Position paper on the use of mandibular advancement devices in adults with sleep-related breathing disorders. A position paper of the German Society of Dental Sleep Medicine (Deutsche Gesellschaft Zahnaerztliche Schlafmedizin, DGZS)

Mandibular advancement device: prescription in adult dental sleep medicine - guideline of the German Society of Dental Sleep Medicine

PURPOSE

Obstructive sleep apnea (OSA) may result in severe health onditions, reduces quality of live, and affects high percentages of the adult population. Due to recent changes in the German health care regulations, mandibular advancement devices (MAD) will become available as a treatment option for OSA to a greater extent for general dentists and their patients.

METHODS

A guideline development group consisting of nine members representing four German dental and medical organizations was formed, in order to provide critical information and orientation to the main stakeholders (dentists and patients), regarding the use of MAD for the treatment of OSA within dental sleep medicine.

RESULTS

This guideline aims to inform physicians and dentists, particularly those with acquired qualification/specialization in sleep medicine (or in the diagnosis and treatment of sleep-related breathing disorders), as well as experts, payers, and patients. It delivers recommendations on technical requirements for MAD prescription and fabrication, clinical procedures, maintenance, and follow-up procedures.

CONCLUSION

A MAD should be designed for long-term therapy and must be a custom made, adjustable, bimaxillary retained two-splint system equipped with adjustable protrusive elements. The fabrication in a dental laboratory should be based on dental impressions or scans and three-dimensional registrations of the starting position taken with a bite gauge.

Patients with Obstructive Sleep Apnea and Cardiovascular Diseases: What, When, and Why Is Mandibular Advancement Device Treatment Required? A Short Review

Obstructive sleep apnea is a potentially dangerous condition with significant risks of comorbidities if left untreated. It represents a cardiovascular risk factor in the general population, and a higher prevalence is observed in patients already suffering from cardiovascular diseases. The gold standard treatment, continuous positive airway pressure, is not always accepted or tolerated. The mandibular advancement device represents an alternative treatment that we propose to implement in our study. The objective here is to first present a brief review of the topic. Due to poor evidence in the field, we propose a pilot study to evaluate the effect of a mandibular advancement device in patients with cardiovascular disease who are not treated for their sleep pathology in order to improve their therapeutic management.

Oral appliance therapy in obstructive sleep apnea and snoring - systematic review and new directions of development

Objective: Oral appliance therapy is a non-invasive treatment that offers a wide variety of oral devices for the treatment of obstructive sleep apnea (OSA). The present review focuses on the effectiveness of mandibular advancement devices for the treatment of OSA. Methods: A systematic review based on the PRISMA checklist was carried out. A detailed electronic database search was conducted using "Obstructive sleep apnea" AND "Oral appliance" AND "Dentistry" as keywords. Results: The initial search in the electronic databases resulted in a total of 262 papers. After the title and abstract analysis and full-text review, the number of eligible papers was reduced to 15. Conclusion: The mandibular advancement device is an effective treatment, improving the Apnea Hypopnea Index and the symptoms of patients with OSA in 92% of the subjects from all the investigated studies. The future may include the integration of a biosensor for the diagnosis and follow-up. Abbreviations: OSA: Obstructive sleep apnea; MADs: Mandibular advancement devices; CPAP: Continuous positive airway pressure; OAT: Oral appliance therapy; MRD: Mandibular repositioning devices; MAS: Mandibular advancement splints; MAA: Mandibular advancement appliances; OA: Oral appliances; AASM: American Academy of Sleep Medicine; AHI: Apnea-hypopnea index; EEG: Sleep-related breathing disorder SRBD; Electroencephalogram; EOG: Electrooculogram; ECG: Electrocardiogram; QOL: Quality of life; TMJ: Temporomandibular joint.

Dental and skeletal changes associated with long-term oral appliance use for obstructive sleep apnea: A systematic review and meta-analysis

An oral appliance (OA) is an effective treatment option for patients with obstructive sleep apnea (OSA), but dental and skeletal changes have been detected by many studies after long-term OA use. Better understanding of the long-term side effects may decrease discontinuation of OA use and assist clinicians to make informed decisions. Accordingly, a systematic review and meta-analysis were performed to evaluate the dental and skeletal changes associated with OAs designed to advance the mandible. The quality of the studies was determined by using the risk of bias assessment tool for non-randomized studies (RoBANS), and 12 studies were included in the meta-analysis. OA use was associated with a significant decrease of overjet (OJ) and overbite (OB), and it was suggested that both parameters decreased along with the duration of treatment. Meta-analysis also demonstrated a significant increase of L1-MP. However, there were no significant changes of skeletal modifications or mandibular rotation. Changes of incisor inclination were suggested to make a contribution to reduction of OJ and OB. In conclusion, long-term OA use was associated with dental changes. The results of this study provide information for clinicians about the long-term effects of OAs.

The effectiveness of two types of MADS for OSA therapy

OBJECTIVES

The purpose of this study was to determine differences in effectiveness between two types of mandibular advancement device (MAD).

MATERIAL AND METHODS

In this retrospective, cohort study, the two devices used were MAD type "Somnodent-Flex" (MAD 1) and MAD type "Herbst" (MAD 2). One hundred thirty-seven patients participated in this study, 67 patients were treated with MAD 1, and 70 patients with MAD 2. The indication MAD with obstructive sleep apnea (OSA) is based on a polysomnography test, in accordance with the CBO guidelines. The effectiveness of MAD therapy can be determined by a second polysomnography test (with the MAD in situ). The apnea-hypopnea index (AHI) is registered during the first and the second polysomnography test. Changes in these values determine the effectiveness.

RESULTS

A significant decrease in AHI was found regarding T1 and T2 for both the MADs: F (1, 134) = 140,850, p < 0,001. The mean differences of both the MADs turned out to correlate to T1. After correcting for this covariance, there was no significant difference between the two MAD devices regarding the AHI value: F (1, 134) = 1160, p = 0,283.

CONCLUSIONS

The results of the present study show no significant difference in effectiveness between MAD 1 and MAD 2 in respect to the AHI value.

CLINICAL RELEVANCE

Since 2012, healthcare insurance companies in the Netherlands refunds MAD type "Somnodent" used for treatment of sleep apnea. It is important to investigate if this type of MAD is as more effective or less effective as other types of MADs. If research points out that other MADs are more effective in reducing the sleep apnea, refund policies have to be adapted.

Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS)

BACKGROUND

The aim of the present article is to present a set of proposed clinical recommendations aimed at Italian dentists involved in the management of patients with obstructive sleep apnea syndrome or snoring.

METHODS

With the purpose of creating a study group, some of the most important Italian scientific societies operating in fields relevant to the issue of sleep medicine in dentistry were asked to appoint a representative. Each member of the study group was required to answer questions regarding the clinical management of OSAS and snoring.

RESULTS

Oral appliances can be used to treat: - simple snoring, in patients who do not respond to, or do not appear to be suitable candidates for behavioral measures such as weight loss or positional therapy; - mild or moderate OSAS, in patients who prefer OAs to continuous positive airway pressure (CPAP) or who are not suitable candidates for CPAP, because of its failure or failure of behavioral approaches like weight loss or positional therapy; - severe OSAS, in patients who do not respond to or do not tolerate CPAP and in whom no indication for either maxillofacial or ENT surgery appears applicable.

CONCLUSIONS

The application of oral appliances is highly desirable in cases of simple snoring or mild to moderate OSAS, whereas considerable caution is warranted when treating severe OSAS. It is fundamental to ensure that the patient understands his problem and, at the same time, to present all the various treatment options.

Two Cases of Severe Obstructive Sleep Apnea Induced by Neck Radiotherapy Treated with an Oral Device

Sleep apnea has been shown to be more prevalent in patients who underwent radiotherapy and or surgery for head and neck cancer. Here we describe two cases of severe OSAS induced by surgery and radiotherapy, treated by Mandibular Advancing Devices as an alternative option to continuous positive airway pressure.

Follow-up study of dental and skeletal changes in patients with obstructive sleep apnea and hypopnea syndrome with long-term treatment with the Silensor appliance

INTRODUCTION

In this study, we aimed to investigate the dental and skeletal changes associated with long-term use of the Silensor appliance (Erkodent, Cologne, Germany) in patients with obstructive sleep apnea and hypopnea syndrome.

METHODS

The sample included 42 patients with mild-to-severe obstructive sleep apnea and hypopnea syndrome (mean apnea-hypopnea index, 27; range, 5-74) who had been treated with the Silensor appliance for an average of 4 years (range, 1-11 years). A questionnaire was used to assess of the side effects subjectively; the cephalometric analysis was conducted to identify the dental and skeletal changes of different treatment times objectively.

RESULTS

The Silensor appliance was associated with few subjective side effects. Most subjective side effects decreased after long-term use of the Silensor appliance. Significant changes after long-term use of the Silensor appliance were observed in incisor angulation, overbite, overjet, mandibular plane angle, anterior lower facial height, and anterior facial height. Overbite and skeletal changes at treatment times between 1 year and 3 years were a decrease in overbite and increases in the mandibular plane angle, anterior lower facial height, and anterior facial height. Overjet and other dental changes at treatment times longer than 3 years were a decrease in overjet, retroclination of the maxillary incisors, and proclination of the mandibular incisors.

CONCLUSIONS

The Silensor appliance was well tolerated and preferred by most subjects. Common but mild dental and skeletal changes resulted from using the appliance over a long period of time. The changes after 1 to 3 years of use were skeletal changes predominantly. Both dental and skeletal changes were observed simultaneously at treatment times longer than 3 years.

[Sk2 guidelines"diagnosis and therapy of snoring in adults" : compiled by the sleep medicine working group of the German Society of Otorhinolaryngology, Head and Neck Surgery]

These guidelines aim to facilitate high quality medical care of adults with snoring problems. The guidelines were devised for application in both in- and outpatient environments and are directed primarily at all those concerned with the diagnosis and therapy of snoring. According to the AWMF three-level concept, these represent S2k guidelines.A satisfactory definition of snoring does not currently exist. Snoring is the result of vibration of soft tissue structures in narrow regions of the upper airway during breathing while asleep. Ultimately, these vibrations are caused by the sleep-associated decrease in muscle tone in the area of the upper airway dilator muscles. A multitude of risk factors for snoring have been described and its occurrence is multifactorial. Data relating to the frequency of snoring vary widely, depending on the way in which the data are collected. Snoring is usually observed in middle-aged individuals and affected males predominate. Clinical diagnosis of snoring should comprise a free evaluation of the patient's medical history. Where possible this should also involve their bed partner and the case history can be complimented by questionnaires. To determine the airflow relevant structures, a clinical examination of the nose should be performed. This examination may also include nasal endoscopy. Examination of the oropharynx is particularly important and should be performed. The larynx and the hypopharynx should be examined. The size of the tongue and the condition of the mucous membranes should be recorded as part of the oral cavity examination, as should the results of a dental assessment. Facial skeleton morphology should be assessed for orientation purposes. Technical examinations may be advisable in individual cases. In the instance of suspected sleep-related breathing disorders, relevant comorbidities or where treatment for snoring has been requested, an objective sleep medicine examination should be performed. Snoring is not-at least as we currently understand it-a disease associated with a medical threat; therefore there is currently no medical necessity to treat the condition. All overweight patients with snoring problems should strive to lose weight. If snoring is associated with the supine position, positional therapy can be considered. Some cases of snoring can be appropriately treated using an intraoral device. Selected minimally invasive surgical procedures on the soft palate can be recommended to treat snoring, provided that examinations have revealed a suitable anatomy. The choice of technique is determined primarily by the individual anatomy. At an appropriate interval after the commencement or completion a therapeutic measure, a follow-up examination should be conducted to assess the success of the therapy and to aid in the planning of any further treatments.

Diagnosis and treatment of snoring in adults-S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery

OBJECTIVES

This guideline aims to promote high-quality care by medical specialists for subjects who snore and is designed for everyone involved in the diagnosis and treatment of snoring in an in- or outpatient setting.

DISCUSSION

To date, a satisfactory definition of snoring is lacking. Snoring is caused by a vibration of soft tissue in the upper airway induced by respiration during sleep. It is triggered by relaxation of the upper airway dilator muscles that occurs during sleep. Multiple risk factors for snoring have been described and snoring is of multifactorial origin. The true incidence of snoring is not clear to date, as the incidence differs throughout literature. Snoring is more likely to appear in middle age, predominantly in males. Diagnostic measures should include a sleep medical history, preferably involving an interview with the bed partner, and may be completed with questionnaires. Clinical examination should include examination of the nose to evaluate the relevant structures for nasal breathing and may be completed with nasal endoscopy. Evaluation of the oropharynx, larynx, and hypopharynx should also be performed. Clinical assessment of the oral cavity should include the size of the tongue, the mucosa of the oral cavity, and the dental status. Furthermore, facial skeletal morphology should be evaluated. In select cases, technical diagnostic measures may be added. Further objective measures should be performed if the medical history and/or clinical examination suggest sleep-disordered breathing, if relevant comorbidities are present, and if the subject requests treatment for snoring. According to current knowledge, snoring is not associated with medical hazard, and generally, there is no medical indication for treatment. Weight reduction should be achieved in every overweight subject who snores. In snorers who snore only in the supine position, positional treatment can be considered. In suitable cases, snoring can be treated successfully with intraoral devices. Minimally invasive surgery of the soft palate can be considered as long as the individual anatomy appears suitable. Treatment selection should be based on individual anatomic findings. After a therapeutic intervention, follow-up visits should take place after an appropriate time frame to assess treatment success and to potentially indicate further intervention.

Aparelhos orais de protrusão mandibular ? IAH, eficiência do sono, sono REM e oxigenação de usuários

Objetivo: avaliar parâmetros polissonográficos de pacientes com indicação para uso de AOPMs.Métodos: estudaram-se, retrospectivamente, os dados de prontuários com base em itens que compunham a polissonografia de 124 pacientes com idade entre 25 e 77 anos, que não estavam fazendo nenhum tratamento para distúrbios do sono. O estudo foi aprovado pelo Comitê de Ética em Pesquisa da instituição de origem (CAE n o 0378.0.133.000-10).Resultados: 46,8% dos pesquisados tinham diagnóstico de apnéia leve, 91,8% roncavam e tinha uma eficiência do sono insatisfatória. Dos pacientes que roncavam, a quase totalidade apresentava SAHOS. A menor saturação de oxigênio durante o exame variou entre 60% e 97%, com mais de quatro quintos da amostra com índices abaixo de 90%.Conclusão: não houve relação significante entre os índices de apnéia e os níveis de saturação de oxi-hemoglobina. A eficiência do sono esteve diretamente relacionada à severidade da SAHOS, com evidências estatísticas; a oximetria pode ser um valioso instrumento para o diagnóstico da SAHOS, mas não pode ser única fonte para referenciar a gravidade da síndrome; o sono REM foi insatisfatório na maioria dos pesquisados, e este esteve significantemente relacionado à eficiência do sono.

The impact of a multidisciplinary approach on response rate of mandibular advancing device therapy in patients with obstructive sleep apnoea syndrome

The aim of the present study was to evaluate the importance of a multidisciplinary approach on increasing the response ratio expectation to mandibular advancing device (MAD) therapy in patients with obstructive sleep apnoea syndrome, especially in severe cases. Forty-two mild-to-severe OSAS patients were selected, after comprehensive evaluation by neurologists, otorhinolaryngologists and orthodontists, and treated with a Somnodent® device. Six months later, a polysomnographic exam with the MAD in situ was performed. The paired t-test evaluated the effectiveness of therapy and the results were compared with data from systematic reviews. The average treatment response was statistically significant for the apnoea/hypopnea index (AHI) and oxygen desaturation index and was higher than the outcomes presented in literature. An optimum therapy response (AHI < 5) was observed in 53% of patients (40% in severe OSAS) and a good response (AHI < 10) in 73% of patients (50% in severe OSAS). The Somnodent® device was effective and the multidisciplinary patient selection improved the response ratio compared to that reported by previous systematic reviews.

Factors associated with the efficacy of mandibular advancing device treatment in adult OSA patients

The aim of this study was to evaluate the anthropometric, demographic, occlusal and cephalometric characteristics of a group of adult obstructive sleep apnea (OSA) patients treated with mandibular advancement devices (MADs) and to determine the factors associated with treatment efficacy. Twenty-three consecutive patients with mild to severe OSA (polysomnographically diagnosed [T0]) were recruited for this prospective study; they were treated with a Silensor(®) appliance, and a polysomnographic exam with the MAD in situ was performed 2 to 3 months later (T1) to evaluate MAD's efficacy. Based on apnea-hypopnea index (AHI) differences between the T0 and T1 values, patients were classified into two groups: completely recovered and not completely recovered patients. The differences in anthropometric, demographic, occlusal and cephalometric parameters between the two groups were analyzed, and significant parameters verified. The sample showed these prevalent characteristics: deep bite, crossbite, tooth wear, dental and skeletal Class II, mesofacial mandibular vertical growth pattern, low position of the hyoid bone, longer soft palate length. The transverse diameters of upper maxilla had the greatest impact on T0 AHI. The factors associated with MAD efficacy were: age under 55 years, distance between the hyoid bone and the mandibular plane (H-MP) less than 20 mm, divergence of mandibular vertical growth pattern (SN^MP) less than 29°.

Treatment of obstructive sleep apnea using a custom-made titratable duobloc oral appliance: a prospective clinical study

PURPOSE

This prospective clinical study investigates the efficacy of a specific custom-made titratable mandibular advancement device (MAD) for the treatment of obstructive sleep apnea (OSA). This MAD has attachments in the frontal teeth area that allow for progressive titration of the mandible.

METHODS

Sixty-one adult OSA patients were included (age, 46.7 ± 9.0 years; male/female ratio, 45/16; apnea-hypopnea index (AHI), 23.2 ± 15.4 events/h sleep; body mass index, 27.9 ± 4.1 kg/m²). After an adaptation period, titration started based on a protocol of symptomatic benefit or upon reaching the physiological limits of protrusion. As a primary outcome, treatment response was defined as an objective reduction in AHI following MAD treatment of ≥50 % compared to baseline, and treatment success as a reduction in AHI with MAD to less than 5 and 10 events/h sleep. Compliance failure was defined as an inability to continue treatment.

RESULTS

A statistically significant decrease was observed in AHI, from 23.4 ± 15.7 at baseline to 8.9 ± 8.6 events/h with MAD (p < 0.01). Treatment response was achieved in 42 out of 61 patients (68.8 %), whereas 42.6 % met criteria of AHI < 5 and 63.9 % achieved an AHI < 10 events/h sleep, respectively. Four patients (6.6 %) were considered as "compliance failures."

CONCLUSIONS

The present study has evaluated the efficacy of a specific custom-made titratable MAD in terms of sleep apnea reduction.

Position paper by Canadian dental sleep medicine professionals on the role of different health care professionals in managing obstructive sleep apnea and snoring with oral appliances

The present Canadian position paper contains recommendations for the management by dentists of sleep-disordered breathing in adults with the use of oral appliances (OAs) as a treatment option for snoring and obstructive sleep apnea (OSA). The recommendations are based on literature reviews and expert panel consensus. OAs offer an effective, first-line treatment option for patients with mild to moderate OSA who prefer an OA to continuous positive airway pressure (CPAP) therapy, or for severe OSA patients who cannot tolerate CPAP, are inappropriate candidates for CPAP or who have failed CPAP treatment attempts. The purpose of the present position paper is to guide interdisciplinary teamwork (sleep physicians and sleep dentists) and to clarify the role of each professional in the management of OA therapy. The diagnosis of OSA should always be made by a physician, and OAs should be fitted by a qualified dentist who is trained and experienced in dental sleep medicine. Follow-up assessment by the referring physician and polysomnography or sleep studies are required to verify treatment efficacy. The present article emphasizes the need for a team approach to OA therapy and provides treatment guidelines for dentists trained in dental sleep medicine. Many of the dentists and sleep physicians who contributed to the preparation of the present article are members of the Canadian Sleep Society and the authors reached a consensus based on the current literature.

Impact of type D personality on adherence to oral appliance therapy for sleep-disordered breathing

PURPOSE

Type D personality, defined as a combination of social inhibition and negative affectivity, has been associated with poor medication adherence and lower adherence to continuous positive airway pressure in patients with sleep-disordered breathing. Up to this date, the association of patient's personality with adherence with a mandibular advancement device (MAD) has not been studied. The purposes of this study were to examine the association between type D personality and poor adherence to MAD treatment and to examine the impact of type D personality on perceived side effects during this treatment.

METHODS

Eighty-two patients out of 113 patients with a known baseline type D scale who have started MAD treatment between June 2006 and December 2009 were included. Information about side effects and adherence were collected via a postal questionnaire. Thirty-three patients were using a monobloc MAD and 49 patients were using a duobloc MAD.

RESULTS

Forty-five percent of type D patients discontinued MAD treatment, whereas only 15 % of non-type D patients reported treatment discontinuation. The odds ratio for treatment discontinuation was 6.03 (95 % confidence interval 1.22-29.81; p = 0.027) for type D personality, adjusted for age, gender, MAD type (monobloc or duobloc), and decrease in apnea severity. In continuing MAD users, no significant difference in perceived side effects was reported between the personality types.

CONCLUSION

This is the first study to examine the relationship between type D personality and adherence to MAD treatment. Type D patients reported a significantly higher discontinuation rate when compared to patients without type D personality.

Comparison of adjustable and fixed oral appliances for the treatment of obstructive sleep apnea

STUDY OBJECTIVES

To compare the efficacy of adjustable and fixed oral appliances for the treatment of OSA.

METHODS

Retrospective review of consecutive patients with OSA treated with either adjustable or fixed oral appliances. Polysomnography was conducted before and during therapy. Effective treatment was defined as an apnea-hypopnea index (AHI) < 5 events/h or < 10 events/h with resolution of sleepiness (Epworth < 10). We compared efficacy rates between fixed and adjustable appliances and sought to identify factors associated with greater success.

RESULTS

We included 805 patients, 602 (74.8%) treated with an adjustable and 203 (25.2%) a fixed oral appliances. Among the cohort, 86.4% were men; mean age was 41.3 ± 9.2 years. Mean AHI was 30.7 ± 25.6, with 34.1% having mild (AHI 5-14.9), 29.2% moderate (AHI 15-29.9), and 36.8% severe (AHI ≥ 30) OSA. Successful therapy was significantly more common with adjustable appliances. Obstructive events were reduced to < 5/h in 56.8% with adjustable compared to 47.0% with fixed appliances (p = 0.02). Similarly, a reduction of events to < 10 with resolution of sleepiness occurred in 66.4% with adjustable appliances versus 44.9% with fixed appliances (p < 0.001). For both devices, success was more common in younger patients, with lower BMI and less severe disease.

CONCLUSIONS

Adjustable devices produced greater reductions in obstructive events and were more likely to provide successful therapy, especially in moderate-severe OSA. Fixed appliances were effective in mild disease, but were less successful in those with higher AHIs. Given these findings, the baseline AHI should be considered when selecting the type of oral appliance.

[Guideline: Treatment of obstructive sleep apnea in adults]

The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC's Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a"S2e guideline". Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.

Systematic assessment of the impact of oral appliance therapy on the temporomandibular joint during treatment of obstructive sleep apnea: long-term evaluation

OBJECTIVE

The aim of the present study was to evaluate the symptoms of temporomandibular dysfunction (TMD) in patients with obstructive sleep apnea treated with long-term use of an oral appliance (OA) using a questionnaire based on the Helkimo Anamnestic Dysfunction Index. A further aim of the study was to evaluate the presence of daytime sleepiness using the Epworth Sleep Scale (ESS) and otologic symptoms.

MATERIALS AND METHODS

Polysomnograms of 34 patients were performed at baseline and after 6 months of OA use. As follow-up, the patients were contacted by telephone interview to answer the same questionnaires after 36.0 +/- 17.0 months.

RESULTS AND DISCUSSION

The intensity of TMD symptoms decreased significantly throughout treatment (p < 0.01). ESS values improved from 12.2 +/- 5.0 to 6.9 +/- 2.6 (p < or = 0.05). Tinnitus was present in nine patients at baseline and decreased in intensity in seven patients by the final assessment while remaining at the same level in two patients.

CONCLUSIONS

We conclude that long-term usage of an OA does not cause impairment to the temporomandibular joint. The Helkimo and otologic indexes are simple and useful in long-term patient follow-up. There was a long-term improvement in the ESS values over the years analyzed. A follow-up program could increase compliance by motivating patients to use the device regularly.