Article

A randomized, controlled, crossover study of a noncustomized tongue retaining device for sleep disordered breathing

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Abstract

Tongue retaining devices (TRDs) are one type of oral appliance used to treat sleep disordered breathing. Previous studies have evaluated customized TRDs in comparison to mandibular repositioner appliances. The purpose of this study was to evaluate a noncustomized TRD compared to a control device. A randomized, controlled, crossover design was utilized. The primary outcome was the difference in reduction of the respiratory disturbance index (RDI) between the active suction device (S) and the control, nonsuction device (NS). Secondary outcomes included snoring index, Epworth Sleepiness Scale as well as patient and partner quality-of-life index. Crossover analysis found that only the S device significantly reduced the RDI by 4.9 (95% confidence interval 0.85-8.9) events more than the NS device. This represented a reduction in mean RDI from baseline of 15.5 (+/-17.6) to 8.9 (+/-7.6) with the S device. Significant reduction in snoring index was also only found with the S device (214.7-132.9 per hour). Fifty-four percent of subjects indicated they would continue to use only the S device. The S device, with suction, showed better objective and subjective outcomes. Future studies are needed to evaluate these types of devices in larger populations with a wide range of disease severity.

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... 5 The device can be recommended for OSA patients when MADs are contraindicated, although these devices are generally less common and less efficacious than MADs. [6][7][8] A tongue-stabilizing device (TSD) is a type of tongueretaining device that is now commercially available (Aveo-TSD, Innovative Health Technologies, New Zealand) (Figure 1). [9][10][11] The great differences between the earlier design of the tongueretaining device reported in 1982 and the TSD are their design and fabrication. ...
... Lazard et al. 7 reported that the conventional tongue-retaining device provided a complete success (post-treatment AHI < 10) rate of 47% and a partial response (10 < follow-up AHI < 20 with > 50% reduction from baseline AHI) rate of 24%. Under the same definition of responder as Lazard et al., 6 the complete and partial response rates in our study were 75% and 12.5%, respectively. A balanced combination of positive predictive value and negative predictive value of 0.75/0.83 ...
... These side effects have been previously reported by Deane et al. 8,9 Dort and Brant reported that 45% of users indicated that they would continue treatment with a tongue-retaining device because their snoring was reduced. 6 While a TSD was likely to benefit OSA patients based on a balanced positive predictive value and negative predict value in this study (Table 3), an unexpectedly higher percentage of intolerance and lost to follow-up within 2 months could be related to an attenuated risk-benefit profile. Therefore, modification of the appliance design to decrease subjective symptoms and discomfort of the tongue may be needed, while retaining the simplicity of the design. ...
Article
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JDSM Study Objectives: Mandibular advancement devices (MADs) may not be acceptable for use in patients with obstructive sleep apnea (OSA) when dental and/or temporomandibular joint side effects are likely. Tongue-stabilizing devices (TSDs) are a potential alternative to MAD therapy. We aimed to document the outcome of TSD treatment at a single multidisciplinary sleep center. Methods: OSA patients for whom MAD treatment was contraindicated due to dental and/or temporomandibular joint problems were prescribed a TSD. Follow-up overnight polysomnography (PSG) was performed with a TSD in place. Responders were defined as patients with a reduction in the apnea-hypopnea index (AHI) to less than 5 events/h as well as more than a 50% reduction in baseline AHI. Results: Of 551 patients who were referred for oral appliance therapy, 76 (100%) were prescribed a TSD. There were patients who were acclimatizing to TSD (n = 6; 8%), intolerant (n = 22; 29%), lost to follow-up (n = 26; 34%), and stopped using TSD by other reasons (n = 6; 8%). Of the 16 subjects (21%) who completed follow-up testing of PSG, the mean baseline AHI was reduced from 21.8 ± 8.6 to 9.3 ± 5.8 events/h (p < 0.01) with a TSD in place. The TSD improved AHI from 14.2 ± 2.9 to 2.1 ± 1.3 events/h in 5 responders (7%) (p < 0.01). Conclusions: The efficacy of the TSD was similar to that reported for MADs as long as the TSD was tolerated, especially in mild OSA patients. However, the high percentage of treatment dropout and/or lost to follow-up suggests the potential need for appliance redesign or modification to improve patients' adherence to therapy.
... Keyword combinations: sleep apnoea AND tongue retaining device or tongue stabilizing device were individually used for searches in PubMed. In total, three randomised controlled trials [59,103,104] and three other trials with small sample sizes were found (table e7) [105][106][107]. ...
... Overview of the evidence The three randomised controlled trials [59,103,104] evaluated the effects of TRDs on sleep apnoeas and symptoms and analysed predictors (table e7). One randomised controlled trial showed significant effects from TRD on sleep apnoeas compared with a control device in patients with mild to moderate sleep apnoea [103]. ...
... Overview of the evidence The three randomised controlled trials [59,103,104] evaluated the effects of TRDs on sleep apnoeas and symptoms and analysed predictors (table e7). One randomised controlled trial showed significant effects from TRD on sleep apnoeas compared with a control device in patients with mild to moderate sleep apnoea [103]. A comparison between a tongue stabilising device and MAD in another randomised controlled trial showed a similar apnoea reduction from the two devices, although the patients preferred MADs [104]. ...
Article
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In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.
... Keyword combinations: sleep apnoea AND tongue retaining device or tongue stabilizing device were individually used for searches in PubMed. In total, three randomised controlled trials [59,103,104] and three other trials with small sample sizes were found (table e7) [105][106][107]. ...
... Overview of the evidence The three randomised controlled trials [59,103,104] evaluated the effects of TRDs on sleep apnoeas and symptoms and analysed predictors (table e7). One randomised controlled trial showed significant effects from TRD on sleep apnoeas compared with a control device in patients with mild to moderate sleep apnoea [103]. ...
... Overview of the evidence The three randomised controlled trials [59,103,104] evaluated the effects of TRDs on sleep apnoeas and symptoms and analysed predictors (table e7). One randomised controlled trial showed significant effects from TRD on sleep apnoeas compared with a control device in patients with mild to moderate sleep apnoea [103]. A comparison between a tongue stabilising device and MAD in another randomised controlled trial showed a similar apnoea reduction from the two devices, although the patients preferred MADs [104]. ...
Article
Optimal treatment of the obstructive sleep apnoea syndrome (OSAS) requires an individually designed and interdisciplinary approach. Continuous positive airway pressure (CPAP) is accepted as the first line therapy for patients with OSAS. However, non-CPAP therapies may be indicated as supportive therapeutical approach in CPAP failure or as an alternative approach in CPAP intolerance. Overall, the level of evidence for the majority of non-CPAP therapies is low. Mandibular advancement devices as a medical non-CPAP treatment have proven to reduce respiratory disturbances to a level which may be sufficient in mild to moderate sleep apnoea. Apnoea triggered neurostimulation of upper airway muscles is an innovative approach that has shown promising results in preclinical studies. Surgical treatment has previously been performed as single level surgery of the nasal, the oropharyngeal or hypopharyngeal level. However, only tonsillectomy in the presence of tonsillar hypertrophy and maxillomandibular advancement are recommended in carefully selected cases. Due to low success rates for single level surgery, multilevel surgery has been proposed as the surgical approach for the future. © Georg Thieme Verlag KG Stuttgart · New York.
... Intraoral appliances are generally indicated for mild to moderate OSA as an alternative to CPAP or craniofacial surgery [4,[9][10][11]. Although CPAP is proven to be more efficient in treatment, it is not tolerated well by patients; therefore, intraoral appliances are frequently preferred [3,5,[12][13][14][15]. After fitting the trays to the patient's upper and lower teeth, the scale readings for maximum voluntary retrusion, protrusion, and rest position (habitual bite position) were recorded. ...
... The use of intraoral appliances can be in the form of mandibular advancement devices (MAD), soft palate lifting, and tongue-retaining devices (TRD) [1,14,16]. Among the entire range of appliances, MAD is the most commonly used and studied form. ...
Article
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.
... Reduced sleep quality, with daytime sleepiness, is associated with performance alterations, decreased concentration, irritability and, in more severe cases, with a true psychomotor slowdown [7] [8]. All of these factors severely affect the quality of life of the patient and are intended to evolve toward more serious clinical frameworks, characterized by the increased chance of emergence of pathologies such as systemic hypertension, ischemic heart disease, heart attack, pulmonary hypertension, and heart arrhythmias [9] [10]. ...
... As a result it reduces obstructive sleep apneas and snoring. A few studies show that TRDs are effective in mild to moderate OSA (but not in severe OSA) and can be as effective as MADs, however more patients prefer MADs92939495. Research studies have shown that using oral appliances that do not provide mandibular advancement has no significant clinical benefit for the treatment of OSA, suggesting that such a mechanism plays a significant role [61, 80]. Therefore TRDs can be used in selected patients with mild to moderate OSA, if other treatments have failed or are not possible. ...
Article
Obstructive sleep apnea (OSA) is a common disorder associated with cardiovascular morbidity. Various methods are offered to improve symptoms of OSA and its outcome. Although positive airway pressure is the most effective treatment for OSA, its clinical effectiveness is limited by patients’ compliance. Other suggested treatments for OSA focus on expanding upper airway and reducing its collapsibility. For example, mandibular advancement device (MAD) achieves this goal by mechanically protruding the mandible. Other available treatments including weight reduction, positional therapy, drugs, nasal dilators, and nasal expiratory pressure device are clearly inferior to CPAP.
... 6 Alternative OA designs which protrude the tongue instead of the mandible (tongue-retaining device [TRD]) are also available. [7][8][9] TRDs feature an extra-oral fl exible bulb and hold the tongue forward by suction, preventing its collapse into the airway. TRDs may be poorly tolerated, with inadequate device ...
Article
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Oral appliances (OA) have emerged as an alternative to continuous positive airway pressure (CPAP) for Obstructive Sleep Apnoea (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 Continuous Positive Airway Pressure (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.
... In 32 mild OSA patients, only the device capable of developing suction produced significant reductions in the respiratory disturbance index (RDI) and snoring index (snores/hour). 104 Deane compared the outcomes of a tongue retention device to a non-adjustable mandibular advancement splint. Although both devices showed a similar reduction in AHI, complete response (AHI < 5/hour) was achieved in 68% of subjects with the mandibular advancement splint and in only 45% of subjects with the tongue retention device. ...
... In 32 mild OSA patients, only the device capable of developing suction produced significant reductions in the respiratory disturbance index (RDI) and snoring index (snores/hour). 104 Deane compared the outcomes of a tongue retention device to a non-adjustable mandibular advancement splint. Although both devices showed a similar reduction in AHI, complete response (AHI < 5/hour) was achieved in 68% of subjects with the mandibular advancement splint and in only 45% of subjects with the tongue retention device. ...
... In a study of mild-to-moderate OSA patients randomized to either 50% or 75% of maximum advancement, there was no difference between these levels in treatment AHI or proportion of patients successfully treated (79% vs. 73%). However in severe OSA, more patients achieved treatment success with 75% compared to 50% maximum advancement (52% vs. 31%), suggesting maximizing advancement may be more important in severe disease (Dort et al., 2008). A dosedependent effect of mandibular advancement was demonstrated using 4 randomized levels of advancement (0%, 25%, 50%, and 75% maximum), with the efficacy of 50% to 75% advancement greater than 25%, and 25% greater than 0%. ...
... C -What are the features of a device employed for the treatment of adult patients affected by OSAS or snoring? 1. Tongue retaining devices (TRD), which seem to be less efficacious and are also less comfortable than mandibular advancement devices (MADs); they are indicated in edentulous patients, or patients who cannot tolerate, or do not qualify as candidates for, mandibular advancement (1,(20)(21)(22). (Level of evidence 2; Power of recommendation C). 2. Mandibular advancement devices (MADs, also referred in the literature as mandibular advance-ment splints -MASs; mandibular repositioning devices -MRDs; or mandibular repositioning appliances -MRAs), which can be: 3. Boil and bite devices: these are less efficient than customized devices in terms of reduction of respiratory events and also in terms of compliance; these devices are still not indicated as a definitive treatment for OSAS. ...
... 31,32 No improvements in quality of life assessed by the SAQLI were reported among 32 partners of patients with mild to moderate OSA participating in a randomized controlled crossover study of OA treatment versus a control device. 33 The short study time period of 1-w acclimatization followed by a 1-w washout could account for these results. ...
Article
Study objectives: Many adults sleep with a significant other; thus, sleep disorder symptoms and treatments of one partner are likely to impact the other partner's health. A literature review was conducted to examine the impact of obstructive sleep apnea (OSA) and OSA treatments on partner-assessed sleep and daytime functioning and partner involvement in OSA treatment. Methods: MEDLINE, EMBASE, and CINAHL searches yielded 38 pertinent quantitative and qualitative studies that described sleep and/or daytime functioning assessed in partners of patients with untreated OSA, sleep and/or daytime functioning assessed in partners who were referred for OSA treatment, including continuous positive airway pressure (CPAP) therapy, oral appliance (OA), or surgery, and/or associations between partner involvement and OSA treatment use. Results: The majority of studies found untreated OSA to have a negative impact on partners' objective and subjective sleep and daytime functioning, in particular mood, quality of life, and relationship quality. Improvements in partner-assessed sleep quality were reported for CPAP, OA, and surgery. Conflicting results were reported for partners' mood, quality of life, daytime sleepiness, and relationship quality. Perceived partner support was associated with greater CPAP use. Conclusions: Symptoms associated with OSA can negatively impact partners' sleep and daytime functioning. Treatment of OSA with CPAP, OA, or surgery can have health benefits for not only patients but also partners. Collaborative partner involvement may be a useful strategy for interventions promoting CPAP adherence.
... Fifteen case series studies (241 patients) [9][10][11][34][35][36][37][38][39][40][41][42][43][44][45] and one case report evaluated outcomes based on AHI [24]. Within these 242 patients, the overall means ± standard deviations (M ± SD) for decreased from 33.6 ± 21.1/h to 15.8 ± 16.0/h (53% reduction), p b 0.0001. ...
Article
Objective Tongue Retaining Devices (TRD) anteriorly displace the tongue with suction forces while patients sleep. TRD provide a non-surgical treatment option for patients with Obstructive Sleep Apnea (OSA). Our objective was to conduct a systematic review of the international literature for TRD outcomes as treatment for OSA. Methods Three authors independently and systematically searched four databases (including PubMed/MEDLINE) through June 26, 2016. We followed guidelines set within the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results Sixteen studies with 242 patients met criteria. The overall means ± standard deviations (M ± SD) for apnea-hypopnea index (AHI) decreased from 33.6 ± 21.1/h to 15.8 ± 16.0/h (53% reduction). Seven studies (81 patients) reported lowest oxygen saturation (LSAT), which improved from 79.8 ± 17.5% to 83.9 ± 8.6%. Four studies (93 patients) reported Epworth sleepiness scale (ESS), which decreased from 10.8 ± 4.8 to 8.2 ± 4.5, p <0.0001. Four studies (31 patients) reported Oxygen Desaturation Index (ODI) which decreased from 29.6 ± 32.1 to 12.9 ± 8.7, a 56.4% reduction. Conclusion Current international literature demonstrates that tongue retaining devices reduce apnea-hypopnea index by 53%, increase lowest oxygen saturation by 4.1 oxygen saturation points, decrease oxygen desaturation index by 56% and decrease Epworth sleepiness scale scores by 2.8 points. Tongue retaining devices provide a statistically effective alternative treatment option for obstructive sleep apnea.
... Similar findings were observed in the present study, as seen by significant improvement in area and volume of upper airway in the present study, which were evaluated using AP. Similar improvement have been observed in other studies in literature which have utilised various 2D and 3D modalities [6,8,[23][24][25]. However, majority of the studies have focussed on cases with mild to moderate OSA whereas, the present study focussed on cases with moderate to severe OSA. ...
Article
To assess effectiveness of titratable Oral Appliance (OA) in management of moderate to severe cases of Obstructive Sleep Apnea (OSA). Thirty Polysomnography (PSG) diagnosed cases of moderate to severe OSA were subjected to a thorough cranio-facial-dental evaluation, a detailed sleep history and three dimensional assessment of upper airway geometry utilising Acoustic Pharyngometry (AP) (Eccovision, sleep group solutions). A titratable OA was delivered to all patients for mandibular advancement. Apnea Hypopnea Index (AHI), Oxygen Saturation (SPO2), Epworth's Sleepiness Scale (ESS), Mean area and volume of upper airway were recorded at Baseline (T0) and after 08 weeks of appliance delivery (T1). The mean AHI & ESS scores were significantly lower and SPO2 was significantly higher at T1 compared to T0 (P-value < 0.05 for all). The mean area and volume of upper airway at T1 were significantly higher compared to values at T0 (P-value < 0.05 for both). The mean area showed 19.51% increase at T1 whereas mean volume increased by 18.55%. OA therapy is highly efficacious in cases with moderate to severe OSA, especially, in those with retrognathic mandible. This modality should be considered as an effective alternate to Continuous Positive Airway Pressure (CPAP) therapy in non-compliant patients rather than no treatment. AP is an effective modality to predict airway changes after advancement with OA, to ascertain follow up changes and is highly recommended in routine clinical practice. Large scale, multicenter studies are recommended to elaborate the findings of the present study and to add better quality evidence in this regard.
... Treatment intolerance was also not significantly different between devices. The most common side effects of CPAP were nasal blockage, mask compression, and inconvenience to carry, and the most common side effects of TRD were tongue pain, toothache or gum pain, and dry mouth-all of which was consistent with previous reports [3,11,26]. Twenty-six percent of patients reported having no hesitation to use the TRD, which was in contrast to hypotheses to the contrary put forth in some review articles [7,10]. Nonetheless, a majority of patients (48%) preferred CPAP to TRD due to their perceptions of greater efficacy and less side effects with CPAP therapy. ...
Article
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Purpose: To compare the efficacy of tongue-retaining device (TRD) versus continuous positive airway pressure (CPAP) for treatment of obstructive sleep apnea (OSA). Study design: Randomized crossover study. Subjects and methods: Thirty-six patients with a mean age of 52.7 ± 10.6 years were enrolled. Inclusion criteria were age ≥ 18 years, apnea-hypopnea index (AHI) ≥ 5 events/h, and minimum oxygen saturation (SO2) ≥ 70% from polysomnography (PSG). Exclusion criteria were severe periodontal disease, unstable cardiopulmonary or neurological diseases, and/or total sleep time < 2 h. A 1-week wash-in period was followed by questionnaires and randomization into two groups: TRD/CPAP and CPAP/TRD (18 patients each). After 3 weeks of intervention, questionnaires were re-administered and WatchPAT was performed. After a 1-week wash-out period, patients were switched to the other treatment. Primary outcome was AHI. Secondary outcomes were SO2, Functional Outcomes of Sleep Questionnaire (FOSQ), and Epworth Sleepiness Scale (ESS) scores, treatment side effects, and adherence. Results: Nine patients withdrew, so 27 patients were included in the final analysis. Mean AHI decreased from 38.7 ± 24.0 to 2.5 ± 0.5 and 12.7 ± 2.6 events/h for CPAP and TRD, respectively (95% confidence interval of mean differences 4.65-15.62; p < 0.001). There was no significant difference in ESS and FOSQ scores between treatments. Common adverse effects were drooling, tongue numbness, and pain for TRD; and nasal blockage, mask compression, and difficult portability for CPAP. Conclusions: CPAP was superior to TRD for resolving PSG parameters; however, both similarly improved QOL and daytime sleepiness. TRD might be considered a short-term alternative treatment for OSA. Trial registration: NCT02788487.
... It is a 'one-size-fits-most' mouthpiece and requires no special fitting by a sleep specialist. [25] Elastic mandibular advancement ...
Article
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The equine upper airway is highly adapted to provide the extremely high oxygen demand associated with strenuous aerobic exercise in this species. The tongue musculature, innervated by the hypoglossal nerve, plays an important role in airway stability in humans who also have a highly adapted upper airway to allow speech. The role of the hypoglossal nerve in stabilizing the equine upper airway has not been established. Isolated tongues from eight mature horses were dissected to determine the distal anatomy and branching of the equine hypoglossal nerve. Using this information, a peripheral nerve location technique was used to perform bilateral block of the common trunk of the hypoglossal nerve in 10 horses. Each horse was subjected to two trials with bilateral hypoglossal nerve block and two control trials (unblocked). Upper airway stability at exercise was determined using videoendoscopy and measurement of tracheal and pharyngeal pressure. Three main nerve branches were identified, medial and lateral branches and a discrete branch that innervated the geniohyoid muscle alone. Bilateral hypoglossal block induced nasopharyngeal instability in 10/19 trials, and none of the control trials (0/18) resulted in instability (P<0.001). Mean treadmill speed (+/-SD) at the onset of instability was 10.8+/-2.5 m/s. Following its onset, nasopharyngeal instability persisted until the end of the treadmill test. This instability, induced by hypoglossal nerve block, produced an expiratory obstruction similar to that seen in a naturally occurring equine disease (dorsal displacement of the soft palate, DDSP) with reduced inspiratory and expiratory pharyngeal pressure and increased expiratory tracheal pressure. These data suggest that stability of the equine upper airway at exercise may be mediated through the hypoglossal nerve. Naturally occurring DDSP in the horse shares a number of anatomic similarities with obstructive sleep apnea. Study of species with extreme respiratory adaptation, such as the horse, may provide insight into respiratory functioning in humans.
Article
Obstructive sleep apnea (OSA) is a prevalent, serious disease that is under-recognized and under-treated. It results from a combination of increased pharyngeal collapsibility and impaired compensatory pharyngeal muscle dilator activity. OSA causes serious morbidity and mortality. OSA is also a public health problem in that it is an independent cause of car crashes, at great cost to society in dollars and lives. OSA is conservatively estimated to affect 2-4% of Americans; however, recent estimates are much higher. To educate emergency physicians on the pathophysiology, epidemiology, diagnosis, and management of OSA and discuss diagnostic approaches and recommendations that can be made from the emergency department (ED). Emergency physicians can play an important role in the recognition and referral of patients at risk for OSA. A focused history and physical examination or the use of a structured evaluation can identify patients at risk for OSA. In addition to referring patients at risk for OSA for further diagnostic work-up, emergency physicians can offer recommendations such as weight loss, moderation of alcohol use and certain medications, and smoking cessation. OSA is a common disease in the United States that is under-recognized and under-treated. ED patients who do not regularly see a primary care provider or have no primary care provider are particularly at risk for undiagnosed OSA. Emergency physicians can play an important role in recognizing patients at risk for OSA, referring them for further diagnostic work-up, and offering recommendations from the ED.
Chapter
Oral appliances (OAs) aim to increase the upper airway size, facilitate breathing during the night, and reduce obstructive sleep apnea (OSA) and snoring (◘ Fig. 13.1a, b). There are two subgroups of OAs: the mandibular advancement device (OAM) (◘ Fig. 13.2) and the tongue-retaining device (OAT) (◘ Fig. 13.3). OAM is attached to the teeth and holds the mandible forward during sleep. This treatment has the highest level of evidence among non-PAP therapies [1–4]. OAT aims to hold the tongue forward into an anterior bulb by suction and can be used irrespective of the presence of teeth. Both devices reduce sleep apneas, but OAM is better tolerated and has been much more studied.
Article
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Oral appliances are increasingly being used for treatment of obstructive sleep apnea (OSA). Mandibular advancement splint (MAS) mechanically protrudes the mandible, while the tongue stabilizing device (TSD) protrudes and holds the tongue using suction. Although both appliances can significantly improve or ameliorate OSA, their comparative effects on upper airway structure have not been investigated. Cohort study. Sleep Investigation Unit. 39 patients undergoing oral appliance treatment for OSA. OSA patients underwent magnetic resonance imaging (MRI) of the upper airway during wakefulness at baseline and with MAS and TSD in randomized order. Treatment efficacy was determined by polysomnography in a subset of 18 patients. Upper airway lumen and surrounding soft tissue structures were segmented using image analysis software. Upper airway dimensions and soft tissue centroid movements were determined. Both appliances altered upper airway geometry, associated with movement of the parapharyngeal fat pads away from the airway. TSD increased velopharyngeal lateral diameter to a greater extent (+0.35 ± 0.07 vs. +0.18 ± 0.05 cm; P<0.001) and also increased antero-posterior diameter with anterior displacement of the tongue (0.68 ± 0.04 cm; P<0.001) and soft palate (0.12 ± 0.03 cm; P<0.001). MAS resulted in significant anterior displacement of the tongue base muscles (0.35 ± 0.04 cm). TSD responders (AHI reduction ≥50%) increased velopharyngeal volume more than non-responders (+2.65 ± 0.9 vs. -0.44 ± 0.8 cm(3); P < 0.05). Airway structures did not differ between MAS responders and non-responders. These results indicate that the patterns and magnitude of changes in upper airway structure differ between appliances. Further studies are warranted to evaluate the clinical relevance of these changes, and whether they can be used to predict treatment outcome.
Article
To evaluate the efficacy of a modified procedure of palatal stiffening for the treatment of snoring. Study Design: A quasi-experimental study. ENT, and Head and Neck Surgery Departments of Pakistan Air Force (PAF) Hospital Masroor, Combined Military Hospital (CMH) Rawalpindi and PAF Hospital Sargodha, from January 2000 to January 2005. Patients of either gender and above 20 years of age having snoring as their primary complaint were registered. Patients with an obvious cause of upper airway obstruction like oropharyngeal swelling, growths and obstructive sleep apnea were excluded. A grading system was designed to classify the patients according to severity and criteria for successful outcome defined; grades were equated with VAS. Palatal stiffening was achieved by using an insulated 22 gauge LP needle for infiltration cautery. Results were analyzed at 6 weeks post operatively on SPSS-16. Paired t-test was applied to compare the improvement in snoring and significance was tested at p-value less than 0.05. Forty four (44) patients underwent the palatal stiffening procedure. Male to female ratio was 42:2. Twenty eight (28) patients (63%) had complete resolution of symptoms after first surgery. Out of the remaining, ten more patients (22.72%) became symptom free after 1st revision surgery while six patients (12.5%) needed 2nd revision. Pain in throat was the main post operative complaint which settled in 10 to 14 days. Palatal stiffening procedure causing relatively less morbidity, simple and minimally invasive, but effective at the same time.
Article
Background Obstructive sleep apnea (OSA) is increasingly being recognized by the public due to its life-threatening and low curability rate nature. Oral appliances (OAs) were introduced as a treatment option for both non-apneic snoring and OSA to maintain the patency of the upper airway during sleep by repositioning the mandible, tongue, and soft palate. Results Over the past decade, OAs are enthusiastically studied and concluded as a simple, silent, bed partner-friendly, less invasive, tolerable, and efficacious choice for mild-to-moderate OSA. In the meantime, some challenges remain uncertain such as titration management, 3D image diagnostic tools reliability, and long-term adherence for adult patients. Improvement of temporomandibular joint (TMJ) monitoring and management is recommended, although there is no scientific evidence suggesting consistent undesirable long-term effects of OA on the TMJ. Now that pediatric OSA is being diagnosed more frequently, OA therapy is becoming a promising option for children as well. Conclusion Consistent follow-up and management are needed to increase clinical success rates in OA therapy for OSA. Further educational preparation and support is required for dental and medical professionals to recognize OSA and ensure the best possible patient care.
Article
The purpose of this study was to determine if subjects with moderate-to-severe obstructive sleep apnea would experience increasing treatment effect when a tongue retention component was added to a mandibular repositioning appliance. Cohort study. Sleep clinic. Forty-four sequentially recruited patients with moderate-to-severe obstructive sleep apnea. Subjects were sleep tested at 4 treatment stages of oral appliance therapy. The 4 stages were: 6-mm mandibular protrusion, 8-mm protrusion, 6-mm protrusion with a tongue retention bulb, and 8-mm protrusion with a tongue retention bulb. Forty-one of 44 subjects completed the protocol. There was a decrease in mean respiratory disturbance index from 33.5 events/h at baseline to 18.1 events/h at stage 4 (p = 0.001). Mean Epworth Sleepiness Scale (ESS) decreased from 12.3 at baseline to 9.0 at stage 4 (p = 0.0001. A combined approach utilizing both mandibular protrusion and tongue retention can provide effective treatment for moderate-to-severe obstructive sleep apnea. The addition of a tongue bulb may provide further treatment effect when mandibular protrusion is limited. Appliance designs that allow for convenient combination therapy need to be developed for this purpose.
Chapter
Oral appliances are increasingly being used for the treatment of obstructive sleep apnea (OSA) and are a simpler alternative to continuous positive airway pressure (CPAP) [1]. Although CPAP is highly efficacious, the obtrusive nature of the mask interface results in suboptimal patient compliance, limiting its clinical effectiveness. This has stimulated interest in alternative treatment strategies which are more acceptable to patients and oral appliance therapy is one such approach. Oral appliances protrude and hold the mandible and/or tongue in a forward position. KeywordsObstructive sleep apnea-Oral appliances-Mandibular advancement-Dental devices-Upper airway
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Obstructive sleep apnea is a common sleep disorder among middle-aged adults. It is characterized by repetitive collaps of upper airway obstruction during sleep. Oral appliances which used for the treatment of obstructive sleep apnea are a simple and influentual alternative for protection of upper airways from obstructions during sleep. Recently, there has been increasing interest about oral appliance usage for obstructive sleep apnea patients because of the limitations of another therapies such as positive airways pressure therapy and surgical methods. This review will be chronicled the usage of oral appliances in obstructive sleep apnea patients. Furthermore, factors which affect treatment success will be tried to discuss.
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Management of snoring is part of the treatment offered to patients with obstructive sleep apnea syndrome. In patients who do not have this syndrome, however, snoring should be treated according to the severity of the condition. General or specific therapeutic measures should be applied to snorers that have concomitant cardiovascular disease or unrefreshing sleep and in cases in which an individual's snoring disturbs his/her partner's sleep. The present review examines the treatments currently available for snorers and the current state of knowledge regarding each option. It will also focus on the possible indications of these treatments and evaluate their effectiveness.
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This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To evaluate the clinical effectiveness and impact on quality of life of oral appliances in the treatment of obstructive sleep apnoea (OSA) in adults.
Article
Objective: To evaluate the effectiveness of oral appliances (OAs) for managing patients with obstructive sleep apnea (OSA). Methods: PubMed, Embase, Web of Science, CENTRAL and SIGLE were electronically searched from January 1980 to September 2015 for randomized or nonrandomized controlled trials that assessed the effectiveness of OAs on OSAS. The processes of study search, selection, data extraction, assessment of risk of bias and evaluation of evidence quality were conducted independently by two reviewer authors. Meta-analyses were performed in Review Manager 5, Stata11.0 and StatsDirect 2.7.9. Results: Finally, we included 17 eligible studies which compared OAs and placebo or blank control. Six outcomes were assessed in this meta-analysis, i.e., apnea hypopnea index (AHI), respiratory arousal index (RAI), minimum oxygen saturation(MinSaO2), rapid eye movement (REM) sleep, sleep efficiency and Epworth Sleepiness Scale (ESS). Meta-analysis revealed that the pooled mean differences were -10.26 [95% CI: (-12.59, -7.93)], -9.03 [95% CI: (-11.89, -6.17)], 3.08 [95% CI: (1.97, 4.19)], 0.36 [95% CI: (-0.30, 1.02)], 1.34 [95% CI: (-0.05, 2.73)] and -1.76 [95% CI: (-2.57, -0.94)], respectively. The sensitivity analysis and subgroup analysis displayed generally robust results except for MinSaO2, REM sleep and Sleep efficiency. Furthermore, publication bias was detected in RAI and MinSaO2. Conclusions: The available evidence indicates benefits in respiration and sleep quality with oral appliances as compared to placebo devices or blank control, while we cannot determine its effectiveness in sleep efficiency and sleep architecture alterations. However, due to low evidence quality as revealed by GRADE, this finding should be interpreted with caution. Clinical significance: Through critical meta-analyses, we found that oral appliances are effective in respiration improving and sleep quality. The existing evidence supports the employment of OAs as a recommendable treatment option for OSA. This meta-analysis helps to direct clinical practice and future research, and promises to be of great interest for both practitioners and researchers.
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Written by Richard Berry, MD, Fundamentals of Sleep Medicine is a brand-new multimedia resource that provides a concise, clinically focused alternative to larger sleep medicine references. Get everything you need to know about the evaluation and management of sleep disorders, including the interpretation of sleep scans and the use of the newly overhauled AASM scoring criteria. Coverage of physiology is limited to what is necessary for clinical decision making. Reference is a snap due to the book's logical, user-friendly format and online features which include the full text and illustrations, numerous video clips, selected case studies, and enhanced sleep tracings. Spend less time searching thanks to a more clinically focused, user-friendly format that concentrates on the "fundamentals" of sleep medicine. Zero in on the practical, "hands-on" information you need, including how to interpret sleep scans. Access the full contents online at expertconsult.com plus additional illustrations, numerous video clips (parasomnias, leg kicks, and more), case studies, and enhanced sleep tracings (showing detailed sleep pattern alterations) Get clear, visual guidance on the new AASM scoring criteria, for which Dr. Berry served on the committee and provided all illustrations used. Provides the essentials needed to deliver accurate treatment.
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Sleep Medicine is a rapidly growing and changing field. Experienced sleep medicine clinicians and educators Richard B. Berry, MD and Mary H. Wagner, MD present the completely revised, third edition of Sleep Medicine Pearls featuring 150 cases that review key elements in the evaluation and management of a wide variety of sleep disorders. The cases are preceded by short fundamentals chapters that present enough basic information so that a physician new to sleep medicine can start reading page 1 and quickly learn the essential information needed to care for patients with sleep disorders. A concise, practical format makes this an ideal resource for sleep medicine physicians in active practice, sleep fellows learning sleep medicine, and physicians studying for the sleep boards.
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There is an effort on several fronts for newer effective therapy for obstructive sleep apnea. This is because, till now the two main modalities of therapy, continuous positive airway pressure therapy or use of various oral appliances are fraught with problems of poor acceptance and long time adherence. Though numerous modalities have been tried which are discussed in the review, there are few novel approaches which hold great promise as probable effective modalities for the future. In children, the simplest cost effective treatment undoubtedly remains a well timed adeno-tonsillectomy which could as well be curative. However, a high flow open nasal cannula based positive airway pressure therapy has been found to be effective in mild and moderately obese children. In adults, oral pressure therapy using an external suction apparatus connected to an intra oral device, that increases the retropharyngeal space and prevents the tongue from falling back, has been found to be effective in initial studies. Stimulation of the genioglossus by hypoglossal nerve pacing with the use of a pulse generator placed in the infraclavicular region is another promising modality. Various new surgical techniques specially the maxilla mandibular advancement procedures and computerized surgical planning methods hold great promise. Lastly, the multimodality approach using the new knowledge on the pathophysiology of sleep apnea is likely to be the therapy for the future.
Article
Recently, attention to oral appliance therapy, as mandibular advancement device (MAD), has increased. Mandibular advancement device is a popular alternative treatment, particularly for mild to moderate obstructive sleep apnea (OSA). Oral appliances for treating severe OSA are recommended for patients who failed to comply with continuous positive airway pressure treatment. This clinical report presents the treatment outcome of oral appliance therapy and bilevel device in a 70-year-old man with severe OSA and also having respiratory disturbance index (RDI) of 62.7. Polysomnographic (PSG) evaluation was performed before and about 1 week after continuous use of the MAD and then with bilevel device. The results were compared, and RDI decreased 27.5 per hour with the custom MAD, whereas RDI decreased 3.1 per hour with bilevel device. Improved PSG parameters showed that bilevel device was efficient in treatment. How to cite this article Keyf F, Firat S, Ciftci B. Efficiency of Mandibular Advancement Device and Bilevel Positive Airway Pressure Treatment for Severe Obstructive Sleep Apnea. Int J Experiment Dent Sci 2017;6(1):35-38.
Article
Management of snoring is part of the treatment offered to patients with obstructive sleep apnea syndrome. In patients who do not have this syndrome, however, snoring should be treated according to the severity of the condition. General or specific therapeutic measures should be applied to snorers that have concomitant cardiovascular disease or unrefreshing sleep and in cases in which an individual's snoring disturbs his/her partner's sleep. The present review examines the treatments currently available for snorers and the current state of knowledge regarding each option. It will also focus on the possible indications of these treatments and evaluate their effectiveness.
Article
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The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.
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Full-text available
Complete paralysis under general anesthesia allowed separating anatomic factors from neural factors which influence pharyngeal patency. We compared static mechanical properties of the passive pharynx in normals and sleep apneics. The passive pharynx was narrower and more collapsible in sleep apneics than normal controls indicating significance of anatomic factors in the pathogenesis of obstructive sleep apnea.
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Full-text available
The gold standard diagnostic test for obstructive sleep apnoea (OSA) is overnight polysomnography (PSG) which is costly in terms of time and money. Consequently, a number of alternatives to PSG have been proposed. Oximetry is appealing because of its widespread availability and ease of application. The diagnostic performance of an automated analysis algorithm based on falls and recovery of digitally recorded oxygen saturation was compared with PSG. Two hundred and forty six patients with suspected OSA were randomly selected for PSG and automated off line analysis of the digitally recorded oximeter signal. The PSG derived apnoea hypopnea index (AHI) and oximeter derived respiratory disturbance index (RDI) were highly correlated (R = 0.97). The mean (2SD) of the differences between AHI and RDI was 2.18 (12.34)/h. The sensitivity and specificity of the algorithm depended on the AHI and RDI criteria selected for OSA case designation. Using case designation criteria of 15/h for AHI and RDI, the sensitivity and specificity were 98% and 88%, respectively. If the PSG derived AHI included EEG based arousals as part of the hypopnea definition, the mean (2SD) of the differences between RDI and AHI was -0.12 (15. 62)/h and the sensitivity and specificity profile did not change significantly. In a population of patients suspected of having OSA, off line automated analysis of the oximetry signal provides a close estimate of AHI as well as excellent diagnostic sensitivity and specificity for OSA.
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Full-text available
Obstructive sleep apnoea (OSA) affects important domains of quality of life which remain unexplored by conventional sleep recordings. The objective of this study was to examine the measurement properties (both discriminative and evaluative) of the Sleep Apnoea Quality of Life Index (SAQLI), a new OSA specific quality of life questionnaire. Consecutive patients recently diagnosed with OSA completed a French version of the SAQLI twice over a 3 month period. Its construct validity and responsiveness were tested by comparing baseline and change scores obtained in each domain (symptoms, activities, emotions, social interactions) with those of questionnaires measuring related constructs (SF-36, Epworth Scale, Beck Depression Inventory, and Symptom Checklist 90). The symptoms scores were also correlated with physiological measures obtained at baseline polysomnographic recording. Forty seven patients (40 men) of mean (SD) age 53 (10) years and mean (SD) apnoea/hypopnoea index 38 (21) participated in the study. During the study period 33 of the 47 patients were treated for OSA (31 with nasal CPAP, one with uvulopalatopharyngoplasty, and one with an oral appliance). Moderate to high correlations were found between the scores in each domain of the SAQLI and the corresponding instruments. There were significant differences in change scores between patients who were treated and those who were not, moderate correlations between SAQLI change scores and changes in the corresponding instruments, and no correlation between the symptoms scores and the baseline nocturnal features. Most of these correlations met the a priori predictions made regarding their magnitude. The SAQLI has strong construct validity and is responsive to change in quality of life but has the disadvantage of having to be administered by an interviewer.
Article
Full-text available
These practice parameters are an update of the previously published recommendations regarding use of oral appliances in the treatment of snoring and Obstructive Sleep Apnea (OSA). Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP. Until there is higher quality evidence to suggest efficacy, CPAP is indicated whenever possible for patients with severe OSA before considering OAs. Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures. Follow-up polysomnography or an attended cardiorespiratory (Type 3) sleep study is needed to verify efficacy, and may be needed when symptoms of OSA worsen or recur. Patients with OSA who are treated with oral appliances should return for follow-up office visits with the dental specialist at regular intervals to monitor patient adherence, evaluate device deterioration or maladjustment, and to evaluate the health of the oral structures and integrity of the occlusion. Regular follow up is also needed to assess the patient for signs and symptoms of worsening OSA. Research to define patient characteristics more clearly for OA acceptance, success, and adherence is needed.
Article
The tarnished gold-standard investigation for diagnosis of the Sleep Apnoea/Hypopnoea Syndrome (SAHS) is polysomnography (PSG), but rising referral rates make limited sleep studies attractive. We have validated and put into practice unsupervised limited sleep studies in the patient's home using the EdenTrace system (Edentec 3711) which records oronasal airflow, heart rate, chest wall movements and Sa02. For validation, 20 patients underwent full overnight PSG and then a limited sleep study in their own home the following night. The frequency of respiratory events observed in the limited studies (mean 23.8 apnoeas+hypopnoeas per hour in bed, SD 12.3) was lower than the Apnoea/Hypopnoea Index (AHI) from PSG (mean 31.4 A+H/hr asleep, SD 19) but the two methods were significantly correlated (r = 0.83, p < 0.001). No patient with a frequency of respiratory events >30/hr on a limited study had an AHI <15/hr on PSG. We then performed a prospective study in which 150 local patients under investigation for possible SAHS had a limited home sleep study as an initial investigation. Forty-three (29%) showed >30 A+H /hr and proceeded direct to inpatient CPAP titration. Twenty-two (15%) patients who did not complain of daytime sleepiness and showed <15 A+H/hr were given no further investigation. Eighty-five (57%) patients, including 27 (18%) in whom the limited study was technically unsuccessful, proceeded to full PSG to establish a diagnosis. One patient defaulted. Compared with a control group of 75 patients who underwent PSG as an initial investigation, this protocol gave a diagnosis more quickly (median 18 days for home study group vs 47 days for controls, p = 0.002) and cheaply (mean £220 vs £309, p <0.001). It did not alter the proportion of patients offered CPAP (63% vs 65%, NS) nor their subsequent usage of CPAP (mean 4.7 vs 5.0 hrs/night, NS). We conclude that limited home sleep studies can be used for the diagnosis of SAHS with benefits in time and cost, but that PSG may still be required in 50-60% for diagnostic reliability.
Article
The tongue-retaining device (TRD) was designed to increase the unobstructed dimension of the nasal breathing passage during sleep. Twenty male patients with diagnoses of sleep apnea syndrome, primarily of the obstructive type, confirmed by clinical polysomnography, were fitted with the device. The TRD holds the tongue in a forward position by negative pressure. Fourteen patients have been tested before and after this treatment, and ten of these have also completed two follow-up recordings four to six months after being trained in the use of this device. There was significantly improved sleep and significantly fewer and shorter apneic events on all nights when the device was worn. On the first night of wearing the TRD for a half night only, there was a significant reduction in the number of obstructive and central apneic episodes. The mean apnea plus hypopnea index while wearing the TRD is comparable with the rate reported for patients who have been treated surgically by either tracheostomy or by uvulopalatopharyngoplasty, although the tracheostomy group contained more severe cases.(JAMA 1982;248:705-709)
Article
Effective compliance (time spent at the effective pressure) with nasal CPAP in obstructive sleep apnea has been reported to be poor. The aim of our study was to evaluate effective compliance in a large European multicenter study. One hundred twenty-one consecutive newly treated patients (initial apnea–hypopnea index [AHI] = 62.0 ± 29.5/h, AHI under CPAP = 6.4 ± 8.1/h, CPAP pressure = 8.7 ± 2.6 cm H2O, BMI = 33.1 ± 6.8 kg/m²) were randomly allocated to a group with (MC⁺) (n = 58) or without (MC⁻) (n = 63) a control unit measuring effective compliance at 1, 2, and 3 mo, which was compared with the built-in time counter data. MC⁺ data were 94 ± 10, 98 ± 5, and 96 ± 9% of counter data at 1, 2, and 3 mo, respectively. Using criteria of regular use already reported in the literature (at least 4 h of nCPAP per day of use and nCPAP administered more than 70% of the days) we found 77, 82, and 79% compliant patients at 1, 2, and 3 mo, respectively, 79% of the patients meeting these criteria each month. Although there were no pulmonary functions or polysomnographic differences between the two subgroups, the compliant patients did report a greater improvement in minor symptoms. We found a close correlation between effective use of CPAP and the machine run time. The main result of our study was a higher effective compliance than previously reported, approximately 80% of the patients being regular users versus 46% in a previously published study. This may result from different technical and medical follow-up.
Article
SUMMARY  Previous studies have reported a great difference in snoring prevalence in different populations. In a recent study on men and women 20–45 y old, living in Sweden (Uppsala, Gothenbourg), Iceland (Reykjavík) and Belgium (Antwerp), data concerning snoring, etc., were collected using the same questions and scales in all the countries. In all four areas the prevalence of snoring was the same: 5% of men and 2–3% of women reported snoring every night. In all areas snoring was positively correlated with age, male sex and body mass index. It was therefore assumed that the previous difference in snoring prevalence is probably an artifact of different methodologies.The connection between snoring and systemic hypertension has been much disputed during the last decade. The high prevalence of hypertension in the sleep apnoea syndrome has been explained by obesity/age/male gender/sleep apnoea and/or snoring. In one recent study snoring did not contribute independently to the prediction of hypertension, while other studies indicate that snoring is an independent risk factor for hypertension.After reviewing some of the epidemiological literature it was found that these studies are bound to identify almost entirely different subgroups of the population as snorers since the prevalence of snoring is rated on different types of frequency scales with words like ‘never’, ‘often’ or the number of nights per week. The questions used are also different. In general it can be stated that the smaller the proportion of the population identified as snorers the more often there is a statistically significant association with hypertension.The relationship between snoring and hypertension is considered to be unclear due to the different research methods used, and to the uncertain role played by confounding factors such as obesity. There is a need for population-based, prospective, studies with more uniform definitions of the term ‘snoring’ based on objective measurements of upper airway resistance during sleep, together with haemodynamic studies.
Article
Objective: To compare three different oral appliances: a mandibular advancement device (Snoreguard), a tongue retaining device, and a soft palate lift, for treatment of severe obstructive sleep apnea syndrome (OSAS).Background: Oral appliances are therapeutic options for patients with OSAS.Methods: Eight patients with a mean apnea hypopnea index (AHI) of 72.1 (SD±39.9) were studied. Polysomnographic measures during each of the treatment nights were compared to baseline.Results: Eight out of 8 patients completed the mandibular advancement device (MAD) night; 5/8 tolerated the tongue retaining device (TRD); only 2/8 could sleep with the soft palate lift (SPL) in place. Improvement using the MAD reached significance: overall AHI (mean±SD) decreased from 72.1±39.9 at baseline to 35.5±39.4 with the appliance in place (P<0.02). There was a non-significant increase in slow wave sleep (SWS) from 9.6%±8.7 to 14.4%±10.5 with the MAD in place. In five responders, the mean AHI decreased from 60.0±36.6 to 9.0±4.8; all were subjectively improved, using the MAD at 1 year follow-up. However, three non-responders had persistence of AHI>40. With the TRD, AHI decreased from 50.3±18.9 at baseline to 43.5±32.5 (ns). The SPL was not effective with an AHI at baseline of 52.4±8.0, and 47.3±31.0 with the device in place (ns), and not well tolerated.Conclusions: A mandibular advancement device is an effective treatment alternative in some patients with severe OSAS. In comparison, the tongue retaining device and the soft palate lift do not achieve satisfactory results.
Article
Factors associated with increased severity of sleep apnea; obesity, the supine sleep posture, and age, were tested for their association with the effectiveness of the Tongue Retaining Device (TRD) for the control of the apneic events in a group of 16 male patients. Sixty-nine percent of the patients (11 of 16) were successful with this treatment. The strongest predictor of this success was the presence of an increased severity associated with the supine sleep posture. Patients with substantial worsening of apnea index while in the supine sleep position were more responsive to the TRD than those who were equally affected in both sleep positions. A discriminant function analysis that entered age, obesity, and the ratio of apneas per hour in side v back sleep posture correctly classified the success of patients' response to this treatment.
Article
The tongue-retaining device (TRD) was designed to increase the unobstructed dimension of the nasal breathing passage during sleep. Twenty male patients with diagnoses of sleep apnea syndrome, primarily of the obstructive type, confirmed by clinical polysomnography, were fitted with the device. The TRD holds the tongue in a forward position by negative pressure. Fourteen patients have been tested before and after this treatment, and ten of these have also completed two follow-up recordings four to six months after being trained in the use of this device. There was significantly improved sleep and significantly fewer and shorter apneic events on all nights when the device was worn. On the first night of wearing the TRD for a half night only, there was a significant reduction in the number of obstructive and central apneic episodes. The mean apnea plus hypopnea index while wearing the TRD is comparable with the rate reported for patients who have been treated surgically by either tracheostomy or by uvulopalatopharyngoplasty, although the tracheostomy group contained more severe cases.
Article
This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee's parameters for the practice of sleep medicine in North America. The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and obstructive sleep apnea. The appliances modify the upper airway by changing the posture of the mandible and tongue. Despite considerable variation in the design of these appliances, the clinical effects are remarkably consistent. Snoring is improved and often eliminated in almost all patients who use oral appliances. Obstructive sleep apnea improves in the majority of patients; the mean apnea-hypopnea index (AHI) in this group of patients was reduced from 47 to 19. Approximately half of treated patients achieved an AHI of < 10; however, as many as 40% of those treated were left with significantly elevated AHIs. Improvement in sleep quality and sleepiness reflects the effect on breathing. Limited follow-up data indicate that oral discomfort is a common but tolerable side effect, that dental and mandibular complications appear to be uncommon and that long-term compliance varies from 50% to 100% of patients. Comparison of the risk and benefit of oral appliance therapy with the other available treatments suggests that oral appliances present a useful alternative to continuous positive airway pressure (CPAP), especially for patients with simple snoring and patients with obstructive sleep apnea who cannot tolerate CPAP therapy.
Article
We conducted a study of the prevalence of sleep-disordered breathing in subjects derived from a random sample of the population. A total of 2,202 subjects 35 to 69 yr of age were approached. Four hundred forty-one answered a questionnaire concerning their sleep symptoms, general health, and habits such as alcohol consumption, and they were monitored for sleep-disordered breathing (SDB). The sample was biased in favor of snorers and those with other subjective sleep complaints. Fifty-six percent of the subjects were men. Of the 441 subjects 79 (17.9%) had SDB (more than 15 episodes of apnea or hypopnea per hour: respiratory distress index [RDI] > or = 15), 289 were snorers but had RDI < 15, and 73 were nonsnorers. The prevalence of SDB in this sample was therefore at least 3.6% (79 of 2,204). The minimum prevalence in men was 5.7%, and in women it was 1.2%. Logistic regression identified only male sex as an independent predictor of snoring without SDB (adjusted odds ratio [OR], 3.24; 95% CI, 1.33 to 7.82), body mass index (adjusted OR for an increase of 5 kg/m2, 0.95; 95% CI, 0.85 to 1.05), and alcohol consumption (adjusted OR for an increase of 10 g/day, 1.05; 95% CI, 0.84 to 1.37) were not significant predictors of snoring. The independent predictors of SDB among snorers were age (adjusted OR for an increase of 5 yr, 1.26; 95% CI, 1.08 to 1.47) and neck circumference (adjusted OR for an increase of 2 cm, 1.53; 95% CI, 1.16 to 2.00).(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Limited data have suggested that sleep-disordered breathing, a condition of repeated episodes of apnea and hypopnea during sleep, is prevalent among adults. Data from the Wisconsin Sleep Cohort Study, a longitudinal study of the natural history of cardiopulmonary disorders of sleep, were used to estimate the prevalence of undiagnosed sleep-disordered breathing among adults and address its importance to the public health. A random sample of 602 employed men and women 30 to 60 years old were studied by overnight polysomnography to determine the frequency of episodes of apnea and hypopnea per hour of sleep (the apnea-hypopnea score). We measured the age- and sex-specific prevalence of sleep-disordered breathing in this group using three cutoff points for the apnea-hypopnea score (> or = 5, > or = 10, and > or = 15); we used logistic regression to investigate risk factors. The estimated prevalence of sleep-disordered breathing, defined as an apnea-hypopnea score of 5 or higher, was 9 percent for women and 24 percent for men. We estimated that 2 percent of women and 4 percent of men in the middle-aged work force meet the minimal diagnostic criteria for the sleep apnea syndrome (an apnea-hypopnea score of 5 or higher and daytime hypersomnolence). Male sex and obesity were strongly associated with the presence of sleep-disordered breathing. Habitual snorers, both men and women, tended to have a higher prevalence of apnea-hypopnea scores of 15 or higher. The prevalence of undiagnosed sleep-disordered breathing is high among men and is much higher than previously suspected among women. Undiagnosed sleep-disordered breathing is associated with daytime hypersomnolence.
Article
To define the effect of a tongue retaining device (TRD) on genioglossus (GG) muscle activity in seven obstructive sleep apnea subjects, two overnight sleep studies were carried out with two TRDs. TRD-A had no anterior bulb and incorporated two electrodes to record GG electromyographic (EMG) activity. TRD-B had a bulb and it had electrodes similar to those in TRD-A. Episodes of apnea/hypopnea (AH) were analyzed during both rapid eye movement (REM) and non-REM (NREM) sleep. The peak GG muscle activity was measured for the breath immediately before the AH (pre-AH), for the first (first-E) and last (last-E) inspiratory efforts during the AH, and for the first breath after the AH (post-AH). The time lag between the peak GG EMG activity and the maximum inspiratory effort was calculated. The AH index decreased with both TRDs. The peak GG EMG activity preceded the maximum inspiratory effort throughout the periods, however the time lag changed considerably with TRD-A. The time lags with TRD-A and TRD-B differed significantly for the first-E and the last-E during NREM sleep and for the first-E during REM sleep. The TRD reduces AH severity, normalizes the time lag, and counteracts fluctuating GG EMG activity observed when no bulb is present.
Article
Effectiveness of continuous positive airway pressure (CPAP) as a treatment of obstructive sleep apnea can be limited by poor compliance, but little is known about how to improve compliance. We performed a randomized, controlled clinical trial among 33 subjects of two interventions to improve compliance. One group of subjects received weekly phone calls to uncover any problems and encourage use, another received written information about sleep apnea and the importance of regular CPAP use, and a third served as control subjects. We found that intervention improved CPAP compliance (p = 0.059) and that the effect was particularly strong when intervention occurred during the first month of CPAP treatment (p = 0.004). Although the sample size did not allow definitive investigation of other explanatory variables, subjects with lower levels of education or those with relatives who used CPAP may have benefited from intervention more than other subjects. We conclude that simple, inexpensive efforts to improve compliance with CPAP can be effective, especially when applied at the start of CPAP treatment, but optimal intervention may vary with certain patient characteristics.
Article
The proportion of sleep apnea syndrome (SAS) in the general adult population that goes undiagnosed was estimated from a sample of 4,925 employed adults. Questionnaire data on doctor-diagnosed sleep apnea were followed up to ascertain the prevalence of diagnosed sleep apnea. In-laboratory polysomnography on a subset of 1,090 participants was used to estimate screen-detected sleep apnea. In this population, without obvious barriers to health care for sleep disorders, we estimate that 93% of women and 82% of men with moderate to severe SAS have not been clinically diagnosed. These findings provide a baseline for assessing health care resource needs for sleep apnea.
Article
A study was undertaken to test the hypothesis that unsupervised domiciliary limited sleep studies do not impair the accuracy of diagnosis when used to investigate the sleep apnoea/hypopnoea syndrome (SAHS) and can be cheaper than laboratory polysomnography. For validation, 23 subjects with suspected SAHS underwent laboratory polysomnography and a home study (EdenTec 3711) on successive nights. All subjects with > 15 apnoeas + hypopnoeas (A + H)/hour on polysomnography showed > 30 A + H/hour on their home study. Thereafter, in a prospective trial 150 subjects had a home study as the initial investigation and studies showing > 30 events/hour were regarded as diagnostic of SAHS. Those showing fewer events were investigated with polysomnography if necessary. Time to treatment, outcome, and costs of this protocol were compared with those of 75 patients investigated initially with polysomnography. Of the prospective trial subjects, 29% had > 30 A + H/hour and proceeded directly from home study to treatment; 15% without daytime sleepiness were not investigated further. Polysomnography was undertaken to establish a diagnosis in 56% of cases, including 18% whose home studies were unsuccessful. Compared with the 75 control patients, this protocol gave a diagnosis faster (median 18 (range 0-221) versus 47 (0-227) days, p < 0.001) and more cheaply (mean (SD) 164 pounds (104) versus 210 pounds (0), p < 0.001). The proportions offered CPAP (61% versus 67%) and subsequent objective CPAP usage (mean 4.7 (2.4) versus 5.0 (2.4) hours/night) were not different. Use of home sleep studies has benefits in time and cost. For diagnostic reliability a further sleep study was required in 56% of cases.
Article
The Calgary Sleep Apnea Quality of Life Index (SAQLI) was developed to record key elements of the disease that are important to patients. All items felt to influence the quality of life of these patients were identified. Final questionnaire items were selected by interviewing 113 patients with sleep apnea and 50 snorers who rated each item on whether it was a problem and the importance of it to their overall quality of life. Items for the final questionnaire were selected based on the rank order of the frequency ximportance product. The rank ordering was similar across strata of disease severity and between sexes. The Calgary SAQLI has 35 questions organized into four domains: daily functioning, social interactions, emotional functioning, and symptoms. A fifth domain, treatment-related symptoms, can be added for clinical intervention trials to record the possible negative impacts of treatment. The SAQLI has a high degree of internal consistency, face validity as judged by content experts and patients, and construct validity as shown by its positive correlations with the SF-36 and the improvement in scores in patients successfully completing a 4-wk trial of continuous positive airway pressure. It includes items shown to be important to patients with sleep apnea and is designed as a measure of outcome in clinical trials in sleep apnea. Flemons WW, Reimer MA. Development of a disease-specific health-related quality of life questionnaire for sleep apnea.
Article
Effective compliance (time spent at the effective pressure) with nasal CPAP in obstructive sleep apnea has been reported to be poor. The aim of our study was to evaluate effective compliance in a large European multicenter study. One hundred twenty-one consecutive newly treated patients (initial apnea-hypopnea index [AHI] = 62.0 +/- 29. 5/h, AHI under CPAP = 6.4 +/- 8.1/h, CPAP pressure = 8.7 +/- 2.6 cm H(2)O, BMI = 33.1 +/- 6.8 kg/m(2)) were randomly allocated to a group with (MC(+)) (n = 58) or without (MC(-)) (n = 63) a control unit measuring effective compliance at 1, 2, and 3 mo, which was compared with the built-in time counter data. MC(+) data were 94 +/- 10, 98 +/- 5, and 96 +/- 9% of counter data at 1, 2, and 3 mo, respectively. Using criteria of regular use already reported in the literature (at least 4 h of nCPAP per day of use and nCPAP administered more than 70% of the days) we found 77, 82, and 79% compliant patients at 1, 2, and 3 mo, respectively, 79% of the patients meeting these criteria each month. Although there were no pulmonary functions or polysomnographic differences between the two subgroups, the compliant patients did report a greater improvement in minor symptoms. We found a close correlation between effective use of CPAP and the machine run time. The main result of our study was a higher effective compliance than previously reported, approximately 80% of the patients being regular users versus 46% in a previously published study. This may result from different technical and medical follow-up.
Article
Our purpose was to compare the effectiveness and side effects of a novel, single-piece mandibular advancement device (OSA-Monobloc) for sleep apnea therapy with those of a two-piece appliance with lateral Herbst attachments (OSA-Herbst) as used in previous studies. An OSA-Monobloc and an OSA-Herbst with equal protrusion were fitted in 24 obstructive sleep apnea patients unable to use continuous positive airway pressure (CPAP) therapy. After an adaptation period of 156 +/- 14 d (mean +/- SE), patients used the OSA-Monobloc, the OSA-Herbst, and no appliance in random order, using each appliance for 1 wk. Symptom scores were recorded and sleep studies were done at the end of each week. Several symptom scores were significantly improved with both appliances, but to a greater degree with the OSA-Monobloc. Epworth Sleepiness Scale scores were 8.8 +/- 0.7 with the OSA-Herbst, and 8.6 +/- 0.8 with the OSA-Monobloc devices, and 13.1 +/- 0.9 without therapy (p < 0.05 versus both appliances). The apnea/hypopnea index was 8.7 +/- 1.5/h with the OSA-Herbst and 7.9 +/- 1.6/h with the OSA-Monobloc device, and 22.6 +/- 3.1/h without therapy (p < 0.05 versus both appliances). Side effects were mild and of equal prevalence with both appliances. Fifteen patients preferred the OSA-Monobloc, eight patients had no preference, and one patient preferred the OSA-Herbst device (p < 0.008 versus OSA-Monobloc). We conclude that both the OSA-Herbst and the OSA-Monobloc are effective therapeutic devices for sleep apnea. The OSA-Monobloc relieved symptoms to a greater extent than the OSA-Herbst, and was preferred by the majority of patients on the basis of its simple application.
Article
Although there is increasing interest in the use of oral appliances to treat obstructive sleep apnea (OSA), the evidence base for this is weak. Furthermore, the precise mechanisms of action are uncertain. We aimed to systematically investigate the efficacy of a novel mandibular advancement splint (MAS) in patients with OSA. The sample consisted of 28 patients with proven OSA. A randomized, controlled three-period (ABB/BAA) crossover study design was used. After an acclimatization period, patients underwent three polysomnographs with either a control oral plate, which did not advance the mandible (A), or MAS (B), 1 wk apart, in either the ABB or BAA sequence. Complete response (CR) was defined as a resolution of symptoms and a reduction in Apnea/Hypopnea Index (AHI) to < 5/h, and partial response (PR) as a > or = 50% reduction in AHI, but remaining > or = 5/h. Twenty-four patients (19 men, 5 women) completed the protocol. Subjective improvements with the MAS were reported by the majority of patients (96%). There were significant improvements in AHI (30 +/- 2/h versus 14 +/- 2/h, p < 0.0001), MinSa(O(2)) (87 +/- 1% versus 91 +/- 1%, p < 0.0001), and arousal index (41 +/- 2/h versus 27 +/- 2/h, p < 0.0001) with MAS, compared with the control. The control plate had no significant effect on AHI and MinSa(O(2)). CR (n = 9) or PR (n = 6) was achieved in 62.5% of patients. The MAS is an effective treatment in some patients with OSA, including those patients with moderate or severe OSA.
Article
Sleep apnea patients were studied three times prior to and 4 wk after a trial of nasal continuous positive airway pressure to determine the measurement properties of the Calgary Sleep Apnea Quality of Life Index (SAQLI), a disease-specific quality of life questionnaire. All patients completed the Medical Outcome Survey Short Form (SF-36), the Ferrans and Powers Quality of Life Index, and a global assessment of quality of life before and after treatment. The SAQLI was found to have a very high responsiveness index of 1.9 and an effect size of 1.1, which was much greater than the domains of the SF-36 and the FPQLI. There were statistically significant longitudinal correlations (range: 0.24 to 0.54) between the SAQLI and seven of the SF-36 domains in a pattern that was predicted beforehand and which demonstrated the validity of the SAQLI as an evaluative instrument. The SAQLI also had a range of correlations at baseline with the SF-36 (range: 0.36 to 0.71), the Epworth Sleepiness Scale (-0.26), and the FPQLI (0.29 to 0.66), and with a global rating of quality of life (0.61). The SAQLI had a high reliability coefficient of 0.92 on testing and retesting at 2 wk. We conclude that the SAQLI has excellent measurement properties for an evaluative instrument, and beginning evidence of validity as a discriminative index. It measures components of quality of life that are important to sleep apnea patients, and will be an important outcome measure in clinical trials.
Article
We hypothesize that clinical recognition rates for obstructive sleep apnea-hypoapnea syndrome (OSAHS) are influenced by comorbidity and demographic factors. Data on medical disorders, symptoms of sleep disorders, and cardiovascular risk factors gathered from 15,699 individuals in the Sleep Heart Health Study were compared. Participants were classified into three groups: those with a self-reported physician diagnosis of OSAHS, those with self-reported physician-diagnosed and -treated OSAHS, and those reporting both frequent snoring and daytime sleepiness (two-symptom group). Among all participants, 4.1% reported two symptoms (range across sites: 1.55 to 7.23%), whereas 1.6% reported a physician diagnosis of OSAHS (range: 0.66 to 2.88%) and 0.6% reported physician diagnosis and treatment (range: 0.11 to 0.88%). Recognized OSAHS groups were similar to the two-symptom group in age, having a sleeping partner, measured blood pressure, total cholesterol, and race. In a logistic model that included age along with characteristics found to vary significantly among the three groups (gender, body mass index [BMI], high-density lipoprotein cholesterol levels, hypertension), only male gender and BMI were increased in those with physician-diagnosed and -treated OSAHS. We conclude that disparities (especially in women and in those with lower BMI) exist between current recognition rates for OSAHS and the estimated prevalence by symptom report across the United States.
Article
Obstructive sleep apnoea is the term used to describe the interruption in normal breathing of individuals during sleep. It is caused by obstruction in the upper airway and is strongly associated with obesity. The mainstay of medical treatment is a night-time ventilator called continuous positive airways pressure (CPAP). This is used to keep the airway open during the night. We searched and reviewed all randomised controlled trials that had been undertaken to evaluate the benefit of CPAP in adult patients with sleep apnoea. Twelve trials involving 475 people were included. Most of the trials had methodological flaws. The overall results demonstrate that CPAP can improve measures of sleepiness; quality of life and mood in patients with sleep apnoea in patients with moderate to severe sleep apnoea. However it does not appear to improve other outcomes such as daytime blood pressure. Although patients prefer CPAP to placebo, they prefer using an alternative treatment with mouth guards to the more intrusive CPAP. Further good quality trials are needed to define who benefits, by how much and at what cost. Further trials are also needed to evaluate the effectiveness of CPAP in comparison to other interventions, particularly those targeted at underlying obesity.
Article
The development of oral appliance treatment for OSA represents an important step in the management of this disease. Randomized, controlled clinical trials have shown them to be an effective treatment option for snoring and OSA in some patients, particularly patients with less severe OSA or simple snoring and patients who have failed other treatment modalities. Although oral appliances are not as effective as CPAP therapy, they work in most patients to relieve symptoms and apnea and are well tolerated by patients. Most patients report improvements in sleep quality and excessive daytime sleepiness. Short-term side effects are generally minor and are related to excessive salivation, jaw and tooth discomfort, and occasional joint discomfort. These symptoms may lead to discontinuation of appliance therapy but usually improve in most patients over time. Serious complications are not common, but occlusal changes are more common than previously believed.
Article
Obstructive sleep apnea (OSA) is a common disorder in many ethnic populations. Patients with OSA have impaired health-related quality of life (HRQOL). No sleep apnea-specific HRQOL measure has been validated in Chinese patients. A cross-sectional sample of 106 Chinese OSA patients and a longitudinal sample of 51 patients in Hong Kong completed a Chinese (Cantonese) version of SAQLI for assessment of its acceptability, scaling assumptions, reliability, validity, and responsiveness. The instrument was understood and seen as relevant by 97% of subjects. Internal consistency, test-retest reliability, item-scale convergent validity and discriminatory validity, and construct validity were good to excellent. Construct validity was confirmed by significant correlations with SF-36 subscale scores. However, factor analysis showed that only items of daily functioning and symptom domains all loaded on the hypothesized scales. Longitudinal data showed that SAQLI was more responsive than SF-36 to changes after treatment. Hence, this version of SAQLI was an acceptable, psychometrically valid, and responsive HRQOL measure for evaluating impact of illness and treatment effectiveness in Chinese OSA patients.
Article
To assess the effectiveness of oral appliances in clinical practice. Survey of 110 subjects. Hospital-based dental practice. Questionnaire. Compliance and control of sleepiness and snoring. Fifty-seven percent of respondents were compliant with therapy, reporting control of sleepiness and snoring. More than 50% of those on oral appliance therapy reported continued use after at least 18 months.
Article
We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suitable for inclusion in the evidence base, including 15 Level I to II randomized controlled trials and 5 of these trials with placebo-controlled treatment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment adherence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been compared favorably to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP.
Article
Continuous positive airways pressure for relieving signs and symptoms of obstructive sleep apnoea Obstructive sleep apnoea is the term used to describe the interruption in normal breathing of individuals during sleep. It is caused by collapse of the upper airways during sleep and is strongly associated with obesity. The mainstay of medical treatment is a machine used at night to apply continuous positive airways pressure (CPAP). The machine blows air through the upper air passages via a mask on the mouth or nose to keep the throat open. We searched and reviewed all randomised controlled trials that had been undertaken to evaluate the benefit of CPAP in adult patients with sleep apnoea. Some of the trials had methodological flaws, although more recent studies have begun to use appropriate forms of control. The overall results demonstrate that in people with moderate to severe sleep apnoea CPAP can improve measures of sleepiness, quality of life and mood and associated daytime sleepiness. CPAP leads to lower blood pressure compared with control, although the degree to which this is achieved may depend upon whether people start treatment with raised blood pressures. Oral appliances are also used to treat sleep apnoea but, whilst some people find them more convenient to use than CPAP, they do not appear to be as effective at keeping the airway open at night. Further good quality trials are needed to define who benefits, by how much and at what cost. Further trials are also needed to evaluate the effectiveness of CPAP in comparison to other interventions, particularly those targeted at obesity.
Canada e-mail: dort@ucalgary.ca R
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2716, 7th Ave NW, Calgary, Alberta T2N 1A7, Canada e-mail: dort@ucalgary.ca R. Brant Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada References