Health-related quality of life in patients with sleep-disordered breathing: effect of mandibular advancement appliances

Impact of oral appliance therapy on quality of life (QoL) in patients with obstructive sleep apnea - a systematic review and meta-analysis

PURPOSE

Treatment of patients with obstructive sleep apnea (OSA) using mandibular advancement appliances enhances the airway and may be an alternative to continuous positive airway pressure (CPAP) in individuals with reduced adherence to CPAP therapy. The effectiveness as well as improved patient compliance associated with these appliances may improve the quality of life in patients with OSA. The aim of this systematic review of studies was to determine the improvement in quality of life amongst patients with OSA who were treated with an oral appliance.

METHODS

The research study was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42021193386). A search was carried out using the search engines Google Scholar, PubMed, Ovid, Cochrane Trial Registry, and LILACS. Patients with OSA treated with oral appliance therapy to advance the mandible were studied. Twenty-five studies were identified through the literature search and all had varying control groups for assessment of quality of life. Seventeen studies were included for the quantitative synthesis.

RESULTS

QoL, evaluated by the Functional Outcomes of Sleep Questionnaire (FOSQ), significantly improved in patients treated with oral appliance therapy. There was a mean difference of 1.8 points between the baseline scores and the scores following treatment with an oral appliance.

CONCLUSION

Overall, a significant improvement in the QoL was observed with the Functional Outcomes of Sleep Questionnaire, following oral appliance therapy.

A pilot study to compare patient perception of obstructive sleep apnea treatment with CPAP or appliance therapy

STATEMENT OF PROBLEM

The continuous positive airway pressure (CPAP) device yields optimum results in treating mild to moderate obstructive sleep apnea (OSA). However it may be bulky, noisy, and difficult to sleep with for the patient. Mandibular advancement devices (MAD) have shown better compliance but at the expense of lesser efficiency.

PURPOSE

The purpose of this study was to evaluate the patient's posttreatment subjective perception of the effectiveness of 2 common treatments of OSA.

MATERIAL AND METHODS

Thirty-two patients diagnosed with OSA filled out the Epworth Sleepiness Scale and Berlin Sleep Quality Questionnaire before treatment and again at 4 to 6 weeks after treatment. Two groups were formed (n=16 each); one group was treated with MAD and the other with CPAP. The data obtained were recorded and compared with the Mann Whitney U test (between groups) and the Wilcoxon signed rank test (within groups) (α=.05).

RESULTS

The analysis showed that the participants perceived significant posttreatment improvement (P<.05) for all variables of the Berlin Sleep Quality Questionnaire and the Epworth Sleepiness Scale for both the MAD and CPAP groups.

CONCLUSIONS

According to the questionnaires, participants perceived significant improvement in OSA symptoms after treatment in both the MAD and CPAP groups. The study was inconclusive as to whether improvement of perceived symptoms was higher with MAD or CPAP.

Mandibular advancement device and CPAP upon cardiovascular parameters in OSA

PURPOSE

This study aims to compare the effects of a mandibular advancement device (MAD) with continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA) on blood pressure (BP), oxidative stress, and heart rate variability (HRV) in a randomized, crossed-over, single-blind, and controlled trial.

METHODS

Twenty-nine moderate-to-severe adult OSA patients underwent MAD, CPAP, and placebo oral appliance treatment. Polysomnography, Epworth sleepiness scale, 24-h ambulatory BP monitoring, oxidative stress parameters (malondialdehyde, catalase, superoxide dismutase, vitamins C, E, B6, B12, folate, homocysteine, uric acid), and HRV were assessed at baseline and after 1 month of each treatment. Diaries were used to evaluate compliance for devices and a pressure-time meter for CPAP.

RESULTS

Both active treatments resulted in decreases in apnea and hypopnea index and Epworth sleepiness scale; CPAP showed a greater effect. Frequency of diastolic BP dipping was higher in the MAD group compared with the CPAP group. A significant drop from baseline levels for catalase activity was observed after MAD. For HRV, there was a significant decrease in total power at night with CPAP and MAD compared with POA, and a decrease in index of sleep autonomic variation with MAD compared with baseline levels. Compliance rates were higher with MAD rather than CPAP.

CONCLUSIONS

Even though CPAP proved to be more effective at attenuating OSA, better compliance with MAD favored the reduction of one of the enzymes which participates in oxidative stress and better autonomic modulation during sleep.

Efficacy and compliance in treatment of sleep apnea with Herbst mandibular advancement splints (OHA version)

The benefits of the Herbst thermoformed advancement splint in the treatment of obstructive breathing disorders during sleep have been assessed in numerous studies. Unfortunately, like all other mandibular advancement devices, patients fail to wear it regularly in the long-term. Injuries, discomfort or pain caused by errors in manufacture or adjustment are generally blamed for this. After a critical review of the literature, some solutions are proposed to improve production of the orthesis and patient management.

Subjective efficacy of oral appliance design features in the management of obstructive sleep apnea: a systematic review

INTRODUCTION

The purpose of this study was to review available evidence on the efficacy of various oral appliances on subjectively perceived symptoms of obstructive sleep apnea syndrome.

METHODS

A search of 4 databases was carried out. Articles were initially selected based on their titles or abstracts. Full articles were then retrieved and further scrutinized according to predetermined criteria. Reference lists of selected articles were searched for any missed publications. The finally selected articles were methodologically evaluated.

RESULTS

Of an initial 1475 references, 14 studies were randomized controlled trials, which formed the basis of this review. Mandibular advancement devices (MADs) were compared with either inactive appliances (6 studies) or MADs with different design features (8 studies). In comparison with inactive appliances, the majority of studies showed improved subjective outcomes with MADs, suggesting that mandibular advancement is a crucial design feature of oral appliance therapy for obstructive sleep apnea syndrome.

CONCLUSIONS

There is no 1 MAD design that most effectively influences subjectively perceived treatment efficacy, but efficacy depends on many factors including materials and method used for fabrication, type of MAD (monoblock or Twin-block), and the degree of protrusion (sagittal and vertical). This review highlights the absence of universally agreed subjective assessment tools and health-related quality of life outcomes in the literature today. Future trials of MAD designs need to assess subjective efficacy with agreed standardized tools and health-related quality of life measures to guide clinical practicitioners about which design might be most effective in the treatment of obstructive sleep apnea syndrome with oral appliances.

Randomised cross-over study of oral appliances for snoring

OBJECTIVES

To compare a mandibular advancement splint to a control bite raising appliance in the treatment of snoring with or without mild obstructive sleep apnoea syndrome.

DESIGN

A prospective two-treatment randomised cross-over clinical trial.

SETTING

Single centre secondary care Dental Hospital.

PARTICIPANTS

Fifty-two subjects (36 men, 16 women) diagnosed with non-apnoeic snoring or mild obstructive sleep apnoea syndrome (apnoea/hypopnoea index < or =15 events/h), were recruited from Departments of Respiratory Medicine and ENT surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust.

MAIN OUTCOME MEASURES

The Snoring Symptoms Inventory questionnaire (SSI) and the Epworth Sleepiness Score (ESS) were used to evaluate changes in symptoms. Patient reported outcomes (compliance, adverse events, splint preference) were recorded by questionnaire. Subjects attended for five study visits and used a mandibular advancement splint and a bite raising appliance at home each for 4 weeks, with a 3-week washout period between devices.

RESULTS AND CONCLUSIONS

Thirty-eight subjects completed the study. Both the mandibular advancement splint and bite raising appliance significantly reduced the SSI compared to the baseline scores: mandibular advancement splint 5.5, P = 0.013; bite raising appliance 3.1, P = 0.005. No statistically significant difference between the two treatment periods was detected (P > 0.05). The reduction in the Epworth Sleepiness Score was: mandibular advancement splint 1.0, P = 0.02; bite raising appliance 0.3, P = 0.4. The change in the Epworth Sleepiness Score was not statistically significantly different between the mandibular advancement splint and bite raising appliance treatment periods (P > 0.05).

CONCLUSIONS

In this cohort of patients diagnosed with snoring +/- mild OSA: 1 both the mandibular advancement splint and bite raising appliance designs of splint appeared to reduce the symptoms of snoring; 2 no difference in the magnitude of this effect was detected in favour of one design of splint.