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Stewart GM, Tong BK, Cistulli PA. Precision medicine approaches in obstructive sleep apnoea: The role of dentist-sleep physician partnerships. Aust Dent J 2024. [PMID: 39354705 DOI: 10.1111/adj.13039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2024] [Indexed: 10/03/2024]
Abstract
Obstructive Sleep Apnoea (OSA) is a common heterogenous sleep disorder that is associated with a wide range of comorbidities and consequences, including the development of neurocognitive and cardiometabolic disorders. The heterogeneity of OSA necessitates a precision medicine approach to accurately diagnose this condition and to effectively manage patients. One of the primary models of precision medicine is described by the P4 approach of predicting those who are susceptible to disease, preventing the occurrence of disease, personalizing treatment, and encouraging patients to participate in their individual healthcare journey. Recent advances in oral appliance therapy and OSA monitoring techniques have fostered an exciting opportunity for enhanced collaboration between dentists and sleep physicians to optimize OSA precision medicine care. This review aims to discuss the sources of heterogeneity among OSA patients, provide an overview of the growing applications of oral appliance therapy and tailored monitoring programs for OSA that are shifting treatment to a more personalized and participatory model of care, and outline the pivotal role of dentists in managing patients with OSA.
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Affiliation(s)
- G M Stewart
- Charles Perkins Centre and Sydney Medical School, University of Sydney, Camperdown, Sydney, Australia
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - B K Tong
- Charles Perkins Centre and Sydney Medical School, University of Sydney, Camperdown, Sydney, Australia
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - P A Cistulli
- Charles Perkins Centre and Sydney Medical School, University of Sydney, Camperdown, Sydney, Australia
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, Sydney, Australia
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Manetta IP, Duarte BB, Nucci LB, Enes CC. Relationship between OSA pathophysiological phenotypes and treatment response to mandibular advancement devices: a pilot study. J Clin Sleep Med 2024; 20:1321-1330. [PMID: 38557332 PMCID: PMC11294123 DOI: 10.5664/jcsm.11138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024]
Abstract
STUDY OBJECTIVES We assessed whether critical pathophysiological phenotypes predict treatment response in patients with obstructive sleep apnea using a mandibular advancement device (MAD). METHODS Thirty-one patients with obstructive sleep apnea were treated with a MAD. Individuals were categorized and graded into 4 pathophysiological phenotypes based on polysomnographic features (anatomical, ventilatory control, arousal threshold, and muscle responsiveness). Morpho-anthropometric data were additionally assessed. Patients were classified as responders or nonresponders. Associations between polysomnographic phenotypes and treatment response were documented, as were morpho-anthropometric data and their impact on therapeutic success. RESULTS There was a male predominance (64.5%), with a median age of 49 years (25th percentile: 40; 75th percentile: 55), body mass index = 27.4 kg/m2 (25th percentile: 26; 75th percentile: 28.8), and apnea-hypopnea index of 18.2 events/h (25th percentile: 11.7; 75th percentile: 27.6). The majority of patients treated with a MAD (58%) were good responders (68.0% mild and moderate vs 16.7% severe). Treatment response was associated with shorter intermolar and interpremolar distances in the lower arch (P = .0092 and .0129). Rapid eye movement sleep apnea-hypopnea index and MAD-related treatment response were inversely correlated (P = .0013). Favorable anatomical (P = .0339) and low muscle response (P = .0447) phenotypes were correlated with outcomes. CONCLUSIONS According to our results, a favorable response occurred in a better "anatomical phenotype" and in the worse "muscular responsiveness phenotype" according to polysomnographic data. Furthermore, other favorable predictors, such as a rapid eye movement sleep apnea-hypopnea index < 16 events/h and a smaller distance between lower molars and premolars, were found. These findings indicate that clinical and polysomnographic aspects can discriminate phenotypes that may guide decisions on MAD treatment for obstructive sleep apnea. CITATION Manetta IP, Duarte BB, Nucci LB, Enes CC. Relationship between OSA pathophysiological phenotypes and treatment response to mandibular advancement devices: a pilot study. J Clin Sleep Med. 2024;20(8):1321-1330.
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Affiliation(s)
- Izabella P. Manetta
- Postgraduate Program in Health Sciences, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
| | - Bruno B. Duarte
- Department of Otolaryngology Head and Neck Surgery, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
| | - Luciana B. Nucci
- Postgraduate Program in Health Sciences, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
| | - Carla C. Enes
- Postgraduate Program in Health Sciences, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
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Navarro RE, Karadede B, Karadede Ünal B, Salvador DM. Predictive factors of therapeutic response according to craniofacial skeletal biotype in patients with sleep apnea syndrome using mandibular advancement devices: a pilot study. Angle Orthod 2024; 94:216-223. [PMID: 37788163 PMCID: PMC10893917 DOI: 10.2319/092822-670.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 08/01/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVES To evaluate the influence of facial biotype in the therapeutic effect of mandibular advancement devices (MADs) according to polysomnographic records in patients diagnosed with sleep apnea-hypopnea syndrome (SAHS). MATERIALS AND METHODS A total of 46 patients were recruited. Patients were classified according to facial biotype (mesofacial, brachyfacial, or dolichofacial). The quantitative variables were described as the arithmetic mean and standard deviation or the median and interquartile range. Hypothesis tests used were Pearson's chi-square, paired-sample Student's t- test, the Wilcoxon test, one-way analysis of variance, Kruskal-Wallis test, and Mann-Whitney U-test. P < .05 was considered statistically significant. RESULTS A total of 46 patients were categorized into three facial biotype subgroups with no significant differences among them in age, body mass index, neck circumference, and sex. The respiratory disturbance index (RDI) results were as follows: brachyfacial patients had a reduction to 15 events/h (P < .001), the mesofacial patients had a reduction to 14 events/h (P < .001), and the dolichofacial patients did not show a significant reduction. The oxygen desaturation index (ODI) results were as follows: brachyfacial patients had a reduction in ODI episodes to 45 episodes/h (P = .001), mesofacial patients had a reduction to 18 episodes/h (P = .001). In the brachyfacial group, the number of awakenings with MAD therapy was reduced to 23 events/h (P = .003), while, in the mesofacial group, it was reduced to 37 episodes/h (P = .012). CONCLUSIONS The facial biotype influences the effectiveness of MAD therapy and is considered a good predictive factor.
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Johal A, Hamoda MM, Almeida FR, Marklund M, Tallamraju H. The role of oral appliance therapy in obstructive sleep apnoea. Eur Respir Rev 2023; 32:220257. [PMID: 37343962 DOI: 10.1183/16000617.0257-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2023] [Indexed: 06/23/2023] Open
Abstract
There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the "gold standard" in nonsurgical OSA management, OAT remains the recognised alternative treatment.This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.
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Affiliation(s)
- Ama Johal
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
| | - Mona M Hamoda
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Fernanda R Almeida
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Marie Marklund
- Department of Otontology, Medical Faculty, Umea University, Umea, Sweden
| | - Harishri Tallamraju
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
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Ma Y, Yu M, Gao X. Role of craniofacial phenotypes in the response to oral appliance therapy for obstructive sleep apnea. J Oral Rehabil 2023; 50:308-317. [PMID: 36681880 DOI: 10.1111/joor.13418] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 11/23/2022] [Accepted: 01/13/2023] [Indexed: 01/23/2023]
Abstract
BACKGROUND Mandibular advancement device (MAD) is a good alternative for patients with obstructive sleep apnea (OSA). However, the treatment response varies amongst individuals. OBJECTIVE This study aimed to explore the role of craniofacial features in the response to MADs to improve prognostication and patient selection. METHODS The retrospective trial contained 42 males aged 41.5 ± 9.0 years, and with an apnea-hypopnea index (AHI) of 21.5 ± 13.8 events/h. According to the mandibular plane angle, participants were divided into three groups: low angle (n = 13), average angle (n = 14) and high angle (n = 15). Under the monitoring of home sleep testing, adjustable MADs were used to titrate the mandible forward from 0 mm with an increment of 0.5 mm every day. The polysomnography outcomes, mandibular protrusion amounts, changes in upper airway MRI measurements and nasal resistance were compared amongst the three groups. RESULTS The normalisation rate (AHI <5 /h) was 92.3%, 57.1% and 46.7%, respectively, in the low-, average- and high-angle groups (p = .027). The effective protrusion where AHI was reduced by half was 20 (11.3 ~ 37.5) %, 31.3 (23.6 ~ 50) % and 50 (36.9 ~ 64.9) % of the maximal mandibular protrusion, in the low-, average- and high-angle groups (p = .004). Multivariate logistic regression revealed that increased gonion angle (OR = 0.878) and baseline AHI(OR = 0.868) can reduce the probability of normalisation. CONCLUSION The high mandibular plane angle might be an unfavourable factor to MAD treatment and more protrusion was needed to achieve a 50% reduction in AHI. Vertical craniofacial pattern (gonion angle) and baseline AHI constituted the model for predicting the effect of MADs.
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Affiliation(s)
- Yanyan Ma
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, China
| | - Min Yu
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, China
| | - Xuemei Gao
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, China
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Craniofacial Morphologic Predictors for Passive Myofunctional Therapy of Pediatric Obstructive Sleep Apnea Using an Oral Appliance with a Tongue Bead. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9071073. [PMID: 35884057 PMCID: PMC9319715 DOI: 10.3390/children9071073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/23/2022]
Abstract
We conducted this retrospective study to identify potential clinical, polysomnographic, and cephalometric predictors for the treatment outcomes of a tongue-beaded oral appliance (OA) in children with obstructive sleep apnea syndrome (OSAS). In total, 63 patients—50 boys and 13 girls ranging in age from 4 to 16 years—underwent OA treatment nightly for at least 6 months. A baseline digital lateral cephalometric radiograph was obtained for each patient. Multivariate logistic regression analysis was performed to examine predictors for the treatment outcome based on the clinical and cephalometric measurements. Overall, 28 patients responded to the treatment (post-treatment improvement > 50% or apnea−hypopnea index (AHI) < 1/h), and 35 did not (post-treatment improvement < 50% and AHI ≥ 1/h). Significantly larger cranial base angle (SNBa), smaller lower gonial angle (LGo Angle), and shorter length of anterior cranial base (SN) were found in responders. Smaller lower gonial angle (LGo Angle) and smaller anterior cranial base (SN) predict a favorable outcome for pediatric OSAS using a tongue-beaded OA. This finding will equip practitioners with additional insights when selecting suitable candidates for OA therapy in pediatric patients.
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Jugé L, Knapman FL, Humburg P, Burke PGR, Lowth AB, Brown E, Butler JE, Eckert DJ, Ngiam J, Sutherland K, Cistulli PA, Bilston LE. The relationship between mandibular advancement, tongue movement, and treatment outcome in obstructive sleep apnea. Sleep 2022; 45:6537599. [DOI: 10.1093/sleep/zsac044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 02/14/2022] [Indexed: 12/30/2022] Open
Abstract
Abstract
Study Objectives
To characterize how mandibular advancement enlarges the upper airway via posterior tongue advancement in people with obstructive sleep apnea (OSA) and whether this is associated with mandibular advancement splint (MAS) treatment outcome.
Methods
One-hundred and one untreated people with OSA underwent a 3T magnetic resonance (MRI) scan. Dynamic mid-sagittal posterior tongue and mandible movements during passive jaw advancement were measured with tagged MRI. Upper airway cross-sectional areas were measured with the mandible in a neutral position and advanced to 70% of maximum advancement. Treatment outcome was determined after a minimum of 9 weeks of therapy.
Results
Seventy-one participants completed the study: 33 were responders (AHI<5 or AHI≤10 events/hr with >50% AHI reduction), 11 were partial responders (>50% AHI reduction but AHI>10 events/hr), and 27 nonresponders (AHI reduction<50% and AHI≥10 events/hr). Responders had the greatest naso- and oropharyngeal tongue anterior movement (0.40 ± 0.08 and 0.47 ± 0.13 mm, respectively) and oropharyngeal cross-sectional area enlargement (6.41 ± 2.12%) per millimeter of mandibular advancement. A multivariate model that included tongue movement and percentage of airway enlargement per millimeter of mandibular advancement along with baseline AHI correctly classified 69.2% (5-fold cross-validated 62.5%, n = 39) of participants in response categories when the jaw was advanced in the range that would usually be regarded as sufficient for clinical efficacy (> 4 mm). In comparison, a model using only baseline AHI correctly classified 50.0% of patients (5-fold cross-validated 52.5%, n = 40).
Conclusions
Tongue advancement and upper airway enlargement with mandibular advancement in conjunction with baseline AHI improve treatment response categorization to a satisfactory level (69.2%, 5-fold cross-validated 62.5%).
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Affiliation(s)
- Lauriane Jugé
- Neuroscience Research Australia , Sydney, NSW , Australia
- Faculty of Medicine and Health, University of New South Wales , Sydney, NSW , Australia
| | - Fiona L Knapman
- Neuroscience Research Australia , Sydney, NSW , Australia
- Faculty of Medicine and Health, University of New South Wales , Sydney, NSW , Australia
| | - Peter Humburg
- Faculty of Medicine and Health, University of New South Wales , Sydney, NSW , Australia
| | - Peter G R Burke
- Neuroscience Research Australia , Sydney, NSW , Australia
- Faculty of Medicine and Health, University of New South Wales , Sydney, NSW , Australia
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University , Sydney, NSW , Australia
| | - Aimee B Lowth
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital , Sydney, NSW , Australia
- Charles Perkins Centre, University of Sydney , Sydney, NSW , Australia
| | - Elizabeth Brown
- Neuroscience Research Australia , Sydney, NSW , Australia
- Respiratory and Sleep Medicine Department and Chest Clinic Prince of Wales Hospital , Sydney, NSW , Australia
| | - Jane E Butler
- Neuroscience Research Australia , Sydney, NSW , Australia
- Faculty of Medicine and Health, University of New South Wales , Sydney, NSW , Australia
| | - Danny J Eckert
- Neuroscience Research Australia , Sydney, NSW , Australia
- Faculty of Medicine and Health, University of New South Wales , Sydney, NSW , Australia
- Adelaide Institute for Sleep Health, Flinders University , Adelaide, SA , Australia
| | - Joachim Ngiam
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital , Sydney, NSW , Australia
| | - Kate Sutherland
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital , Sydney, NSW , Australia
- Charles Perkins Centre, University of Sydney , Sydney, NSW , Australia
| | - Peter A Cistulli
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital , Sydney, NSW , Australia
- Charles Perkins Centre, University of Sydney , Sydney, NSW , Australia
| | - Lynne E Bilston
- Neuroscience Research Australia , Sydney, NSW , Australia
- Faculty of Medicine and Health, University of New South Wales , Sydney, NSW , Australia
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Ferraz PD, Francisco I, Borges MI, Guimarães A, Carvalho F, Caramelo F, Figueiredo JP, Vale F. Pharyngeal Airspace Alterations after Using the Mandibular Advancement Device in the Treatment of Obstructive Sleep Apnea Syndrome. Life (Basel) 2022; 12:life12060835. [PMID: 35743866 PMCID: PMC9224702 DOI: 10.3390/life12060835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Mandibular Advancement Devices (MADs), inserted in non-surgical treatments for obstructive sleep apnea and hypopnea syndrome (OSAHS), are used intra-orally during the sleep period, with the aim of promoting mandibular protrusion. The aim of the study is to analyze the changes in the upper airway after the use of an MAD in the treatment of OSAHS. Methods: 60 patients diagnosed with OSAHS, as established by the Sleep Medicine Service, underwent treatment with the Silensor SL device at the Stomatology Service of the University Hospital Center of Coimbra, from January 2018 to January 2019. All patients completed two polysomnographies and two lateral teleradiographies: one before starting treatment (T0) and one after 1 year of treatment (T1). In the lateral teleradiography performed after one year of treatment, the patient had the MAD placed intra-orally. The linear measurements of the airspace proposed by the Arnett/Gunson FAB Surgery cephalometric analysis were measured at four craniometric points: A, MCI, B, Pog. Results: The results demonstrate an anteroposterior airway enlargement in two of the four points studied with the MAD placed intra-orally (B and Pog point). The greatest average increase is observed at point Pog (3 mm), followed by B (1 mm), and finally, point A (0.6 mm). Conclusions: This study proved that there is an improvement in anteroposterior measurements at various points in the upper airways after treatment with MAD.
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Affiliation(s)
- Pedro Dias Ferraz
- Coimbra Hospital and University Centre (CHUC), 3000-075 Coimbra, Portugal; (M.I.B.); (F.C.); (J.P.F.)
- Correspondence: (P.D.F.); (F.V.)
| | - Inês Francisco
- Faculty of Medicine, Institute of Orthodontics, University of Coimbra, 3000-075 Coimbra, Portugal; (I.F.); (A.G.)
- Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, 3000-075 Coimbra, Portugal;
| | - Maria Inês Borges
- Coimbra Hospital and University Centre (CHUC), 3000-075 Coimbra, Portugal; (M.I.B.); (F.C.); (J.P.F.)
| | - Adriana Guimarães
- Faculty of Medicine, Institute of Orthodontics, University of Coimbra, 3000-075 Coimbra, Portugal; (I.F.); (A.G.)
| | - Fátima Carvalho
- Coimbra Hospital and University Centre (CHUC), 3000-075 Coimbra, Portugal; (M.I.B.); (F.C.); (J.P.F.)
| | - Francisco Caramelo
- Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, 3000-075 Coimbra, Portugal;
- Laboratory of Biostatistics and Medical Informatics (LBIM), Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Centre for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, 3000-075 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3030-370 Coimbra, Portugal
| | - José Pedro Figueiredo
- Coimbra Hospital and University Centre (CHUC), 3000-075 Coimbra, Portugal; (M.I.B.); (F.C.); (J.P.F.)
- Clinical Academic Center of Coimbra (CACC), 3030-370 Coimbra, Portugal
| | - Francisco Vale
- Faculty of Medicine, Institute of Orthodontics, University of Coimbra, 3000-075 Coimbra, Portugal; (I.F.); (A.G.)
- Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, 3000-075 Coimbra, Portugal;
- Correspondence: (P.D.F.); (F.V.)
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Camañes-Gonzalvo S, Bellot-Arcís C, Marco-Pitarch R, Montiel-Company JM, García-Selva M, Agustín-Panadero R, Paredes-Gallardo V, Puertas-Cuesta FJ. Comparison of the phenotypic characteristics between responders and non-responders to obstructive sleep apnea treatment using mandibular advancement devices in adult patients: systematic review and meta-analysis. Sleep Med Rev 2022; 64:101644. [DOI: 10.1016/j.smrv.2022.101644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 12/28/2022]
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Mosca EV, Bruehlmann S, Zouboules SM, Chiew AE, Westersund C, Hambrook DA, Jahromi SAZ, Grosse J, Topor ZL, Charkhandeh S, Remmers JE. In-home mandibular repositioning during sleep using MATRx plus predicts outcome and efficacious positioning for oral appliance treatment of obstructive sleep apnea. J Clin Sleep Med 2022; 18:911-919. [PMID: 34747691 PMCID: PMC8883079 DOI: 10.5664/jcsm.9758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Oral appliance therapy is not commonly used to treat obstructive sleep apnea due to inconsistent efficacy and lack of established configuration procedures. Both problems may be overcome by information gathered while repositioning the mandible during sleep. The purpose of this investigation was to determine if an unattended sleep study with a mandibular positioner can predict therapeutic success and efficacious mandibular position, assess the contribution of artificial intelligence analytics to such a system, and evaluate symptom resolution using an objective titration approach. METHODS Fifty-eight individuals with obstructive sleep apnea underwent an unattended sleep study with an auto-adjusting mandibular positioner followed by fitting of a custom oral appliance. Therapeutic outcome was assessed by the 4% oxygen desaturation index with therapeutic success defined as oxygen desaturation index < 10 h-1. Outcome was prospectively predicted by an artificial intelligence system and a heuristic, rule-based method. An efficacious mandibular position was also prospectively predicted by the test. Data on obstructive sleep apnea symptom resolution were collected 6 months following initiation of oral appliance therapy. RESULTS The artificial intelligence method had significantly higher predictive accuracy (sensitivity: 0.91, specificity: 1.00) than the heuristic method (P = .016). The predicted efficacious mandibular position was associated with therapeutic success in 83% of responders. Appliances titrated based on oxygen desaturation index effectively resolved obstructive sleep apnea symptoms. CONCLUSIONS The MATRx plus device provides an accurate means for predicting outcome to oral appliance therapy in the home environment and offers a replacement to blind titration of oral appliances. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Predictive Accuracy of MATRx plus in Identifying Favorable Candidates for Oral Appliance Therapy; Identifier: NCT03217383; URL: https://clinicaltrials.gov/ct2/show/NCT03217383. CITATION Mosca EV, Bruehlmann S, Zouboules SM, et al. In-home mandibular repositioning during sleep using MATRx plus predicts outcome and efficacious positioning for oral appliance treatment of obstructive sleep apnea. J Clin Sleep Med. 2022;18(3):911-919.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Zbigniew L. Topor
- Zephyr Sleep Technologies, Calgary, Canada,University of Calgary, Calgary, Canada
| | | | - John E. Remmers
- Zephyr Sleep Technologies, Calgary, Canada,University of Calgary, Calgary, Canada,Address correspondence to: John Remmers, MD, Chief Medical Officer, Zephyr Sleep Technologies Inc., #102, 701 64 Ave SE, Calgary, AB, Canada;
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Li WY, Masse JF, Gakwaya S, Zhao Z, Wang W, Sériès F. Differences in Predicted Therapeutic Outcome of Mandibular Advancement Determined by Remotely Controlled Mandibular Positioner in Canadian and Chinese Apneic Patients. Nat Sci Sleep 2022; 14:1611-1622. [PMID: 36105925 PMCID: PMC9467296 DOI: 10.2147/nss.s377758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/28/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In-lab mandibular protrusive titration using a remotely controlled mandibular positioner (RCMP) could predict the success rate of mandibular advancement device (MAD) and reliably determine the Optimal Protrusive Position (OPP) for obstructive sleep apnea (OSA) patients. The aim of this study was to compare MAD success rate using in-lab RCMP manual titration performed in Caucasian and Chinese OSA patients. METHODS Manual RCMP titration was performed during an in-lab sleep study using the same procedure that had been previously reported in untreated Caucasian and Chinese OSA patients. Success rate was determined according to classical success criteria or to those previously used for RCMP titration. RESULTS A total of 160 subjects were included in this study, and conclusive data were obtained from 141 (71 Chinese and 70 Caucasian OSA patients). Chinese patients were significantly younger, with lower BMI and more severe OSA disease than the Canadian counterparts. Among patients with predicted success, the OPP expressed in % of full protrusion position did not differ between the two ethnic groups. Chinese ethnicity, younger age and lower baseline AHI were significant determinants of RCMP success. In a multivariate analysis, only ethnicity and AHI were found to significantly account for success, the odds ratio for success in Chinese compared to Caucasians corrected for AHI being 3.7 and 4.6 depending on criteria used to define success. CONCLUSION Although the OSA disease was more severe in Chinese patients, the predicted success rate of MAD according to RCMP titration was higher in Chinese than in Caucasians. This study was registered on ClinicalTrials.gov (NCT03231254).
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Affiliation(s)
- Wen-Yang Li
- Institute of Respiratory and Critical Care, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | | | - Simon Gakwaya
- Unité de Recherche en Pneumologie, Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Zhenjin Zhao
- Institute of Orthodontics, The Stomatological Hospital of China Medical University, Shenyang, People's Republic of China
| | - Wei Wang
- Institute of Respiratory and Critical Care, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | - Frédéric Sériès
- Unité de Recherche en Pneumologie, Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
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Vena D, Azarbarzin A, Marques M, Op de Beeck S, Vanderveken OM, Edwards BA, Calianese N, Hess LB, Radmand R, Hamilton GS, Joosten SA, Taranto-Montemurro L, Kim SW, Verbraecken J, Braem M, White DP, Sands SA, Wellman A. Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow. Sleep 2021; 43:5733095. [PMID: 32043131 DOI: 10.1093/sleep/zsaa004] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/20/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES Oral appliance therapy is an increasingly common option for treating obstructive sleep apnea (OSA) in patients who are intolerant to continuous positive airway pressure (CPAP). Clinically applicable tools to identify patients who could respond to oral appliance therapy are limited. METHODS Data from three studies (N = 81) were compiled, which included two sleep study nights, on and off oral appliance treatment. Along with clinical variables, airflow features were computed that included the average drop in airflow during respiratory events (event depth) and flow shape features, which, from previous work, indicates the mechanism of pharyngeal collapse. A model was developed to predict oral appliance treatment response (>50% reduction in apnea-hypopnea index [AHI] from baseline plus a treatment AHI <10 events/h). Model performance was quantified using (1) accuracy and (2) the difference in oral appliance treatment efficacy (percent reduction in AHI) and treatment AHI between predicted responders and nonresponders. RESULTS In addition to age and body mass index (BMI), event depth and expiratory "pinching" (validated to reflect palatal prolapse) were the airflow features selected by the model. Nonresponders had deeper events, "pinched" expiratory flow shape (i.e. associated with palatal collapse), were older, and had a higher BMI. Prediction accuracy was 74% and treatment AHI was lower in predicted responders compared to nonresponders by a clinically meaningful margin (8.0 [5.1 to 11.6] vs. 20.0 [12.2 to 29.5] events/h, p < 0.001). CONCLUSIONS A model developed with airflow features calculated from routine polysomnography, combined with age and BMI, identified oral appliance treatment responders from nonresponders. This research represents an important application of phenotyping to identify alternative treatments for personalized OSA management.
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Affiliation(s)
- Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Turner Institute for Brain and Mental Health, Notting Hill, Australia
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Reza Radmand
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,School of Clinical Sciences, Monash University, Clayton, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,School of Clinical Sciences, Monash University, Clayton, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sang-Wook Kim
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Department of Otorhinolaryngology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Marc Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Division of Special Care Dentistry, Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Haskell BS, Voor MJ, Roberts AM. A consideration of factors affecting palliative oral appliance effectiveness for obstructive sleep apnea: a scoping review. J Clin Sleep Med 2021; 17:833-848. [PMID: 33196434 PMCID: PMC8020709 DOI: 10.5664/jcsm.9018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES This scoping review allows physicians, researchers, and others interested in obstructive sleep apnea to consider effectiveness of oral appliances (OAs). The intent is to improve understanding of OA effectiveness by considering morphologic interaction in patients with obstructive sleep apnea. METHODS Morphologic and biomechanical criteria for positional alterations of the mandible assessed success rates of OA appliances. Searches of databases (Medline, PubMed, The Cochrane Library, EBSCO) using terms: OA treatment effectiveness and positive and/or negative outcome predictors. Craniofacial predictors of OAs and obstructive sleep apnea biomechanical factors of anatomical traits associated with OA effectiveness were included. Databases searched radiographic cephalometric imaging for morphology/phenotypes and apnea-hypopnea index responses. Articles were excluded if title or abstract was not relevant or a case report. If the analysis did not report mean or standard deviation for apnea-hypoxia index, it was excluded. No language, age, or sex restrictions were applied. RESULTS Analysis of 135 articles included in searched literature indicated alterations in musculature and pharyngeal airway structure through OA use. These alterations were individually unpredictable with wide variability 61.81% ± 12.29 (apnea-hypoxia index mean ± standard deviation). Morphologic variations as predictors were typically weak and idiosyncratic. Biomechanical factors and wide variations in the metrics of appliance application were unclear, identifying gaps in knowledge and practice of OAs. CONCLUSIONS An integrated basis to identify morphologic and biomechanical elements of phenotypic expressions of sleep-disordered breathing in the design and application of OAs is needed. Current knowledge is heterogeneous and shows high variability. Identification of subgroups of patients with obstructive sleep apnea responding to OAs is needed.
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Affiliation(s)
- Bruce S. Haskell
- Division of Orthodontics, University of Kentucky College of Dentistry, Lexington Kentucky
- Department of Physiology, School of Medicine, University of Louisville, Louisville, Kentucky
- Comprehensive Dentistry, School of Dentistry, University of Louisville, Louisville, Kentucky
| | - Michael J. Voor
- Department of Orthopedics, School of Medicine, University of Louisville, Louisville, Kentucky
- Department of Biomedical Engineering, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Andrew M. Roberts
- Department of Physiology, School of Medicine, University of Louisville, Louisville, Kentucky
- Department of Pediatrics, School of Medicine, University of Louisville, Louisville, Kentucky
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Trzepizur W, Adrian B, Le Vaillant M, Meslier N, Kün-Darbois JD, Gagnadoux F. Predicting treatment response to mandibular advancement therapy using a titratable thermoplastic device. Clin Oral Investig 2021; 25:5553-5561. [PMID: 33650081 DOI: 10.1007/s00784-021-03865-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/25/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Mandibular advancement device (MAD) therapy is the most commonly used second-line treatment for obstructive sleep apnea (OSA), but MAD may be ineffective in a subgroup of patients. We describe the use of a trial of a titratable thermoplastic MAD to predict treatment outcomes with a custom-made MAD. MATERIALS AND METHODS Patients treated with a thermoplastic MAD as a trial before custom-made MAD manufacturing were included in the study. Sleep recordings and clinical outcomes assessed after 6 months of treatment with each device were compared. Predictive utility of thermoplastic MAD to identify custom-made MAD treatment success defined as a reduction greater than 50% and final apnea-hypopnea index (AHI) less than 10 events/h was evaluated. RESULTS Thermoplastic MADs were installed in 111 patients, but only 36 patients were finally treated with both devices and were included in the analysis. A significant correlation was observed between the impact of the two devices on the AHI (r=0.85, p<0.0001), oxygen desaturation index (r=0.73, p<0.0001), snoring index (r=0.85, p<0.0001), and Epworth sleepiness scale (r=0.77, p<0.0001). A high positive predictive value (86%) but a low negative predictive value (46%) was observed regarding AHI decrease. CONCLUSIONS Similar impacts of both MADs were observed on major OSA severity markers and symptoms. The ability of thermoplastic MAD to indicate likelihood of success with custom-made MAD will require further controlled studies. CLINICAL RELEVANCE Thermoplastic MADs could represent a useful and easily implemented tool to predict the likelihood of success of a custom-made MAD as treatment for OSA.
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Affiliation(s)
- Wojciech Trzepizur
- INSERM U1063, SOPAM, Angers University, F-49045, Angers, France. .,Department of Respiratory and Sleep Medicine, Angers University Hospital, Angers, France. .,Département de Pneumologie, CHU, 4 rue Larrey, 49100, Angers, France.
| | - Benjamin Adrian
- Department of Respiratory and Sleep Medicine, Angers University Hospital, Angers, France
| | - Marc Le Vaillant
- Institut de Recherche en Santé Respiratoire des Pays de la Loire, Beaucouzé, France
| | - Nicole Meslier
- INSERM U1063, SOPAM, Angers University, F-49045, Angers, France.,Department of Respiratory and Sleep Medicine, Angers University Hospital, Angers, France
| | | | - Frédéric Gagnadoux
- INSERM U1063, SOPAM, Angers University, F-49045, Angers, France.,Department of Respiratory and Sleep Medicine, Angers University Hospital, Angers, France
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García M, Cabrera JA, Bataller A, Vila J, Mayoral P. Mandibular movement analisys by means of a kinematic model applied to the design of oral appliances for the treatment of obstructive sleep apnea. Sleep Med 2020; 73:29-37. [PMID: 32769030 DOI: 10.1016/j.sleep.2020.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mandibular advancement devices (MADs) are one of the treatment options used for the obstructive sleep apnea syndrome (OSAS). At present, MADs are designed with standard titration systems, without considering each patient's anatomical characteristics of the temporomandibular joint and mandible shape. The main objective of this study is to evaluate if a variability in mandibular morphology will influence the displacement of the jaw with a MAD. Such knowledge will be of help to find optimal mandibular positions with MAD even when opening the mouth. METHODS By using a mandibular movement model, the movement patterns of different points on the chin have been analyzed. The influence of different skeletal mandibular shapes on these movements have also been studied. The results show differences in the movement patterns of the lower front teeth depending on its distance to the center of the condyle, with a more horizontal direction in those in which there is a greater distance. RESULTS Variations in mandibular morphology imply differences in movement patterns of the analyzed points of the mandible. Consequently, MADs should be designed according to each patient's anatomy to avoid mandibular retrusion in those areas that may narrow the upper airways. CONCLUSIONS This study may help to understand why not all patients move their lower jaws forwards equally with the same degree of mandibular protrusion measured in relation to the teeth. These results might also partially explain why airway obstruction is more severe in certain untreated sleep apnea subjects than in others when opening their mouth during sleep.
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Affiliation(s)
- Marcos García
- Department of Mechanical Engineering, University of Málaga, Spain
| | - Juan A Cabrera
- Department of Mechanical Engineering, University of Málaga, Spain.
| | - Alex Bataller
- Department of Mechanical Engineering, University of Málaga, Spain
| | - Javier Vila
- Otorhinolaryngology, Hospital Vall d Hebron, Barcelona, Spain
| | - Pedro Mayoral
- Master Program of Dental Sleep Medicine, Catholic University of Murcia, Spain
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16
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Chen H, Eckert DJ, van der Stelt PF, Guo J, Ge S, Emami E, Almeida FR, Huynh NT. Phenotypes of responders to mandibular advancement device therapy in obstructive sleep apnea patients: A systematic review and meta-analysis. Sleep Med Rev 2020; 49:101229. [DOI: 10.1016/j.smrv.2019.101229] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 12/12/2022]
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17
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Marques M, Genta PR, Azarbarzin A, Taranto-Montemurro L, Messineo L, Hess LB, Demko G, White DP, Sands SA, Wellman A. Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea. J Physiol 2019; 597:5399-5410. [PMID: 31503323 PMCID: PMC8359733 DOI: 10.1113/jp278164] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/25/2019] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS •Some patients with obstructive sleep apnoea (OSA) respond well to oral appliance therapy, whereas others do not for reasons that are unclear. •In the present study, we used gold-standard measurements to demonstrate that patients with a posteriorly-located tongue (natural sleep endoscopy) exhibit a preferential improvement in collapsibility (lowered critical closing pressure) with oral appliances. •We also show that patients with both posteriorly-located tongue and less severe collapsibility (predicted responder phenotype) exhibit greater improvements in severity of obstructive sleep apnoea (i.e. reduction in event frequency by 83%, in contrast to 48% in predicted non-responders). •The present study suggests that the structure and severity of pharyngeal obstruction determine the phenotype of sleep apnoea patients who benefit maximally from oral appliance efficacy. ABSTRACT A major limitation to the administration of oral appliance therapy for obstructive sleep apnoea (OSA) is that therapeutic responses remain unpredictable. In the present study, we tested the hypotheses that oral appliance therapy (i) reduces pharyngeal collapsibility preferentially in patients with posteriorly-located tongue and (ii) is most efficacious (reduction in apnoea-hypopnea index; AHI) in patients with a posteriorly-located tongue and less-severe baseline pharyngeal collapsibility. Twenty-five OSA patients underwent upper airway endoscopy during natural sleep to assess tongue position (type I: vallecula entirely visible; type II: vallecula obscured; type III: vallecula and glottis obscured), as well as obstruction as a result of other pharyngeal structures (e.g. epiglottis). Additional sleep studies with and without oral appliance were performed to measure collapsibility (critical closing pressure; Pcrit) and assess treatment efficacy. Overall, oral appliance therapy reduced Pcrit by 3.9 ± 2.4 cmH2 O (mean ± SD) and AHI by 69 ± 19%. Therapy lowered Pcrit by an additional 2.7 ± 0.9 cmH2 O in patients with posteriorly-located tongue (types II and III) compared to those without (type I) (P < 0.008). Posteriorly-located tongue (p = 0.03) and lower collapsibility (p = 0.04) at baseline were significant determinants of (greater-than-average) treatment efficacy. Predicted responders (type II and III and Pcrit < 1 cmH2 O) exhibited a greater reduction in the AHI (83 ± 9 vs. 48 ± 8% baseline, P < 0.001) and a lower treatment AHI (9 ± 6 vs. 32 ± 15 events h-1 , P < 0.001) than predicted non-responders. The site and severity of pharyngeal collapse combine to determine oral appliance efficacy. Specifically, patients with a posteriorly-located tongue plus less-severe collapsibility are the strongest candidates for oral appliance therapy.
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Affiliation(s)
- Melania Marques
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Laboratorio do sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Pedro R Genta
- Laboratorio do sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Respiratory Medicine and Sleep Laboratory, Department of Experimental and Clinical Sciences, University of Brescia and Spedali Civili, Brescia, Italy
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gail Demko
- Sleep Apnea Dentists of New England, Weston, MA, USA
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, VIC, Australia
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. Kaohsiung J Med Sci 2019; 36:7-12. [PMID: 31512369 DOI: 10.1002/kjm2.12130] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/21/2019] [Indexed: 11/07/2022] Open
Abstract
Sleep-related breathing disorders are complex problems that decrease quality of life and increase morbidity and mortality in patients. Comprehensive evaluation is essential for selecting and planning obstructive sleep apnea (OSA) treatments. However, the many proposed OSA treatments are rarely compared in the literature. The literature on OSA consists largely of case series studies, and the paucity of controlled studies makes comparisons of OSA treatments difficult. This article provides a brief overview of the most common OSA interventions. Because of the controversies and unanswered questions about OSA treatments, further studies are needed to define what treatments are best for specific OSA patients.
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Affiliation(s)
- Hong-Po Chang
- School of Dentistry and Graduate Program of Dental Science, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Dentistry (Orthodontics), Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Yu-Feng Chen
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Institute of Oral Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Je-Kang Du
- School of Dentistry and Graduate Program of Dental Science, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Prosthodontics, Faculty of Dentistry, Kaohsiung Medical University, Hospital, Kaohsiung, Taiwan
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Prediction of tongue obstruction observed from drug induced sleep computed tomography by cephalometric parameters. Auris Nasus Larynx 2018; 46:384-389. [PMID: 30262210 DOI: 10.1016/j.anl.2018.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/15/2018] [Accepted: 08/26/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To elucidate potential role of cephalometric measurements to predict tongue base obstruction as observed on drug Induced Sleep Computed Tomography (DIS-CT). METHODS Study included 35 patients with moderate to severe sleep apnea who underwent DIS-CT & cephalometric examination to assess tongue base obstruction. RESULTS Statistically significant difference was noted for SNA angle & Mandibular posterior airway space (PAS) among groups with total tongue obstruction versus Non-total tongue obstruction identified on DIS-CT. CONCLUSION Lateral cephalogram can be used as a standard screening tool with commonly used skeletal and soft tissue parameters to predict the possibility of tongue collapse/obstruction during sleep in patient with moderate to severe OSAS.
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20
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Lee GS, Kim HK, Kim ME. Risk factors for the efficacy of oral appliance for treating obstructive sleep apnea: A preliminary study. Cranio 2017; 36:352-359. [DOI: 10.1080/08869634.2017.1398285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Geun-Shin Lee
- Department of Oral Medicine, College of Dentistry, Dankook University, Cheonan, South Korea
| | - Hye-Kyoung Kim
- Department of Oral Medicine, College of Dentistry, Dankook University, Cheonan, South Korea
| | - Mee-Eun Kim
- Department of Oral Medicine, College of Dentistry, Dankook University, Cheonan, South Korea
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21
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Remmers JE, Topor Z, Grosse J, Vranjes N, Mosca EV, Brant R, Bruehlmann S, Charkhandeh S, Zareian Jahromi SA. A Feedback-Controlled Mandibular Positioner Identifies Individuals With Sleep Apnea Who Will Respond to Oral Appliance Therapy. J Clin Sleep Med 2017; 13:871-880. [PMID: 28502280 DOI: 10.5664/jcsm.6656] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/03/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Mandibular protruding oral appliances represent a potentially important therapy for obstructive sleep apnea (OSA). However, their clinical utility is limited by a less-than-ideal efficacy rate and uncertainty regarding an efficacious mandibular position, pointing to the need for a tool to assist in delivery of the therapy. The current study assesses the ability to prospectively identify therapeutic responders and determine an efficacious mandibular position. METHODS Individuals (n = 202) with OSA participated in a blinded, 2-part investigation. A system for identifying therapeutic responders was developed in part 1 (n = 149); the predictive accuracy of this system was prospectively evaluated on a new population in part 2 (n = 53). Each participant underwent a 2-night, in-home feedback-controlled mandibular positioner (FCMP) test, followed by treatment with a custom oral appliance and an outcome study with the oral appliance in place. A machine learning classification system was trained to predict therapeutic outcome on data obtained from FCMP studies on part 1 participants. The accuracy of this trained system was then evaluated on part 2 participants by examining the agreement between prospectively predicted outcome and observed outcome. A predicted efficacious mandibular position was derived from each FCMP study. RESULTS Predictive accuracy was as follows: sensitivity 85%; specificity 93%; positive predictive value 97%; and negative predictive value 72%. Of participants correctly predicted to respond to therapy, the predicted mandibular protrusive position proved efficacious in 86% of cases. CONCLUSIONS An unattended, in-home FCMP test prospectively identifies individuals with OSA who will respond to oral appliance therapy and provides an efficacious mandibular position. CLINICAL TRIAL REGISTRATION The trial that this study reports on is registered on www.clinicaltrials.gov, ID NCT03011762, study name: Feasibility and Predictive Accuracy of an In-Home Computer Controlled Mandibular Positioner in Identifying Favourable Candidates for Oral Appliance Therapy.
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Affiliation(s)
- John E Remmers
- University of Calgary, Calgary, Canada.,Zephyr Sleep Technologies, Calgary, Canada
| | - Zbigniew Topor
- University of Calgary, Calgary, Canada.,Zephyr Sleep Technologies, Calgary, Canada
| | | | | | | | - Rollin Brant
- University of British Columbia, Vancouver, Canada
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Lian YC, Huang YS, Guilleminault C, Chen KT, Hervy-Auboiron M, Chuang LC, Tsai AI. The preliminary results of the differences in craniofacial and airway morphology between preterm and full-term children with obstructive sleep apnea. J Dent Sci 2017; 12:253-260. [PMID: 30895059 PMCID: PMC6400011 DOI: 10.1016/j.jds.2017.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 03/22/2017] [Indexed: 01/08/2023] Open
Abstract
Background/purpose The prematurely born and obstructive sleep apnea (OSA) could affect craniofacial and airway growth. The purpose of this study is to compare the differences in craniofacial and airway morphology between preterm and full-term children both with OSA problem. Materials and methods The differences in craniofacial and airway morphology between preterm children and full-term children both with OSA problem during the prepubertal (age 6–10) and pubertal (age 11–14) period were measured using lateral cephalometric radiograph. Results In the prepubertal period, effective maxillary length, and length from Go to Gn were smaller in the preterm group (n = 6) compared to the full-term (n = 8). The length of the soft palate was smaller and the distance soft palate-posterior side of nasopharynx was longer in preterm children. During puberty, (1) position of maxilla relative to cranial base: there was an anteroposterior maxilla and a mandibular discrepancy, a convexity of facial profile, (2) the distance from point A to nasion perpendicular, the distance from Pog to nasion perpendicular, and the ratio of effective maxillary length/effective mandibular length were smaller in the preterm group (n = 5) compare to the full-term (n = 6). Conclusion During prepuberty, the preterm children had a significantly shorter effective maxillary and mandibular length but the catch up growth resulted during the pubertal period in reduction in facial profile convexity and more important mandibular vertical growth toward a dolichocephalic profile. Due to preterm birth, OSA children have a different craniofacial morphology compared to the full-term. When using an oral device for passive myofunctional therapy, the treatment outcome maybe different.
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Affiliation(s)
- Yun-Chia Lian
- Department of Pediatric Dentistry, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Graduate Institute of Craniofacial and Dental Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Shu Huang
- Department of Child Psychiatry and Sleep Center, Chang Gung Memorial Hospital and College of Medicine, Taoyuan, Taiwan.,Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | - Kuang-Tai Chen
- Department of Child Psychiatry and Sleep Center, Chang Gung Memorial Hospital and College of Medicine, Taoyuan, Taiwan
| | | | - Li-Chuan Chuang
- Department of Pediatric Dentistry, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Graduate Institute of Craniofacial and Dental Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Aileen I Tsai
- Department of Pediatric Dentistry, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Graduate Institute of Craniofacial and Dental Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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23
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Prediction of oral appliance treatment outcomes in obstructive sleep apnea: A systematic review. Sleep Med Rev 2016; 30:25-33. [DOI: 10.1016/j.smrv.2015.11.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 10/14/2015] [Accepted: 11/25/2015] [Indexed: 11/21/2022]
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Alessandri-Bonetti G, Ippolito DR, Bartolucci ML, D'Antò V, Incerti-Parenti S. Cephalometric predictors of treatment outcome with mandibular advancement devices in adult patients with obstructive sleep apnea: a systematic review. Korean J Orthod 2015; 45:308-21. [PMID: 26629477 PMCID: PMC4664907 DOI: 10.4041/kjod.2015.45.6.308] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/15/2015] [Accepted: 05/06/2015] [Indexed: 02/01/2023] Open
Abstract
Objective The efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA) ranges between 42% and 65%. However, it is still unclear which predictive factors can be used to select suitable patients for MAD treatment. This study aimed to systematically review the literature on the predictive value of cephalometric analysis for MAD treatment outcomes in adult OSA patients. Methods The MEDLINE, Google Scholar, Scopus, and Cochrane Library databases were searched through December 2014. Reference lists from the retrieved publications were also examined. English language studies published in international peer-reviewed journals concerning the predictive value of cephalometric analysis for MAD treatment outcome were considered for inclusion. Two review authors independently assessed eligibility, extracted data, and ascertained the quality of the studies. Results Fifteen eligible studies were identified. Most of the skeletal, dental, and soft tissue cephalometric measurements examined were widely recognized as not prognostic for MAD treatment outcome; however, controversial and limited data were found on the predictive role of certain cephalometric measurements including cranial base angle, mandibular plane angle, hyoid to mandibular plane distance, posterior nasal spine to soft-palate tip distance, anterior nasal spine to epiglottis base distance, and tongue/oral cross sectional area ratio thus justifying additional studies on these parameters. Conclusions Currently available evidence is inadequate for identification of cephalometric parameters capable of reliably discriminating between poor and good responders to MAD treatment. To guide further research, methodological weaknesses of the currently available studies were highlighted and possible reasons for their discordant results were analyzed.
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Affiliation(s)
- Giulio Alessandri-Bonetti
- Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | | | - Maria Lavinia Bartolucci
- Department of Neuroscience, Reproductive Science and Oral Science, University of Naples "Federico II", Naples, Italy
| | - Vincenzo D'Antò
- Department of Neuroscience, Reproductive Science and Oral Science, University of Naples "Federico II", Naples, Italy. ; Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Serena Incerti-Parenti
- Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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Guarda-Nardini L, Manfredini D, Mion M, Heir G, Marchese-Ragona R. Anatomically Based Outcome Predictors of Treatment for Obstructive Sleep Apnea with Intraoral Splint Devices: A Systematic Review of Cephalometric Studies. J Clin Sleep Med 2015; 11:1327-34. [PMID: 25979102 DOI: 10.5664/jcsm.5198] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 04/10/2015] [Indexed: 11/13/2022]
Abstract
AIMS The aim of this review is to summarize data from the literature on the predictive value of anatomy-based parameters, as identified by cephalometry, for the efficacy of mandibular advancement devices (MAD) for the treatment of obstructive sleep apnea (OSA). METHODS Articles were initially selected based on their titles or abstracts. Full articles were then retrieved and further scrutinized according to predetermined criteria. Reference lists of selected articles were searched for any missed publications. The selected articles were methodologically evaluated. RESULTS Of an initial 311 references, 13 were selected that assessed correlations between polysomnographic and cephalometric variables. The majority of studies demonstrated a correlation between treatment effectiveness and features as determined by cephalometric analysis, such as the mandibular plane angle, hyoid bone distance to mandible, antero-posterior diameter of the maxilla, tongue area, cranial base, and soft palate. CONCLUSIONS The mandibular plane angle and the distance between hyoid bone and mandibular plane was found to have a predictive value for MAD effectiveness in OSA patients. However, the relative weak and somewhat inconsistent cephalometric data suggest that decisions based solely on these factors cannot be recommended, especially because an integrated analysis of other risk factors (e.g., age, sex, BMI) should also be taken into account.
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Affiliation(s)
- Luca Guarda-Nardini
- Department of Maxillofacial Surgery, TMD Clinic, University of Padova, Padova, Italy
| | - Daniele Manfredini
- Institute of Otolaryngology, Department of Neurosciences, Padova University, Padova, Italy
| | - Marta Mion
- Institute of Otolaryngology, Department of Neurosciences, Padova University, Padova, Italy
| | - Gary Heir
- Center for Temporomandibular Disorders and Orofacial Pain, Rutgers University School of Dental Medicine, Newark, NJ
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The status of cephalometry in the prediction of non-CPAP treatment outcome in obstructive sleep apnea patients. Sleep Med Rev 2015; 27:56-73. [PMID: 26452001 DOI: 10.1016/j.smrv.2015.05.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 04/26/2015] [Accepted: 05/26/2015] [Indexed: 12/24/2022]
Abstract
Obstructive sleep apnea syndrome (OSAS) is the most common sleep disordered breathing disorder (SDB) in adults and is characterized by a recurrent partial or complete collapse of the upper airway during sleep. This can be caused by many factors, sometimes interacting, such as skeletal malformations, soft tissue crowding, respiratory instability and the various effects of aging, obesity and gender that dictate craniofacial and upper airway anatomy. Research has demonstrated that the majority of patients exhibit at least one anatomical component such as retrognathia or a narrow posterior airway space that predisposes to the development of OSAS. Within the predisposing elements for OSAS many seem to point to anatomical characteristics. A standardized and relatively simple radiologic technique to evaluate anatomical craniofacial relationships is cephalometry. This has been used already for a long time in orthodontics, but is now gradually being introduced in OSAS treatment to envisage optimal treatment selection as well as to predict treatment outcomes. The purpose of the present review is to evaluate the contribution of cephalometry in the prediction of outcomes from OSAS treatments that depend on the upper airway morphology in their mechanisms of action such as oral appliances that advance the mandible as well as various surgical methods. In addition, an overview of imaging modalities and methods that currently are being used in cephalometric analysis in OSAS patients is provided. The findings indicate that isolated cephalometric parameters cannot be used to reliably predict treatment outcomes from mandibular advancement devices and surgical methods for OSAS. Extreme or outlying values of cephalometric parameters may rather be used as contra-indicators or 'red flags' instead of predictors.
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Ogawa T, Long J, Sutherland K, Chan ASL, Sasaki K, Cistulli PA. Effect of mandibular advancement splint treatment on tongue shape in obstructive sleep apnea. Sleep Breath 2015; 19:857-63. [DOI: 10.1007/s11325-014-1101-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 12/11/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
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Weaver TE, Calik MW, Farabi SS, Fink AM, Galang-Boquiren MT, Kapella MC, Prasad B, Carley DW. Innovative treatments for adults with obstructive sleep apnea. Nat Sci Sleep 2014; 6:137-47. [PMID: 25429246 PMCID: PMC4242689 DOI: 10.2147/nss.s46818] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and reduced quality of life. For over 25 years, the primary treatment has been continuous positive airway pressure, which introduces a column of air that serves as a pneumatic splint for the upper airway, preventing the airway collapse that is the physiologic definition of this syndrome. However, issues with patient tolerance and unacceptable levels of treatment adherence motivated the exploration of other potential treatments. With greater understanding of the physiologic mechanisms associated with OSA, novel interventions have emerged in the last 5 years. The purpose of this article is to describe new treatments for OSA and associated complex sleep apnea. New approaches to complex sleep apnea have included adaptive servoventilation. There is increased literature on the contribution of behavioral interventions to improve adherence with continuous positive airway pressure that have proven quite effective. New non-surgical treatments include oral pressure devices, improved mandibular advancement devices, nasal expiratory positive airway pressure, and newer approaches to positional therapy. Recent innovations in surgical interventions have included laser-assisted uvulopalatoplasty, radiofrequency ablation, palatal implants, and electrical stimulation of the upper airway muscles. No drugs have been approved to treat OSA, but potential drug therapies have centered on increasing ventilatory drive, altering the arousal threshold, modifying loop gain (a dimensionless value quantifying the stability of the ventilatory control system), or preventing airway collapse by affecting the surface tension. An emerging approach is the application of cannabinoids to increase upper airway tone.
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Affiliation(s)
- Terri E Weaver
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Michael W Calik
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Sarah S Farabi
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Anne M Fink
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Maria T Galang-Boquiren
- Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA ; Department of Orthodontics, University of Illinois at Chicago College of Dentistry, Chicago, IL, USA
| | - Mary C Kapella
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Bharati Prasad
- Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA ; Sleep Center, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - David W Carley
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
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Is the growth pattern in mouth breathers comparable with the counterclockwise mandibular rotation of nasal breathers? Am J Orthod Dentofacial Orthop 2013; 144:341-8. [DOI: 10.1016/j.ajodo.2013.03.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 03/01/2013] [Accepted: 03/01/2013] [Indexed: 11/20/2022]
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