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Concept: Mandibular advancement splint

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The purpose of this study was to determine differences in effectiveness between two types of mandibular advancement device (MAD).

Concepts: Obstructive sleep apnea, Mandibular advancement splint

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This study aims to evaluate the incidence and prevalence of temporomandibular disorders (TMD) in patients receiving a mandibular advancement device (MAD) to treat obstructive sleep apnea using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). In addition, it also aims to assess the development of posterior open bite (POB).

Concepts: Medical terms, Diagnosis, Sleep apnea, Obstructive sleep apnea, Abnormal respiration, Sleep disorders, Temporomandibular joint disorder, Mandibular advancement splint

2

Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality, and decreased quality of life. Treatment with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is effective for many symptoms of OSA. However, it remains controversial whether treatment with CPAP or MAD also improves depressive symptoms.

Concepts: Medical statistics, Sleep, Sleep apnea, Polysomnography, Obstructive sleep apnea, Positive airway pressure, Meta-analysis, Mandibular advancement splint

1

Continuous positive airway pressure (CPAP) is the standard treatment for moderate-to-severe obstructive sleep apnoea (OSA). However, adherence to CPAP is limited and non-CPAP therapies are frequently explored. Oral appliance (OA) therapy is currently widely used for the treatment of snoring, mild, moderate and severe OSA. The most commonly used and studied OA consists of a maxillary and mandibular splint which hold the lower jaw forward during sleep. The efficacy of OA is inferior to CPAP; however, the effectiveness as measured by sleepiness, quality of life, endothelial function and blood pressure is similar likely due to higher acceptance and subjective adherence. Upper airway stimulation augments neural drive by unilaterally stimulating the hypoglossal nerve. The Stimulation Therapy for Apnea Reduction (STAR) study enrolled 126 patients and demonstrated a 68% reduction in OSA severity. A high upfront cost and variable response are the main limitations. Oropharyngeal exercises consist of a set of isometric and isotonic exercises involving the tongue, soft palate and lateral pharyngeal wall. The collective reported trials (n = 120) showed that oropharyngeal exercises can ameliorate OSA and snoring (~30-40%). Nasal EPAP devices consist of disposable one-way resister valve. A systematic review (n = 345) showed that nasal EPAP reduced OSA severity by 53%. The Winx device consists of a mouthpiece placed inside the oral cavity that is connected by tubing to a console that generates negative pressure. Winx may provide successful therapy for ~30-40% of OSA patients. In conclusion, several non-CPAP therapies to treat OSA are currently available.

Concepts: Sleep, Sleep apnea, Polysomnography, Obstructive sleep apnea, Snoring, Tongue, Mandibular advancement splint, Soft palate

1

Mandibular advancement devices (MADs) are used to treat obstructive sleep apnoea-hypopnoea syndrome (OSAHS) but evidence is lacking regarding their clinical and cost-effectiveness in less severe disease.

Concepts: Epidemiology, Clinical trial, The Canon of Medicine, Randomized controlled trial, Avicenna, Clinical research, Obstructive sleep apnea, Mandibular advancement splint

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RATIONALE: Continuous Positive Airway Pressure (CPAP) and Mandibular Advancement Device (MAD) therapy are commonly used to treat Obstructive Sleep Apnea (OSA). Differences in efficacy and compliance of these treatments are likely to influence improvements in health outcomes. Objectives and METHODS: To compare health effects after 1 month of optimal CPAP and MAD therapy in OSA using a randomised crossover design. MEASUREMENTS AND MAIN RESULTS: Cardiovascular (24-hour blood pressure, arterial stiffness), neuro-behavioural (subjective sleepiness, driving simulator performance) and Quality of Life (FOSQ, SF-36) were compared between treatments. Our primary outcome was 24-hour mean arterial pressure (24MAP). 126 patients with moderate-severe OSA (AHI = 25.6 (SD 12.3)) were randomly assigned to a treatment order and 108 completed the trial with both devices. CPAP was more efficacious than MAD in reducing AHI (CPAP AHI=4.5±6.6/hr, MAD AHI=11.1±12.1/hr, p<0.01) but reported compliance was higher on MAD (MAD: 6.50±1.3 hrs/night versus CPAP: 5.20±2.0 hrs/night, p<0.00001). 24MAP was not inferior on treatment with MAD compared to CPAP (CPAP-MAD difference, 0.2mmHg [95%CI -0.7 to 1.1], however overall, neither treatment improved BP. In contrast, sleepiness, driving simulator performance and disease-specific QOL improved on both treatments by similar amounts although MAD was superior to CPAP for improving four general QOL domains. CONCLUSIONS: Important health outcomes were similar after 1 month of optimal MAD and CPAP treatment in patients with moderate-severe OSA. The results may be explained by greater efficacy of CPAP being offset by inferior compliance relative to MAD, resulting in similar effectiveness. Trial Registration: Australian and New Zealand Clinical Trials Registry at https://www.anzctr.org.au, trial number ACTRN12607000289415.

Concepts: Clinical trial, Randomized controlled trial, Blood pressure, Effectiveness, Sleep, Sleep apnea, Obstructive sleep apnea, Mandibular advancement splint

0

This study aimed to determine the effectiveness of a mandibular advancement device in a sample of obstructive sleep apnea syndrome patients by the evaluation of respiratory and neurophysiologic parameters and clinical symptoms. Second, the influence of certain predictor factors related with the patient and the intraoral device, were considered in the final response with this treatment option.

Concepts: Sleep apnea, Obstructive sleep apnea, Mandibular advancement splint

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Background Oral appliance therapy for obstructive sleep apnea can be helpful in mild and moderate cases. This clinical report evaluates the efficacy of a protocol that predicts an optimal jaw position and describes the response of a young OSA patient to treatment. Clinical Presentation A 27-year-old woman was diagnosed with moderate OSA and had an apnea-hypopnea index (AHI) of 25.8/hr. In order to fabricate a custom device, an alternative procedure to determine the optimal protrusion and vertical positioning of the jaw was applied. After a follow-up period of 14 months, her apnea-hypopnea index (AHI) significantly decreased from 25.8 to 1.0 per hr with the appliance. The total number of respiratory events decreased from 211 to 8. Conclusion Improved polysomnographic parameters showed that the oral device was efficient in treatment. The advantages of the device in this study are that it is comfortable, economical, and simple to fabricate.

Concepts: Sleep, Sleep disorder, Sleep apnea, Polysomnography, Obstructive sleep apnea, Sleep medicine, Hypopnea, Mandibular advancement splint

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Many treatments have been proposed for adult obstructive sleep apnea (OSA), but no comprehensive comparison of all interventions has been performed. We aimed to compare and rank the effectiveness of all minimally invasive treatments for adult OSA in a systematic review and network meta-analysis. Literature was searched within Ovid MedLine, EMBASE Classic+Embase, Cochrane library, and Cochrane Database of Systematic Reviews from inception to Aug 9th, 2016 for randomized controlled trials comparing minimally invasive treatments for adult OSA. The outcomes were the changes in apnea-hypopnea index (AHI) and Epworth sleepiness scale (ESS). Frequentist approach to network meta-analysis was used and treatment hierarchy was summarized according to the surfaces under the cumulative ranking curves. Eighty-nine randomized controlled trials comprising 6346 adult OSA participants and comparing 18 different interventions were included. In comparison with no treatment, positive airway pressure (PAP) was most effective in reducing AHI (23.28 [weighted mean difference]; 95% confidence interval: 19.20-27.35). PAP was ranked first followed by mandibular advancement device (MAD) in reducing AHI. Exercise was ranked first followed by cervico-mandibular support collar in reducing ESS. Considering the effectiveness in reducing both AHI and ESS, PAP was ranked the best, followed by MAD and positional therapy, while lifestyle modification alone was the least effective intervention. Interventions that are highly effective in reducing objective laboratory-derived AHI do not demonstrate equivalent effectiveness in improving patients' subjective sleepiness. Future improvement of the interventions is necessary to simultaneously improve both objective and subjective outcomes.

Concepts: Evidence-based medicine, Systematic review, Randomized controlled trial, Sleep, Efficacy, Sleep apnea, Obstructive sleep apnea, Mandibular advancement splint

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In 2005, the American Academy of Sleep Medicine stated, “Oral appliances are indicated for use in patients with mild to moderate obstructive sleep apnea (OSA) who prefer them to CPAP therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP.” However, this recommendation is based upon variable results from only six studies with more than 100 participants. These studies have assessed the effectiveness of mandibular advancement devices (MADs) in specific groups (military populations, academic institutions, or hospital settings) with no large study conducted in a fee-for-service private practice where the majority of patients receive MADs for OSA. The purpose of this study is to report outcomes of a board-certified dental sleep practitioner managing mild, moderate, and severe OSA using customized titratable MADs. We hypothesize that patients will demonstrate a significant reduction in apnea-hypopnea index (AHI) scores after adjusting their customized titratable MADs.

Concepts: Cohort study, Sleep, Sleep deprivation, Sleep apnea, Obstructive sleep apnea, Hypopnea, Mandibular advancement splint, American Academy of Sleep Medicine