|
Mandibular Devices
Barnes and colleagues performed a randomized controlled crossover trial of 3 months of treatment with nasal CPAP, a mandibular advancement splint (MAS), or a placebo tablet in 114 patients with mild to moderate OSA (AHI 5–30). Both CPAP and MAS reduced the AHI and frequency of arousals and improved nocturnal O2 saturation, but CPAP had a greater effect. The quality of life, symptoms, and subjective but not objective sleepiness improved to a similar degree with both treatments; however, many of the changes seen in neuropsychologic function and mood were not better than during the placebo period. This study demonstrated that both CPAP and MAS treated OSA and sleepiness effectively, and improved some, but not all, aspects of neurobehavioral function. The relatively small beneficial effects of CPAP and MAS on neuropsychologic function may be from the splint having a lesser effect on OSA than CPAP, and from CPAP being used less in this patient group. Nevertheless, patients preferred CPAP to both MAS and placebo at the end of the trial, suggesting that the better objective improvement in AHI was associated with improved outcomes and greater patient preference.
Anterior mandibular positioners (AMPs) are an alternative to CPAP for the treatment of OSA. However, AMP use is limited by an efficacy rate of 50 to 80% and an inability to predict which patients will respond to therapy. Tsai and coworkers evaluated 23 patients with OSA (respiratory disturbance index  15/hour) with a remotely controlled mandibular positioner, a temporary oral appliance that can advance or retract the mandible. The authors tested the hypothesis that elimination of respiratory events during a remotely controlled mandibular positioner overnight study would predict AMP efficacy, as defined by an absolute reduction in respiratory disturbance index to less than 15 per hour, a relative reduction in respiratory disturbance index of more than 30% from baseline, and a subjective improvement in symptoms. AMP compliance was 82%, and therapeutic efficacy was 53%. Among compliant patients, the positive and negative predictive value of a remotely controlled mandibular positioner study in predicting AMP treatment success was 90 and 89%, respectively. The authors concluded that an overnight remotely controlled mandibular positioner study is highly predictive of a clinical AMP response.
The precise mechanism whereby oral appliances achieve improvement in obstructive sleep apnea is not known. To investigate the effect on upper airway collapsibility, Ng and coworkers
studied 10 patients with obstructive sleep apnea treated with a custom-made mandibular advancement splint. During an acclimatization period, the splint was incrementally adjusted to achieve the greatest anterior advance of the mandible that was comfortable; polysomnography was then performed to document efficacy. Patients underwent no treatment for 1 week, and polysomnography was again performed. Compared with no therapy, the mandibular advancement splint decreased the apnea–hypopnea index (13 versus 25 events per hour), and decreased collapsibility of the upper airway: upper airway closing pressures of -3.9 versus -1.6 cm H2O during Stage 2 sleep and -4.7 versus -2.5 cm H2O during slow-wave sleep. Change in apnea–hypopnea index was correlated with change in upper airway closing pressure during Stage 2 sleep (r = 0.64). The authors conclude that a mandibular advancement sleep decreases collapsibility of the upper airway during sleep.
To determine the effectiveness of a mandibular advancement splint in the treatment of patients with obstructive sleep apnea, Gotsopoulos and coworkers
did a randomized control trial in 73 patients (respiratory disturbance index of 27 events per hour). Compared with an inactive oral appliance, the active splint produced improvements in sleep latency on a multiple sleep latency test (10.3 versus 9.1 minutes) and in the Epworth sleepiness score (7 versus 9 minutes). The proportion of patients with normal subjective sleepiness was higher in the active splint group (82 versus 62%), although objective sleepiness did not differ between the two groups. The authors conclude the four weeks of treatment with a mandibular advancement splint improves daytime sleepiness and a range of other symptoms in patients with obstructive sleep apnea.
In 48 patients with sleep apnea (apnea–hypopnea index of 22 events per hour), Engleman and coworkers
did a randomized crossover trial of 8 weeks of CPAP versus 8 weeks of treatment with a mandibular repositioning splint. Seven of 21 measured variables improved to a significantly greater extent with CPAP than with the splint: apnea–hypopnea index (8 versus 15 events per hour), Epworth sleepiness scale (8 versus 12), effectiveness rating, functional outcomes of sleepiness on a questionnaire, the mental component on short-form SF health survey and health transition scores. No differences between the two treatments were seen for objective sleepiness, cognitive performance, and preference for treatment. Patients with mild disease (apnea–hypopnea index of less than 15 events per hour) also had a better response to CPAP than with the splint. The authors conclude that a mandibular repositioning splint does not represent the first-line treatment of patients with sleep apnea syndrome.
To determine the efficacy and tolerance of an oral jaw-positioning appliance in children with sleep apnea, Villa and coworkers
studied 32 patients (aged 4 to 10 years). Nineteen patients were randomized to 6 months treatment with the device and 13 served as controls. Four treated patients and five untreated patients were lost to follow up. Of the 14 treated patients, 9 (64%) showed a 50% or greater decrease in apnea–hypopnea index. Symptoms of sleep apnea decreased in all treated patients and completely resolved in half. Untreated patients showed no change. The authors conclude that use of a jaw-positioning appliance is effective in treating sleep apnea in children and the appliance is reasonably well tolerated.
The effectiveness of a mandibular advancement device is usually evaluated after several weeks of use. To determine whether the effectiveness could be judged during a single night of polysomnography, Petelle and coworkers
studied seven patients with obstructive sleep apnea. During an initial titration night, a hydraulic system connected to two lateral arches advanced the mandible by 1 mm every 15 minutes. The mean advance was 13 mm. The patients were then fitted with a permanent device, set at the final advancement achieved during the titration night, and another polysomnogram was performed. Apnea–hypopnea index was 67 events per hour at baseline, 26 events per hour during the titration night, and 20 events per hour during the treatment night. The authors conclude that it is possible to judge the efficacy of a mandibular advancement device during a single night of polysomnography.
To determine the proportion of patients with contraindications to the use of a mandibular advancement device, Petit and coworkers
studied 100 unselected patients with sleep apnea. The clinical charts and X-rays were analyzed by two expert maxillofacial surgeons (one blinded to the other). The surgeons agreed on absolute contraindications in 96 of the 100 patients. Contraindications were found in 34% of the patients. Contraindications included: insufficient remaining teeth (mean tooth loss was eight); periodontal abnormalities in half the patients; and a disorder of the temporomandibular joint in two patients. Sixteen patients required dental and periodontal care before use of the mandibular advancement device. The authors conclude that about a third of patients with sleep apnea syndrome have contraindications to the use of a mandibular advancement device.
To determine whether the efficacy and acceptance of a mandibular advancement splint is influenced by the extent that it increases bite opening along the vertical axis, Pitsis and coworkers
did a randomized crossover trial in 23 patients with obstructive sleep apnea. Patients were randomized to splints that produced inter-incisal opening of either 4 or 12 mm for over 2 weeks, followed by washout for 1 week, and the other splint was then applied for another 2 weeks. Compared with an apnea–hypopnea index of 21 events per hour at baseline, the 4-mm splint decreased the index to 8 events per hour and the 12-mm splint decreased the index to 10 events per hour. The apnea–hypopnea index decreased by at least 50% and to 6 or fewer events per hour in 74% of the patients treated with the 4-mm splint and in 61% of the patients treated with the 12-mm splint. Patient preference was greater for the 4-mm splint than for the 12-mm splint: 78 versus 22%. The authors conclude that a mandibular advancement splint that induces 4 mm of bite opening is as effective as a splint that induces 12 mm of bite opening, but patients prefer a splint that produces a smaller degree of bite opening.
Citations 1-3 of 3 total displayed.
Efficacy of Positive Airway Pressure and Oral Appliance in Mild to Moderate Obstructive Sleep Apnea
- Maree Barnes, R. Douglas McEvoy, Siobhan Banks, Natalie Tarquinio, Christopher G. Murray, Norman Vowles, and Robert J. Pierce
Am. J. Respir. Crit. Care Med. 170: 656 -664. First published online as doi:10.1164/rccm.200311-1571OC
[Abstract]
[Full text]
Remotely Controlled Mandibular Positioner Predicts Efficacy of Oral Appliances in Sleep Apnea
- Willis H. Tsai, Juan-Carlos Vazquez, Tsutomu Oshima, Leslie Dort, Brian Roycroft, Alan A. Lowe, Eric Hajduk, and John E. Remmers
Am. J. Respir. Crit. Care Med. 170: 366 -370. First published online as doi:10.1164/rccm.200310-1446OC
[Abstract]
[Full text]
Effect of Oral Appliance Therapy on Upper Airway Collapsibility in Obstructive Sleep Apnea
- Andrew T Ng, Helen Gotsopoulos, Jin Qian, and Peter A Cistulli
Am. J. Respir. Crit. Care Med. 168: 238 -241. First published online as doi:10.1164/rccm.200211-1275OC
[Abstract]
[Full text]
|
|
