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Lo Giudice A, La Rosa S, Ronsivalle V, Isola G, Cicciù M, Alessandri-Bonetti G, Leonardi R. Indications for Dental Specialists for Treating Obstructive Sleep Apnea with Mandibular Advancement Devices: A Narrative Review. Int J Dent 2024; 2024:1007237. [PMID: 38585252 PMCID: PMC10999292 DOI: 10.1155/2024/1007237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/09/2024] Open
Abstract
Obstructive sleep apnea (OSA) syndrome is characterized by repeated airway collapse during sleep. It determines cardiovascular, pulmonary, and neurocognitive consequences and is associated with several daytime and nighttime symptoms that influence the patient's quality of life. The contribution of the dental specialist in the clinical management of OSA patients entails participating in the screening process as diagnostic sentinels and providing adequate treatment using mandibular advancement devices (MADs). Since the treatment of OSA requires a multidisciplinary approach, including different medical specialists, dentists should have a comprehensive understanding of medical and dental factors that influence the strategy and effectiveness of OSA treatment with MAD. Such expertise is crucial in determining the appropriate treatment indications and helps clinicians establish a consolidated position within the multidisciplinary OSA team. In this regard, this review summarizes the evidence of the clinical indications for MAD treatment and provides the dental specialist with helpful information about medical, functional, and other relevant factors that should be considered during diagnosis, treatment plan, and follow-up stages. Information retrieved was organized and discussed, generating specific domains/queries oriented to the clinical management of OSA patients from the clinical perspective of dental specialists.
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Affiliation(s)
- Antonino Lo Giudice
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthodontics, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Salvatore La Rosa
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthodontics, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Vincenzo Ronsivalle
- Department of General Surgery and Medical-Surgical Specialties, Section of Oral Surgery, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Gaetano Isola
- Department of General Surgery and Medical-Surgical Specialties, Section of Periodontology, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Marco Cicciù
- Department of General Surgery and Medical-Surgical Specialties, Section of Oral Surgery, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
| | - Giulio Alessandri-Bonetti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Section of Orthodontics, University of Bologna, Bologna, Italy
| | - Rosalia Leonardi
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthodontics, Policlinico Universitario “Gaspare Rodolico—San Marco”, University of Catania, Via Santa Sofia 78, Catania 95123, Italy
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van der Hoek LH, Rosenmöller BRAM, van de Rijt LJM, de Vries R, Aarab G, Lobbezoo F. Factors associated with treatment adherence to mandibular advancement devices: a scoping review. Sleep Breath 2023; 27:2527-2544. [PMID: 37386300 PMCID: PMC10656313 DOI: 10.1007/s11325-023-02862-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is frequently treated with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs). For various reasons, both treatment options are often affected by low adherence. While factors associated with low CPAP adherence are described in the literature extensively, less is known about adherence to MAD therapy. This scoping review aimed to synthesize the body of literature on the factors associated with adherence to MAD treatment. METHODS A systematic literature search was conducted using bibliographic databases PubMed, Embase.com , Web of Science, and the Cochrane Library (Wiley) to identify relevant studies that described factors associated with adherence to MAD in the treatment of OSA or snoring combined with OSA in adults. RESULTS The literature search yielded a total of 694 references. Forty studies were found eligible for inclusion. The literature showed that factors with a possible negative influence on the adherence to MAD treatment are personality aspects; failing effectiveness of MAD; side effects during MAD therapy; using a thermoplastic MAD; dental treatments during MAD therapy; and a poor first experience with the MAD with inadequate guidance by professionals. Factors that may have a positive effect on MAD adherence include effectiveness of therapy, custom-made MAD, good communication skills of the practitioner, early recognition of side effects, stepwise titration of the MAD, and positive first experience with MAD. CONCLUSIONS The knowledge of factors associated with MAD adherence can be used to provide further insight into individual adherence to OSA treatments.
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Affiliation(s)
- Liselotte H van der Hoek
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Boudewijn R A M Rosenmöller
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Liza J M van de Rijt
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ghizlane Aarab
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Beri A, Pisulkar SG, Dubey SA, Sathe S, Bansod A, Shrivastava A. Appliances Therapy in Obstructive Sleep Apnoea: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e48280. [PMID: 38058324 PMCID: PMC10695854 DOI: 10.7759/cureus.48280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/04/2023] [Indexed: 12/08/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a recurrent partial or complete obstruction of the upper airway during sleep caused by narrowing or collapse of the pharyngeal wall. It leads to microstimulation and oxyhemoglobin desaturation, resulting in sleepiness and loud snoring. OSA negatively affects the cardiovascular system and may contribute to neurocognitive impairment. The aim of this systematic review is to evaluate the effectiveness and efficacy of appliance therapy in obstructive sleep apnea. The effectiveness was assessed by using the Apnea Hypopnea Index (AHI). An electronic search of the Cochrane Library, PubMed, and Google Scholar was conducted between 1998 and 2021. Articles were independently assessed by three reviewers. The quality of a randomised control trial (RCT) is assessed using the Cochrane risk of bias method. The tool GRADE was used to achieve the desired level of confidence for each outcome reported. Several studies used continuous positive airway pressure (CPAP), mandibular advancement devices (MAD), and tongue retention devices (TRD). The meta-analysis included a total of six papers that met the inclusion criteria. Results showed that CPAP significantly improved AHI compared with an oral appliance (random effects: difference in means = 8.40, 95% CI = 7.21 to 9.60). It was also found that oral appliance (OA) therapy significantly improved AHI compared with baseline before appliance therapy (random effects: mean difference = 13.40, 95% CI = 10.87 to 15.93; p.00001). For mild to moderate OSA, CPAP is considered the gold standard. Our meta-analysis of six RCTs found favorable evidence for OSA patients receiving oral devices; however, they were less effective than CPAP. A subgroup analysis found that MAD may be a beneficial treatment for mild to moderate OSA patients who do not respond to CPAP. The findings suggest that oral appliances may be an effective treatment for OSA, especially in patients with mild to moderate OSA.
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Affiliation(s)
- Arushi Beri
- Prosthodontics, Sharad Pawar Dental College and Hospital, Acharya Vinoba Bhave Rural Hospital (AVBRH), Wardha, IND
| | - Sweta G Pisulkar
- Prosthodontics and Crown & Bridge, Sharad Pawar Dental College and Hospital, Wardha, IND
| | - Surekha A Dubey
- Prosthodontics, Sharad Pawar Dental College and Hospital, Wardha, IND
| | - Seema Sathe
- Prosthodontics, Sharad Pawar Dental College and Hospital, Wardha, IND
| | - Akansha Bansod
- Prosthodontics, Sharad Pawar Dental College and Hospital, Wardha, IND
| | - Akshay Shrivastava
- Orthodontics and Dentofacial Orthopaedics, Kalinga Institute of Dental Sciences, Orissa, IND
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4
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Johal A, Hamoda MM, Almeida FR, Marklund M, Tallamraju H. The role of oral appliance therapy in obstructive sleep apnoea. Eur Respir Rev 2023; 32:220257. [PMID: 37343962 DOI: 10.1183/16000617.0257-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2023] [Indexed: 06/23/2023] Open
Abstract
There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the "gold standard" in nonsurgical OSA management, OAT remains the recognised alternative treatment.This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.
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Affiliation(s)
- Ama Johal
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
| | - Mona M Hamoda
- 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
| | - Marie Marklund
- Department of Otontology, Medical Faculty, Umea University, Umea, Sweden
| | - Harishri Tallamraju
- Oral Bioengineering, Institute of Dentistry, Queen Mary, University of London, London, UK
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5
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Levine M, Cantwell M, Postol K, Schwartz D. Comparison of a noncustom vs custom mandibular advancement device to treat obstructive sleep apnea. J Clin Sleep Med 2023; 19:205-206. [PMID: 36148629 PMCID: PMC9806772 DOI: 10.5664/jcsm.10316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Mitchell Levine
- Saint Louis University Center for Advanced Dental Education, St. Louis, Missouri
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Fagundes NCF, Minervini G, Furio Alonso B, Nucci L, Grassia V, d'Apuzzo F, Puigdollers A, Perillo L, Flores-Mir C. PATIENT-REPORTED OUTCOMES WHILE MANAGING OBSTRUCTIVE SLEEP APNEA WITH ORAL APPLIANCES: A SCOPING REVIEW. J Evid Based Dent Pract 2023; 23:101786. [PMID: 36707161 DOI: 10.1016/j.jebdp.2022.101786] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/21/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
| | - Giuseppe Minervini
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Berta Furio Alonso
- Department of Orthodontics and Craniofacial Orthopedics, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ludovica Nucci
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Vincenzo Grassia
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Fabrizia d'Apuzzo
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Andreu Puigdollers
- Department of Orthodontics and Craniofacial Orthopedics, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Letizia Perillo
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlos Flores-Mir
- School of Dentistry, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.
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7
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Bosschieter PF, Uniken Venema JA, Vonk PE, Ravesloot MJ, Hoekema A, Plooij JM, Lobbezoo F, de Vries N. Equal effect of a noncustom vs a custom mandibular advancement device in treatment of obstructive sleep apnea. J Clin Sleep Med 2022; 18:2155-2165. [PMID: 35532113 PMCID: PMC9435323 DOI: 10.5664/jcsm.10058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Numerous types of mandibular advancement devices (MADs) are available to treat patients with obstructive sleep apnea, varying from noncustom to custom devices. Only a limited number of studies have been performed to determine whether a noncustom MAD could be used to predict treatment success of a custom MAD. In this study, we investigated the potential of a new-generation noncustom MAD, by comparing its effectiveness with a custom MAD. We hypothesized that the effectiveness of the devices is similar with regard to both objective (polysomnography) and self-reported (questionnaires, adherence, and patient satisfaction) outcomes. METHODS This was a single-center prospective randomized crossover study including a consecutive series of patients with obstructive sleep apnea. Patients were randomized to start either with the noncustom or custom MAD. Both MADs were applied for 12 weeks, followed by polysomnography with MAD in situ and questionnaires. After the first 12 weeks of follow-up, a washout period of 1 week was applied. Equal effectiveness was defined as no significant differences in both objective and self-reported outcomes between both devices. RESULTS Fifty-eight patients were included; 40 completed the full follow-up. The median apnea-hypopnea index significantly decreased from 16.3 (7.7, 24.8) events/h to 10.7 (5.6, 16.6) events/h with the custom MAD (P = .010) and to 7.8 (2.9, 16.1) events/h with the noncustom MAD (P < .001). Self-reported outcomes significantly improved in both groups. No significant differences were found between both devices. CONCLUSIONS The effectiveness of a noncustom and custom MAD is comparable, which suggests that a noncustom MAD can be used as a selection tool for MAD treatment eligibility to improve MAD treatment outcome. CLINICAL TRIAL REGISTRATION Registry: Netherlands Trial Register; Name: The Use of a Boil and Bite Mandibular Advancement Device vs a Custom Mandibular Advancement Device in Obstructive Sleep Apnea Management; URL: https://www.trialregister.nl/trial/7249; Identifier: NL64738.100.18. CITATION Bosschieter PFN, Uniken Venema JAM, Vonk PE, et al. Equal effect of a noncustom vs a custom mandibular advancement device in treatment of obstructive sleep apnea. J Clin Sleep Med. 2022;18(9):2155-2165.
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Affiliation(s)
- Pien F.N. Bosschieter
- Department of Otorhinolaryngology, Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
| | - Julia A.M. Uniken Venema
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Patty E. Vonk
- Department of Otorhinolaryngology–Head and Neck surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Aarnoud Hoekema
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joanneke M. Plooij
- Department of Oral and Maxillofacial Surgery, OLVG, Amsterdam, The Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Nico de Vries
- Department of Otorhinolaryngology, Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Antwerp, Antwerp, Belgium
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Hoff S, Collop N. A Brief Review of Treatment of Obstructive Sleep Apnea. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mohammadieh AM, Sutherland K, Chan ASL, Cistulli PA. Mandibular Advancement Splint Therapy. Advances in the Diagnosis and Treatment of Sleep Apnea 2022; 1384:373-385. [PMID: 36217096 DOI: 10.1007/978-3-031-06413-5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Mandibular advancement splint (MAS) therapy is the leading alternative to continuous positive airway pressure (CPAP) therapy for the treatment of obstructive sleep apnoea. A MAS is an oral appliance which advances the mandible in relation to the maxilla, thus increasing airway calibre and reducing collapsibility. Although it is less effective than CPAP in reducing the apnoea-hypopnoea index (AHI), it has demonstrated equivalence to CPAP in a number of key neurobehavioural and cardiovascular health outcomes, perhaps due to increased tolerability and patient adherence when compared to CPAP. However, response to MAS is variable, and reliable prediction tools for patients who respond best to MAS therapy have thus far been elusive; this is one of the key clinical barriers to wider uptake of MAS therapy. In addition, the most effective MAS devices are custom-made by a dentist specialising in the treatment of sleep disorders, which may present financial or accessibility barriers for some patients. MAS devices are generally well tolerated but may have side effects including temporomandibular joint (TMJ) dysfunction, hypersalivation, tooth pain and migration as well as occlusal changes. A patient-centred approach to treatment from a multidisciplinary team perspective is recommended. Evidence-based clinical practice points and areas of future research are summarised at the conclusion of the chapter.
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Affiliation(s)
- Anna M Mohammadieh
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia.
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia.
| | - Kate Sutherland
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Andrew S L Chan
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Peter A Cistulli
- Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
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Bortolotti F, Corazza G, Bartolucci ML, Incerti Parenti S, Paganelli C, Alessandri-Bonetti G. Dropout and adherence of obstructive sleep apnoea patients to mandibular advancement device therapy: A systematic review of randomised controlled trials with meta-analysis and meta-regression. J Oral Rehabil 2021; 49:553-572. [PMID: 34865235 DOI: 10.1111/joor.13290] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 11/19/2021] [Accepted: 11/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mandibular advancement devices (MADs) are used as an alternative to continuous positive airways pressure to treat obstructive sleep apnoea (OSA) patients, but to date, specific data on the adherence to MAD therapy are lacking. OBJECTIVES The aim of the present systematic review was to investigate the dropout rate and adherence of OSA patients to different custom-made (CM) and non-custom-made (NCM) MAD therapies. SEARCH METHODS An electronic search was performed in MEDLINE, Cochrane Database of Systematic Reviews, Scopus, LILACS and Web of Science. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing the compliance to customised and not customised MADs in the treatment of adult OSA patients were included. DATA COLLECTION AND ANALYSIS The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in RCT. The dropout rate of each study was computed and the adherence to MAD therapy in terms of hours per night and nights per week was extracted from each study. RESULTS Thirty-two RCTs were included. The risk of bias resulted low in most of the studies. The GRADE scores indicated that the quality of evidence was from very low to moderate. The meta-analyses showed that the mean dropout rate did not significantly differ between CM and NCM MADs: The overall mean dropout rate was 0.171 [0.128-0.213] with a mean follow-up of 4.1 months. The hours per night adherence was significantly higher for CM MADs (6.418 [6.033-6.803]) compared to NCM MADs (5.107 [4.324-5.890]. The meta-regression showed that the dropout rate increases significantly during time (p < .05). CONCLUSIONS There is a very low to moderate quality of evidence that the dropout rate of MAD therapy is similar among CM and NCM MADs, that the dropout rate increases significantly during time and that CM MADs have higher hours per night adherence compared with NCM MAD. REGISTRATION The study protocol was registered on PROSPERO (n. CRD42020199866).
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Affiliation(s)
- Francesco Bortolotti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Giulia Corazza
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
| | - Maria Lavinia Bartolucci
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Serena Incerti Parenti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Corrado Paganelli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
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11
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Venema JAMU, Rosenmöller BRAM, de Vries N, de Lange J, Aarab G, Lobbezoo F, Hoekema A. Mandibular advancement device design: A systematic review on outcomes in obstructive sleep apnea treatment. Sleep Med Rev 2021; 60:101557. [PMID: 34662769 DOI: 10.1016/j.smrv.2021.101557] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/03/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
Obstructive Sleep Apnea (OSA) is often treated with Mandibular Advancement Devices (MADs). It is unclear whether particular design features are superior to others in terms of OSA alleviation. In order to facilitate clinical decision-making, this systematic review summarizes the objective and subjective outcomes of different available MAD designs. Studies comparing different MAD designs in OSA treatment were searched. After screening 1887 titles and abstracts, 20 original RCTs and six cohort studies were included. 14 articles were systematically reviewed in a meta-analysis. The decrease in AHI was significantly different between some of the MAD designs. The clinical relevance of the observed differences was however limited. Monoblock appliances performed more favorable, compared to bilateral thrust (effect size:-0.37; CI:-1.81 to 0.07). Midline traction appliances performed more favorable, compared to other designs. Custom appliances performed more favorable, compared to thermoplastic appliances (effect size:0.86; CI:-0.62 to 2.35). Furthermore, there were no clinically relevant differences between MAD designs in reduction of ESS, compliance, preference, side effects, and cost effectiveness. With respect to the included trials, presently there is not one superior custom MAD design in OSA treatment regarding the effect on AHI reduction, ESS improvement, compliance, preference, side effects, cost effectiveness, and other disease-related outcomes. We confirm custom MAD designs perform superior to thermoplastic MAD designs.
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Affiliation(s)
- Julia A M Uniken Venema
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Boudewijn R A M Rosenmöller
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nico de Vries
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Otorhinolaryngology, Ear Nose and Throat, Onze Lieve Vrouwen Gasthuis (OLVG), Amsterdam, the Netherlands; Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Jan de Lange
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ghizlane Aarab
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Aarnoud Hoekema
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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12
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Op de Beeck S, Dieltjens M, Azarbarzin A, Willemen M, Verbraecken J, Braem MJ, Wellman A, Sands SA, Vanderveken OM. Mandibular Advancement Device Treatment Efficacy Is Associated with Polysomnographic Endotypes. Ann Am Thorac Soc 2021; 18:511-8. [PMID: 32946702 DOI: 10.1513/AnnalsATS.202003-220OC] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [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).
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Tallamraju H, Newton JT, Fleming PS, Johal A. Factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med 2021; 17:1485-1498. [PMID: 33660611 DOI: 10.5664/jcsm.9184] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
STUDY OBJECTIVES The review aimed to identify the factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea. METHODS The protocol was initially registered with the International Register of Systematic Reviews (Prospero: CRD42019122615) prior to undertaking a comprehensive electronic search of databases and references without language and date restrictions. Quality assessment was undertaken using the Cochrane Collaboration's risk of bias tool and Quality in Prognosis Studies (QUIPS) tool. RESULTS Studies exhibited low or unclear risk of bias for the domains assessed by the respective quality assessment tools. The influence of independent variables such as disease characteristics, patient characteristics, appliance features, and psychological and social factors on adherence levels was also assessed. There was a total of 31 included studies, which consisted of 8 randomized controlled trials, 2 controlled clinical trial, 7 prospective cohorts, 11 retrospective cohorts, and the remaining 3 studies were a case-series, case-control, and a mixed-methods. All 31 included studies were subject to qualitative analysis, with only 4 studies included in the quantitative analysis. Results of the meta-analysis demonstrated increased adherence with custom-made appliances, with a pooled mean difference of -1.34 (-2.02 to -0.66) and low levels of heterogeneity (I² = 0%). CONCLUSIONS A weak relationship was observed between objective adherence and patient and disease characteristics, such as age, sex, obesity, apnea-hypopnea index, and daytime sleepiness, to oral appliance therapy. Nonadherent patients reported more side effects with oral appliance therapy than users and tended to discontinue the treatment within the first 3 months. Custom-made oral appliances were preferred and increased adherence reported in comparison to ready-made appliances. Further research is imperative to examine the relationship between psychosocial factors and adherence to oral appliance therapy.
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Affiliation(s)
- Harishri Tallamraju
- Department of Oral Bioengineering, Institute of Dentistry, Queen Mary University of London, London, United Kingdom
| | - J Tim Newton
- Department of Population and Patient Health, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, United Kingdom
| | - Padhraig S Fleming
- Department of Oral Bioengineering, Institute of Dentistry, Queen Mary University of London, London, United Kingdom
| | - Ama Johal
- Department of Oral Bioengineering, Institute of Dentistry, Queen Mary University of London, London, United Kingdom
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14
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Abstract
Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.
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15
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Aziz R, Somaiah S, Kalha AS, Reddy G, Muddaiah S, Shetty B. Comparative assessment of changes in pharyngeal airway space in cases of obstructive sleep apnoea with a customized mandibular repositioning appliance - a clinical study. Sleep Sci 2021; 14:16-24. [PMID: 34917269 PMCID: PMC8663729 DOI: 10.5935/1984-0063.20200072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 11/11/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives The present study aims at evaluating the effects of a customized mandibular repositioning appliance on the pharyngeal airway, nocturnal sleep patterns, daytime discomfort and occlusal changes in established cases of adult obstructive sleep apnoea. Material and Methods Ten consecutive patients with a complaint of snoring and disturbed sleep were included in the study. The primary diagnosis was established by the Epworth sleepiness scale, clinical examination, history and subsequently the diagnosis was substantiated through assessment of the pharyngeal airway space on a lateral cephalogram and polysomnography. A customized mandibular repositioning appliance was used to advance the mandible sequentially every 6 months, using 4 sets of the appliance. Pre and post-treatment evaluations were performed to establish, effects and changes in the outcome of obstructive sleep apnoea. Results The study revealed significant increase in the mean pharyngeal widths of upper airway and velum dimension with antero-superior repositioning of hyoid bone. Epworth sleepiness scale score improved significantly from baseline with clinically evident change in daytime discomforts. Significant decline in the mean apnoea/hypopnea index, oxygen desaturation index, respiratory disturbance index, heart rate, snoring and a significant increase in mean oxygen saturation of arterial blood was observed. No evident change noticed in occlusion except lower incisor inclination. Conclusion The customized mandibular repositioning appliances are effective in the management of adult obstructive sleep apnoea with a significant improvement observed in the airway patency and polysomnography parameters with clinically non-significant effects on dental occlusion..
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Affiliation(s)
- Rezeen Aziz
- Coorg Institute of Dental Sciences, Orthodontics and Dentofacial Orthopedics - Virajpet - Karnataka - India
| | - Sanju Somaiah
- Coorg Institute of Dental Sciences, Orthodontics and Dentofacial Orthopedics - Virajpet - Karnataka - India
| | - Anmol S Kalha
- Coorg Institute of Dental Sciences, Orthodontics and Dentofacial Orthopedics - Virajpet - Karnataka - India
| | - Goutham Reddy
- Coorg Institute of Dental Sciences, Orthodontics and Dentofacial Orthopedics - Virajpet - Karnataka - India
| | - Sunil Muddaiah
- Coorg Institute of Dental Sciences, Orthodontics and Dentofacial Orthopedics - Virajpet - Karnataka - India
| | - Balakrishna Shetty
- Coorg Institute of Dental Sciences, Orthodontics and Dentofacial Orthopedics - Virajpet - Karnataka - India
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16
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Abstract
Obstructive sleep apnea (OSA) is a prevalent condition causing unrefreshing sleep and excessive daytime sleepiness. It has individual socioeconomic impacts and, through association with increased risk of road traffic accidents, diabetes, and cardiovascular disease, OSA is a public health issue. Continuous positive airway pressure (CPAP) is the first-line treatment for moderate-to-severe OSA. It is effective in improving excessive daytime sleepiness and quality of life. There is also evidence that CPAP therapy has cardiovascular benefits although nature and extent remain uncertain. Despite its benefits, a significant proportion of patients are unable to tolerate CPAP. There are also patients with mild but symptomatic disease, for whom CPAP is usually not available or appropriate, so there is a need for other treatment options. Mandibular advancement devices (MADs) offer an effective alternative to CPAP and can improve daytime symptoms and quality of life. There are many devices available, representing a range of complexity and cost. It is challenging to properly evaluate the effectiveness of this ever-evolving range. The more basic MADs are cheaper and more accessible but are less well tolerated. More complex devices are better tolerated and may be more effective. However, they are more expensive and often require dental expertise, so access is more limited. Efforts continue to try to improve accessibility to effective MAD therapy. Alongside increasing awareness, this may be facilitated by developing and refining devices that could be fitted by non-dental clinicians, and potentially by patients themselves. Research efforts need to focus on determining how to efficiently identify patients who are likely to respond to MAD therapy, so as to improve clinical and cost-effectiveness of OSA therapy overall.
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Affiliation(s)
| | - Tim Quinnell
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
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17
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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: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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18
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Bartolucci ML, Bortolotti F, Corazza G, Incerti Parenti S, Paganelli C, Alessandri Bonetti G. Effectiveness of different mandibular advancement device designs in obstructive sleep apnoea therapy: A systematic review of randomised controlled trials with meta-analysis. J Oral Rehabil 2020; 48:469-486. [PMID: 32805753 DOI: 10.1111/joor.13077] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 11/28/2022]
Abstract
Mandibular advancement devices (MADs) are used to treat patients with obstructive sleep apnoea (OSA). To date, there are no data that identify the most effective MAD design for apnoea-hypopnea index (AHI) reduction. The purpose of this systematic review is to investigate the effectiveness of different MAD designs in AHI reduction and oxygen saturation improvement in OSA patients. An electronic search was performed in MEDLINE, Cochrane Database, Scopus, Web of Knowledge and LILACS. Randomised controlled trials (RCTs) investigating the reduction of AHI on adult patients wearing MAD for OSA were included. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in randomised controlled trial. The success rate of each study was computed: [(mean baseline AHI - mean AHI after treatment)/mean baseline AHI]. Fifty RCTs were included. The risk of bias resulted with some concerns in most of the studies. The GRADE scores indicated that the quality of evidence was very low. The meta-analysis showed a success rate with mono-bloc and duo-bloc MADs respectively of 0.821 [0.722-0.887] and 0.547 [0.443-0.637]. The mono-bloc compared with duo-bloc better improved the minimum oxygen saturation (10.048 [7.733-12.363] and 3.357 [2.290-4.423], respectively). There is a very low quality body of evidence that mono-bloc MADs are more effective in reducing AHI and improving minimum oxygen saturation compared with duo-bloc MADs. The study protocol was registered on PROSPERO (n. CRD42019118084).
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Affiliation(s)
- Maria Lavinia Bartolucci
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Francesco Bortolotti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Giulia Corazza
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
| | - Serena Incerti Parenti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Corrado Paganelli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
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Sutherland K, Cistulli PA. Oral Appliance Therapy for Obstructive Sleep Apnoea: State of the Art. J Clin Med 2019; 8:jcm8122121. [PMID: 31810332 PMCID: PMC6947472 DOI: 10.3390/jcm8122121] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/17/2022] Open
Abstract
Obstructive sleep apnoea (OSA) represents a significant global health burden, with impact on cardiometabolic health, chronic disease, productivity loss and accident risk. Oral appliances (OA) are an effective therapy for OSA and work by enlarging and stabilising the pharyngeal airway to prevent breathing obstructions during sleep. Although recommended in clinical guidelines for OSA therapy, they are often considered only as second-line therapy following positive airway pressure (PAP) therapy failure. There has been a long-standing barrier to selecting OA over PAP therapy due to the inability to be certain about the level of efficacy in individual OSA patients. A range of methods to select OSA patients for OA therapy, based on the outcome of a single sleep study night, have been proposed, although none has been widely validated for clinical use. Emergent health outcome data suggest that equivalent apnoea–hypopnea index reduction may not be necessary to produce the same health benefits of PAP. This may be related to the more favourable adherence to OA therapy, which can now be objectively verified. Data on longer term health outcomes are needed, and there are additional opportunities for device improvement and combination therapy approaches. OAs have an important role in precision care of OSA as a chronic disorder through a multi-disciplinary care team. Future studies on real-world health outcomes following OA therapy are needed.
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Affiliation(s)
- Kate Sutherland
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia;
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Correspondence:
| | - Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia;
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW 2065, Australia
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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: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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21
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Marklund M, Braem MJ, Verbraecken J. Update on oral appliance therapy. Eur Respir Rev 2019; 28:28/153/190083. [DOI: 10.1183/16000617.0083-2019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/14/2019] [Indexed: 12/26/2022] Open
Abstract
Oral appliances are increasingly recommended for selected patients with obstructive sleep apnoea (OSA) and those who do not tolerate nor prefer continuous positive airway pressure. The most commonly used oral appliance advances the lower jaw during sleep, the so-called mandibular advancement device (MAD). Patients seek treatment because of disturbing snoring, daytime symptoms, apnoeas that disturb sleep and the longer term consequences with regard to cardiovascular risks. MADs reduce the apnoea–hypopnoea index, although to various degrees among patients. Effects on daytime sleepiness have been observed mainly among the more severe OSA patients. Blood pressure may be reduced in MAD-treated OSA patients. There is, however, uncertainty about which patients will respond to this therapy in terms of apnoea reductions, decreased sleepiness and other symptoms, and reduced risk for future impaired health. The occurrence of side-effects also remains difficult to predict at present. The majority of sleep apnoea patients suffer from various comorbidities in terms of cardiovascular diseases, type 2 diabetes and depression. The most recent findings indicate that phenotyping of patients, considering various aspects of this multifaceted disease, will shed more light on the indications for MADs in patients with nightly sleep breathing disturbances. This review summarises the most recent knowledge about MAD treatment.
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Affiliation(s)
- Kate Sutherland
- Department of Respiratory and Sleep Medicine, Center for Sleep Health and Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Oyku Dalci
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, University of Sydney, Dental Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
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Pépin JL, Raymond N, Lacaze O, Aisenberg N, Forcioli J, Bonte E, Bourdin A, Launois S, Tamisier R, Molinari N. Heat-moulded versus custom-made mandibular advancement devices for obstructive sleep apnoea: a randomised non-inferiority trial. Thorax 2019; 74:667-674. [PMID: 31053619 DOI: 10.1136/thoraxjnl-2018-212726] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/07/2019] [Accepted: 03/18/2019] [Indexed: 11/03/2022]
Abstract
RATIONALE Custom-made mandibular advancement devices (MADs) are reported as providing higher efficacy rates compared with thermoplastic heat-moulded MADs but at the price of higher costs and treatment delays. OBJECTIVE To determine whether a thermoplastic heat-moulded titratable MAD (ONIRIS; ONIRIS SAS, Rueil Malmaison, France) is non-inferior to a custom-made acrylic titratable MAD (TALI; ONIRIS SAS, Rueil Malmaison, France) for obstructive sleep apnoea (OSA). METHODS We conducted a multicentre, open, randomised controlled trial of patients with OSA refusing or not tolerating continuous positive airway pressure (CPAP). Participants were randomly assigned to a thermoplastic heat-moulded titratable device or a custom-made acrylic device for 2 months with stratification by centre and OSA severity. The non-inferiority primary outcome was a ≥50% reduction in apnoea-hypopnoea index (AHI) or achieving AHI <10 events/hour at 2 months. The non-inferiority margin was preset as a difference between groups of 20% for the primary outcome in the per-protocol analysis. MAIN RESULTS Of 198 patients (mean age 51 [SD, 12] years; 138 [72.6%] men; mean body mass index 26 [SD, 2.7] kg/m2; mean AHI 26.6/hour [SD, 10.4]), 100 received TALI and 98 ONIRIS. In per-protocol analysis, the response rate was 51.7% in the TALI group versus 53.6% in the ONIRIS group (absolute difference 1.9%; 90% CI: 11% to 15%, within the non-inferiority margin). Effectiveness was the same for severity, symptoms, quality of life and blood pressure reduction. Patients in ONIRIS group reported more side effects and adherence was slightly better with TALI. CONCLUSION In patients with OSA refusing or not tolerating CPAP, the thermoplastic heat-moulded titratable MAD was non-inferior in the short-term to the custom-made acrylic MAD. TRIAL REGISTRATION NUMBER NCT02348970.
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Affiliation(s)
- Jean Louis Pépin
- HP2 (Hypoxia Pathopysiologies) Laboratory, Universite Grenoble Alpes, Saint-Martin-d'Heres 38400, France .,Rééducation et Physiologie, Pôle Locomoteur, Grenoble Alpes University Hospital (CHU), Grenoble, France
| | | | | | | | - Jérôme Forcioli
- Ear, Nose and Throat Department, New Bel-Air Clinic, Bordeaux, France
| | - Eric Bonte
- Odontology Department, Hôpital Bretonneau, AP-HP, Paris, French Polynesia
| | - Arnaud Bourdin
- Department of Pneumology, CHRU Montpellier, Montpellier, France
| | - Sandrine Launois
- HP2 (Hypoxia Pathopysiologies) Laboratory, INSERM U1042 Unit, University Grenoble Alpes, Grenoble, France.,EFCR (cardio-respiratory function explorations) Laboratory, Pole Thorax and Vessels, Grenoble Alpes University Hospital (CHU), Grenoble, France
| | - Renaud Tamisier
- HP2 (Hypoxia Pathopysiologies) Laboratory, INSERM U1042 Unit, University Grenoble Alpes, Grenoble, France.,EFCR (cardio-respiratory function explorations) Laboratory, Pole Thorax and Vessels, Grenoble Alpes University Hospital (CHU), Grenoble, France
| | - Nicolas Molinari
- Medical Information, CHRU Montpellier, UMR 729 MISTEA, University of Montpellier I, Montpellier, France
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Johal A, Agha B. Ready-made versus custom-made mandibular advancement appliances in obstructive sleep apnea: A systematic review and meta-analysis. J Sleep Res 2018; 27:e12660. [PMID: 29405512 DOI: 10.1111/jsr.12660] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 12/06/2017] [Accepted: 12/18/2017] [Indexed: 11/30/2022]
Abstract
Mandibular advancement appliances (MAAs) are an increasingly accepted treatment choice in obstructive sleep apnea management. The ready-made MAAs has questioned the need for a customised MAAs, given the former is more accessible and considerably cheaper. We conducted a systematic review and meta-analysis to evaluate both objective and patient-centred outcomes in relation to ready-made and custom-made MAAs s. Biomedical electronic databases, clinical trials registers and Grey literature were searched to January 2017, for randomised controlled trials. Meta-analyses of clinical trials were conducted for a range of objective (apnea-hypopnea index, treatment response) and subjective scales (daytime sleepiness; quality of life; patient preference and adherence). The review included three randomised controlled trials, which revealed low risk of bias. Custom-made MAAs s achieved a significant mean difference in the apnea-hypopnea index (-3.2; 95% confidence interval -5.18, -1.22; p = .004), daytime sleepiness (-0.98; 95% confidence interval -1.97, 0.01; p = .05), observed mean difference in Functional Outcomes of Sleep Questionnaire scores (0.76; 95% confidence interval 0.14, 1.38; p = .02), self-reported adherence (6.4-7 nights per week and 5-6.3 hr per night) and expressed preference (p ≤ .001) when compared with the ready-made MAAs s. Custom-made MAAs s offer clear definable advantages, demonstrating significant clinical effectiveness, patient preference and adherence.
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Affiliation(s)
- Ama Johal
- Oral Bioengineering Department, Institute of Dentistry, Queen Mary University of London, London, UK
| | - Bahn Agha
- Oral Bioengineering Department, Institute of Dentistry, Queen Mary University of London, London, UK
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