Principles and Practice of Sleep Medicine

Introduction:Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clini...

Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015.

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Obstructive sleep apnea (OSA) is a common disorder, and continuous airway positive pressure (CPAP) is considered to be the gold standard of therapy. CPAP however is known to have problems with adherence, with many patients eventually abandoning the device. The purpose of this paper is to assess secular trends in CPAP adherence over the long term to see if there have been meaningful improvements in adherence in light of the multiple interventions proposed to do so. A comprehensive systematic literature review was conducted using the Medline-Ovid, Embase, and Pubmed databases, searching for data regarding CPAP adherence over a twenty year timeframe (1994–2015). Data was assessed for quality and then extracted. The main outcome measure was reported CPAP non-adherence. Secondary outcomes included changes in CPAP non-adherence when comparing short versus long-term, and changes in terms of behavioral counseling. Eighty-two papers met study inclusion/exclusion criteria. The overall CPAP non-adherence rate based on a 7-h/night sleep time that was reported in studies conducted over the twenty year time frame was 34.1 %. There was no significant improvement over the time frame. Behavioral intervention improved adherence rates by ~1 h per night on average. The rate of CPAP adherence remains persistently low over twenty years worth of reported data. No clinically significant improvement in CPAP adherence was seen even in recent years despite efforts toward behavioral intervention and patient coaching. This low rate of adherence is problematic, and calls into question the concept of CPAP as gold-standard of therapy for OSA.

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Trends in CPAP adherence over twenty years of data collection: a flattened curve

Oral appliances (OA) have emerged as an alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) treatment. The most commonly used OA reduces upper airway collapse by advancing the mandible (OAm). There is a strong evidence base demonstrating OAm improve OSA in the majority of patients, including some with more severe disease. However OAm are not efficacious for all, with approximately one-third of patients experiencing no therapeutic benefit. OAm are generally well tolerated, although short-term adverse effects during acclimatization are common. Long-term dental changes do occur, but these are for the most part subclinical and do not preclude continued use. Patients often prefer OAm to gold-standard CPAP treatment. Head-to-head trials confirm CPAP is superior in reducing OSA parameters on polysomnography; however, this greater efficacy does not necessarily translate into better health outcomes in clinical practice. Comparable effectiveness of OAm and CPAP has been attributed to higher reported nightly use of OAm, suggesting that inferiority in reducing apneic events may be counteracted by greater treatment adherence. Recently, significant advances in commercially available OAm technologies have been made. Remotely controlled mandibular positioners have the potential to identify treatment responders and the level of therapeutic advancement required in single night titration polysomnography. Objective monitoring of OAm adherence using small embedded temperature sensing data loggers is now available and will enhance clinical practice and research. These technologies will further enhance efficacy and effectiveness of OAm treatment for OSA.

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Oral appliance treatment for obstructive sleep apnea: An update

The aim of the study was to assess the influence of four mandibular protrusion positions, at a constant vertical dimension, on obstructive sleep apnea (OSA). Seventeen OSA patients (49.2 +/- 8.5 years) received an adjustable mandibular advancement device (MAD). The patients underwent four polysomnographic recordings with their MAD in situ at, in random order, 0%, 25%, 50%, and 75% of the maximum protrusion. The mean apnea-hypopnea index (AHI) values of the patients differed significantly between the protrusion positions (P < 0.000). The 25% protrusion position resulted in a significant reduction of the AHI with respect to the 0% position, while in the 50% and 75% positions, even lower AHI values were found. The number of side effects was larger starting at the 50% protrusion position. We therefore recommend coming to a weighted compromise between efficacy and side effects by starting a MAD treatment in the 50% protrusion position.

http://www.mysilentsleep.com/docs/Research-11.pdf

Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea.

Background: Previous randomized controlled trials have addressed the efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA). Their common control condition, nasal continuous positive airway pressure (nCPAP), was frequently found to be superior to MAD therapy. However, in most of these studies, only nCPAP was titrated objectively but not MAD. To enable an unbiased comparison between both treatment modalities, the MAD should be titrated objectively as well. Objective: The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device. Methods: Sixty-four mild/moderate patients with obstructive sleep apnea (OSA; 52.0 ± 9.6 years) were randomly assigned to three parallel groups: MAD, nCPAP and placebo device. From all patients, two polysomnographic recordings were obtained at the hospital: one before treatment and one after approximately 6 months of treatment. Results: The change in the apnea-hypopnea index (ΔAHI) between baseline and therapy evaluation differed significantly between the three therapy groups (ANCOVA; p = 0.000). No differences in the ΔAHI were found between the MAD and nCPAP therapy (p = 0.092), whereas the changes in AHI in these groups were significantly larger than those in the placebo group (p = 0.000 and 0.002, respectively). Conclusion: There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.

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Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial

Background: Long-term trials are needed to capture information regarding the persistence of efficacy and loss to follow-up of both mandibular advancement device (MAD) therapy and continuous positive airway pressure (CPAP) therapy. Objectives: The aim of the study was to compare these treatment aspects between MAD and nasal CPAP (nCPAP) in a 1-year follow-up. Methods:Forty-three mild/moderate obstructive sleep apnea patients (52.2 ± 9.6 years) with a mean apnea-hypopnea index (AHI) of 20.8 ± 9.9 events/h were randomly assigned to two parallel groups: MAD (n = 21) and nCPAP (n = 22). Four polysomnographic recordings were obtained: one before treatment, one for the short-term evaluation, and two recordings 6 and 12 months after the short-term evaluation. Excessive daytime sleepiness (EDS) was also evaluated at the polysomnographic recordings. Results: The initially achieved improvements in the AHI remained stable over time within both groups (p = 0.650). In the nCPAP group, the AHI improved 4.1 events/h more than in the MAD group (p = 0.000). The EDS values showed a gradual improvement over time (p = 0.000), and these improvements were similar for both groups (p = 0.367). In the nCPAP group, more patients withdrew from treatment due to side effects than in the MAD group. Conclusions: The absence of significant long-term differences in EDS improvements between the MAD and the nCPAP groups with mild/moderate obstructive sleep apnea may indicate that the larger improvements in AHI values in the nCPAP group are not clinically relevant. Moreover, nCPAP patients may show more problems in accepting their treatment modality than MAD patients.

Long-term follow-up of a randomized controlled trial of oral appliance therapy in obstructive sleep apnea.

Objectives Tooth wear is a common finding in adult patients with dental sleep disorders. The aim of this paper was to review the literature on the possible associations between tooth wear and the following dental sleep disorders: sleep-related oro-facial pain, oral moistening disorders, gastroesophageal reflux disease (GERD), obstructive sleep apnoea syndrome (OSAS) and sleep bruxism. Methods A PubMed search was performed on 1 June 2018 using MeSH terms in the following query: Tooth Wear AND (Facial Pain OR Temporomandibular Joint Disorders OR Xerostomia OR Sialorrhea OR Gastroesophageal Reflux OR Sleep Apnea Syndrome OR Sleep Bruxism). Results The query yielded 706 reports on tooth wear and the mentioned dental sleep disorders. Several associations between tooth wear and the dental sleep disorders were suggested in the literature. It could be concluded that: (a) tooth wear is associated with dental pain and/or hypersensitivity; (b) oral dryness is associated with tooth wear, oro-facial pain and sleep bruxism; (c) GERD is associated with tooth wear, oro-facial pain, oral dryness, OSAS and sleep bruxism; (d) OSAS is associated with oral dryness, GERD and sleep bruxism; and (e) sleep bruxism is associated with tooth wear. Conclusions Tooth wear is associated with the dental sleep disorders oro-facial pain, oral dryness, GERD and sleep bruxism. The dental sleep disorders are interlinked with each other, which leads to indirect associations as well, and makes the consequences of each single condition difficult to disentangle. Knowledge of these associations is clinically relevant, but more research is needed to confirm their validity.

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Associations between tooth wear and dental sleep disorders: A narrative overview

Background: The apnea-hypopnea index (AHI) is frequently used to recognize obstructive sleep apnea (OSA) and to evaluate therapy. Objectives: The aim of this stud

Ghizlane Aarab

Papers

Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea.

Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial

Long-term follow-up of a randomized controlled trial of oral appliance therapy in obstructive sleep apnea.

Associations between tooth wear and dental sleep disorders: A narrative overview

Variability in the apnea-hypopnea index and its consequences for diagnosis and therapy evaluation.