placebo or comparator drugs in cardiovascular adverse events in patients with COPD and corrected QT interval values within the normal range. In conclusion, inhaled formoterol improved lung function and health-related quality of life and reduced symptoms relative to placebo in clinical trials in patients with COPD. The drug had greater bronchodilator efficacy than oral slow-release theophylline or inhaled ipratropium bromide and showed efficacy in combination with ipratropium bromide. The adverse events profile (including cardiovascular adverse events) with formoterol was similar to that with placebo. Thus, inhaled formoterol may be considered as a first-line option for the management of bronchoconstriction in patients with COPD who require regular bronchodilator therapy for the management of symptoms.

Long-term follow-up of a randomized controlled trial of oral appliance therapy in obstructive sleep apnea

BACKGROUND

Long-term trials are needed to capture information regarding the persistence of efficacy and loss to follow-up of both mandibular advancement device (MAD) therapy and continuous positive airway pressure (CPAP) therapy.

OBJECTIVES

The aim of the study was to compare these treatment aspects between MAD and nasal CPAP (nCPAP) in a 1-year follow-up.

METHODS

Forty-three mild/moderate obstructive sleep apnea patients (52.2 ± 9.6 years) with a mean apnea-hypopnea index (AHI) of 20.8 ± 9.9 events/h were randomly assigned to two parallel groups: MAD (n = 21) and nCPAP (n = 22). Four polysomnographic recordings were obtained: one before treatment, one for the short-term evaluation, and two recordings 6 and 12 months after the short-term evaluation. Excessive daytime sleepiness (EDS) was also evaluated at the polysomnographic recordings.

RESULTS

The initially achieved improvements in the AHI remained stable over time within both groups (p = 0.650). In the nCPAP group, the AHI improved 4.1 events/h more than in the MAD group (p = 0.000). The EDS values showed a gradual improvement over time (p = 0.000), and these improvements were similar for both groups (p = 0.367). In the nCPAP group, more patients withdrew from treatment due to side effects than in the MAD group.

CONCLUSIONS

The absence of significant long-term differences in EDS improvements between the MAD and the nCPAP groups with mild/moderate obstructive sleep apnea may indicate that the larger improvements in AHI values in the nCPAP group are not clinically relevant. Moreover, nCPAP patients may show more problems in accepting their treatment modality than MAD patients.

Effects of mandibular advancement on upper airway dimension and collapsibility in patients with obstructive sleep apnea using dynamic upper airway imaging during sleep

OBJECTIVES

The objective of this study was to evaluate the effects of mandibular advancement on oropharyngeal dimension and collapsibility and reveal the predominate site of change produced by mandibular advancement in patients with obstructive sleep apnea (OSA).

STUDY DESIGN

Sixteen adults (13 males and 3 females) with symptomatic mild to severe OSA participated. Custom-made silicone mandibular positioners were used to keep the mandible at 67% of maximum advancement. Changes in the oropharyngeal size and collapsibility with mandibular advancement were evaluated using ultrafast computed tomography taken during wakefulness and midazolam-induced sleep. Cross-sectional areas were assessed using electron beam tomography at 4 levels: high retropalatal (HRP), low retropalatal (LRP), high retroglossal (HRG), and low retroglossal (LRG).

RESULTS

During sleep, the minimum cross-sectional areas decreased 36.5%, 67.8%, 75.5%, and 65.8% at each level of HRP, LRP, HRG, and LRG respectively, as compared with those measured during wakefulness. Mandibular advancement during sleep increased 75.7%, 141.3%, 128.1%, and 119.9% at each level. The oropharynx showed 70.3%, 110.4%, 140.3%, and 156.9% increase in the Collapsibility Indices during sleep at each level of HRP, LRP, HRG, and LRG, respectively, compared with wakefulness. However, collapsibility indices decreased 29.1%, 23.2%, 21.4%, and 34.1% at each level with mandibular advancement.

CONCLUSION

Mandibular advancement increases oropharyngeal diameter and decreases oropharyngeal collapsibility during midazolam-induced sleep respiration at the retropalatal as well as the retroglossal region in most patients with OSA.

Principles of oral appliance therapy for the management of snoring and sleep disordered breathing

Oral appliance (OA) therapy for snoring, obstructive sleep apnea, or both is simple, reversible, quiet, and cost-effective and may be indicated in patients who are unable to tolerate nasal continuous positive airway pressure (nCPAP) or are poor surgical risks. OAs are effective in varying degrees and seem to work because of an increase in airway space, the provision of a stable anterior position of the mandible, advancement of the tongue or soft palate, and possibly a change in genioglossus muscle activity. This article provides a detailed clinical protocol and titration sequence for OAs, because this clinical procedure is often not well understood by practitioners new to the field. Prediction of treatment success is addressed, OA treatment is compared with surgery and nCPAP, OA compliance is described, and the possible adverse effects associated with this type of therapy are discussed.

Five years of sleep apnea treatment with a mandibular advancement device. Side effects and technical complications

OBJECTIVE

To determine the variation in prevalence of temporomandibular disorders (TMD), other side effects, and technical complications during 5 years of sleep apnea treatment with a mandibular advancement device.

MATERIALS AND METHODS

Forty patients diagnosed with obstructive sleep apnea received an adjustable appliance at 70% of the maximum protrusion. The protrusion was then progressively increased. TMD (diagnosed according to the Research Diagnostic Criteria for TMD), overjet, overbite, occlusal contacts, subjective side effects, and technical complications were recorded before and a mean of 14, 21, and 58 months after treatment and analyzed by the Wilcoxon test (P < .05).

RESULTS

Fifteen patients still used the oral appliance at the 5-year follow-up, and no significant variation in TMD prevalence was observed. Subjective side effects were common, and a significant reduction was found in overjet, overbite, and in the number of occlusal contacts. Furthermore, the patients made a mean of 2.5 unscheduled dental visits per year and a mean of 0.8 appliance repairs/relines per year by a dental technician. The most frequent unscheduled visits were needed during the first year and were a result of acrylic breakage on the lateral telescopic attachment, poor retention, and other adjustments to improve comfort.

CONCLUSIONS

Five-year oral appliance treatment does not affect TMD prevalence but is associated with permanent occlusal changes in most sleep apnea patients during the first 2 years. Patients seek several unscheduled visits, mainly because of technical complications.