Obstructive sleep apnoea: patients' experiences of oral appliance treatment

Mandibular device treatment in obstructive sleep apnea -A structured therapy adjustment considering night-to-night variability night-to-night variability in mandibular devices

BACKGROUND

Mandibular advancement devices (MAD) are a well-established treatment option for obstructive sleep apnea (OSA). MAD are considered preferably for patients with mild to moderate OSA presenting with a elevated night-to-night variability (NNV). This study aimed to determine the treatment effect of MAD on NNV considering different protrusion distances and patient related outcome (PRO).

METHODS

We conducted a prospective cohort analysis of patients before MAD with 60% and 80% of the maximum protrusion. OSA severity was assessed using a home-sleep test for two consecutive nights. PRO contained the Epworth Sleepiness Scale (ESS) and sleep related quality of life (FOSQ).

RESULTS

Twenty patients with a median overweight body-mass-index of 27.1 (interquartile range (IQR) 16.3 kg/m²), with a mainly mild to moderate OSA with an apnea -hypopnea index (AHI) of 18.3 / h (IQR 17.7) and elevated ESS of 12.5 (IQR 8.0) were included. As opposed to 80%, 60% protrusion significantly but not 80% relevantly reduced AHI (60%%: 11.2 (IQR 5.5)/h, p = 0.01; 80%: 12.9 (IQR18,0)/h, p = 0.32) and improved the ESS (60%: 8.0 (IQR 10,0); 80%: 10 (IQR 9.0)), with therapy settings. No correlation could be detected between NNV and ESS, and FOSQ changes. Higher baseline NNV was associated with severe OSA (p = 0.02) but not with gender, overweight, or status post-tonsillectomy.

CONCLUSIONS

OSA improvement is associated with lower NNV; both OSA and NNV are connected to the degree of protrusion. Therefore, higher NNV does not justify the exclusion of candidates for MAD treatment. PRO changes are not visibly affected by NNV but by general OSA changes. These findings may help to define and optimize future study designs for the primary outcome decision between objective OSA parameters and PRO.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CITATION

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

PATIENT-REPORTED OUTCOMES WHILE MANAGING OBSTRUCTIVE SLEEP APNEA WITH ORAL APPLIANCES: A SCOPING REVIEW

OBJECTIVE

This scoping review aims to describe dental treatment-related patient-reported outcomes (dPROs) while using oral appliances (OAs) to manage obstructive sleep apnea (OSA) in children and adults.

METHODS

Available literature that assessed dPROs in children and adults with OSA managed through OAs. Any clinical studies were included without restrictions of year or country. The results were analyzed and reported using narrative text and tables accompanying a descriptive summary.

RESULTS

The searches identified 1718 citations, and of these, forty-five studies were finally included. A total of 3498 adults were included in all 42 primary studies included in this review, in which all the studies presented adults as participants. The dPROs assessed were quality of life (QoL), reported side effects after OA usage, patient satisfaction, and experience with treatment, and subjective perception of occlusal changes after treatment.

CONCLUSION

This scoping review suggests that dPROs are mostly investigated as a secondary outcome from major studies exploring the effects of OAs on OSA severity, and often, dPROs are not well discussed or displayed on their report. As no risk of bias or certainty level assessment was completed, findings need to be carefully considered. Although in general terms management with OAs among adults with OSA does not seem to be uncomfortable or causing major problems to their lives, some mild discomfort and endured occlusal disturbances was reported in some studies. QoL seems to improve but consistent agreement was elusive. Data does not include experiences among those that dropped OA use. No data seems to exist about dPROs in children.

Oral health problems linked to obstructive sleep apnea are not always recognized within dental care-As described by dental professionals

Objectives

Obstructive sleep apnea (OSA) has an impact on an individual's quality of life and general health, and can also affect their oral health. The patient's experiences, together with intraoral signs and symptoms could indicate the presence of OSA. Knowledge that the patient has, or is at high risk for having OSA can help the dental healthcare provider maintain the oral health and general health for these patients. The purpose was to explore dentists and dental hygienists' experiences when encountering adult patients with potential, untreated and treated OSA.

Methods

A qualitative inductive approach was used. Experienced dentists and dental hygienists working within Swedish Public Dental Service were strategically selected. Semi‐structured face‐to‐face interviews were performed followed by qualitative content analysis.

Results

Interviews from 13 participants, seven dental hygienist and six dentists, led to three areas describing varied experience: Importance of the patient encounter and identifying intraoral signs both of which describe experiences related to the importance of the initial unstructured conversation and focused clinical assessments, and strategies for nurturing care which point to interest about care, treatment, and collaborations with medical health care providers.

Conclusions

Dental professionals are not able to consistently recognize patients who have, or are at high risk for OSA. During the patient encounter, is it important to determine if a patient is at risk for, or has oral signs of OSA.

Partner perceptions are associated with objective sensor-measured adherence to oral appliance therapy in obstructive sleep apnea

The aims of the present prospective clinical study were to determine objective, sensor-measured adherence to a mandibular advancement device (MAD) in patients with obstructive sleep apnea (OSA) and to identify partner-specific adherence-related factors. A total of 77 eligible participants with mild, moderate, or severe OSA and who were non-adherent to continuous positive airway pressure (mean age 56.2 years) participated in the study (32.5% women). The mean (range) observation time between MAD delivery and final follow-up was 8.3 (3.4-16.5) months. The mean apnea-hypopnea index (AHI) was 26.6 events/hr at baseline and 12.5 events/hr at the 8-month follow-up (both p < 0.001). The mean sensor-measured adherence at the 8-month follow-up was 60.1% for ≥4 hr/night of appliance use for ≥5 days/week. Average usage was 6.4 hr/night, when worn. The mean reduction in the AHI was significantly greater in the "good adherence" (Δ 17.4) than the "poor adherence" group (Δ11.0; p < 0.05). From the partner's perspective, the appliance had a positive effect on sharing a bedroom in the good- (55%) compared to the poor-adherence group (25%; p < 0.05) and on their relationship (51.7% versus 17.9%, respectively; p < 0.05). Regression analyses identified the partner's snoring and apneas to be the most significant factor predicting good adherence to MAD (odds ratio 4.4, 95% confidence interval 1.4-14.0). In conclusion, social factors, like partner perceptions, were positively associated with adherence, which indicate that partner's attitudes and support may be a resource that can be utilised to improve adherence in oral appliance treatment of OSA.

[Oral appliances for obstructive sleep apnoea: What can we expect?]

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.

Oral appliance therapy in obstructive sleep apnea: Long-term adherence and patients experiences

BACKGROUND

Despite the advances in the treatment of obstructive sleep apnea (OSA) with mandibular advancement appliances (MAA), their effectiveness is dependent on the patients compliance. Our aims were to evaluate the long-term adherence to MAA therapy and patients experiences of the treatment in OSA.

MATERIAL AND METHODS

Sixty-nine patients (52 males, 17 females; Mean age: 54.4±10.8 years) were included in the study. The subjects were mild (56%) and moderate (44%) OSA patients who had been treated using MAA at least 4 years prior to the study. A phone survey was used to determine the demographic characteristics of the patients, as well as to assess self-reported adherence to therapy, subjective long-term effectiveness, and patient experiences with the appliance. Descriptive statistics, Pearson Chi-square test, and independent samples t-test were used for data analysis.

RESULTS

Only 22 (32%) patients reported using the appliance regularly. Most of the non-adherent patients had stopped using their appliances in the first year (55%). The mean duration of appliance use was 33.5 months (Median: 12 months). No significant differences in appliance type, OSA severity, educational level, gender, marital status, income status, employment status or place of residence existed between adherent and non-adherent subjects. Adherent subjects were significantly younger than non-adherent subjects (Age: 50.6 ± 11.9 versus 56.1 ± 9.9, p < 0.05). The most common reasons reported by patients were inability to adapt to the appliance (62%) and pain in the temporomandibular joint (38%). The most common factors associated with continued usage were effectiveness (100%) and ease of use (64%).

CONCLUSIONS

The overall long-term nonadherence to MAA therapy in mild-to moderate OSA patients was high suggesting that barriers to MAA therapy adherence should be prevented to increase the efficiency of oral appliance treatment in OSA and achieve better outcomes for this disease.