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Opsahl UL, Berge M, Lehmann S, Bjorvatn B, Johansson A. Elastic Bands Improve Oral Appliance Treatment Effect on Obstructive Sleep Apnoea: A Randomised Crossover Trial. J Oral Rehabil 2024. [PMID: 39344419 DOI: 10.1111/joor.13870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/26/2024] [Accepted: 09/15/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Oral appliances (OAs) that limit mouth opening during sleep, such as monobloc appliances, have shown superior treatment effects in subgroups of patients with obstructive sleep apnoea. The application of elastic bands on bibloc appliances may resemble these benefits. OBJECTIVES The primary objective was to investigate if application of elastic bands to bibloc appliances improves treatment success (> 50% reduction of respiratory event index (REI)), in addition to other subjective variables. Furthermore, we aimed to identify variables predicting the need for elastic bands in OA treatment. METHODS Included patients (n = 69) were randomly assigned to OA treatment with or without elastic bands. After 3 weeks, treatment effect was investigated with home respiratory polygraphy and questionnaires. Thereafter, patients changed treatment modality, with identical follow-up regime. Statistical analyses were performed using Student's t-test and Pearson's chi-squared test to investigate differences between the two treatment modalities, and logistic regression analysis was conducted to investigate variables tentatively associated with treatment success. RESULTS Based on REI, the success rate with OA treatment was in favour of elastic bands (53.9% vs. 34.6%, p = 0.002). Male sex and larger maximum mouth opening were identified as predictors for increased treatment success with elastic bands. The main benefit with elastic bands seemed to be greater reduction of REI when supine. However, patients seem to prefer OA without elastic bands. CONCLUSIONS Elastic bands improved OA treatment effect by reducing the REI in supine position. Patient groups that seemed to benefit from elastic bands in OA treatment were men with large maximum mouth openings.
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Affiliation(s)
- Ulrik Leidland Opsahl
- Department of Clinical Dentistry, Faculty of Medicine, Center for Translational Oral Research (TOR), University of Bergen, Bergen, Norway
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Morten Berge
- Department of Clinical Dentistry, Faculty of Medicine, Center for Translational Oral Research (TOR), University of Bergen, Bergen, Norway
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sverre Lehmann
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Bjorvatn
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Anders Johansson
- Department of Clinical Dentistry, Faculty of Medicine, Center for Translational Oral Research (TOR), University of Bergen, Bergen, Norway
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
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Guo MY, Li PJ, Xiao Y, Cao Y, Liang ZA. Effectiveness of mandibular advancement devices in the treatment of obstructive sleep apnea and the impact of different body positions on treatment: A systematic review and meta-analysis. Sleep Med 2024; 113:275-283. [PMID: 38071926 DOI: 10.1016/j.sleep.2023.11.1134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/24/2023] [Accepted: 11/30/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE The meta-analysis aimed to evaluate the efficacy of mandibular advancement device (MAD) for the treatment of obstructive sleep apnea (OSA) and explore the effect of different positions on MAD for OSA. METHODS The Embase, PubMed, Medline, and Cochrane Library databases were searched for relevant studies evaluating the effect of MAD on the treatment of OSA from database inception to November 2022. The Bayesian random-effects mode was used to calculate the pooled outcome. Subgroup analysis and sensitivity analysis were applied to investigate the heterogeneity. RESULTS A total of 6 studies enrolling 643 patients were eligible for further analysis. MAD treatment led to improvements in total apnea-hypopnea index (AHI) for both positional OSA(POSA) and Non-POSA groups, but there was no significant difference in the effect of MAD on Non-POSA and POSA (MD = -1.46,95%CI [-4.89,1.97], P = 0.40). In the supine position, AHI improvement after MAD treatment in POSA group was more than that in Non-POSA group by 15 events/hour in average (MD = 14.82, 95%CI [11.43,18.22], P<0.00001), while in the non-supine position, the change of AHI in Non-POSA group was significantly better than that in POSA group by approximately 8 events/hour (MD = -7.55,95%CI[-10.73,-4.38],p < 0.00001). CONCLUSION MAD is more suitable for POSA compared to Non-POSA in patients with habitual sleep in the supine or supine predominant position. While for patients with habitual sleep in the non-supine position, MAD is an effective treatment option for Non-POSA.
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Affiliation(s)
- Meng-Yao Guo
- West China School of Medicine/West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan, 610041, PR China
| | - Pei-Jun Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan, 610041, PR China.
| | - Yao Xiao
- West China School of Medicine/West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan, 610041, PR China
| | - Yuan Cao
- West China School of Medicine/West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan, 610041, PR China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan, 610041, PR China
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Iftikhar IH, Cistulli PA, Jahrami H, Alamoud KA, Saeed M, Soulimiotis AP, BaHammam AS. Comparative efficacy of mandibular advancement devices in obstructive sleep apnea: a network meta-analysis. Sleep Breath 2023; 27:1365-1381. [PMID: 36374442 DOI: 10.1007/s11325-022-02744-6] [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: 08/08/2022] [Revised: 10/25/2022] [Accepted: 11/05/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE To analyze relative efficacies of mandibular advancement devices (MAD) in sleep apnea treatment. METHODS From eligible randomized controlled trials (RCT), MADs were classified based on their mechanistic designs. Data on apnea-hypopnea index (AHI), Epworth sleepiness scale (ESS), nadir oxygen saturation (minSaO2), and sleep efficiency (SE%) from RCTs were then analyzed in network meta-analyses, and relative ranking of different MADs was computed based on P scores (a method of ranking similar to SUCRA). Similar analyses were conducted based on the different brands of MADs. RESULTS There were no statistically significant differences between MADs in any of the outcomes analyzed. However, the P-scores, based on the point estimates and standard errors of the network estimates, ranked some MADs higher than others in some of the outcomes. Of the different mechanistic designs, the highest P scores were achieved for attached midline traction (P score = 0.84) and unattached bilateral interlocking (P score = 0.78) devices for AHI reduction, attached bilateral traction (P score = 0.78) and unattached bilateral interlocking (P score = 0.76) for ESS, monobloc (P score = 0.91) and unattached bilateral interlocking (P score = 0.64) for minSaO2, and unattached bilateral interlocking (P score = 0.82) and attached bilateral traction (P score = 0.77) for SE%. Notable findings in the network meta-analyses based on MAD brands, of the limited number of studies that specified them were the effects of SomnoDent Flex™, TAP™, and IST® in their effects on AHI reduction, with P scores of 0.94, 0.83, and 0.82, respectively. Monobloc decreased supine-AHI the most (- 44.46 [- 62.55; - 26.36], P score = 0.99), and unattached bilateral interlocking had the greatest effect on REM-AHI (- 11.10 [- 17.10; - 5.10], P score = 0.87). CONCLUSIONS Findings from this study show clinically (but not statistically) significant differences between MADs in terms of their relative efficacy when analyzed for different sleep apnea treatment outcomes and sleep apnea phenotypes.
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Affiliation(s)
- Imran H Iftikhar
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, USA.
- Atlanta Veterans Affairs Medical Center, Atlanta, USA.
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Haitham Jahrami
- Ministry of Health, Manama, Bahrain
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Khalid A Alamoud
- Department of Preventive Dental Science, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Maarij Saeed
- Dental College, HITEC Institute of Medical Sciences, Rawalpindi, Pakistan
| | - Andrew P Soulimiotis
- Sleep Apnea & Snoring Solutions (Private Practice), North Druid Hills Georgia, Atlanta, USA
| | - Ahmed S BaHammam
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia (08-MED511-02), Riyadh, Saudi Arabia
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Taweesedt P, Najeeb H, Surani S. Patient-Centered Therapy for Obstructive Sleep Apnea: A Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1338. [PMID: 36295499 PMCID: PMC9612386 DOI: 10.3390/medicina58101338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/06/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022]
Abstract
Obstructive sleep apnea (OSA) is one of the most common sleep problems defined by cessation or decreased airflow despite breathing efforts. It is known to be related to multiple adverse health consequences. Positive airway pressure (PAP) is considered an effective treatment that is widely used. Various modes of PAP and other emerging treatment options are now available. A multidisciplinary approach, understanding diverse phenotypes of OSA, and shared decision-making are necessary for successful OSA treatment. Patient-centered care is an essential modality to support patient care that can be utilized in patients with OSA to help improve outcomes, treatment adherence, and patient satisfaction.
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Affiliation(s)
| | - Hala Najeeb
- Dow Medical College, Dow University of Health Science, Karachi 74200, Pakistan
| | - Salim Surani
- Health Science Center, Texas A&M University, College Station, TX 79016, USA
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5
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Ciavarella D, Campobasso A, Suriano C, Lo Muzio E, Guida L, Salcuni F, Laurenziello M, Illuzzi G, Tepedino M. A new design of mandibular advancement device (IMYS) in the treatment of obstructive sleep apnea. Cranio 2022:1-8. [PMID: 35171757 DOI: 10.1080/08869634.2022.2041271] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The mandibular advancement device (MAD) is currently suggested in patients with mild to moderate obstructive sleep apnea (OSA). This study investigated the effects of a new fully customizable MAD-type device called, "It Makes You Sleep" (IMYS), in patients with mild to moderate OSA. METHODS Sixteen patients (14 men and 2 women; mean age 62; SD ± 11 years) were retrospectively enrolled. Each patient received home sleep apnea testing (HSAT) at baseline (T0) and after three months (T1) of IMYS treatment. The Apnea-Hypopnea Index (AHI), the Oxygen Desaturation Index (ODI), the Minimum Oxygen Saturation (minSO2) and the Medium Oxygen Saturation (medSO2) were analyzed. RESULTS From T0 to T1, the IMYS treatment showed a significant reduction of AHI and ODI and a significant increase of minSO2 and medSO2. CONCLUSION The IMYS appliance is an effective device for treating mild or moderate OSA.
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Affiliation(s)
- Domenico Ciavarella
- Department of Clinical and Experimental Medicine, Dental School of Foggia, University of Foggia, Foggia, Italy
| | - Alessandra Campobasso
- Department of Clinical and Experimental Medicine, Dental School of Foggia, University of Foggia, Foggia, Italy
| | - Carmela Suriano
- Department of Clinical and Experimental Medicine, Dental School of Foggia, University of Foggia, Foggia, Italy
| | | | - Laura Guida
- Department of Clinical and Experimental Medicine, Dental School of Foggia, University of Foggia, Foggia, Italy
| | - Fabio Salcuni
- Department of Clinical and Experimental Medicine, Dental School of Foggia, University of Foggia, Foggia, Italy
| | - Michele Laurenziello
- Department of Clinical and Experimental Medicine, Dental School of Foggia, University of Foggia, Foggia, Italy
| | - Gaetano Illuzzi
- Department of Clinical and Experimental Medicine, Dental School of Foggia, University of Foggia, Foggia, Italy
| | - Michele Tepedino
- Department of Biotecnologica and Applied Clinical Sciences, Dental School of L'Aquila, University of L'Aquila, L'Aquila, Italy
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Fernández-Sanjuán P, Arrieta JJ, Sanabria J, Alcaraz M, Bosco G, Pérez-Martín N, Pérez A, Carrasco-Llatas M, Moreno-Hay I, Ríos-Lago M, Lugo R, O’Connor-Reina C, Baptista P, Plaza G. Optimizing Mandibular Advancement Maneuvers during Sleep Endoscopy with a Titratable Positioner: DISE-SAM Protocol. J Clin Med 2022; 11:jcm11030658. [PMID: 35160107 PMCID: PMC8836970 DOI: 10.3390/jcm11030658] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/21/2022] Open
Abstract
Mandibular advancement devices (MAD) are an effective alternative treatment to CPAP. Different maneuvers were performed during drug sleep-induced endoscopy (DISE) to mimic the effect of MAD. Using the Selector Avance Mandibular (SAM) device, we aimed to identify MAD candidates during DISE using a titratable, reproducible, and measurable maneuver. This DISE-SAM protocol may help to find the relationship between the severity of the respiratory disorder and the degree of response and determine the advancement required to improve the collapsibility of the upper airway. Explorations were performed in 161 patients (132 males; 29 females) with a mean age of 46.81 (SD = 11.42) years, BMI of 27.90 (SD = 4.19) kg/m2, and a mean AHI of 26.51 (SD = 21.23). The results showed no relationship between severity and MAD recommendation. Furthermore, there was a weak positive relationship between the advancement required to obtain a response and the disease severity. Using the DISE-SAM protocol, the response and the range of mandibular protrusion were assessed, avoiding the interexaminer bias of the jaw thrust maneuver. We suggest prescribing MAD as a single, alternative, or multiple treatment approaches following the SAM recommendations in a personalized design.
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Affiliation(s)
- Patricia Fernández-Sanjuán
- Department of Maxillofacial Surgery and Dentistry, Hospital Universitario San Francisco de Asís, Universidad Rey Juan Carlos, 28002 Madrid, Spain;
- Dental Sleep Medicine, Hospital Universitario Sanitas La Zarzuela, 28942 Madrid, Spain
| | - Juan José Arrieta
- Department of Stomatology, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Jaime Sanabria
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Marta Alcaraz
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Sanitas La Zarzuela, 28942 Madrid, Spain; (M.A.); (G.B.); (N.P.-M.)
| | - Gabriela Bosco
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Sanitas La Zarzuela, 28942 Madrid, Spain; (M.A.); (G.B.); (N.P.-M.)
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28942 Madrid, Spain
| | - Nuria Pérez-Martín
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Sanitas La Zarzuela, 28942 Madrid, Spain; (M.A.); (G.B.); (N.P.-M.)
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28942 Madrid, Spain
| | - Adriana Pérez
- Department of Otolaryngology Head and Neck Surgery, Hospital La Milagrosa, 28010 Madrid, Spain;
| | - Marina Carrasco-Llatas
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Dr. Peset., 46017 Valencia, Spain;
| | - Isabel Moreno-Hay
- Division of Orofacial Pain, Department of Oral Health Science, College of Dentistry, University of Kentucky, Lexington, KY 40536, USA;
| | - Marcos Ríos-Lago
- Department of Basic Psychology II, Faculty of Psychology, UNED, 28040 Madrid, Spain;
| | - Rodolfo Lugo
- Department of Otolaryngology Head and Neck Surgery, Hospital San José, Monterrey 64718, Mexico;
| | - Carlos O’Connor-Reina
- Department of Otolaryngology Head and Neck Surgery, Hospital Quironsalud Marbella, 29603 Marbella, Spain;
- Department of Otolaryngology Head and Neck Surgery, Hospital Quironsalud Campo de Gibraltar, 11379 Palmones, Spain
| | - Peter Baptista
- Department of Otolaryngology Head and Neck Surgery, Clínica Universitaria de Navarra, 31008 Pamplona, Spain;
| | - Guillermo Plaza
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Sanitas La Zarzuela, 28942 Madrid, Spain; (M.A.); (G.B.); (N.P.-M.)
- Department of Otolaryngology Head and Neck Surgery, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28942 Madrid, Spain
- Correspondence:
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Kent D, Stanley J, Aurora RN, Levine CG, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:2507-2531. [PMID: 34351849 PMCID: PMC8726364 DOI: 10.5664/jcsm.9594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation. METHODS The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations. RESULTS The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations. CITATION Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.
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Affiliation(s)
- David Kent
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - R. Nisha Aurora
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Daniel J. Gottlieb
- VA Boston Healthcare System, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Carlos A. Torre
- University of Miami, Miller School of Medicine, Miami, Florida
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Caples SM, Anderson WM, Calero K, Howell M, Hashmi SD. Use of polysomnography and home sleep apnea tests for the longitudinal management of obstructive sleep apnea in adults: an American Academy of Sleep Medicine clinical guidance statement. J Clin Sleep Med 2021; 17:1287-1293. [PMID: 33704050 DOI: 10.5664/jcsm.9240] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Obstructive sleep apnea is an important and common disorder with associated health risks. Assuring successful longitudinal management is vital to patient health and sleep-related quality of life. This paper provides guidance from the American Academy of Sleep Medicine (AASM) regarding the use of polysomnography (PSG) and home sleep apnea tests (HSATs) after a diagnosis of obstructive sleep apnea has been established and, in most cases, treatment implemented. METHODS The AASM commissioned a task force of five sleep medicine experts. A literature search was conducted to identify studies that included adult patients with OSA who underwent follow-up PSG or an HSAT. The task force developed clinical guidance statements based on a review of these studies and expert opinion. The AASM Board of Directors approved the final clinical guidance statements. CLINICAL GUIDANCE STATEMENTS The AASM supports the following clinical guidance statements on indications for follow-up PSG and HSAT in adult patients with OSA. 1. Follow-up PSG or HSAT is not recommended for routine reassessment of asymptomatic patients with obstructive sleep apnea on PAP therapy, however, follow-up PSG or HSAT can be used to reassess patients with recurrent or persistent symptoms, despite good PAP adherence. 2. Follow-up PSG or HSAT is recommended to assess response to treatment with non-PAP interventions. 3. Follow-up PSG or HSAT may be used if clinically significant weight gain or loss has occurred since diagnosis of OSA or initiation of its treatment. 4. Follow-up PSG may be used for reassessment of sleep-related hypoxemia and/or sleep-related hypoventilation following initiation of treatment for OSA. 5. Follow-up PSG or HSAT may be used in patients being treated for OSA who develop or have a change in cardiovascular disease. 6. Follow-up PSG may be used in patients with unexplained PAP device-generated data. The ultimate judgment regarding propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options and resources.
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Sanz PM, Reyes MG, Torras AB, Castillo JAC, Vich MOL. Craniofacial morphology/phenotypes influence on mandibular range of movement in the design of a mandibular advancement device. BMC Oral Health 2021; 21:19. [PMID: 33413283 PMCID: PMC7791719 DOI: 10.1186/s12903-020-01369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 12/16/2020] [Indexed: 12/02/2022] Open
Abstract
Background The mandibular opening path movements have different directions according to the craniofacial morphology of the patient but always downward and backward, therefore increasing the collapse of the upper airway. The aim of this work is to determine if there is a relationship between the craniofacial morphology and the mandibular movement to help understand the impact on the mandibular position. Methods 52 students with full permanent dentition aged 19 to 23 years (mean 21.3 SD 1.7; 29 females and 23 males), participated in the study. Each subject had a lateral cephalometric radiograph taken. The opening angle was determined for two levels of vertical openings at 5 and 10 mm. Results The opening angle showed a greater variability between subjects ranging from 63.15 to 77.08 for 5 mm angle and from for 61.65 to 75.72 for the 10 mm angle. Differences of facial phenotypes was evident when comparing the individual dissoccluding angle of the low angle horizontal pattern and high angle vertical pattern. Conclusions The opening angle is related to craniofacial morphology with higher vertical anterior and shorter anteroposterior faces having a more horizontal path of mandibular movement than shorter vertical anterior and longer anteroposterior subjects who have a more vertical path.
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Affiliation(s)
- P Mayoral Sanz
- Master Program Dental Sleep Medicine, Catholic University of Murcia UCAM, Conde de Peñalver 61, 28006, Madrid, Spain
| | - M Garcia Reyes
- Faculty of Engineering, University of Malaga, Flauta Mágica 22, 29006, Málaga, Spain
| | - A Bataller Torras
- Faculty of Engineering, University of Malaga, Flauta Mágica 22, 29006, Málaga, Spain
| | - J A Cabrera Castillo
- Faculty of Engineering, University of Malaga, Flauta Mágica 22, 29006, Málaga, Spain
| | - M O Lagravère Vich
- Faculty of Medicine and Dentistry, School of Dentistry, University of Alberta ECHA, 5-524, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.
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Francis CE, Quinnell T. Mandibular Advancement Devices for OSA: An Alternative to CPAP? Pulm Ther 2020; 7:25-36. [PMID: 33170490 PMCID: PMC8137783 DOI: 10.1007/s41030-020-00137-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/19/2020] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a prevalent condition causing unrefreshing sleep and excessive daytime sleepiness. It has individual socioeconomic impacts and, through association with increased risk of road traffic accidents, diabetes, and cardiovascular disease, OSA is a public health issue. Continuous positive airway pressure (CPAP) is the first-line treatment for moderate-to-severe OSA. It is effective in improving excessive daytime sleepiness and quality of life. There is also evidence that CPAP therapy has cardiovascular benefits although nature and extent remain uncertain. Despite its benefits, a significant proportion of patients are unable to tolerate CPAP. There are also patients with mild but symptomatic disease, for whom CPAP is usually not available or appropriate, so there is a need for other treatment options. Mandibular advancement devices (MADs) offer an effective alternative to CPAP and can improve daytime symptoms and quality of life. There are many devices available, representing a range of complexity and cost. It is challenging to properly evaluate the effectiveness of this ever-evolving range. The more basic MADs are cheaper and more accessible but are less well tolerated. More complex devices are better tolerated and may be more effective. However, they are more expensive and often require dental expertise, so access is more limited. Efforts continue to try to improve accessibility to effective MAD therapy. Alongside increasing awareness, this may be facilitated by developing and refining devices that could be fitted by non-dental clinicians, and potentially by patients themselves. Research efforts need to focus on determining how to efficiently identify patients who are likely to respond to MAD therapy, so as to improve clinical and cost-effectiveness of OSA therapy overall.
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Affiliation(s)
| | - Tim Quinnell
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
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Treatment of Obstructive Sleep Apnea-Hypopnea Syndrome With a Mandible Advanced Device Increases Nitric Oxide Release and Ameliorates Pulmonary Hypertension in Rabbits. J Oral Maxillofac Surg 2020; 79:694.e1-694.e12. [PMID: 33259783 DOI: 10.1016/j.joms.2020.09.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate the effects of mandible advanced device (MAD) therapy for obstructive sleep apnea-hypopnea syndrome (OSAHS) on nitric oxide (NO) release and changes in pulmonary artery pressure and structure. METHODS Thirty male New Zealand white rabbits were randomly divided into OSAHS, MAD, and control groups (n = 10 per group). The soft palate of rabbits in the OSAHS and MAD groups was injected with hydrophilic polyacrylamide gel to induce OSAHS. The MAD group wore a MAD, and the control group was not treated. Cone-beam computed tomography scans and polysomnography recordings were performed to confirm successful model establishment. All rabbits slept in a supine position for 4 to 6 hours daily and were observed for 8 consecutive weeks. The pulmonary artery pressure was measured by right heart catheterization. Pulmonary artery morphometry was analyzed by hematoxylin and eosin staining. NO levels in plasma and lung homogenate supernatants were detected by Griess reaction assay kits. RESULTS The OSAHS group exhibited higher pulmonary artery pressure (57.74 ± 1.79 mm Hg) than the MAD (19.99 ± 2.04 mm Hg) and control (14.49 ± 0.54 mm Hg) groups. The media thickness percentage of the pulmonary artery was higher in the OSAHS group (46.89 ± 2.72%) than the control group (15.87 ± 1.18%) and was markedly reduced by MAD (21.64 ± 1.45%). Blood oxygen saturation was positively correlated with the NO concentration in both the lung and plasma, and the NO concentration was negatively correlated with the media thickness percentage and media section percentage. CONCLUSIONS OSAHS induced a decrease in NO and pulmonary hypertension, which was relieved by MAD therapy.
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Akahoshi R, Yanamoto S, Sakamoto Y, Naruse T, Hayashida S, Soutome S, Nakamura W, Umeda M. Effects of sleep position on the treatment response of oral appliance for obstructive sleep apnea. Cranio 2020; 40:262-267. [PMID: 32401178 DOI: 10.1080/08869634.2020.1764271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective: This retrospective study aimed to clarify the characteristics of positional obstructive sleep apnea (P-OSA) patients and to examine the relationship between sleep position and the efficacy of oral appliance (OA) therapy.Methods: Seventy-three patients who underwent polysomnography before and after OA therapy were divided into P-OSA or non-positional OSA (NP-OSA) and examined.Results: Forty-seven patients had P-OSA and 26 had NP-OSA. P-OSA was characterized by a relatively high ratio of supine to lateral apnea hypopnea index (AHI) because the lateral AHI of P-OSA was significantly lower than that of NP-OSA. OA therapy was more effective for P-OSA than NP-OSA. Younger age and the presence of P-OSA are useful as predictors of OA therapy efficacy.Discussion: Even for relatively severe OSA, in the case of younger age and/or P-OSA, the application of simple, cost-effective OA therapy might be recommended over other treatment modalities.
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Affiliation(s)
- Ryoichi Akahoshi
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Souichi Yanamoto
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.,Oral Management Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuki Sakamoto
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.,Department of Oral Surgery, Hironokogen Hospital, Kobe, Japan
| | - Tomofumi Naruse
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Saki Hayashida
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sakiko Soutome
- Oral Management Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Wataru Nakamura
- Department of Oral Chrono-Physiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masahiro Umeda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Marklund M, Braem MJA, Verbraecken J. Update on oral appliance therapy. Eur Respir Rev 2019; 28:190083. [PMID: 31554705 PMCID: PMC9488498 DOI: 10.1183/16000617.0083-2019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/14/2019] [Indexed: 12/26/2022] Open
Abstract
Oral appliances are increasingly recommended for selected patients with obstructive sleep apnoea (OSA) and those who do not tolerate nor prefer continuous positive airway pressure. The most commonly used oral appliance advances the lower jaw during sleep, the so-called mandibular advancement device (MAD). Patients seek treatment because of disturbing snoring, daytime symptoms, apnoeas that disturb sleep and the longer term consequences with regard to cardiovascular risks. MADs reduce the apnoea-hypopnoea index, although to various degrees among patients. Effects on daytime sleepiness have been observed mainly among the more severe OSA patients. Blood pressure may be reduced in MAD-treated OSA patients. There is, however, uncertainty about which patients will respond to this therapy in terms of apnoea reductions, decreased sleepiness and other symptoms, and reduced risk for future impaired health. The occurrence of side-effects also remains difficult to predict at present. The majority of sleep apnoea patients suffer from various comorbidities in terms of cardiovascular diseases, type 2 diabetes and depression. The most recent findings indicate that phenotyping of patients, considering various aspects of this multifaceted disease, will shed more light on the indications for MADs in patients with nightly sleep breathing disturbances. This review summarises the most recent knowledge about MAD treatment.
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Affiliation(s)
- Marie Marklund
- Dept of Odontology, Medical Faculty, Umeå University, Umeå, Sweden
| | - Marc J A Braem
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Dept of Special Dentistry Care, Antwerp University Hospital, Antwerp, Belgium
| | - Johan Verbraecken
- LEMP, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium
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Mayoral P, Lagravère MO, Míguez-Contreras M, Garcia M. Antero-posterior mandibular position at different vertical levels for mandibular advancing device design. BMC Oral Health 2019; 19:85. [PMID: 31113410 PMCID: PMC6530129 DOI: 10.1186/s12903-019-0783-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/08/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Mandibular Advancement Devices (MAD) have been reported to be an alternative treatment to CPAP in moderate to severe obstructive sleep apnea (OSA) cases. The design of MAD has a major influence on its success rate on the patient, and design features that have an influence on efficacy, tolerance, and compliance. The aim of this study was to determine the range of mandibular protrusion at different vertical points; 2, 5, 8 and 11 mm in a young adult population. METHODS Fifty two students aged 19 to 23 years (mean 21.3 ± 1.7; 29 females and 23 males), with full permanent dentition participated in the study. The absolute range of maximal mandibular protrusion and retrusion was measured (mm) with the use of the George Gauge. Descriptive statistics, ANOVA and paired t-test using SPSS were used. RESULTS Range of mandibular advancement was possible to be determined for the 4 levels of vertical opening with the gauges: 2 mm fork mean mandibular advance 13,10 mm ± 0.604; 5 mm mean 11.98 mm ± 1.075; 8 mm mean 11.20 mm ± 1.369; 11 mm mean 9.87 mm ± 1.886. No significant differences were found between class I, II, and III. CONCLUSIONS There is an impact of increased inter-incisal distance of effective mandibular protrusion when constructing a MAD. As vertical dimension increases the mandible rotates posteriorly and places itself in a more retrusive location, and the range of mandibular advancement reduces (0.3 mm for every 1 mm of vertical increase).
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Affiliation(s)
- P Mayoral
- Catholic University of Murcia UCAM, Faculty of Medicine and Dentistry, School of Dentistry and Scientific Committee Orthoapnea, Flauta Mágica 22, 29006, Málaga, Spain
| | - M O Lagravère
- University of Alberta, Faculty of Medicine and Dentistry, School of Dentistry, ECHA 5-524, 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - M Míguez-Contreras
- Catholic University of Murcia UCAM, Faculty of Medicine and Dentistry, School of Dentistry, Madrid, Spain
| | - M Garcia
- University of Malaga, Faculty of Engineering and Scientific Committee Orthoapnea, Flauta Mágica 22, 29006, Málaga, Spain
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Rhinological interventions for obstructive sleep apnoea - a systematic review and descriptive meta-analysis. The Journal of Laryngology & Otology 2019; 133:168-176. [PMID: 30789116 DOI: 10.1017/s0022215119000240] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Obstructive sleep apnoea is a common chronic sleep disorder characterised by collapse of the upper airway during sleep. The nasal airway forms a significant part of the upper airway and any obstruction is thought to have an impact on obstructive sleep apnoea. A systematic review was performed to determine the role of rhinological surgical interventions in the management of obstructive sleep apnoea. METHODS A systematic review of current literature was undertaken; studies were included if they involved comparison of a non-surgical and/or non-rhinological surgical intervention with a rhinological surgical intervention for treatment of obstructive sleep apnoea. RESULTS Sixteen studies met the selection criteria. The pooled data suggest that there are reductions in the apnoea/hypopnea index and respiratory disturbance index following nasal surgery. However, the current body of studies is too heterogeneous for statistically significant meta-analysis to be conducted. CONCLUSION Nasal surgery may have limited benefit for a subset of patients based on current evidence.
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Petri N, Christensen IJ, Svanholt P, Sonnesen L, Wildschiødtz G, Berg S. Mandibular advancement device therapy for obstructive sleep apnea: a prospective study on predictors of treatment success. Sleep Med 2019; 54:187-194. [DOI: 10.1016/j.sleep.2018.09.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/28/2018] [Accepted: 09/30/2018] [Indexed: 10/27/2022]
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Never say never: circumventing a contraindication to control apnoea-induced epileptic events with a mandibular advancement device. The Journal of Laryngology & Otology 2018; 132:1036-1038. [PMID: 30394239 DOI: 10.1017/s0022215118001858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The benefit of mandibular advancement devices in patients with sleep-disordered breathing and as a potential option for obstructive sleep apnoea syndrome is well recognised. Their use in the setting of epilepsy or other seizure disorders is typically contraindicated.Case reportA 48-year-old patient with a history of poorly controlled epilepsy and obstructive sleep apnoea syndrome was referred for ENT review for possible tracheostomy. The patient was wheelchair-bound with 24-hour continuous positive airway pressure, but sleep studies demonstrated persistent, severe episodes of apnoea and notable sleep disturbance. Sleep nasendoscopy demonstrated marked improvement on capnography with the laryngeal mask airway in situ, and this was maintained with mandibular advancement using jaw thrust following removal of the laryngeal mask airway. A mandibular advancement device was subsequently trialled; this had no subjective benefit for the patient, but the seizures resolved and control of apnoea was achieved with the combination of a mandibular advancement device and continuous positive airway pressure. CONCLUSION This paper highlights a novel application of mandibular advancement devices, used in combination with continuous positive airway pressure, which resulted in complete resolution of sleep deprivation and apnoea-induced epileptic events.
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Randerath W, Bassetti CL, Bonsignore MR, Farre R, Ferini-Strambi L, Grote L, Hedner J, Kohler M, Martinez-Garcia MA, Mihaicuta S, Montserrat J, Pepin JL, Pevernagie D, Pizza F, Polo O, Riha R, Ryan S, Verbraecken J, McNicholas WT. Challenges and perspectives in obstructive sleep apnoea. Eur Respir J 2018; 52:13993003.02616-2017. [DOI: 10.1183/13993003.02616-2017] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 04/25/2018] [Indexed: 12/21/2022]
Abstract
Obstructive sleep apnoea (OSA) is a major challenge for physicians and healthcare systems throughout the world. The high prevalence and the impact on daily life of OSA oblige clinicians to offer effective and acceptable treatment options. However, recent evidence has raised questions about the benefits of positive airway pressure therapy in ameliorating comorbidities.An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field, and proposed topics for future research on epidemiology, phenotyping, underlying mechanisms, prognostic implications and optimal treatment of patients with OSA.The group concluded that a revision to the diagnostic criteria for OSA is required to include factors that reflect different clinical and pathophysiological phenotypes and relevant comorbidities (e.g.nondipping nocturnal blood pressure). Furthermore, current severity thresholds require revision to reflect factors such as the disparity in the apnoea–hypopnoea index (AHI) between polysomnography and sleep studies that do not include sleep stage measurements, in addition to the poor correlation between AHI and daytime symptoms such as sleepiness. Management decisions should be linked to the underlying phenotype and consider outcomes beyond AHI.
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Annual review of selected scientific literature: Report of the committee on scientific investigation of the American Academy of Restorative Dentistry. J Prosthet Dent 2017; 118:281-346. [DOI: 10.1016/j.prosdent.2017.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/27/2017] [Accepted: 04/27/2017] [Indexed: 01/19/2023]
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Abstract
Purpose of Review The majority of the adult population is affected by obstructive sleep apnea (OSA), according to recent epidemiological research. Oral appliance (OA) therapy is increasingly recommended, particularly for patients with milder OSA. This review updates the evidence in favor of OA therapy. Recent Findings A high level of evidence shows that OA is effective in the treatment of OSA, but continuous positive airway pressure (CPAP) is more efficient. Higher adherence with OAs may compensate for this difference. Daytime sleepiness is better treated with CPAP than with OA in patients with severe OSA. In patients with milder OSA, it is unclear whether sleepiness is significantly reduced. The long-term effectiveness of OAs is uncertain because of side-effects and the risk of OSA deterioration. Summary OAs are effective, but their efficacy is more variable than that of CPAP. More research is needed about the mechanism of action of OA, subjective effects and long-term health outcomes.
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Affiliation(s)
- M Marklund
- Department of Odontology, Medical Faculty, Umeå University, SE-906 87 Umeå, Sweden
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Iftikhar IH. MADs and Positional Sleep Apnea: More than Meets the Eye! J Clin Sleep Med 2016; 12:1079-80. [PMID: 27448423 DOI: 10.5664/jcsm.6036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 11/13/2022]
Affiliation(s)
- Imran H Iftikhar
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
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