Initial Evaluation of a Titration Appliance for Temporary Treatment of Obstructive Sleep Apnea

Oral Health Implications of Obstructive Sleep Apnea: A Literature Review

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep. While the systemic implications of OSA are well documented, the dental consequences are less frequently discussed yet equally significant. This review aims to elucidate the oral health impacts of OSA, emphasizing the importance of interdisciplinary care.

METHODS

A comprehensive literature search was conducted across several databases to identify studies examining the relationship between OSA and various oral health parameters. The review included observational studies, clinical trials, and systematic reviews published in English up to January 2024.

RESULTS

OSA was significantly associated with heightened risks of bruxism, dry mouth, periodontal disease, temporomandibular joint disorders, palatal and dental changes, and alterations in taste sensation. Mouth breathing associated with OSA was a critical factor in exacerbating xerostomia and dental caries. Furthermore, the systemic inflammation induced by OSA appeared to correlate with the severity of periodontal disease. Patients using oral appliance therapy for OSA also showed notable changes in dental occlusion and required ongoing dental monitoring.

CONCLUSIONS

The findings underscore the bidirectional relationship between OSA and oral health, highlighting the need for dental professionals to be integral participants in the management of OSA. Early dental evaluation and intervention can contribute to the overall health and quality of life of individuals with OSA. The review advocates for the development of clinical guidelines to facilitate the early identification and management of OSA-related oral health issues within dental practice and encourages a collaborative approach to patient care.

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

BACKGROUND

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

OBJETIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Criteria for oral appliance and/or supine avoidance therapy selection based on outcome optimization and cost-effectiveness

AIM

Produce empirical support for further enhancements to a therapy selection protocol for obstructive sleep apnea (OSA) patients intolerant of positive airway pressure.

METHODS

A retrospective analysis was conducted in 101 men and 69 women patients. Two-night home sleep apnea studies were conducted at baseline and with a trial oral appliance. Twenty-minutes in-position sleep was required to compute supine and non-supine apnea-hypopnea indexes (AHI). Data analyses were applied after stratification by sex and response to oral appliance therapy (OAT), and the results used for to calculate incremental cost-effectiveness ratios (ICER).

RESULTS

Compared with men, women had significantly lower pre-treatment supine and non-supine AHI values (p < .05). OAT non-responders had higher non-supine AHIs, resulting in less positional-OSA and more cases with severe OSA (p < .05). Across the cohort, 21% had positional-OSA with a pre-treatment non-supine AHI < 5 events/h. In those who met this criterion, supine avoidance therapy (SAT) could have reduced the AHI values more than OAT by an average of 33% (p < .0001). The ICER for SAT instead of OAT in this group was negative, a condition that only occurs when one therapy is both less expensive and more effective than the other. A greater proportion of non-responders had post-OAT overall AHI ≥ 10 events/h with residual positional-OSA compared with responders (p < .0001). Combination therapy could reduce the AHI values by an average of 68%, resulting in ICER estimates five-times less than the reimbursement decision-making threshold.

CONCLUSIONS AND LIMITATIONS

Based on pre-treatment non-supine AHI values, SAT would provide a superior first-line treatment outcome as compared to OAT in 21% of patients diagnosed with OSA. SAT would also provide a cost-effective adjuvant to OAT in an additional 15% of cases. The benefit of SAT could not be determined in one-fifth of the cohort who slept exclusively supine.

[Oral appliances for obstructive sleep apnoea: What can we expect?]

INTRODUCTION

Mandibular appliances are a treatment option for obstructive sleep apnea. There are many designs, but in the literature they tend to be grouped into a single entity without considering that efficiency, tolerance, compliance, or side effects are inherent in the design of each of them. A more detailed literature review is therefore warranted for the reader who wants to understand the relative effectiveness of each appliance.

STATE OF KNOWLEDGE

We conducted a literature search using the "oral appliance" and "obstructive sleep apnea" criteria on Pubmed, Embase and Cochrane. This allowed us to compare outcome parameters by appliance class and to highlight the rare studies comparing different appliances.

CONCLUSIONS

Mandibular appliances are not a homogeneous entity. Common use includes only appliances designed for propulsion (with rods and jacks) and retention. However, the few comparative studies available do not identify which are the most effective types or the types with an optimal efficacy/tolerance ratio.

PERSPECTIVES

Further appliance comparison studies are needed to determine the most effective type or with an optimal efficacy/tolerance ratio.

High-Resolution Pulse Oximetry and Titration of a Mandibular Advancement Device for Obstructive Sleep Apnea

Background: To determine whether utilizing high-resolution pulse oximetry is a viable method for evaluating the successful titration of oral appliances for the treatment of obstructive sleep apnea (OSA) patients.

Methods: Of 136 consecutive potentially eligible OSA patients, 133 were fitted with mandibular advancement devices (MADs), and 101 completed all phases of treatment. The vertical and horizontal dimensions of the appliances were adjusted based on three-nights with a high-resolution pulse oximeter during sleep and associated software after each adjustment.

Results: Significant improvements in OSA severity were apparent in patients at all disease severity levels. High-resolution pulse oximetry provided reliable guidance in the titration process of mandibular advancement therapy. In 67 subjects (66.3%), a respiratory event index of <5 events/hour was achieved.

Conclusions: OSA can be effectively treated with a MAD at any severity level, and high-resolution pulse oximetry provides critical information to guide oral appliance titration.

The use of oral appliances in obstructive sleep apnea: a retrospective cohort study spanning 14 years of private practice experience

PURPOSE

In 2005, the American Academy of Sleep Medicine stated, "Oral appliances are indicated for use in patients with mild to moderate obstructive sleep apnea (OSA) who prefer them to CPAP therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP." However, this recommendation is based upon variable results from only six studies with more than 100 participants. These studies have assessed the effectiveness of mandibular advancement devices (MADs) in specific groups (military populations, academic institutions, or hospital settings) with no large study conducted in a fee-for-service private practice where the majority of patients receive MADs for OSA. The purpose of this study is to report outcomes of a board-certified dental sleep practitioner managing mild, moderate, and severe OSA using customized titratable MADs. We hypothesize that patients will demonstrate a significant reduction in apnea-hypopnea index (AHI) scores after adjusting their customized titratable MADs.

METHODS

This is a 14-year retrospective study design with pre- and post-treatment sleep studies. An AHI score < 10 respiratory events per hour with therapy is defined as treatment success. This study was performed by a single private practitioner.

RESULTS

Of 2419 patient records analyzed, 544 (22%) had pre- and post-treatment sleep studies (89% polysomnograms). Of 510 patients with complete data, 459 (90%) revealed a decrease in AHI score < 10 respiratory events per hour indicating treatment success. Only 51 of these patients (10%) had a final AHI ≥ 10 and were considered treatment failures. Among the patients who lacked post overnight polysomnogram, 66/1921 (3%) discontinued the MAD due to adverse effects. Considering these patients as treatment failures as well, and therefore adding their number to the patients with complete sleep study data, the total treatment failures were 117/576 or 20%. Of the treatment successes, OSA was categorized by AHI at baseline as mild in 170 (34%), moderate in 181 (36%), and severe in 138 (28%).

CONCLUSIONS

In patients with evaluable data, there was an 80% success rate for treatment of OSA using a custom-fabricated adjustable MAD including substantial numbers of patients with moderate and severe disease.

Efficiency of the Ocluch©MAD in the treatment of patients with OSAS and its association with craniofacial morphology

Objective

This study uses polysomnography and the Epworth sleepiness scale to assess the efficiency of the Ocluch^©MAD in patients with Obstructive sleep apnea-hypopnea syndrome (OSAS), on overall respiratory disturbance indices (RDI), supine respiratory disturbance index (SRDI), minimum oxygen saturation, microarousals, CT90 (or ID90), sleep efficacy and snoring. These data are associated with skeletal class and facial biotype in order to establish predictive parameters for its effectiveness according to craniofacial morphology.

Methods

22 adult patients (between 38 and 60 years of age) of both sexes (7 women, 15 men) diagnosed with OSAS in the Hospital de Carabineros de Chile (HOSCAR) Neurology Unit were recruited and given the Ocluch^© MAD in the hospital’s dental clinic, for its use during a three-month period. Patients were assess at the beginning and in the end of this period.

Results

87.5% of patients with mild OSAS achieved the success criterion and normalization; 71.5% of patients with moderate OSAS achieved the success criterion and 33.3% achieved normalization; 85.7% of patients with severe OSAS achieved the success criterion and 57.1% achieved normalization. All class I and mesofacial patients achieved normalization, but class II patients had the greatest proportional improvement.

Conclusions

The Ocluch MAD is an efficient low-cost alternative that should be considered among the therapeutic arsenal for a multidisciplinary approach to treating this disease.

A Feedback-Controlled Mandibular Positioner Identifies Individuals With Sleep Apnea Who Will Respond to Oral Appliance Therapy

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.

Assessment of oral appliance for obstructive sleep apnea patients

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

Remotely controlled mandibular protrusion during sleep predicts therapeutic success with oral appliances in patients with obstructive sleep apnea

STUDY OBJECTIVES

The present study addresses the need for a validated tool that prospectively identifies favorable candidates for oral appliance therapy in treatment of obstructive sleep apnea. The objective of the study was to evaluate the ability of a mandibular titration study, performed with a remotely controlled mandibular positioner (RCMP), to predict treatment outcome with a mandibular repositioning appliance (MRA) and to predict an effective target protrusive position (ETPP).

DESIGN

A prospective, blinded, outcome study.

SETTING

Standard clinical care with tests performed in the polysomnographic laboratory.

PARTICIPANTS

Consecutive patients (n = 67) recruited from a sleep center or a dental practice using broad inclusion criteria (age 21-80 years; AHI > 10/h; BMI < 40 kg/m(2)).

INTERVENTIONS

Therapeutic outcome with a mandibular protruding oral appliance was predicted following a mandibular protrusive titration study in the polysomnographic laboratory using a remotely controlled positioner and prospectively established predictive rules. An ETPP was also prospectively determined for participants predicted to be therapeutically successful with MRA therapy. All participants were blindly treated with a MRA, at either the predicted ETPP or a sham position, and therapeutic outcome was compared against prediction.

MEASUREMENTS AND RESULTS

At the final protrusive position, standard predictive parameters (sensitivity, specificity, positive and negative predictive values) showed statistically significant predictive accuracy (P < 0.05) in the range of 83% to 94%. The predicted ETPP provided an efficacious protrusive position in 87% of participants predicted to be therapeutically successful with MRA therapy (P < 0.05).

CONCLUSIONS

Using prospectively established rules for interpreting the polysomnographic data, the mandibular titration study predicted mandibular repositioning appliance therapeutic outcome with significant accuracy, particularly with regard to accurately predicting therapeutic success. As well, among the participants predicted to be therapeutically successful with mandibular repositioning appliance therapy, the effective target protrusive position provided efficacious mandibular protrusion in the majority.