Appliances Therapy in Obstructive Sleep Apnoea: A Systematic Review and Meta-Analysis

Obstructive sleep apnea (OSA) is a recurrent partial or complete obstruction of the upper airway during sleep caused by narrowing or collapse of the pharyngeal wall. It leads to microstimulation and oxyhemoglobin desaturation, resulting in sleepiness and loud snoring. OSA negatively affects the cardiovascular system and may contribute to neurocognitive impairment. The aim of this systematic review is to evaluate the effectiveness and efficacy of appliance therapy in obstructive sleep apnea. The effectiveness was assessed by using the Apnea Hypopnea Index (AHI). An electronic search of the Cochrane Library, PubMed, and Google Scholar was conducted between 1998 and 2021. Articles were independently assessed by three reviewers. The quality of a randomised control trial (RCT) is assessed using the Cochrane risk of bias method. The tool GRADE was used to achieve the desired level of confidence for each outcome reported. Several studies used continuous positive airway pressure (CPAP), mandibular advancement devices (MAD), and tongue retention devices (TRD). The meta-analysis included a total of six papers that met the inclusion criteria. Results showed that CPAP significantly improved AHI compared with an oral appliance (random effects: difference in means = 8.40, 95% CI = 7.21 to 9.60). It was also found that oral appliance (OA) therapy significantly improved AHI compared with baseline before appliance therapy (random effects: mean difference = 13.40, 95% CI = 10.87 to 15.93; p.00001). For mild to moderate OSA, CPAP is considered the gold standard. Our meta-analysis of six RCTs found favorable evidence for OSA patients receiving oral devices; however, they were less effective than CPAP. A subgroup analysis found that MAD may be a beneficial treatment for mild to moderate OSA patients who do not respond to CPAP. The findings suggest that oral appliances may be an effective treatment for OSA, especially in patients with mild to moderate OSA.

Development and initial validation of a questionnaire to measure patient experience with oral appliance therapy

STUDY OBJECTIVES

To develop and validate a questionnaire to measure patient experience with oral appliance therapy.

METHODS

The AMEE Guide No. 87 was followed in the development and validation of a patient questionnaire to assess patient experience with oral appliance therapy.

RESULTS

Our search identified 522 articles; 5 of these articles described the use and/or validation of questionnaires to measure changes in symptoms and patient-reported outcomes in the treatment of obstructive sleep apnea. A total of 27 questions were developed. Five patients participated in pilot testing. A final review of the questionnaire was conducted by an expert panel.

CONCLUSIONS

The creation and validation of a questionnaire to assess patient experience with oral appliance therapy may provide new methods for advancing research in the field of dental sleep medicine.

CITATION

Ng ET, Perez-Garcia A, Lagravère-Vich MO. Development and initial validation of a questionnaire to measure patient experience with oral appliance therapy. J Clin Sleep Med. 2023;19(8):1437-1445.

Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device

Treatment of moderate to severe obstructive sleep apnea poses clinical challenges in persons with intolerance or inadequate response to traditional treatment modalities, including positive airway pressure and mandibular advancement devices. Hypoglossal nerve stimulation is a new treatment option, but few management guidelines exist when it is intolerable or ineffective. Combining several treatment modalities has been an effective strategy for improving symptoms, tolerance, and efficacy. We describe a patient intolerant to positive airway pressure therapy who had continued sleepiness, morning headaches, and snoring with a mandibular advancement device. He underwent hypoglossal nerve stimulation implantation but was intolerant of the voltages required to adequately control his obstructive sleep apnea. Multimodal management with hypoglossal nerve stimulation, mandibular advancement device, and positional therapy was successfully implemented to improve sleepiness, nocturnal symptoms, and the apnea-hypopnea index. This case highlights the personalization and adaptability of combination therapy to suit patient needs while effectively controlling obstructive sleep apnea.

CITATION

Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med. 2023;19(2):403-408.

Mandibular Advancement Device Therapy in Japanese Rugby Athletes with Poor Sleep Quality and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) may contribute to poor sleep quality. This study assessed subjective sleep quality, the Respiratory Event Index (REI), reaction times, and the therapeutic effects of a custom-made mandibular advancement device (MAD) in male Japanese elite rugby athletes. The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and level III sleep test (REI and minimum oxygen saturation [SpO2 min]) were used to evaluate sleep quality. MAD therapy was used daily for 3 weeks. A telephone-based reaction time test of kinetic vision (the ability to identify moving objects) was recorded within 15 min of waking and over 5 days of pre- and post-MAD therapy. Differences in variables were evaluated using paired t-tests. Of the 42 players (mean age, 26.3 ± 3.7 years; mean body mass index, 28.7 ± 3.2 kg/m2) included in this study, 29 (69.0%) had poor sleep quality (PSQI > 5.5), and 27 were diagnosed with OSA (64.3%) (mild = 16/moderate = 9/severe = 2). Six were treated with MAD therapy, which significantly improved the REI (p < 0.01), SpO2 min (p < 0.001), ESS score (p < 0.001), reaction times (p < 0.01), and sleep quality. A significant reduction in reaction times suggests that OSA treatment can improve kinetic vision. Future studies should systematically evaluate the impact of sleep-disordered breathing on kinetic vision in athletes.

Snoring Remediation with Oral Appliance Therapy Potentially Reverses Cognitive Impairment: An Intervention Controlled Pilot Study

Respiration rate (RR) dynamics entrains brain neural networks. RR differences between mild cognitive impairment (MCI) and Alzheimer’s disease (AD) in response to oral appliance therapy (OAT) are unknown. This pilot study investigated if RR during stable sleep shows a relationship to pathological severity in subjects with MCI and AD who snore and if RR is influenced following stabilization of the upper airway using OAT. The study cohort was as follows: cognitively normal (CN; n = 14), MCI (n = 14) and AD (n = 9); and a sub-population receiving intervention, CN (n = 5), MCI (n = 7), AD (n = 6) subjects. The intervention used was an oral appliance plus a mouth shield (Tx). RR maximum (max) rate (breaths/minute) and RR fluctuation during 2116 stable sleep periods were measured. The Montreal cognitive assessment (MoCA) was administered before and after 4 weeks with Tx. Baseline data showed significantly higher RR fluctuation in CN vs. AD (p < 0.001) but not between CN vs. MCI (p = 0.668). Linear mixed model analysis indicated Tx effect (p = 0.008) for RR max. Tx after 4 weeks lowered the RR-max in MCI (p = 0.022) and AD (p < 0.001). Compared with AD RR max, CN (p < 0.001) and MCI (p < 0.001) were higher with Tx after 4 weeks. Some MCI and AD subjects improved executive and memory function after 4 weeks of Tx.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of mandibular advancement device on plasticity in corticomotor control of tongue and jaw muscles

STUDY OBJECTIVES

This study aims to investigate if the use of a mandibular advancement device (MAD) is associated with neuroplasticity in corticomotor control of tongue and jaw muscles.

METHODS

Eighteen healthy individuals participated in a randomized crossover study with 3 conditions for 2 weeks each: baseline, wearing an oral appliance (OA: sham MAD) or MAD during sleep. The custom-made MAD was constructed by positioning the mandible to 50% of its maximal protrusion limit. Transcranial magnetic stimulation (TMS) was applied to elicit motor evoked potentials (MEPs). The MEPs were assessed by constructing stimulus-response curves at four stimulus intensities: 90%, 100%, 120%, and 160% of the motor threshold (MT) from the right tongue and right masseter, and the first dorsal interosseous muscles (FDI, control) at baseline, after the first and the second intervention.

RESULTS

There was a significant effect of condition and stimulus intensity both on the tongue and as well as on masseter MEPs (P < 0.01). Tongue and masseter MEPs were significantly higher at 120% and 160% following the MAD compared to the OA (P < 0.05). There were no effects of condition on FDI MEPs (P = 0.855).

CONCLUSIONS

The finding suggests that MAD induces neuroplasticity in the corticomotor pathway of the tongue and jaw muscles associated with the new jaw position. Further investigations are required in patients with obstructive sleep apnea (OSA) to see if this cortical neuroplasticity may contribute or perhaps predict treatment effects with MADs in OSA.

Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow

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.

Treatment usage patterns of oral appliances for obstructive sleep apnea over the first 60 days: a cluster analysis

STUDY OBJECTIVES

Oral appliance (OA) therapy usage can be objectively measured through temperature-sensing data chips embedded in the appliance. Initial reports of group data for short-term treatment usage suggest good nightly hours of usage. However, individual variability in treatment usage patterns has not been assessed. We aimed to identify OA treatment usage subtypes in the first 60 days and the earliest predictors of these usage patterns.

METHODS

OSA patients were recruited for a study of OA therapy with an embedded compliance chip (DentiTrac, Braebon, Canada). Fifty-eight participants with 60 days of downloadable treatment usage data (5-minute readings) were analyzed. A hierarchical cluster analysis was used to group participants with similar usage patterns. A random forest classification model was used to identify the minimum number of days to predict usage subtype.

RESULTS

Three user groups were identified and named "consistent users" (48.3%), "inconsistent users" (32.8%) and "non-users" (19.0%). The first twenty days provided optimal data to predict which treatment usage group a patient would belong to at 60-days (90% accuracy). The strongest predictors of user group were downloaded usage data; average wear time and number of days missed.

CONCLUSIONS

Granular analysis of OA usage data suggests the existence of treatment user subtypes (consistent, inconsistent and non-users). Our data suggest that 60-day usage patterns can be identified in the first twenty days of treatment using downloaded treatment usage data. Understanding initial treatment usage patterns provide an opportunity for early intervention to improve long-term usage and outcomes.

A singular oral appliance to treat obstructive sleep apnea in CPAP non-adherent patients

INTRODUCTION

The most prescribed treatment option for Obstructive Sleep Apnea (OSA) is CPAP; however, its adherence is limited. Oral Appliance therapy (OAT) is frequently an option or even an adjuvant, being the mandibular advancement Oral Appliance (OAm) the most used prescription. It modifies the upper airway, improving the airway patency. OAm construction is based on the occlusal plane to disocclusion. In this study, the DIORS® appliance was used, a singular OAm, based on Neuro-Occlusal Rehabilitation concepts, that uses Camper's plane as a disocclusion reference, in order to achieve neuromuscular balance and functional stability.

OBJECTIVE

This study primarily aimed to assess the DIORS® effectiveness in relation to clinical and polysomnographic outcomes. It was also evaluated if the use of DIORS® is as effective as titrated CPAP to treat CPAP non-adherent patients.

METHODS

Twenty patients were included in this study. Objective and subjective clinical data were assessed at a sleep laboratory using all-night polysomnography, and Epworth Sleepiness Scale (ESS), taken at three moments: Baseline, CPAP titration, and using DIORS®. Analysis of respiratory parameters as apnea/hypopnea index (AHI), oxyhemoglobin saturation levels, the arousal index and daytime sleepiness were taken as criteria for a successful OAT.

RESULTS

Respiratory and arousal parameters improved in both therapies, while DIORS® promoted a better ESS.

CONCLUSION

Results from the present work support that DIORS® is a viable and effective adjuvant therapy for patients with moderate to severe OSA non-adherent to CPAP.

What every dentist needs to know about obstructive sleep apnea

Sleep apnea has 2 variants that are classified by their etiologic mechanism, namely, an obstructive or a central origin. Despite the clinical and scientific advancements in obstructive sleep apnea (OSA) over the past 20 years, a majority of affected patients remain undiagnosed. This article reviews aspects of unmanaged OSA, including the oral and maxillofacial signs and symptoms, systemic risk factors, diagnostic criteria, guidelines for patient referral to a sleep physician, and clinical management techniques. Additionally, the role of dentists in oral appliance therapy is explored.

Vertical dimension in dental sleep medicine oral appliance therapy

The objective of this pilot study was to evaluate the effect of a multidimensional approach to occlusal registration, including vertical dimension as assessed using pharyngometry, on the success of oral appliance therapy. Successful medical improvements resulting from therapy were determined by secondary polysomnographic studies. Thirty patients were enrolled in this pilot study. Their initial apnea-hypopnea index (AHI) scores ranged from 6.0 (mild obstructive sleep apnea) to 81.6 (severe obstructive sleep apnea). Occlusal registrations were taken using pharyngometer readings to establish vertical and anteroposterior (AP) positions for each patient and compared to the AP-only position in the same patient, determined using a George Gauge at 70% protrusion. All follow-up sleep tests occurred 31-45 days after the delivery of oral appliances set at the multidimensional vertical and AP positions determined by pharyngometry. No appliance titration was required. In the 26 patients who completed the study, the mean AHI before therapy was 20.7, and the mean AHI after therapy was 7.8, a 62.3% decrease. Within the limitations of this study, the pharyngometer-established occlusal position was effective in lowering AHI without the need for appliance titration procedures, which are typically required when the 70% protrusive George Gauge occlusal registration method is used. Additionally, the position determined with the 70% George Gauge was, on average, 5.0 mm more protrusive than the pharyngometer registration.

Changes in pediatric paranasal sinuses following biomimetic oral appliance therapy: 3 case reports

Objective: In this pilot study, craniofacial changes associated with biomimetic oral appliance therapy (BOAT) were investigated to test the hypothesis of non-surgical remodeling of the maxillary air sinuses in rhinosinusitis.Methods: Three consecutive Korean patients (mean age 9.3 yrs) presented to a dental office with a history of chronic rhinosinusitis. After obtaining informed consent, 3D cone-beam CT scans were taken that showed circumferential mucosal thickening and inflammatory maxillary sinus disease, obstructed ostiomeatuses, and enlarged inferior turbinates. All cases were treated using BOAT (DNA appliance®).Results: Approximately 10 months after BOAT, the paranasal sinuses were aerated without mucosal thickening; the sinus walls were intact, and the ostiomeatal units were patent. All mean craniofacial parameters measured increased, except the transpalatal bone width, which remained unchanged.Discussion: Although enhancement of the maxillary air sinuses through non-surgical remodeling is suspected in these three cases of pediatric rhinosinusitis, additional studies are warranted.

Efficacy of oral appliance therapy in patients following uvulopalatopharyngoplasty failure

Objective

Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure performed to treat obstructive sleep apnea (OSA). This surgery, when performed alone, benefits only a minority of patients. This study was undertaken to determine the efficacy of oral appliance (OA) therapy following unsuccessful UPPP and assess for specific patient and polysomnographic characteristics that may identify those patients most likely to benefit from this combined treatment strategy.

Study Design

Retrospective of clinical outcomes in patients undergoing UPPP followed by treatment with an OA.

Methods

Polysomnographic results (baseline, status post‐UPPP, and status post‐UPPP with oral appliance use), age, gender, race, and body mass index were subjected to statistical analysis.

Results

The mean apnea hypopnea index (AHI) decreased from 23.6 at baseline to 8.6 following UPPP and oral appliance therapy. The mean O2 nadir increased from 83% at baseline to 89.9% following UPPP and treatment with an oral appliance. Fifty percent of patients (9/18) achieved an AHI <5 and were deemed “cured” of their disease. Seventy‐three percent of patients (13/18) achieved benefit with an AHI <20 and ≥50% reduction in their baseline AHI, deemed “successful therapy.” No statistically relevant demographic or polysomnographic differences were found between those who were “cured” and those with persistent disease with the exception that the O2 nadir status post UPPP was found to be lower in the “cured” group.

Conclusion

Oral appliance therapy is an effective treatment option for the majority of patients who have persistent obstructive sleep apnea following unsuccessful UPPP.

Level of Evidence

4

Awake Multimodal Phenotyping for Prediction of Oral Appliance Treatment Outcome

STUDY OBJECTIVES

An oral appliance (OA) is a validated treatment for obstructive sleep apnea (OSA). However, therapeutic response is not certain in any individual and is a clinical barrier to implementing this form of therapy. Therefore, accurate and clinically applicable prediction methods are needed. The goal of this study was to derive prediction models based on multiple awake assessments capturing different aspects of the pharyngeal response to mandibular advancement. We hypothesized that a multimodal model would provide robust prediction.

METHODS

Patients with OSA (apnea-hypopnea index [AHI] > 10 events/h) were recruited for treatment with a customized OA (n = 142, 59% male). Participants underwent facial photography (craniofacial structure), spirometry (mid-inspiratory flow at 50% vital capacity [MIF₅₀] and mid-expiratory flow at 50% vital capacity [MEF₅₀] and the ratio MEF₅₀/MIF₅₀) and nasopharyngoscopy (velopharyngeal collapse with Mueller maneuver and mandibular advancement). Treatment response was defined by 3 criteria: (1) AHI < 5 events/h plus ≥ 50% reduction, (2) AHI < 10 events/h plus ≥ 50% reduction, (3) ≥ 50% AHI reduction. Multivariable regression models were used to assess predictive utility of phenotypic assessments compared to clinical characteristics alone (age, sex, obesity, baseline AHI).

RESULTS

Craniofacial structure and flow-volume loops predicted treatment response. Accuracy of the prediction models (area under the receiver operating characteristic curve) for each criterion were 0.90 (criterion 1), 0.79 (criterion 2), and 0.78 (criterion 3). However, these prediction models including phenotypic assessments did not provide a statistically significant improvement over clinical predictors only.

CONCLUSIONS

Multimodal awake phenotyping does not enhance OA treatment outcome prediction. These office-based, awake assessments have limited utility for robust clinical prediction models. Future work should focus on sleep-related assessments.

COMMENTARY

A commentary on this article appears in this issue on page 1837.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry, Title: Multimodal phenotyping for the prediction of oral appliance treatment outcome in obstructive sleep apnoea, Identifier: ACTRN12611000409976, URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336663.

Predicting Success of Oral Appliance Therapy in Treating Obstructive Sleep Apnea Using Drug-Induced Sleep Endoscopy

STUDY OBJECTIVES

Oral appliance therapy (OAT) can be an effective treatment option for patients with obstructive sleep apnea unable to tolerate continuous positive airway pressure. We hypothesize that drug-induced sleep endoscopy (DISE) can be useful in identifying patients who will benefit from OAT.

METHODS

A retrospective review of all patients who underwent DISE (DISE group) between January 2014 and June 2016 was carried out. We included patients if they received OAT based on recommendations made by DISE findings. A control group was designed by selecting a sample of patients undergoing polysomnography (PSG) with an oral appliance in place who had not undergone prior DISE (no DISE group). The two cohorts were compared to evaluate the hypothesis.

RESULTS

A total of 20 patients fit inclusion criteria for the DISE group and 20 patients for the no DISE group. There was no difference between the DISE and no DISE cohorts with respect to mean age, sex, pre-OAT body mass index, post-OAT body mass index, or pre-OAT PSG characteristics including: apneahypopnea index (AHI), oxygen desaturation nadir, or Epworth Sleepiness Scale score. There was a significantly lower treatment AHI (P = .04) and increased number of patients reaching an AHI less than 5 events/h with OAT therapy (P = .04) in the DISE group.

CONCLUSIONS

Patients showing increased airway dimensions at the level of the velum and/or oropharynx with a jaw thrust may benefit the most from OAT. The use of DISE to identify this subset of patients is helpful in optimizing outcomes with OAT.

Long-Term Oral Appliance Therapy Improves Daytime Function and Mood in Upper Airway Resistance Syndrome Patients

Objectives

To evaluate the long-term effects of an oral appliance on clinical symptoms, respiratory sleep parameters, sleep quality, and sustained attention in patients with upper airway resistance syndrome (UARS) were compared with placebo.

Methods

This study was a randomized placebo-controlled clinical trial. Thirty UARS patients were randomized in two groups: placebo and mandibular advancement device (MAD) groups. UARS criteria were presence of sleepiness (Epworth Sleepiness Scale ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea/hypopnea index ≤ 5 and a respiratory disturbance index (RDI) > 5 events/hour of sleep, and/or flow limitation in more than 30% of total sleep time. All patients completed the Pittsburgh Sleep Quality Index (PSQI), the Functional Outcomes of Sleep Questionnaire, the Beck Anxiety and Depression Inventories, underwent full-night polysomnography, multiple sleep latency test, and Psychomotor Vigilance Test (PVT). Evaluations were performed before and after 1.5 years of treatment.

Results

RDI, number of respiratory effort-related arousal, percentage of total sleep time with flow limitation, and arousal index significantly decreased after 1.5 years of MAD treatment. PSQI total score improved, severity of depression symptoms decreased, and mean reaction time in the PVT, based on the first measurement taken at 8:00 am, significantly decreased (p = .03) at the end of the protocol.

Conclusions

The MAD was effective in decreasing respiratory events in UARS patients. For UARS, 1.5 years of oral appliance therapy also improved sleep quality and sustained attention, and decreased the severity of depression symptoms.

Clinical Trial

Efficacy of Oral Appliance for Upper Airway Resistance Syndrome: Randomized, Parallel, Placebo-Controlled Study, NCT02636621.

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.

Management of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force

ABSTRACT

The American Academy of Sleep Medicine Sleep and Transportation Safety Awareness Task Force responded to the Federal Motor Carrier Safety Administration and Federal Railroad Administration Advance Notice of Proposed Rulemaking and request for public comments regarding the evaluation of safety-sensitive personnel for moderate-to-severe obstructive sleep apnea (OSA). The following document represents this response. The most salient points provided in our comments are that (1) moderate-to-severe OSA is common among commercial motor vehicle operators (CMVOs) and contributes to an increased risk of crashes; (2) objective screening methods are available and preferred for identifying at-risk drivers, with the most commonly used indicator being body mass index; (3) treatment in the form of continuous positive airway pressure (CPAP) is effective and reduces crashes; (4) CPAP is economically viable; (5) guidelines are available to assist medical examiners in determining whether CMVOs with moderate-to-severe OSA should continue to work without restrictions, with conditional certification, or be disqualified from operating commercial motor vehicles.

Perceived Effectiveness, Self-efficacy, and Social Support for Oral Appliance Therapy Among Older Veterans With Obstructive Sleep Apnea

PURPOSE

Obstructive sleep apnea is a prevalent sleep disorder among older adults. Oral appliances are increasingly prescribed as therapy for obstructive sleep apnea. Adherence to oral appliance therapy is highly variable. Based on value-expectancy theory and other social-psychological theories, adherence to oral appliance therapy may be influenced by patients' perceived effectiveness of the therapy, self-efficacy, and availability of social support. We examined these perceptions among older adults with obstructive sleep apnea who were prescribed oral appliance therapy.

METHODS

We mailed surveys to all patients aged ≥65 years who had been prescribed oral appliance therapy for obstructive sleep apnea over the prior 36 months at a Veterans Affairs medical center. We examined frequencies of responses to items that assessed perceived effectiveness, self-efficacy, and social support for nightly use of oral appliances from friends, family, or health care staff.

FINDINGS

Thirty-nine individuals responded (response rate, 30%; mean [SD] age 71.4 [SD 6.3] years; 97% male). Thirty-six percent of the respondents perceived regular use of oral appliance therapy to be effective in managing obstructive sleep apnea; 39% agreed that they felt confident about using oral appliances regularly; 41% felt supported by people in their life in using oral appliance therapy; and 38% agreed that health care staff would help them to use their oral appliance regularly. These rates represented less than half of respondents despite the finding that 65% of patients believed that they would use their oral appliance regularly.

IMPLICATIONS

Although oral appliance therapy is increasingly prescribed for obstructive sleep apnea, only about one third of older adults prescribed it perceived it to be an effective treatment, were confident about oral appliance use, and/or believed that they would receive needed support. Future research is needed to better understand older adults' perceptions so that interventions can be designed to improve the effectiveness of oral appliances, their self-efficacy for using oral appliances, and their social support for this therapy, which may, in turn, improve oral appliance therapy adherence.

Management of sleep apnea: a critical look at intra-oral appliances

With so many disciplines of both medicine and dentistry involved in the treatment of obstructive sleep apnea (OSA), several forms of therapy are available. The orthodontist is rarely considered when the diagnosis of chronic obstructive sleep apnea (OSA) is delivered. However, the scope of orthodontic care today is much broader than the mere alignment of teeth. While the current gold standard for OSA care remains continuous positive air pressure (CPAP), the patient may be given a prescription for an intra-oral sleep appliance. When orthodontists work in concert with their medical colleagues to provide a sleep appliance, several considerations must be made including the evidence regarding oral appliance efficacy. For some patients, oral appliances are highly successful; however, even for responsive patients, there are risks associated with oral appliance therapy. The aim of the paper was to present a critical review of the current level of evidence for the use of oral appliances in the treatment of OSA. A substantial number of publications ranging from case reports, uncontrolled and controlled case series, prospective randomized studies, and even a small number of systematic reviews were available. The existing systematic reviews were based on either a limited number of prospective studies with limited numbers of patients or in some cases were based on subjective data only. As a result, a narrative review of the literature was performed that discusses objective clinically testable criteria and recent developments that may aid future research investigations.

Sleep medicine content in dental hygiene education

According to the National Research Council, 70 million Americans chronically suffer from approximately 60 medically recognized sleep disorders. With most clinicians unaware of these disorders, many individuals remain undiagnosed. To effectively address this issue, health care professionals must work collaboratively to educate, identify, and treat patients with sleep disorders. However, medical and dental clinicians do not receive adequate education in sleep medicine. On the frontline regarding prevention and counseling, dental hygienists play an important role in patient education, screening, and management of sleep disorders. The aim of this study was to assess the amount of sleep medicine content in U.S. dental hygiene programs. An electronic survey was emailed to all 334 accredited U.S. dental hygiene programs. The 18-question survey assessed the sleep medicine content presented during the 2012-13 academic year. A total of 35.3% (n=118) of the programs responded. The mean number of hours devoted to sleep medicine in their curricula was 1.55 hours (SD=1.37). Although 69% (n=79) of the responding programs reported spending time on sleep bruxism (mean=1.38 hours, SD=0.85), only 28% (n=32) reported spending time on other topics such as snoring and obstructive sleep apnea (mean=1.39 hours, SD=0.72). These results suggest that sleep medicine is included in the majority of U.S. dental hygiene programs, but the content is limited and focused on sleep bruxism. This level of training is inadequate to prepare dental hygienists for their potential role in patient education, screening, and management of sleep-related breathing disorders.

Prevalence and clinical significance of supine-dependent obstructive sleep apnea in patients using oral appliance therapy

STUDY OBJECTIVE

The prevalence of supine-dependent obstructive sleep apnea (sdOSA) in a general population ranges from 20% to 60%, depending on the criteria used. Currently, the prevalence and evolution of sdOSA once oral appliance therapy with a mandibular advancement device (OAm) has started is unknown. In addition, literature on the correlation between sdOSA and treatment success with OAm is not unequivocal. The first purpose of this study was to assess the prevalence of sdOSA before and under OAm therapy. Second, the conversion rate from non-sdOSA to sdOSA during OAm therapy was evaluated. The third and final goal was to analyze the correlation between sdOSA and treatment success with OAm therapy in the patient population.

METHODS

Two hundred thirty-seven consecutive patients (age 48 ± 9 years; male/female ratio 173/64; AHI 20.1 ± 14.7 events/h; BMI 27.2 ± 4.3 kg/m(2)) starting OAm therapy were included.

RESULTS

The prevalence of sdOSA before the start of OAm therapy, ranged from 27.0% to 67.5%. The prevalence of residual sdOSA under OAm therapy in this study ranged from 17.5% to 33.9%. Second, the conversion rate from non-sdOSA to sdOSA ranged from 23.0% to 37.5%. Third, the presence of sdOSA at baseline was not a significant factor for treatment success with OAm therapy.

CONCLUSIONS

The results of this study indicate that the prevalence of sdOSA before and under OAm therapy is relatively high. One-third of patients shift from non-sdOSA to sdOSA. Finally, treatment success for OAm therapy was not significantly correlated with the presence of sdOSA at baseline.

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.