1
|
Mayoral Sanz P, Lagravère Vich M. Oral Appliances for Obstructive Sleep Apnea. Dent Clin North Am 2024; 68:495-515. [PMID: 38879283 DOI: 10.1016/j.cden.2024.02.005] [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] [Indexed: 06/26/2024]
Abstract
The use of mandibular repositioning devices (MRDs) in the management of patients with obstructive sleep apnea (OSA) has gained extensive recognition with relevant clinical evidence of its effectiveness. MRDs are designed to advance and hold the mandible in a protrusive position to widen the upper airway and promote air circulation. This review of the MRD aims to provide an evidence-based update on the optimal design features of an MRD, an analysis of the variety of appliances available, and the current understanding of the action mechanism.
Collapse
Affiliation(s)
- Pedro Mayoral Sanz
- Catholic University of Murcia UCAM, Calle Conde de Peñalver 61 - 1º, Madrid 28029, Spain.
| | - Manuel Lagravère Vich
- School of Dentistry, 5-488 Edmonton Clinic Health Academy, University of Alberta, 11405-87 Avenue Northwest, Edmonton, Alberta T6G 1C9, Canada
| |
Collapse
|
2
|
Zhu N, Buiret G. Effects of mandibular advancement devices on the evolution of obstructive sleep apnea. Sleep Breath 2024; 28:1127-1135. [PMID: 38180684 DOI: 10.1007/s11325-023-02988-w] [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: 10/05/2023] [Revised: 12/13/2023] [Accepted: 12/27/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE Mandibular advancement devices (MADs) are a treatment for obstructive sleep apnea (OSA). Titration is a necessary component of proper fitting of MADs, yet little is known about what happens at each step of the titration. The objectives of this study were to determine the clinical and paraclinical evolution of OSA at every mm of MAD advancement. METHODS Volunteers were fitted with MADs set to 50% of maximum advancement. MAD clinical and paraclinical results were recorded at every additional mm-titration, including apnea-hypopnea index (AHI), as well as symptoms of sleepiness and fatigue. RESULTS In 20 volunteers with OSA, the MAD had a significant effect on every polygraphic parameter at the onset of use. The mean AHI with MAD fell by 15.2/h (p < 0.001). The mean Epworth Sleepiness Score and Pichot Fatigue questionnaire with MAD fell by 2.0 (p = 0.0687) and 2.4 (p = 0.1073) respectively. There was no proportionality between clinical gains (drowsiness and fatigue) and AHI improvements. CONCLUSIONS MADs led to a significant improvement in AHI and other polygraphic parameters from the onset of use. The decrease of clinical symptoms (drowsiness and fatigue) was more complex to interpret because of the small decreases observed. The absence of concordance between AHI improvement and clinical symptoms was nevertheless objectively quantified and symptoms were alleviated with advancements. The findings suggest that it may be appropriate to use clinical symptoms as a main aim of titration, since the improvement in AHI is reached at the onset of MAD use.
Collapse
Affiliation(s)
- Nessie Zhu
- CH de Valence, Service Chirurgie ORL Et Cervico Faciale, CH de Valence, 179 Boulevard du Maréchal Juin, 26000, Valence, France
| | - Guillaume Buiret
- CH de Valence, Service Chirurgie ORL Et Cervico Faciale, CH de Valence, 179 Boulevard du Maréchal Juin, 26000, Valence, France.
| |
Collapse
|
3
|
Buiret G, Molta CT. Does oral appliance efficacy in treating obstructive sleep apnea depend on the appliance specialist's experience? Sleep Breath 2024; 28:555-560. [PMID: 37676348 DOI: 10.1007/s11325-023-02908-y] [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: 05/09/2023] [Revised: 07/27/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE In France, oral appliances (OAs) are the first-line treatment for moderate and second-line treatment for severe obstructive sleep apnea-hypopnea syndrome. In general, the sleep specialist refers his/her patient to the appliance specialist for the impressions and the fitting. However, is there a relationship between the volume of activity of the appliance specialist and the efficacy of this device? METHODS Our unit includes seven appliance otolaryngology specialists whose activities are highly variable (number of patients varying by a factor of almost 10). Data from a prospective follow-up registry of patients treated with an OA for moderate and severe obstructive sleep apnea-hypopnea syndrome were studied, and differences in outcomes between practitioners in the team were sought. RESULTS Among 859 patients, OAs significantly reduced the apnea-hypopnea index. Even if the patients were not completely comparable from one practitioner to another, there was a significant heterogeneity in efficacy (complete or partial response of the apnea-hypopnea index and failure of OAs) between practitioners (p = 0.0038; 0.0011; 0.0007 respectively), with better results in practitioners with a higher level of OA activity. CONCLUSION The findings suggest that it may be preferable to refer patients to OA practitioners who see a higher volume of patients with moderate or severe obstructive sleep apnea-hypopnea syndrome treated with an OA.
Collapse
Affiliation(s)
- G Buiret
- Service ORL, Centre Hospitalier de Valence, 179 Boulevard du Maréchal Juin, 26953, Valence, cedex, France.
| | - C T Molta
- Service ORL, Centre Hospitalier de Valence, 179 Boulevard du Maréchal Juin, 26953, Valence, cedex, France
| |
Collapse
|
4
|
Ghosh P, Janakiram C, Nilambur Kovilakam SV, Vallikat Velath A, Kadekuzhi S. Oral appliance therapy for the management of obstructive sleep apnea in adults: an umbrella review protocol. JBI Evid Synth 2023; 21:1624-1631. [PMID: 36951737 DOI: 10.11124/jbies-22-00220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVE The objective of this review is to summarize the evidence on the effectiveness of oral appliance therapy compared with other therapeutic approaches (continuous positive airway pressure, maxillomandibular and upper airway surgeries, behavioral techniques) for the management of obstructive sleep apnea in adults. INTRODUCTION For primary snoring, mild to moderate obstructive sleep apnea, and patients with a severe condition who are intolerant of continuous positive airway pressure therapy, an oral appliance is the treatment of choice among conservative procedures. The effectiveness of these appliances is largely determined by a variety of parameters, including the severity of sleep apnea (mild, moderate, severe), materials and methods used to fabricate the appliance, and the degree of mandibular protrusion. Thus, it is important to evaluate the effectiveness of oral appliances in the reduction of sleep apnea. INCLUSION CRITERIA This review will include systematic reviews of quantitative studies reporting on the effectiveness of oral appliances for the treatment of obstructive sleep apnea of any severity, confirmed using polysomnography. The primary outcome will be measured by reduction in the apnea-hypopnea index. METHODS A search will be conducted of MEDLINE, Cochrane Database of Systematic Reviews, Scopus, Web of Science, CINAHL, Epistemonikos, Embase, ProQuest Dissertations and Theses, and Shodhganga Dissertations and Theses from database inception until the present, with no language restrictions. Google Scholar will be searched manually. Two independent reviewers will screen titles, abstracts, and full-text articles and perform data extraction. Quality assessment will be conducted using the standard JBI critical appraisal tool. Data will be extracted from systematic reviews and a synthesis of the findings will be presented. The certainty will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). REVIEW REGISTRATION PROSPERO CRD42021258515.
Collapse
Affiliation(s)
- Parvathy Ghosh
- Department of Orthodontics and Dentofacial Orthopedics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
- Amrita Centre for Evidence Based Oral Health: A JBI Affiliated Group, Ernakulam, Kerala, India
| | - Chandrashekar Janakiram
- Amrita Centre for Evidence Based Oral Health: A JBI Affiliated Group, Ernakulam, Kerala, India
- Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sapna Varma Nilambur Kovilakam
- Department of Orthodontics and Dentofacial Orthopedics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
- Amrita Centre for Evidence Based Oral Health: A JBI Affiliated Group, Ernakulam, Kerala, India
| | - Ajith Vallikat Velath
- Department of Orthodontics and Dentofacial Orthopedics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
- Amrita Centre for Evidence Based Oral Health: A JBI Affiliated Group, Ernakulam, Kerala, India
| | - Sarika Kadekuzhi
- Department of Orthodontics and Dentofacial Orthopedics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
- Amrita Centre for Evidence Based Oral Health: A JBI Affiliated Group, Ernakulam, Kerala, India
| |
Collapse
|
5
|
Van Gaver H, Op de Beeck S, Dieltjens M, De Backer J, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Functional imaging improves patient selection for mandibular advancement device treatment outcome in sleep-disordered breathing: a prospective study. J Clin Sleep Med 2022; 18:739-750. [PMID: 34608859 PMCID: PMC8883076 DOI: 10.5664/jcsm.9694] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Mandibular advancement devices (MADs) are a noninvasive treatment option for patients with obstructive sleep apnea (OSA) and act by increasing the upper airway volume. However, the exact therapeutic mechanism of action remains unclear. The aim of this study was to assess MAD mechanisms using functional imaging that combines imaging techniques and computational fluid dynamics and assess associations with treatment outcome. METHODS One hundred patients with OSA were prospectively included and treated with a custom-made MAD at a fixed 75% protrusion. A low-dose computed tomography scan was made with and without MADs for computational fluid dynamics analysis. Patients underwent a baseline and 3-month follow-up polysomnography to evaluate treatment efficacy. A reduction in apnea-hypopnea index ≥ 50% defined treatment response. RESULTS Overall, 71 patients completed both 3-month follow-up polysomnography and low-dose computed tomography scan with computational fluid dynamics analysis. MAD treatment significantly reduced the apnea-hypopnea index (16.5 [10.4-23.6] events/h to 9.1 [3.9-16.4] events/h; P < .001, median [quartile 1-quartile 3]) and significantly increased the total upper airway volume (8.6 [5.4-12.8] cm3 vs 10.7 [6.4-15.4] cm3; P = .003), especially the velopharyngeal volume (2.1 [0.5-4.1] cm3 vs 3.3 [1.8-6.0] cm3; P < .001). However, subanalyses in responders and nonresponders only showed a significant increase in the total upper airway volume in responders, not in nonresponders. CONCLUSIONS MAD acts by increasing the total upper airway volume, predominantly due to an increase in the velopharyngeal volume. Responders showed a significant increase in the total upper airway volume with MAD treatment, while there was no significant increase in nonresponders. Findings add evidence to implement functional imaging using computational fluid dynamics in routine MAD outcome prediction. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Predicting Therapeutic Outcome of Mandibular Advancement Device Treatment in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT01532050; Identifier: NCT01532050. CITATION Van Gaver H, Op de Beeck S, Dieltjens M, et al. Functional imaging improves patient selection for mandibular advancement device treatment outcome in sleep-disordered breathing: a prospective study. J Clin Sleep Med. 2022;18(3):739-750.
Collapse
Affiliation(s)
- Hélène Van Gaver
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Address correspondence to: Hélène Van Gaver, MD, University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium;
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium,Department of Special Dentistry Care, Antwerp University Hospital, Antwerp, Belgium
| | | | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium,Department of Pulmonary Medicine, Antwerp University Hospital, Antwerp, Belgium
| | | | - Paul H. Van de Heyning
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Marc J. Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Special Dentistry Care, Antwerp University Hospital, Antwerp, Belgium
| | - Olivier M. Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium
| |
Collapse
|
6
|
Les orthèses d’avancées mandibulaires chez les patients souffrant d’un SAHOS sévère. Éfficacité à court et long terme, facteurs prédictifs d’efficacité. Rev Mal Respir 2022; 39:321-327. [DOI: 10.1016/j.rmr.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022]
|
7
|
Gogou ES, Psarras V, Giannakopoulos NN, Koutsourelakis I, Halazonetis DJ, Tzakis MG. Drug-induced sleep endoscopy improves intervention efficacy among patients treated for obstructive sleep apnea with a mandibular advancement device. Sleep Breath 2022; 26:1747-1758. [DOI: 10.1007/s11325-021-02561-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/12/2021] [Accepted: 12/30/2021] [Indexed: 12/01/2022]
|
8
|
Mandibular advancement device therapy in patients with epiglottic collapse. Sleep Breath 2022; 26:1915-1920. [DOI: 10.1007/s11325-021-02532-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/03/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
|
9
|
Which Three-Dimensional Printing Technology Can Replace Conventional Manual Method of Manufacturing Oral Appliance? A Preliminary Comparative Study of Physical and Mechanical Properties. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app12010130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Three-dimensional printing technology is widely being adopted in the manufacturing of oral appliances. The purpose of this study was to determine the most suitable method of manufacturing oral appliances by comparing the physical and mechanical properties of various 3D printing methods with the conventional method. Experimental groups consisted of six 3D-printed specimens via FDM, two polyjets, SLS, SLA, and DLP, and the milling methods. The control group consisted of an acrylic resin specimen made by the conventional manual method. The water absorption and solubility, color stability, flexural strength, and surface hardness were tested and statistically analyzed. The FDM, SLS, and DLP methods exhibited comparable water absorption and solubility with the control group, and only the SLA method exhibited significantly higher water solubility than the control group. In terms of the color stability, only the milling method met the requirements of the allowable clinical range. The FDM, SLA, and DLP methods exhibited comparable flexural strength with the control group. The surface hardness of the PJ-2, DLP, and milling methods was acceptable for replacing conventional manual method. Therefore, the most suitable method of manufacturing oral appliances among the experimental groups was the DLP method in terms of its water absorption and solubility, flexural strength, and surface hardness.
Collapse
|
10
|
Camañes-Gonzalvo S, Marco-Pitarch R, Plaza-Espín A, Puertas-Cuesta J, Agustín-Panadero R, Fons-Font A, Fons-Badal C, García-Selva M. Correlation between Polysomnographic Parameters and Tridimensional Changes in the Upper Airway of Obstructive Sleep Apnea Patients Treated with Mandibular Advancement Devices. J Clin Med 2021; 10:5255. [PMID: 34830533 PMCID: PMC8621062 DOI: 10.3390/jcm10225255] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/05/2021] [Accepted: 11/06/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The effectiveness of mandibular advancement devices has been solidly demonstrated in the past. They are considered a valid alternative treatment to continuous positive airway pressure for patients with obstructive sleep apnea. Nevertheless, the relationship between polysomnographic parameters and the increase in the volume of the upper airway in patients with obstructive sleep apnea syndrome has not been clearly established so far. This study aimed to determine the impact of these oral appliances upon the volume of the airway after the device titration phase and correlate it with the degree of mandibular advancement and the improvement of polysomnographic parameters. METHODS All patients were diagnosed by polysomnography and were treated with a customized, titratable mandibular advancement device. Three-dimensional volumetric measurements were performed using cone beam computed tomography. RESULTS The present study included 45 patients diagnosed with obstructive sleep apnea hypopnea syndrome (mild in 23 patients, moderate in 11 and severe in 11). Forty-four percent of the patients presented with an apnea hypopnea index <5/h at the end of treatment. The volume of the upper airway increased an average of 4.3 ± 5.9 cm3, this represents a percentage increase of 20.9%, which was significantly correlated with an apnea hypopnea index and a minimum oxygen saturation improvement. CONCLUSIONS The mandibular advancement device used was found to be effective in improving polysomnographic parameters. Moreover, the oral appliance was able to significantly increase the tridimensional dimensions of the upper airway. Moreover, this finding was correlated with a reduction in the apnea hypopnea index (p = 0.007) and an increase on minimum oxygen saturation (p = 0.033).
Collapse
Affiliation(s)
- Sara Camañes-Gonzalvo
- Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; (S.C.-G.); (A.P.-E.); (R.A.-P.); (A.F.-F.); (C.F.-B.); (M.G.-S.)
| | - Rocío Marco-Pitarch
- Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; (S.C.-G.); (A.P.-E.); (R.A.-P.); (A.F.-F.); (C.F.-B.); (M.G.-S.)
| | - Andrés Plaza-Espín
- Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; (S.C.-G.); (A.P.-E.); (R.A.-P.); (A.F.-F.); (C.F.-B.); (M.G.-S.)
| | - Javier Puertas-Cuesta
- Medical School of Medicine, Universidad Católica de Valencia, 46002 Valencia, Spain;
| | - Rubén Agustín-Panadero
- Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; (S.C.-G.); (A.P.-E.); (R.A.-P.); (A.F.-F.); (C.F.-B.); (M.G.-S.)
| | - Antonio Fons-Font
- Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; (S.C.-G.); (A.P.-E.); (R.A.-P.); (A.F.-F.); (C.F.-B.); (M.G.-S.)
| | - Carla Fons-Badal
- Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; (S.C.-G.); (A.P.-E.); (R.A.-P.); (A.F.-F.); (C.F.-B.); (M.G.-S.)
| | - Marina García-Selva
- Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain; (S.C.-G.); (A.P.-E.); (R.A.-P.); (A.F.-F.); (C.F.-B.); (M.G.-S.)
| |
Collapse
|
11
|
Mandibular Advancement Device Treatment Efficacy Is Associated with Polysomnographic Endotypes. Ann Am Thorac Soc 2021; 18:511-518. [PMID: 32946702 DOI: 10.1513/annalsats.202003-220oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Rationale: Mandibular advancement device (MAD) treatment efficacy varies among patients with obstructive sleep apnea.Objectives: The current study aims to explain underlying individual differences in efficacy using obstructive sleep apnea endotypic traits calculated from baseline clinical polysomnography: collapsibility (airflow at normal ventilatory drive), loop gain (drive response to reduced airflow), arousal threshold (drive preceding arousal), compensation (increase in airflow as drive increases), and the ventilatory response to arousal (increase in drive explained by arousal). On the basis of previous research, we hypothesized that responders to MAD treatment have a lower loop gain and milder collapsibility.Methods: Thirty-six patients (median apnea-hypopnea index [AHI], 23.5 [interquartile range (IQR), 19.7-29.8] events/h) underwent baseline and 3-month follow-up full polysomnography, with MAD fixed at 75% of maximal protrusion. Traits were estimated using baseline polysomnography according to Sands and colleagues. Response was defined as an AHI reduction ≥ 50%.Results: MAD treatment significantly reduced AHI (49.7%baseline [23.9-63.6], median [IQR]). Responders exhibited lower loop gain (mean [95% confidence interval], 0.53 [0.48-0.58] vs. 0.65 [0.57-0.73]; P = 0.020) at baseline than nonresponders, a difference that persisted after adjustment for baseline AHI and body mass index. Elevated loop gain remained associated with nonresponse after adjustment for collapsibility (odds ratio, 3.03 [1.16-7.88] per 1-standard deviation (SD) increase in loop gain [SD, 0.15]; P = 0.023).Conclusions: MAD nonresponders exhibit greater ventilatory instability, expressed as higher loop gain. Assessment of the baseline degree of ventilatory instability using this approach may improve upfront MAD treatment patient selection.Clinical trial registered with www.clinicaltrials.gov (NCT01532050).
Collapse
|
12
|
Van de Perck E, Op de Beeck S, Dieltjens M, Vroegop AV, Verbruggen AE, Willemen M, Verbraecken J, Van de Heyning PH, Braem MJ, Vanderveken OM. The relationship between specific nasopharyngoscopic features and treatment deterioration with mandibular advancement devices: a prospective study. J Clin Sleep Med 2021; 16:1189-1198. [PMID: 32267227 DOI: 10.5664/jcsm.8474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVES The variable efficacy of mandibular advancement device (MAD) treatment necessitates both accessible and accurate methods for patient selection. However, the role of awake nasopharyngoscopy for this purpose remains dubious. We introduced an assessment method based on anatomical upper airway features during tidal breathing for nasopharyngoscopy. The current study aimed to relate these features to MAD treatment outcome. METHODS One hundred patients diagnosed with obstructive sleep apnea were prospectively recruited for MAD treatment in a fixed 75% degree of maximal protrusion. Nasopharyngoscopic observations during Müller's maneuver and tidal breathing were recorded both with and without MAD. Treatment outcome, confirmed by 3-month follow-up polysomnography with MAD, was classified as (1) apnea-hypopnea index reduction ≥ 50%, (2) treatment apnea-hypopnea index < 5 events/h, and (3) ≥ 10% increase in apnea-hypopnea index compared with baseline (treatment deterioration). RESULTS A complete dataset was obtained in 65 patients. After adjusting for baseline apnea-hypopnea index, body mass index, and supine dependency, the position of the soft palate (odds ratio, 4.0; 95% confidence interval, 1.3-11.8; P = .013) and crowding of the oropharynx (odds ratio, 7.7; 95% confidence interval, 1.4-41.4; P = .017) were related to treatment deterioration. Addition of both features significantly (P = .031) improved the accuracy of baseline models based on clinical measurements alone. Moreover, with the MAD in situ, a posteriorly located soft palate (odds ratio, 9.8; 95% confidence interval, 1.7-56.3; P = .010) and a posteriorly located tongue base (odds ratio, 7.4; 95% confidence interval, 1.5-35.9; P = .013) were associated with treatment deterioration. CONCLUSIONS Awake nasopharyngoscopy might be a valuable office-based examination to exclude the risk of treatment deterioration and improve patient selection for MAD treatment. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Predicting Therapeutic Outcome of Mandibular Advancement Device Treatment in Obstructive Sleep Apnea (PROMAD); URL: https://clinicaltrials.gov/ct2/show/NCT01532050; Identifier: NCT01532050.
Collapse
Affiliation(s)
- Eli Van de Perck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Anneclaire V Vroegop
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Annelies E Verbruggen
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Paul H Van de Heyning
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc J Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| |
Collapse
|
13
|
Buiret G, Bechara M, Plouin-Gaudon I, Bavozet F, Dancea O, Pujo K, Chidiac F. Predictive Factors for Efficacious Oral Appliance Therapy in Moderate to Severe Obstructive Sleep Apnea Patients. Laryngoscope 2021; 131:E2089-E2096. [PMID: 33605446 DOI: 10.1002/lary.29439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 01/12/2021] [Accepted: 01/16/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Oral appliances (OAs) are a treatment for obstructive sleep apnea hypopnea syndrome (OSAHS). The main objective of the study was to determine the predictive factors of OA efficacy. The secondary objective was to measure the efficacy rates and determine OAs' tolerance and dropout. STUDY DESIGN Retrospective study. METHODS Efficacy results of the OAs based on the apnea hypopnea index (AHI) reduction, complications, and dropout rates were retrospectively collected from 347 patients with a moderate to severe OSAHS treated by a retention OA. The procedure was entirely performed by otolaryngologists. RESULTS The AHI with OA was more significantly reduced in patients with a higher initial AHI and a higher initial body mass index but reduction was not related to age and not proportional to the degree of mandibular advancement. The 50% AHI reduction rate after OA was 65.2%, the AHI ≤5/hr rate after OA was 26.1%, and the <50% AHI reduction and residual AHI > 10/hr rate was 50.1%. The OA significantly reduced the mean AHI (-14.9/hr, P < .0001). In 7.8% of patients, the AHI increased with OA. Seven patients (1.5%) experienced adverse effects. Thirty-seven (7.8%) patients stopped using OA mainly because of its ineffectiveness. Advancement can be considered beyond the initial maximal advancement. It can be effective sometimes; however, increasing advancement did not significantly reduce AHI. CONCLUSIONS OA is an effective and well-tolerated treatment for moderate to severe OSAHS. This treatment was effective for reduction of the AHI ≥50% in two-thirds of cases studied and it should be considered in more cases. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2089-E2096, 2021.
Collapse
Affiliation(s)
- Guillaume Buiret
- Service d'ORL et de chirurgie cervicofaciale, Centre Hospitalier de Valence, Valence, France
| | - Maroun Bechara
- Service d'ORL et de chirurgie cervicofaciale, Centre Hospitalier de Valence, Valence, France
| | - Isabelle Plouin-Gaudon
- Service d'ORL et de chirurgie cervicofaciale, Centre Hospitalier de Valence, Valence, France
| | - Frederique Bavozet
- Service d'ORL et de chirurgie cervicofaciale, Centre Hospitalier de Valence, Valence, France
| | - Olivia Dancea
- Service d'ORL et de chirurgie cervicofaciale, Centre Hospitalier de Valence, Valence, France
| | - Kevin Pujo
- Service d'ORL et de chirurgie cervicofaciale, Centre Hospitalier de Valence, Valence, France
| | - Frederic Chidiac
- Service d'ORL et de chirurgie cervicofaciale, Centre Hospitalier de Valence, Valence, France
| |
Collapse
|
14
|
Op de Beeck S, Dieltjens M, Verbruggen AE, Vroegop AV, Wouters K, Hamans E, Willemen M, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Phenotypic Labelling Using Drug-Induced Sleep Endoscopy Improves Patient Selection for Mandibular Advancement Device Outcome: A Prospective Study. J Clin Sleep Med 2020; 15:1089-1099. [PMID: 31482830 DOI: 10.5664/jcsm.7796] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVES Mandibular advancement device (MAD) outcome varies between patients. We hypothesized that upper airway collapse sites, patterns, and degrees assessed during baseline drug-induced sleep endoscopy (DISE) affect MAD outcome. METHODS One hundred patients with obstructive sleep apnea (OSA) were included and underwent baseline type 1 polysomnography. MAD was fitted intraorally at fixed 75% maximal protrusion. A total of 72 patients completed 3-month follow-up polysomnography and baseline DISE. Response was defined as apnea-hypopnea index (AHI) reduction ≥ 50%, deterioration as AHI increases during MAD treatment compared to baseline. RESULTS Adjusting for baseline AHI and body mass index, patients with tongue base collapse showed 3.69 higher odds (1.27-10.73; P = .0128) for response. Complete concentric collapse at the level of the palate (5.32 [1.21-23.28]; P = .0234) and complete laterolateral oropharyngeal collapse (6.62 [1.14-38.34]; P = .0330) related to deterioration. Results for tongue base collapse and complete concentric collapse at the level of the palate were confirmed in the moderate to severe OSA subgroup. Applying these results to this selected subgroup increased response rate with 54% and decreased deterioration rate with 53%. These results were confirmed using other response and deterioration definitions. CONCLUSIONS Three baseline DISE phenotypes identified during drug-induced sleep were significantly related to MAD treatment outcome: one beneficial, tongue base collapse, and two adverse, complete concentric collapse at the level of the palate and complete laterolateral oropharyngeal collapse. If confirmed in future prospective studies, these results could guide patient selection for MAD outcome. CLINICAL TRIAL REGISTRATION This prospective clinical trial (PROMAD) was registered on Clinicaltrials.gov with identifier: NCT01532050. CITATION Op de Beeck S, Dieltjens M, Verbruggen AE, Vroegop AV, Wouters K, Hamans E, Willemen M, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Phenotypic labelling using drug-induced sleep endoscopy improves patient selection for mandibular advancement device outcome: a prospective study. J Clin Sleep Med. 2019;15(8):1089-1099.
Collapse
Affiliation(s)
- Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Annelies E Verbruggen
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Anneclaire V Vroegop
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Clinical Trial Centre (CTC), CRC Antwerp, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Evert Hamans
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium; Department of Pulmonology, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Wilfried A De Backer
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Paul H Van de Heyning
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marc J Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| |
Collapse
|
15
|
Tegelberg Å, Nohlert E, Bornefalk-Hermansson A, Fransson A, Isacsson G. Respiratory outcomes after a 1-year treatment of obstructive sleep apnoea with bibloc versus monobloc oral appliances: a multicentre, randomized equivalence trial. Acta Odontol Scand 2020; 78:401-408. [PMID: 32125197 DOI: 10.1080/00016357.2020.1730436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: The benefit of bibloc over monobloc appliances in treating obstructive sleep apnoea (OSA) has not been evaluated in randomized trials. We hypothesized that these types of appliances would be equally effective.Material and methods: In this multicentre, randomized equivalence trial, patients with OSA received one type of bibloc or one type of monobloc treatment. At baseline, a 1-night polygraphy study was done, and this was repeated after 1 year. The outcome was any change in the apnoea-hypopnoea index (AHI) and the limits of equivalence between the two devices were set at ±5 AHI units.Results: Of 302 patients, 146 were randomly assigned to bibloc and 156 to monobloc appliances. In 88 and 104 patients, respectively, there were significant reductions in the AHI (p < .001) with a mean change of -16.7 (95% CI -19.4 to -14.1) in the bibloc and -11.8 (-14.9 to -8.7) in the monobloc groups. The proportions of responders defined as having an AHI <10 were 68% and 65% for the bibloc and monobloc groups, respectively. Treatment-related adverse events were mild, transient and the dropouts were more frequent in the bibloc group.Conclusions: Both types of treatments positively and significantly reduced respiratory disturbances, but at the 1-year follow-up, they were not significantly different in treating OSA, with a numerically greater reduction of the AHI value with the bibloc appliance. However, the higher proportion of treatment-related adverse events and higher proportion of dropouts among bibloc users should be balanced against the advantage of a greater reduction in the AHI.
Collapse
Affiliation(s)
- Åke Tegelberg
- Department of Orofacial Pain and Jaw Function, Malmö University, Malmö, Sweden
| | - Eva Nohlert
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | | | - Anette Fransson
- Postgraduate Dental Education Center and Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Göran Isacsson
- Department of Orofacial Pain and Jaw Function, Västmanland County Hospital, Västerås, Sweden
| |
Collapse
|
16
|
[Oral appliances for obstructive sleep apnoea: What can we expect?]. Rev Mal Respir 2020; 37:526-549. [PMID: 32636050 DOI: 10.1016/j.rmr.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/28/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Mandibular appliances are a treatment option for obstructive sleep apnea. There are many designs, but in the literature they tend to be grouped into a single entity without considering that efficiency, tolerance, compliance, or side effects are inherent in the design of each of them. A more detailed literature review is therefore warranted for the reader who wants to understand the relative effectiveness of each appliance. STATE OF KNOWLEDGE We conducted a literature search using the "oral appliance" and "obstructive sleep apnea" criteria on Pubmed, Embase and Cochrane. This allowed us to compare outcome parameters by appliance class and to highlight the rare studies comparing different appliances. CONCLUSIONS Mandibular appliances are not a homogeneous entity. Common use includes only appliances designed for propulsion (with rods and jacks) and retention. However, the few comparative studies available do not identify which are the most effective types or the types with an optimal efficacy/tolerance ratio. PERSPECTIVES Further appliance comparison studies are needed to determine the most effective type or with an optimal efficacy/tolerance ratio.
Collapse
|
17
|
A stepwise titration protocol for oral appliance therapy in positional obstructive sleep apnea patients: proof of concept. Sleep Breath 2020; 24:1229-1236. [PMID: 32162278 PMCID: PMC7426292 DOI: 10.1007/s11325-020-02045-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/12/2020] [Accepted: 02/28/2020] [Indexed: 11/21/2022]
Abstract
Purpose In patients with positional obstructive sleep apnea (POSA), oral appliance therapy (OAT) is among the first-line treatments. The aim of this study was to evaluate the effects of a new standardized stepwise titration protocol for OAT in a group of patients with POSA. Methods This was an observational intervention trial. Patients who were previously randomized to the OAT intervention arm of a comparison study comprised the subjects for this study. These patients, who had mild to moderate POSA, were assessed after 3 and 12 months for treatment efficacy, objective adherence by temperature microsensor, and side effects. The titration of OAT was performed using a standardized stepwise titration protocol including advancement levels of 60%, 75%, and 90% of the maximum mandibular protrusion. The optimal advancement level per individual was based on a weighted compromise between efficacy and side effects. Results In total, 36 patients were included and all completed the titration protocol after 3 months. At baseline, the OAT was set at 60% of the maximal mandibular protrusion position. At a 3-month evaluation, the advancement remained at 60% in 16 patients (44%) and reached 75% advancement in 20 patients (56%). Mean apnea-hypopnea index decreased from 12.9 events per hour (9.1–16.7) to 6.9 (3.7–10.3) (P < 0.001), and median objective adherence was 97.4 (61.4–100.00) after 3 months. The 12-month analysis showed consistent results and good OAT tolerance. Six patients (16.7%) terminated OAT and one patient (2.8%) was lost to follow-up. Conclusions This standardized stepwise titration protocol for OAT showed good efficacy, good OAT tolerance, and good objective adherence in patients with mild to moderate POSA. Therefore, the protocol is recommended in research projects to improve standardization of methods between studies and in clinical practice for its practical feasibility. Electronic supplementary material The online version of this article (10.1007/s11325-020-02045-w) contains supplementary material, which is available to authorized users.
Collapse
|
18
|
Ilea A, Timuș D, Höpken J, Andrei V, Băbțan AM, Petrescu NB, Câmpian RS, Boșca AB, Șovrea AS, Negucioiu M, Mesaros AȘ. Oral appliance therapy in obstructive sleep apnea and snoring - systematic review and new directions of development. Cranio 2019; 39:472-483. [PMID: 31588866 DOI: 10.1080/08869634.2019.1673285] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- Aranka Ilea
- Department of Oral Rehabilitation, Oral Health and Dental Office Management, Faculty of Dentistry, "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Daniela Timuș
- Faculty of Dentistry, Student in the 6th year of "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Julian Höpken
- Faculty of Dentistry, Postgraduate student of "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Vlad Andrei
- Department of Periodontology, Clinical County Hospital of Târgu Mureș , Romania
| | - Anida-Maria Băbțan
- Department of Oral Rehabilitation, Oral Health and Dental Office Management, Faculty of Dentistry, "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Nausica Bianca Petrescu
- Department of Oral Rehabilitation, Oral Health and Dental Office Management, Faculty of Dentistry, "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Radu Septimiu Câmpian
- Department of Oral Rehabilitation, Oral Health and Dental Office Management, Faculty of Dentistry, "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Adina Bianca Boșca
- Department of Histology, Faculty of Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Alina Simona Șovrea
- Department of Histology, Faculty of Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Marius Negucioiu
- Department of Prosthodontics, "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| | - Anca Ștefania Mesaros
- Department of Dental Propedeutics and Esthetics, Faculty of Dentistry, "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca , Cluj-Napoca , Romania
| |
Collapse
|
19
|
The effectiveness of two types of MADS for OSA therapy. Clin Oral Investig 2017; 22:1995-2003. [PMID: 29214378 PMCID: PMC5945916 DOI: 10.1007/s00784-017-2290-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 11/21/2017] [Indexed: 10/27/2022]
Abstract
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.
Collapse
|
20
|
Fernández-Julián E, Pérez-Carbonell T, Marco R, Pellicer V, Rodriguez-Borja E, Marco J. Impact of an oral appliance on obstructive sleep apnea severity, quality of life, and biomarkers. Laryngoscope 2017; 128:1720-1726. [PMID: 29152745 DOI: 10.1002/lary.26913] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/28/2017] [Accepted: 08/18/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE/HYPOTHESIS To investigate outcomes including efficacy, quality of life, and levels of inflammatory markers of a mandibular advancement device (MAD) for moderate-to-severe obstructive sleep apnea (OSA). STUDY DESIGN Case-control study. METHODS Patients with apnea-hypopnea index (AHI) ≥ 15/hr who only accepted MAD therapy (study group) or who refused any treatment (control group) were recruited. At baseline and at 6 months, polysomnography, Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), C-reactive protein (CRP), interleukin 1β, interleukin 6, and tumor necrosis factor α (TNF-α) were assessed in both groups. RESULTS At baseline, the study group (n = 30) showed a higher percentage of rapid eye movement sleep and higher CRP levels (P < .05) than the control group (n = 10). At 6 months, the MAD significantly improved AHI and lowest oxygen saturation (P < .01), non-rapid eye movement (N)1 and N3 sleep stages (P < .05), ESS score (P < .05), FOSQ total score (P < .01), interleukin 1β (P < .05), and TNF-α (P < .01) compared with the untreated group. In the overall, moderate, and severe OSA groups, 63.3%, 75%, and 50%, respectively, achieved at least good response. CONCLUSIONS Use of a MAD significantly improved polysomnographic parameters, quality of life, and some inflammatory markers (CRP, IL-β, and TNF-α) in a significant proportion of patients with moderate OSA and in some patients with severe OSA. Hence, a MAD may be a viable alternative therapy in patients with moderate-to-severe OSA who refuse continuous positive airway pressure. LEVEL OF EVIDENCE 3b. Laryngoscope, 128:1720-1726, 2018.
Collapse
Affiliation(s)
- Enrique Fernández-Julián
- Otorhinolaryngology Department, Clinical University Hospital, University of Valencia, Valencia, Spain
| | - Tomás Pérez-Carbonell
- Otorhinolaryngology Department, Clinical University Hospital, University of Valencia, Valencia, Spain
| | - Rocío Marco
- Prosthodontic and Occlusion Department , Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain
| | - Verónica Pellicer
- Otorhinolaryngology Department, Clinical University Hospital, University of Valencia, Valencia, Spain
| | - Enrique Rodriguez-Borja
- Biochemistry Laboratory, Clinical University Hospital, University of Valencia, Valencia, Spain
| | - Jaime Marco
- Otorhinolaryngology Department, Clinical University Hospital, University of Valencia, Valencia, Spain
| |
Collapse
|
21
|
Wang TC, Tsou YA, Wu YF, Huang CC, Lin WWY, Li YF, Chen MYC, Tai CJ, Tsai MH. Treatment success with titratable thermoplastic mandibular advancement devices for obstructive sleep apnea: A comparison of patient characteristics. EAR, NOSE & THROAT JOURNAL 2017; 96:E25-E32. [PMID: 28346652 DOI: 10.1177/014556131709600322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A titratable thermoplastic mandibular advancement device (MAD) is clearly an effective treatment option in some patients with obstructive sleep apnea (OSA). Determining which patients may be more likely to respond to treatment with thermoplastic MADs and to adhere to treatment would be of obvious clinical relevance. This was an experimental descriptive study (N = 60). Patients with OSA were instructed to wear a titratable thermoplastic MAD for 3 months. Treatment success was defined as a ≥50% reduction from baseline in the apnea-hypopnea index (AHI) or AHI <10 when wearing MAD. Adherence was defined as MAD use ≥5 nights/week. Treatment was successful in 66.7% of patients and 60.0% were adherent. All polysomnographic parameters and visual analogue scale scores (sleep quality, snoring, waking refreshed) were significantly improved after treatment. The patients in whom treatment failed had significantly higher neck circumferences (39.3 cm vs. 37.5 cm, p = 0.014), higher baseline AHI values (26.6 vs. 18.0, p = 0.016), and smaller AHI reduction (-31.8 vs -53.1, p < 0.001) than those in the group in whom treatment succeeded. There were no significant differences in polysomnographic, cephalometric, or visual analogue scale measures between patients for whom treatment was and was not successful, regardless of baseline values or the change rates after the MAD was placed. Titratable thermoplastic MADs can improve indicators of sleep quality, even in patients in whom treatment is considered to have failed.
Collapse
Affiliation(s)
- Tang-Chuan Wang
- Department of Otolaryngology, China Medical University and Hospital, Taiwan, ROC
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Cui DM, Han DM, Nicolas B, Hu CL, Wu J, Su MM. Three-dimensional Evaluation of Nasal Surgery in Patients with Obstructive Sleep Apnea. Chin Med J (Engl) 2017; 129:651-6. [PMID: 26960367 PMCID: PMC4804410 DOI: 10.4103/0366-6999.177971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Obstructive sleep apnea (OSA) is a common sleep disorder and is characterized by airway collapse at multiple levels of upper airway. The effectiveness of nasal surgery has been discussed in several studies and shows a promising growing interest. In this study, we intended to evaluate the effects of nasal surgery on the upper airway dimensions in patients with OSA using three-dimensional (3D) reconstruction of cone-beam computed tomography (CT). Methods: Twelve patients with moderate to severe OSA who underwent nasal surgery were included in this study. All patients were diagnosed with OSA using polysomnography (PSG) in multi sleep health centers associated with Massachusetts General Hospital, Massachusetts Eye and Ear Infirmary and the Partners Health Care from May 31, 2011 to December 14, 2013. The effect of nasal surgery was evaluated by the examination of PSG, subjective complains, and 3D reconstructed CT scan. Cross-sectional area was measured in eleven coronal levels, and nasal cavity volume was evaluated from anterior nasal spine to posterior nasal spine. The thickness of soft tissue in oral pharynx region was also measured. Results: Five out of the 12 patients were successfully treated by nasal surgery, with more than 50% drop of apnea–hypopnea index. All the 12 patients showed significant increase of cross-sectional area and volume postoperatively. The thickness of soft tissue in oral pharynx region revealed significant decrease postoperatively, which decreased from 19.14 ± 2.40 cm2 and 6.11 ± 1.76 cm2 to 17.13 ± 1.91 cm2 and 5.22 ± 1.20 cm2. Conclusions: Nasal surgery improved OSA severity as measured by PSG, subjective complaints, and 3D reconstructed CT scan. 3D assessment of upper airway can play an important role in the evaluation of treatment outcome.
Collapse
Affiliation(s)
| | - De-Min Han
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730; Key Laboratory of Otorhinolaryngology Head and Neck Surgery, Ministry of Education, Beijing Institute of Otorhinolaryngology, Beijing 100005, China
| | | | | | | | | |
Collapse
|
23
|
Sakamoto Y, Yanamoto S, Rokutanda S, Naruse T, Imayama N, Hashimoto M, Nakamura A, Yoshida N, Tanoue N, Ayuse T, Yoshimine H, Umeda M. Predictors of obstructive sleep apnoea-hypopnea severity and oral appliance therapy efficacy by using lateral cephalometric analysis. J Oral Rehabil 2016; 43:649-55. [PMID: 27132249 DOI: 10.1111/joor.12408] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 11/27/2022]
Abstract
Obstructive sleep apnoea-hypopnea (OSAH) is a common disorder characterised by repetitive complete or partial closure of the upper airway during sleep, which results in sleep fragmentation and oxygen desaturation. There is growing interest in the use of oral appliances (OAs) to treat OSAH. The purpose of this study was to clarify the cephalometric factors that are associated with OSAH severity and that predict the outcome of OA therapy. Two hundred nine patients with OSAH were recruited and analysed retrospectively. They had a polysomnographically documented apnoea-hypopnea index (AHI) of more than five respiratory events per hour. Lateral skull radiographs were used for cephalometric analysis. Only 67 of the 209 recruited patients underwent a second polysomnography (PSG) to evaluate the efficacy of OA therapy. In all recruited patients, the angle formed by the subspinal point (A) to the nasion (N) to the supramental point (B) (i.e. ANB angle) and the distance between the mandibular plane and hyoid bone (MP-H) were predictive factors of OSAH severity. In only 67 patients underwent PSG with an OA, the mean rate of decrease in the AHI was 47·8 ± 29·1%. OA therapy effectively treated OSAH in some patients with a very severe form of OSAH. However, patients who had a high position of the hyoid bone had a poor response to OA therapy. This study suggested that cephalometric analysis is useful for predicting OSAH severity and OA therapy efficacy.
Collapse
Affiliation(s)
- Y Sakamoto
- Department of Clinical Oral Oncology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - S Yanamoto
- Department of Clinical Oral Oncology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - S Rokutanda
- Department of Clinical Oral Oncology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - T Naruse
- Department of Clinical Oral Oncology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - N Imayama
- Department of Clinical Oral Oncology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - M Hashimoto
- Division of Orthodontics and Dentofacial Orthopedics, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - A Nakamura
- Division of Orthodontics and Dentofacial Orthopedics, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - N Yoshida
- Division of Orthodontics and Dentofacial Orthopedics, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - N Tanoue
- Division of Pediatric Prosthodontics, Nagasaki University Hospital, Nagasaki, Japan
| | - T Ayuse
- Department of Clinical Physiology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - H Yoshimine
- Department of Internal Medicine, Inoue Hospital, Nagasaki, Japan
| | - M Umeda
- Department of Clinical Oral Oncology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| |
Collapse
|
24
|
Zhu Y, Long H, Jian F, Lin J, Zhu J, Gao M, Lai W. The effectiveness of oral appliances for obstructive sleep apnea syndrome: A meta-analysis. J Dent 2015; 43:1394-402. [PMID: 26485532 DOI: 10.1016/j.jdent.2015.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/08/2015] [Accepted: 10/14/2015] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the effectiveness of oral appliances (OAs) for managing patients with obstructive sleep apnea (OSA). METHODS PubMed, Embase, Web of Science, CENTRAL and SIGLE were electronically searched from January 1980 to September 2015 for randomized or nonrandomized controlled trials that assessed the effectiveness of OAs on OSAS. The processes of study search, selection, data extraction, assessment of risk of bias and evaluation of evidence quality were conducted independently by two reviewer authors. Meta-analyses were performed in Review Manager 5, Stata11.0 and StatsDirect 2.7.9. RESULTS Finally, we included 17 eligible studies which compared OAs and placebo or blank control. Six outcomes were assessed in this meta-analysis, i.e., apnea hypopnea index (AHI), respiratory arousal index (RAI), minimum oxygen saturation(MinSaO2), rapid eye movement (REM) sleep, sleep efficiency and Epworth Sleepiness Scale (ESS). Meta-analysis revealed that the pooled mean differences were -10.26 [95% CI: (-12.59, -7.93)], -9.03 [95% CI: (-11.89, -6.17)], 3.08 [95% CI: (1.97, 4.19)], 0.36 [95% CI: (-0.30, 1.02)], 1.34 [95% CI: (-0.05, 2.73)] and -1.76 [95% CI: (-2.57, -0.94)], respectively. The sensitivity analysis and subgroup analysis displayed generally robust results except for MinSaO2, REM sleep and sleep efficiency. Furthermore, publication bias was detected in RAI and MinSaO2. CONCLUSIONS The available evidence indicates benefits in respiration and sleep quality with oral appliances as compared to placebo devices or blank control, while we cannot determine its effectiveness in sleep efficiency and sleep architecture alterations. However, due to low evidence quality as revealed by GRADE, this finding should be interpreted with caution. CLINICAL SIGNIFICANCE Through critical meta-analyses, we found that oral appliances are effective in respiration improving and sleep quality. The existing evidence supports the employment of OAs as a recommendable treatment option for OSA. This meta-analysis helps to direct clinical practice and future research, and promises to be of great interest for both practitioners and researchers.
Collapse
Affiliation(s)
- Yafen Zhu
- Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China
| | - Hu Long
- Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China
| | - Fan Jian
- Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China
| | - Jianchang Lin
- Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China
| | - Jingyi Zhu
- Department of stomatology, Kiang Wu Hospital, Macao, China
| | - Meiya Gao
- Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China
| | - Wenli Lai
- Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
| |
Collapse
|
25
|
Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome. World J Otorhinolaryngol Head Neck Surg 2015; 1:17-27. [PMID: 29204536 PMCID: PMC5698527 DOI: 10.1016/j.wjorl.2015.08.001] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/26/2015] [Indexed: 12/21/2022] Open
Abstract
Objective To provide an overview of the healthcare and societal consequences and costs of untreated obstructive sleep apnea syndrome. Data sources PubMed database for English-language studies with no start date restrictions and with an end date of September 2014. Methods A comprehensive literature review was performed to identify all studies that discussed the physiologic, clinical and societal consequences of obstructive sleep apnea syndrome as well as the costs associated with these consequences. There were 106 studies that formed the basis of this analysis. Conclusions Undiagnosed and untreated obstructive sleep apnea syndrome can lead to abnormal physiology that can have serious implications including increased cardiovascular disease, stroke, metabolic disease, excessive daytime sleepiness, work-place errors, traffic accidents and death. These consequences result in significant economic burden. Both, the health and societal consequences and their costs can be decreased with identification and treatment of sleep apnea. Implications for practice Treatment of obstructive sleep apnea syndrome, despite its consequences, is limited by lack of diagnosis, poor patient acceptance, lack of access to effective therapies, and lack of a variety of effective therapies. Newer modes of therapy that are effective, cost efficient and more accepted by patients need to be developed.
Collapse
|
26
|
Serra-Torres S, Bellot-Arcís C, Montiel-Company JM, Marco-Algarra J, Almerich-Silla JM. Effectiveness of mandibular advancement appliances in treating obstructive sleep apnea syndrome: A systematic review. Laryngoscope 2015; 126:507-14. [DOI: 10.1002/lary.25505] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/08/2015] [Accepted: 06/18/2015] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | - Jaime Marco-Algarra
- Otorhinolaryngology Unit; University Clinical Hospital, Faculty of Medicine and Dentistry, University of Valencia; Valencia Spain
| | | |
Collapse
|
27
|
Wang X, Gong X, Yu Z, Gao X, Zhao Y. 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. Am J Orthod Dentofacial Orthop 2015; 147:559-65. [PMID: 25919101 DOI: 10.1016/j.ajodo.2015.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 01/01/2015] [Accepted: 01/01/2015] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Xiaoyu Wang
- Resident, Department of Dentistry, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xu Gong
- Lecturer, Department of Orthodontics, School and Hospital of Stomatology, Peking University, Beijing, China
| | - Zhe Yu
- Lecturer, Department of Dentistry, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuemei Gao
- Professor, Department of Orthodontics, School and Hospital of Stomatology, Peking University, Beijing, China
| | - Ying Zhao
- Professor, Department of Dentistry, Xuanwu Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
28
|
Effects of mandibular advancement device treatment on arterial stiffness and glucose metabolism in patients with mild to moderate obstructive sleep apnea: a prospective 1 year study. Sleep Breath 2015; 20:69-77. [DOI: 10.1007/s11325-015-1186-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 03/18/2015] [Accepted: 04/15/2015] [Indexed: 11/26/2022]
|
29
|
Raunio A, Mattila P, Huuskonen U, Oikarinen K, Sándor GK. The influence of a mandibular advancement plate on polysomnography in different grades of obstructive sleep apnea. EJOURNAL OF ORAL MAXILLOFACIAL RESEARCH 2015; 6:e4. [PMID: 25937875 PMCID: PMC4414235 DOI: 10.5037/jomr.2014.6104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/12/2015] [Indexed: 01/11/2023]
Abstract
Objectives The purpose of this study was to investigate the effect of a mandibular advancement device on different grades of obstructive sleep apnea using a relatively simple test for the apnea-hypopnea index to determine if a mandibular device will be effective. Material and Methods A total of 68 patients with obstructive sleep apnea syndrome (OSAS) including, 31 with mild, 23 with moderate and 14 with severe OSAS were treated with a mandibular advancement device (MAD) and monitored with polysomnography. Results 25 of the 31 mild, 15 of the 23 moderate and 2 of the 14 severe OSAS patients were cured of their OSAS if a post treatment apnea-hypopnea index of less than 5 is regarded as cured. The odds ratios for success with MAD therapy are 3 for women over men, 14.9 for mild obstructive sleep apnea, 5.42 for moderate obstructive sleep apnea if severe obstructive sleep apnea is assigned an odds ratio of 1. Conclusions The use of the apnea-hypopnea index alone is useful in mild and moderate disease to predict the effectiveness of mandibular advancement device. Treatment with a mandibular advancement device is very effective in treating mild and moderate obstructive sleep apnea. Conservative treatment with a mandibular advancement device can be successful in less severe grades of sleep apnea and may be an alternative for non-surgical patients with severe obstructive sleep apnea intolerant of Continuous Positive Airway Pressure management.
Collapse
Affiliation(s)
- Antti Raunio
- Department of Oral and Maxillofacial Surgery, Medical Research Center, Oulu University Hospital, Oulu Finland
| | - Pauli Mattila
- Department of Oral and Maxillofacial Surgery, Medical Research Center, Oulu University Hospital, Oulu Finland
| | - Usko Huuskonen
- Department of Oral and Maxillofacial Surgery, Medical Research Center, Oulu University Hospital, Oulu Finland
| | - Kyösti Oikarinen
- Department of Oral and Maxillofacial Surgery, Medical Research Center, Oulu University Hospital, Oulu Finland
| | - George K Sándor
- Department of Oral and Maxillofacial Surgery, Medical Research Center, Oulu University Hospital, Oulu Finland
| |
Collapse
|
30
|
Pliska BT, Nam H, Chen H, Lowe AA, Almeida FR. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med 2014; 10:1285-91. [PMID: 25325593 DOI: 10.5664/jcsm.4278] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 07/21/2014] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To evaluate the magnitude and progression of dental changes associated with long-term mandibular advancement splint (MAS) treatment of obstructive sleep apnea (OSA). METHODS Retrospective study of adults treated for primary snoring or mild to severe OSA with MAS for a minimum of 8 years. The series of dental casts of patients were analyzed with a digital caliper for changes in overbite, overjet, dental arch crowding and width, and inter-arch relationships. The progression of these changes over time was determined and initial patient and dental characteristics were evaluated as predictors of the observed dental side effects of treatment. RESULTS A total of 77 patients (average age at start of treatment: 47.5 ± 10.2 years, 62 males) were included in this study. The average treatment length was 11.1 ± 2.8 years. Over the total treatment interval evaluated there was a significant (p < 0.001) reduction in the overbite (2.3 ± 1.6 mm), overjet (1.9 ± 1.9 mm), and mandibular crowding (1.3 ± 1.8 mm). A corresponding significant (p < 0.001) increase of mandibular intercanine (0.7 ± 1.5 mm) and intermolar (1.1 ± 1.4 mm) width as well as incidence of anterior crossbite and posterior open bite was observed. Overbite and mandibular intermolar distance were observed to decrease less with time, while overjet, mandibular intercanine distance, and lower arch crowding all decreased continuously at a constant rate. CONCLUSIONS After an average observation period of over 11 years, clinically significant changes in occlusion were observed and were progressive in nature. Rather than reaching a discernible end-point, the dental side effects of MAS therapy continue with ongoing MAS use. COMMENTARY A commentary on this article appears in this issue on page 1293.
Collapse
Affiliation(s)
- Benjamin T Pliska
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Hyejin Nam
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Hui Chen
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Alan A Lowe
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| | - Fernanda R Almeida
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
31
|
Dieltjens M, Braem MJ, Van de Heyning PH, Wouters K, Vanderveken OM. Prevalence and clinical significance of supine-dependent obstructive sleep apnea in patients using oral appliance therapy. J Clin Sleep Med 2014; 10:959-64. [PMID: 25142766 DOI: 10.5664/jcsm.4024] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
Collapse
|
32
|
Dieltjens M, Braem MJ, Vroegop AVMT, Wouters K, Verbraecken JA, De Backer WA, Van de Heyning PH, Vanderveken OM. Objectively measured vs self-reported compliance during oral appliance therapy for sleep-disordered breathing. Chest 2014; 144:1495-1502. [PMID: 23928873 DOI: 10.1378/chest.13-0613] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Assessment of the overall therapeutic effectiveness of oral appliance therapy can only be realized through objectively measured compliance. The aims of this study were to assess objectively measured compliance during oral appliance therapy at 1-year follow-up and to compare these data with self-reported use. METHODS Fifty-one eligible patients were enrolled in this 1-year prospective clinical study (men, 61%; mean age, 49 ± 10 years; apnea-hypopnea index, 18.0 ± 11.9 events/h sleep; BMI, 26.6 ± 4.1 kg/m²). Objective compliance during oral appliance therapy at 1-year follow-up was assessed with a microsensor thermometer. Subjective compliance was assessed by self-report. Patients with a mean objectively measured use of ≥ 4 h/night on 70% of nights monitored were considered regular users. The mean disease alleviation was calculated as a measure of overall therapeutic effectiveness. RESULTS High agreement between objective and subjective compliance data at 1-year follow-up was reported (intraclass correlation coefficient, 0.8; 95% CI, 0.5-0.9), showing a mean subjective overestimation of 30 min (95% CI, -3.1 to 1.9; P = .02). The discontinuation rate at 1-year follow-up was 9.8%. The objective mean use rate was 6.4 ± 1.7 h/night at 1-year follow-up in continuing users, with a regular use rate of 83%. The mean disease alleviation was 54.9%. CONCLUSIONS This study is the first to our knowledge to report the 1-year results of objectively measured compliance during oral appliance therapy. In addition, a high agreement between objective and subjective compliance data were reported, with a mean subjective overestimation of 30 min. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01284881; URL: www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Marijke Dieltjens
- Department of Special Care Dentistry, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Marc J Braem
- Department of Special Care Dentistry, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Anneclaire V M T Vroegop
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Kristien Wouters
- Department of Scientific Coordination and Biostatistics, Antwerp University Hospital, Edegem
| | - Johan A Verbraecken
- Department of Pneumology, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Wilfried A De Backer
- Department of Pneumology, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Paul H Van de Heyning
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Olivier M Vanderveken
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
33
|
Verbruggen AER, Dieltjens M, Wouters K, De Volder I, Van de Heyning PH, Braem MJ, Vanderveken OM. Prevalence of residual excessive sleepiness during effective oral appliance therapy for sleep-disordered breathing. Sleep Med 2013; 15:269-72. [PMID: 24424099 DOI: 10.1016/j.sleep.2013.11.781] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 10/04/2013] [Accepted: 11/01/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Oral appliance therapy with a mandibular advancement device (OAm) can yield to complete therapeutic response (apnea-hypopnea index [AHI]<5 events/h), though some patients show little or no improvement in daytime sleepiness. The prevalence of residual excessive sleepiness (RES) despite effective treatment with OAm therapy is unknown. We aimed to determine the prevalence of RES in patients treated with a titratable custom-made duobloc OAm. METHODS A prevalence study was performed, collecting data from 185 patients with an established diagnosis of sleep-disordered breathing (SDB) under OAm therapy with a titratable custom-made duobloc device (baseline data were male:female ratio, 129:56; age, 48±9 years; body mass index [BMI], 27±4 kg/m2; Epworth Sleepiness Scale [ESS] score, 10±5; and AHI, 19±12 events/h). A full-night polysomnography was performed at baseline and after 3 months of OAm therapy. Daytime sleepiness was assessed using the ESS with RES defined as an ESS score of 11 or higher out of 24, despite complete therapeutic response. RESULTS Out of 185 patients, 84 patients (45%) showed a complete therapeutic response with an AHI of <5 events per hour after 3 months of OAm therapy. Despite this normalization of AHI, 27 out of these 84 patients (32%) showed RES and had a significantly higher baseline ESS (15±4 vs. 9±4; P<.001) and were younger (43±9 vs. 47±9; P=.028) compared to patients without RES. CONCLUSION RES under OAm therapy showed a prevalence of up to 32% in SDB patients effectively treated with respect to AHI. Patients with RES were younger and had higher baseline daytime sleepiness.
Collapse
Affiliation(s)
- A E R Verbruggen
- ENT Department and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - M Dieltjens
- ENT Department and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Department of Special Care Dentistry, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - K Wouters
- Scientific Coordination and Biostatistics, Antwerp University Hospital, Antwerp, Belgium
| | - I De Volder
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium; Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
| | - P H Van de Heyning
- ENT Department and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - M J Braem
- Department of Special Care Dentistry, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - O M Vanderveken
- ENT Department and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
34
|
Evaluation of the impact of a clinical pathway on the organization of a multidisciplinary dental sleep clinic. Sleep Breath 2013; 18:325-34. [PMID: 23999833 DOI: 10.1007/s11325-013-0888-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 07/16/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Clinical pathways are used to organize complex care processes by providing structure and standardization. The multidisciplinary approach of oral appliance (OA) therapy for sleep-disordered breathing (SDB) is a complex and dynamic process suitable for such a structured pathway approach. METHODS A clinical pathway for patients referred for OA therapy was developed and implemented. The aim of this study was to evaluate the impact of this clinical pathway on the time to delivery of the OA and the organization of the multidisciplinary dental sleep clinic (MDSC). The latter was achieved using the care process self-evaluation tool (CPSET). RESULTS First, development and implementation of the clinical pathway gave structure and shortened the mean time to delivery by 102 days (240 ± 70 vs. 138 ± 33 days) (Mann-Whitney U: P < 0.001). Second, the CPSET scores were obtained in a cohort of 49 healthcare professionals involved in the pathway. Overall, patient-focused organization received the highest scores (80.5 ± 9.0%), whereas cooperation with primary care received the lowest score (66.7 ± 12.4%). CONCLUSIONS This is the first project on clinical pathways in OA therapy for SDB. The implementation of the pathway in our MDSC has created a significant shortening of the time to delivery. A first evaluation of the clinical pathway using the CPSET scores indicates that all disciplines involved should be thoroughly informed in an ongoing approach.
Collapse
|
35
|
Furuhashi A, Yamada S, Shiomi T, Sasanabe R, Aoki Y, Yamada Y, Kazaoka Y. Effective three-dimensional evaluation analysis of upper airway form during oral appliance therapy in patients with obstructive sleep apnoea. J Oral Rehabil 2013; 40:582-9. [DOI: 10.1111/joor.12059] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2013] [Indexed: 11/27/2022]
Affiliation(s)
- A. Furuhashi
- Department of Oral and Maxillofacial Surgery; Aichi Medical University; Nagakute Japan
| | - S. Yamada
- Department of Oral and Maxillofacial Surgery; Aichi Medical University; Nagakute Japan
| | - T. Shiomi
- Sleep Disorders Center; Aichi Medical University Hospital; Nagakute Japan
| | - R. Sasanabe
- Sleep Disorders Center; Aichi Medical University Hospital; Nagakute Japan
| | - Y. Aoki
- Department of Oral and Maxillofacial Surgery; Aichi Medical University; Nagakute Japan
| | - Y. Yamada
- Department of Oral and Maxillofacial Surgery; Aichi Medical University; Nagakute Japan
| | - Y. Kazaoka
- Department of Oral and Maxillofacial Surgery; Aichi Medical University; Nagakute Japan
| |
Collapse
|
36
|
Vroegop AVMT, Vanderveken OM, Dieltjens M, Wouters K, Saldien V, Braem MJ, Van de Heyning PH. Sleep endoscopy with simulation bite for prediction of oral appliance treatment outcome. J Sleep Res 2012. [PMID: 23205856 DOI: 10.1111/jsr.12008] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of this study was to assess the value of drug-induced sleep endoscopy (DISE) using a custom-made simulation bite in maximal comfortable protrusion (MCP) of the mandible, in the prediction of treatment outcome for obstructive sleep apnea (OSA) with a mandibular advancement device (MAD). Two hundred patients (74% male; age 46 ± 9 years; apnea-hypopnea index [AHI] 19 ± 13 h(-1) sleep; body mass index [BMI] 27 ± 4 kg m(-2) ) with sleep-disordered breathing underwent DISE with a simulation bite in MCP. One hundred and thirty-five patients with an established diagnosis of OSA commenced MAD treatment. The associations between the findings during DISE with simulation bite and treatment outcome were evaluated. Treatment response was defined as a reduction in AHI following MAD treatment of ≥ 50% compared to baseline. Overall MAD treatment response in the studied population was 69%. The results of this study demonstrated a statistically significant association between a positive effect of the simulation bite on the upper airway patency during DISE and treatment response with MAD (P < 0.01). The results of this study suggest that the use of a simulation bite in maximal comfortable protrusion (MCP) of the mandible, as used during DISE in patients with OSA, tends to be effective in predicting treatment response of MAD treatment.
Collapse
Affiliation(s)
- Anneclaire V M T Vroegop
- Departments of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Wilrijkstraat 10, Antwerp, Belgium.
| | | | | | | | | | | | | |
Collapse
|
37
|
Dieltjens M, Vanderveken OM, Van den Bosch D, Wouters K, Denollet J, Verbraecken JA, Van de Heyning PH, Braem MJ. Impact of type D personality on adherence to oral appliance therapy for sleep-disordered breathing. Sleep Breath 2012; 17:985-91. [PMID: 23149877 DOI: 10.1007/s11325-012-0788-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 10/30/2012] [Accepted: 11/02/2012] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- M Dieltjens
- Department of Special Care Dentistry, Antwerp University Hospital, Edegem, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, Van de Heyning PH, Braem MJ. Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax 2012; 68:91-6. [PMID: 22993169 PMCID: PMC3534260 DOI: 10.1136/thoraxjnl-2012-201900] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Oral appliance (OA) therapy is increasingly prescribed as a non-continuous positive airway pressure treatment modality for sleep-disordered breathing (SDB). Although OA therapy is reported to be efficacious for the treatment of SDB, data on compliance remain limited to self-report. Methods In this 3-month prospective clinical trial, the main outcome was to assess the safety and feasibility of an objective measurement of compliance during OA therapy using an embedded microsensor thermometer with on-chip integrated readout electronics in 51 consecutive patients with an established diagnosis of SDB (AHI 18.0±11.9/h; age 47±10 y; BMI 26.6±4.0 kg/m2; men/women: 31/20). Patients were unaware of the purpose of the study. Results No microsensor-related adverse events were recorded. In addition, no problems were encountered during the readout of the compliance data. Out of 51 microsensors, one had a technical defect and was lost to follow-up. In this study, the overall objective mean rate of OA use was 6.6±1.3 h per day with a regular OA users’ rate of 82% at the 3-month follow-up. Statistical analysis revealed no significant differences between objective and self-reported OA compliance data in this study. Measurement of the objective OA compliance allowed us to calculate the mean disease alleviation (MDA) as the product of objective compliance and therapeutic efficacy. MDA serves as a measure of the overall therapeutic effectiveness, and turned out to be 51.1%. Conclusions The results illustrate the safety and feasibility of objective measurement of OA compliance. The objective measurement of OA compliance allows for calculation of the MDA.
Collapse
Affiliation(s)
- Olivier M Vanderveken
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.
| | | | | | | | | | | |
Collapse
|