Dental side effects of long-term obstructive sleep apnea therapy: a 10-year follow-up study.

OBJECTIVES: Patients with obstructive sleep apnea (OSA) are usually treated with either mandibular advancement device (MAD) or continuous positive airway pressure (CPAP) therapy. The objective of this study is to evaluate changes in dental occlusion associated with long-term MAD and CPAP therapy. MATERIALS AND METHODS: Data from 14 OSA patients using MAD and 17 OSA patients using CPAP therapy were evaluated at baseline, 2-year and 10-year follow-up. Changes in dental occlusion were analyzed from dental plaster casts with a digital sliding caliper. RESULTS: At 2-year follow-up, MAD therapy resulted in significant dental changes when compared with baseline values. In MAD therapy, overjet and overbite decreased with 1.1 ± 1.8 mm and 1.1 ± 1.2 mm respectively. With CPAP therapy overjet and overbite decreased significantly with 0.2 ± 0.5 mm and 0.3 ± 0.5 mm, respectively. Both groups also showed significant changes in molar occlusion. After a 10-year follow-up, significant and more pronounced changes were seen in overjet and overbite. In MAD therapy, overjet and overbite decreased with 3.5 ± 1.5 mm and 2.9 ± 1.5 mm respectively when compared with baseline values. In CPAP therapy, overjet and overbite decreased with 0.7 ± 1.5 mm and 0.8 ± 1.4 mm respectively when compared with baseline values. CONCLUSIONS: This study demonstrates that MAD and CPAP therapy result in significant changes in dental occlusion. These changes appear progressive and more pronounced with MAD compared to CPAP therapy. CLINICAL RELEVANCE: Long-term OSA treatment results in significant dental side effects that may progress over time. Informed consent is fundamental before starting MAD treatment and individualized long-term follow-up is of eminent importance.

Validity and Predictive Value of a Portable Two-Channel Sleep-Screening Tool in the Identification of Sleep Apnea in Patients With Heart Failure.

BACKGROUND: Sleep apnea is an important comorbidity in heart failure (HF) and is associated with an adverse outcome. Diagnosing sleep apnea is difficult, and polysomnography, considered to be the criterion standard, is not widely available. We assessed the validity of a portable 2-channel sleep-screening tool for the identification of sleep apnea in patients with HF. METHODS AND RESULTS: One hundred patients with stable HF had simultaneous recordings of home-based polysomnography and the screening tool (Apnealink). To compare the apnea-hypopnea index of the screening tool with polysomnography, intraclass correlation (ICC), sensitivity, and specificity were calculated, and a Bland-Altman plot and receiver operating characteristic (ROC) curves were constructed. Ninety valid measurements with the screening tool were obtained (mean age 65.5 ± 11.0 y, 72% male, mean left ventricular ejection fraction 34.6 ± 11.0%). Agreement between the screening tool and polysomnography was high (ICC 0.85). The optimal cutoff value was apnea-hypopnea index ≥15/h (area under the ROC curve 0.94). Sensitivity and specificity were 92.9% and 91.9%, respectively. CONCLUSIONS: The screening tool is useful in excluding the presence of sleep apnea in HF patients to refer only high-risk patients for more extensive polysomnography. This method may potentially reduce the need for the more expensive polysomnography.

Oral appliance to assist non-invasive ventilation in a patient with amyotrophic lateral sclerosis.

BACKGROUND: From the moment the respiratory muscle groups are affected in amyotrophic lateral sclerosis (ALS), respiratory complications will be the major cause of morbidity and mortality. Untreated respiratory muscle impairment leads to respiratory insufficiency and additionally to difficulties in airway secretion clearance. Non-invasive ventilation (NIV) is the first choice in treating respiratory insufficiency in ALS as it improves sleep-related symptoms, quality of life and life expectancy. Nevertheless, NIV is not always effective, probably due to bulbar dysfunction or anatomical abnormalities. As a result, tracheostomy ventilation (TV) may become necessary. METHODS: In this case report, we present a 60-year-old female with ALS, for whom it was not possible to provide a sufficient tidal volume with NIV. A chin lift was performed while the patient was awake to see if a more anterior jaw position would lead to an increased tidal volume. As this was the case, a mandibular advancement device (MAD) was fabricated. RESULTS: With a combination of a MAD and NIV, the upper airway obstructions were overcome and a good ventilation and adherence to therapy were seen. CONCLUSIONS: When there is the presumption of airway obstructions in combination with an ineffective NIV, we advise to perform a chin lift to assess whether the obstructions can be overcome by a more anterior jaw position. If that is the case, NIV may be combined with MAD to establish effective ventilation and avoid the use of TV.

Inflammation is more distinct in temporomandibular joint osteoarthritis compared to the knee joint.

PURPOSE: Most of the current understanding of articular cartilage maintenance and degradation is derived from large load-bearing synovial joints, in particular the knee joint. The aim of this study was to identify valuable degradation markers for cartilage degradation in the temporomandibular joint (TMJ) by comparing the relative concentrations of carboxyterminal telopeptides of collagen types I and II (CTX-I and CTX-II), cartilage oligomeric matrix protein (COMP), and prostaglandin E2 (PGE2) in synovial fluid (SF) of TMJ and knee joints with cartilage degradation. MATERIALS AND METHODS: In this cross-sectional comparative study, participants were recruited from the University Medical Center Groningen, The Netherlands. Patients with TMJ osteoarthritis were compared with patients with knee osteoarthritis. The outcome variables were the relative SF concentrations of CTX-I, CTX-II, COMP, and PGE2. An independent samples Mann-Whitney U test was used to compare the relative concentrations. RESULTS: Thirty consecutive patients (9 male, 21 female; mean age, 40.1 yr; standard deviation, 15.3 yr) with TMJ osteoarthritis and 31 consecutive patients (20 male, 11 female; mean age, 37.4 yr; standard deviation, 13.7 yr) who were scheduled for arthroscopy of the knee joint participated in this study. Significant differences were found between relative concentrations of COMP (P = .000) and PGE2 (P = .005), and no significant differences were found between relative concentrations of CTX-I (P = .720) and CTX-II (P = .242). CONCLUSIONS: Relative SF concentrations of COMP and PGE2 showed significant differences between the TMJ and the knee joint, suggesting that there are differences in pathophysiology and that the inflammatory component may be more distinct in the TMJ.

Lavage therapy versus nonsurgical therapy for the treatment of arthralgia of the temporomandibular joint: a systematic review of randomized controlled trials.

AIMS: To carry out a systematic review of randomized controlled trials (RCTs) to investigate in patients with arthralgia of the temporomandibular joint (TMJ) the effectiveness of TMJ lavage compared to nonsurgical treatment with regard to pain intensity and mandibular range of motion. METHODS: The electronic databases Cochrane Controlled Trials Register (1960-2012), PubMed÷Medline (1966-2012), and Embase (1966-2012) were systematically searched for relevant RCTs. References of relevant articles were searched for additional studies, as well as citing reports. Two authors independently performed data extraction by using predefined quality indicators. Relevant outcome data included reduction in pain, as assessed by a visual analog scale (VAS) or a pain score, and maximal mouth opening (MMO) before and 6 months after treatment. Included trials were combined using fixed and random effects meta-analysis. RESULTS: Three RCTs (222 patients) were included for meta-analysis. The statistically significant overall standardized mean difference (SMD) (P < .001) with regard to pain intensity was -1.07 (95% CI = -1.38, - 0.76) in favor of TMJ lavage. The MMO did not change significantly (P > .05, SMD = .05 [95% CI = -0.33, 0.23]). CONCLUSIONS: The results suggest that lavage of the TMJ may be slightly more effective than nonsurgical treatment for pain reduction. However, this difference is not likely to be clinically relevant.

Alteration of cartilage degeneration and inflammation markers in temporomandibular joint osteoarthritis occurs proportionally.

PURPOSE: There is a growing interest in markers for cartilage degradation in synovial joints because of their potential diagnostic and prognostic value. Therefore, the aim of this study was to identify valuable degradation markers for temporomandibular joint (TMJ) osteoarthritis (OA) by comparing the relative concentrations of carboxyterminal telopeptides type I and II (CTX-I and II), cartilage oligomeric matrix protein (COMP), and prostaglandin E2 (PGE2) in the synovial fluid (SF) of TMJs with OA with those of healthy symptom-free TMJs. MATERIALS AND METHODS: In this cross-sectional case-control study, participants were recruited from the University Medical Center Groningen (Groningen, the Netherlands). Cases were defined as patients with TMJ OA, and control patients had symptom-free TMJs. The outcome variables were the relative concentrations of CTX-I, CTX-II, COMP, and PGE2 in osteoarthritic TMJ SF compared with symptom-free joints. An independent-samples Mann-Whitney U test was used to compare the relative concentrations. RESULTS: Thirty cases (9 male, 21 female; mean age, 40.1 yr; standard deviation, 15.3 yr) and 10 controls (5 male, 5 female; mean age, 30.3 yr; standard deviation, 10.8 yr) were studied. No significant differences in relative concentrations of CTX-I (P = .548), CTX-II (P = .842), COMP (P = .140), and PGE2 (P = .450) were found between the groups. Unexpected low relative concentrations of CTX-I and high relative concentrations of CTX-II were observed. CONCLUSIONS: Assumed changes in the SF concentration of CTX-I, CTX-II, COMP, and PGE2 in TMJ OA seem to occur proportionally. Furthermore, the unexpected large contribution of CTX-II suggests that this marker may be useful to quantify cartilage degradation in TMJ OA.

Does hypoxia-reperfusion injury occur in osteoarthritis of the temporomandibular joint?

AIMS: To determine the available evidence in the literature for whether hypoxia-reperfusion injury plays a role in the pathogenesis of joint diseases in general and of osteoarthritis (OA) of the temporomandibular joint (TMJ) in particular. METHODS: The electronic databases CENTRAL, PubMed, and EMBASE were systematically searched. The search strategy combined thesaurus terms "reperfusion injury" and "joints" and excluded "tourniquet," which possibly induces iatrogenic reperfusion injury. Inclusion and exclusion criteria were applied, data were extracted, and quality was assessed. RESULTS: Four studies could be included, investigating four different aspects of the hypoxia-reperfusion mechanism in joints. All studies investigated several arthritides in the knee or shoulder joint and were observational studies, except for one section of one of the studies, which was a randomized controlled trial. These studies do not provide any evidence to support or reject the hypothesis that hypoxia reperfusion occurs in TMJ OA. Positive but weak evidence is provided to support the hypothesis that hypoxia-reperfusion injury occurs in OA of the knee joint. Furthermore, some results of the included studies suggest differences between OA and other types of arthritis in relation to the hypoxia-reperfusion mechanism. CONCLUSION: There is no evidence to support or reject the hypothesis that hypoxia reperfusion occurs in TMJ OA, and limited evidence is provided to support that hypoxia-reperfusion injury occurs in OA of the knee joint. Since the studies suggest differences between OA and other types of arthritis in relation to hypoxia-reperfusion mechanisms, further research in this field needs to distinguish OA from other types of arthritis.

Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on temporomandibular side effects.

The objective of this study was to assess variations in the occurrence of temporomandibular disorders (TMDs) and the risk of developing pain and function impairment of the temporomandibular complex in obstructive sleep apnea syndrome (OSAS) patients treated with either an oral appliance (mandibular advancement device) or continuous positive airway pressure (CPAP) in a 2-year follow-up study. In addition, we assessed the relationship between the mean mandibular protrusion and the frequency of wearing the appliance during follow-up with the occurrence of pain and function impairment of the temporomandibular complex. Fifty-one patients were randomized to oral appliance therapy and 52 patients to CPAP therapy. TMDs (diagnosed according to the Axis I Research Diagnostic Criteria for TMD), pain intensity and disability and mandibular function impairment were recorded at baseline, after 2 months, 1 year and 2 years of therapy. Only in the initial period of treatment the occurrence of pain-related TMDs was considerably higher (24%) in the oral appliance group compared to CPAP (6%). Oral appliance therapy furthermore resulted in more temporomandibular pain compared to CPAP (odds ratio 2.33, 95% confidence interval (1.22-4.43)). However, there were no limitations in mandibular function in both groups during the (entire) follow-up period. Although generally not serious and of transient nature, oral appliance therapy results in more pain-related TMDs in the initial period of use compared with CPAP therapy. Oral appliance therapy is associated with increased pain in the temporomandibular complex in the initial period of use. Because of the transient nature, this pain is not a reason to contra-indicate an oral appliance in OSAS patients. Moreover, TMDs and the risk of developing pain and function impairment of the temporomandibular complex appear limited with long-term oral appliance use.

Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial.

BACKGROUND: Shoulder pain is a common musculoskeletal problem that is often chronic or recurrent. Myofascial trigger points (MTrPs) cause shoulder pain and are prevalent in patients with shoulder pain. However, few studies have focused on MTrP therapy. The aim of this study was to assess the effectiveness of multimodal treatment of MTrPs in patients with chronic shoulder pain. METHODS: A single-assessor, blinded, randomized, controlled trial was conducted. The intervention group received comprehensive treatment once weekly consisting of manual compression of the MTrPs, manual stretching of the muscles and intermittent cold application with stretching. Patients were instructed to perform muscle-stretching and relaxation exercises at home and received ergonomic recommendations and advice to assume and maintain good posture. The control group remained on the waiting list for 3 months. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score (primary outcome), Visual Analogue Scale for Pain (VAS-P), Global Perceived Effect (GPE) scale and the number of muscles with MTrPs were assessed at 6 and 12 weeks in the intervention group and compared with those of a control group. RESULTS: Compared with the control group, the intervention group showed significant improvement (P < 0.05) on the DASH after 12 weeks (mean difference, 7.7; 95% confidence interval (95% CI), 1.2 to 14.2), on the VAS-P1 for current pain (mean difference, 13.8; 95% CI, 2.6 to 25.0), on the VAS-P2 for pain in the past 7 days (mean difference, 10.2; 95% CI, 0.7 to 19.7) and VAS-P3 most severe pain in the past 7 days (mean difference, 13.8; 95% CI, 0.8 to 28.4). After 12 weeks, 55% of the patients in the intervention group reported improvement (from slightly improved to completely recovered) versus 14% in the control group. The mean number of muscles with active MTrPs decreased in the intervention group compared with the control group (mean difference, 2.7; 95% CI, 1.2 to 4.2). CONCLUSIONS: The results of this study show that 12-week comprehensive treatment of MTrPs in shoulder muscles reduces the number of muscles with active MTrPs and is effective in reducing symptoms and improving shoulder function in patients with chronic shoulder pain. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN75722066.

Single implants with different neck designs in the aesthetic zone: a randomized clinical trial.

OBJECTIVES: To compare single implants in the aesthetic zone with different neck designs for marginal bone-level changes and clinical outcome measures. MATERIALS AND METHODS: Ninety-three patients with a missing anterior tooth in the maxilla were randomly assigned to be treated with an implant with a 1.5 mm smooth neck ("smooth group"), a moderately rough neck with grooves ("rough group") or a scalloped moderately rough neck with grooves ("scalloped-group"). Implants were installed in healed sites and were loaded after 3 months. Follow-up visits were conducted at 6 and 18 months after implant placement. RESULTS: The scalloped group showed significantly more radiographic bone loss from implant placement to 18 months (2.01 ± 0.77 mm) compared with the smooth group (1.19 ± 0.82 mm) and rough group (0.9 ± 0.57 mm). Furthermore the scalloped group showed significantly deeper pocket depths and a higher bleeding score. There were no between-group differences in soft tissue levels. Survival rates were 97% for the smooth group and 100% for the rough and scalloped groups (P>0.05). No significant differences in outcome were found between the smooth group and rough group. CONCLUSION: For anterior tooth replacements, implants with a scalloped neck showed more marginal bone loss and less favourable clinical outcome compared with implants with a 1.5 mm smooth neck or implants with a rough neck.

High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain.

BACKGROUND: Shoulder pain is reported to be highly prevalent and tends to be recurrent or persistent despite medical treatment. The pathophysiological mechanisms of shoulder pain are poorly understood. Furthermore, there is little evidence supporting the effectiveness of current treatment protocols. Although myofascial trigger points (MTrPs) are rarely mentioned in relation to shoulder pain, they may present an alternative underlying mechanism, which would provide new treatment targets through MTrP inactivation. While previous research has demonstrated that trained physiotherapists can reliably identify MTrPs in patients with shoulder pain, the percentage of patients who actually have MTrPs remains unclear. The aim of this observational study was to assess the prevalence of muscles with MTrPs and the association between MTrPs and the severity of pain and functioning in patients with chronic non-traumatic unilateral shoulder pain. METHODS: An observational study was conducted. Subjects were recruited from patients participating in a controlled trial studying the effectiveness of physical therapy on patients with unilateral non-traumatic shoulder pain. Sociodemographic and patient-reported symptom scores, including the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, and Visual Analogue Scales for Pain were compared with other studies. To test for differences in age, gender distribution, and education level between the current study population and the populations from Dutch shoulder studies, the one sample T-test was used. One observer examined all subjects (n = 72) for the presence of MTrPs. Frequency distributions, means, medians, standard deviations, and 95% confidence intervals were calculated for descriptive purposes. The Spearman's rank-order correlation (ρ) was used to test for association between variables. RESULTS: MTrPs were identified in all subjects. The median number of muscles with MTrPs per subject was 6 (active MTrPs) and 4 (latent MTrPs). Active MTrPs were most prevalent in the infraspinatus (77%) and the upper trapezius muscles (58%), whereas latent MTrPs were most prevalent in the teres major (49%) and anterior deltoid muscles (38%). The number of muscles with active MTrPs was only moderately correlated with the DASH score. CONCLUSION: The prevalence of muscles containing active and latent MTrPs in a sample of patients with chronic non-traumatic shoulder pain was high.

TMD pain: the effect on health related quality of life and the influence of pain duration.

OBJECTIVES: As impact of literature concerning this subject is scarce, the objectives of this study were to assess whether the Health Related Quality of Life (HRQoL) is decreased in patients with painful temporomandibular disorders as compared to the HRQoL in the general population, and to evaluate to what extent pain duration affects HRQoL. METHODS: Data concerning physical and mental health were retrieved from patients with painful temporomandibular disorders. Assessment tools used were: the Mandibular Function Impairment Questionnaire (MFIQ), the Short-Form-36 (SF-36), the Hospital Anxiety and Depression Schedule (HADS), and the General Health Questionnaire (GHQ). In order to examine the influence of the duration of pain on HRQoL, the total sample was divided into three different subgroups. Subgroup 1 consisted of patients with complaints existing less than one year. Patients with complaints from 1 to 3 years were allocated to the second group. The 3rd subgroup included patients with complaints longer than 3 years. RESULTS: The total sample consisted of 95 patients (90 females and 5 males). On most physical and social functioning items, groups 2 and 3 scored significantly worse than the general population. On the other hand, none of the groups differed from the general population when comparing the mental items. Duration of pain was significantly correlated with SF-36 subscale physical functioning and the mandibular impairment. CONCLUSION: Patients with TMD pain less than one year score better than compared to the population norm. With a longer duration of pain, mental health scores and role limitations due to emotional problems do not appear to be seriously affected by reduced physical health, while social functioning appears to be considerably affected.

Long-term obstructive sleep apnea therapy: a 10-year follow-up of mandibular advancement device and continuous positive airway pressure.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder, commonly managed by either continuous positive airway pressure (CPAP) or a mandibular advancement device (MAD). Long-term follow-up and comparison regarding efficacy of these therapies is scarce. In this study the results of treatment, patient adherence, and satisfaction over a 10-year follow-up of these therapies are reported. METHODS: This is a longitudinal follow-up study taken from a subset of patients initially enrolled in a randomized controlled clinical trial of 103 patients with OSA (51 and 52 patients randomized for MAD and CPAP, respectively). After a 10-year follow-up period, 14 patients using MAD and 17 patients using CPAP could be evaluated for this longitudinal follow-up study. Data were analyzed at baseline, after 3 months and at 1-, 2-, and 10-year follow-up. All 31 patients with OSA underwent polysomnography and self-reported measurements. RESULTS: Polysomnography results showed a favorable outcome of both therapies at 10-year follow-up. At baseline, included patients in both groups did not significantly differ in apnea-hypopnea index (AHI) values. At 10-year follow-up, both the MAD and CPAP groups showed a significant reduction in AHI. At baseline the mean AHI in the MAD group was 31.7 ± 20.6 events/h whereas in the CPAP group it was 49.2 ± 26.1 events/h. At 10-year follow-up the mean AHI in the MAD group was 9.9 ± 10.3 events/h and in the CPAP group it was 3.4 ± 5.4 events/h. Both therapies resulted in a substantial improvement in self-reported neurobehavioral outcomes at 10-year follow-up. CONCLUSIONS: Both CPAP and MAD therapy demonstrate good and stable treatment effects after a 10-year follow-up period. Therefore, when indicated, both therapies are appropriate modalities for the long-term management of OSA. CLINICAL TRIAL REGISTRATION: Registry: Netherlands Trial Register; Name: Management of the Obstructive Sleep Apnea-Hypopnea Syndrome: Oral Appliance versus Continuous Positive Airway Pressure Therapy; Identifier: NL75; URL: https://www.trialregister.nl/trial/75.

Mechanical strength and stiffness of the biodegradable SonicWeld Rx osteofixation system.

PURPOSE: To determine the mechanical strength and stiffness of the new 2.1 mm biodegradable ultrasound-activated SonicWeld Rx (Gebrüder Martin GmbH & Co, Tuttlingen, Germany) osteofixation system in comparison with the conventional 2.1 mm biodegradable Resorb X (Gebrüder Martin GmbH & Co) osteofixation system. MATERIALS AND METHODS: Plates and screws were fixed to 2 polymethylmethacrylate blocks to simulate bone segments and were subjected to tensile, side bending, and torsion tests. During testing, force and displacement were recorded and graphically presented in force-displacement diagrams. For the tensile tests, the strength of the osteofixation system was measured. The stiffness was calculated for the tensile, side bending, and torsion tests. RESULTS: The tensile strength and stiffness as well as the side bending stiffness of the SonicWeld Rx system presented up to 11.5 times higher mean values than the conventional Resorb X system. The torsion stiffness of both systems presents similar mean values and standard deviations. CONCLUSIONS: The SonicWeld Rx system is an improvement in the search for a mechanically strong and stiff as well as a biodegradable osteofixation system. Future research should be done to find out whether the promising in vitro results can be transferred to the in situ clinical situation.

Long-Term Objective Adherence to Mandibular Advancement Device Therapy Versus Continuous Positive Airway Pressure in Patients With Moderate Obstructive Sleep Apnea.

STUDY OBJECTIVES: Comparable health effects of mandibular advancement device (MAD) and continuous positive airway pressure (CPAP) therapy have been attributed to higher adherence with MAD compared with CPAP therapy. The objective of this study was to make a direct comparison of the objective adherence between MAD and CPAP in patients with moderate obstructive sleep apnea (OSA). METHODS: Adherence was monitored for 12 months in 59 patients with moderate OSA (apnea-hypopnea index 15-30 events/h) as part of a randomized controlled trial. Objective adherence with MAD was assessed using the TheraMon microsensor. Objective adherence with CPAP was assessed using the built-in registration software with readout on SD card. Self-reported adherence with both therapies was assessed using a questionnaire. RESULTS: Forty patients (68%) completed the study with the therapy to which they were randomly assigned. Median (interquartile range) objective adherence (h/night) in the 3rd month was 7.4 (5.2-8.2) for MAD and 6.8 (5.7-7.6) for CPAP (P = .41), compared to 6.9 (3.5-7.9) with MAD and 6.8 (5.2-7.6) with CPAP (P = .85) in the 12th month. There were no significant changes between the 3rd and 12th month for both MAD (P = .21) and CPAP (P = .46). Changes in adherence were not significantly different between MAD and CPAP (P = .51). Self-reported adherence was significantly higher with MAD than CPAP at all follow-ups. Self-reported adherence with CPAP was lower than objective CPAP adherence at the 6th and 12th month (P = .02). CONCLUSIONS: Objective adherence with MAD and CPAP is comparable and consistent over time. Self-reported adherence is higher with MAD than with CPAP giving rise to interesting discrepancy between objective and self-reported adherence with CPAP. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Identifier: NCT01588275.

Clinical- and Cost-Effectiveness of a Mandibular Advancement Device Versus Continuous Positive Airway Pressure in Moderate Obstructive Sleep Apnea.

STUDY OBJECTIVES: Limited evidence exists on the cost-effectiveness of mandibular advancement device (MAD) compared to continuous positive airway pressure (CPAP) therapy in moderate obstructive sleep apnea (OSA). Therefore, this study compares the clinical and cost-effectiveness of MAD therapy with CPAP therapy in moderate OSA. METHODS: In a multicentre randomized controlled trial, patients with an apnea-hypopnea index (AHI) of 15 to 30 events/h were randomized to either MAD or CPAP. Incremental cost-effectiveness and cost-utility ratios (ICER/ICUR, in terms of AHI reduction and quality-adjusted life-years [QALYs, based on the EuroQol Five-Dimension Quality of Life questionnaire]) were calculated after 12 months, all from a societal perspective. RESULTS: In the 85 randomized patients (n = 42 CPAP, n = 43 MAD), AHI reduction was significantly greater with CPAP (median reduction AHI 18.3 [14.8-22.6] events/h) than with MAD therapy (median reduction AHI 13.5 [8.5-18.4] events/h) after 12 months. Societal costs after 12 months were higher for MAD than for CPAP (mean difference €2.156). MAD was less cost-effective than CPAP after 12 months (ICER -€305 [-€3.003 to €1.572] per AHI point improvement). However, in terms of QALY, MAD performed better than CPAP after 12 months (€33.701 [-€191.106 to €562.271] per QALY gained). CONCLUSIONS: CPAP was more clinically effective (in terms of AHI reduction) and cost-effective than MAD. However, costs per QALY was better with MAD as compared to CPAP. Therefore, CPAP is the first-choice treatment option in moderate OSA and MAD may be a good alternative. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Identifier: NCT01588275.

Vivosorb, Bio-Gide, and Gore-Tex as barrier membranes in rat mandibular defects: an evaluation by microradiography and micro-CT.

OBJECTIVES: The objectives of this study were to determine whether a new degradable synthetic barrier membrane (Vivosorb) composed of poly(dl-lactide-epsilon-caprolactone) (PDLLCL) can be useful in implant dentistry and to compare it with collagen and expanded polytetrafluoroethylene (ePTFE) membranes. MATERIAL AND METHODS: In 192 male Sprague-Dawley rats, a standardized 5 mm circular defect was created through the right angle of the mandible. New bone formation was evaluated by post-mortem microradiography and micro-CT (muCT) imaging. Four groups (control, PDLLCL, collagen, ePTFE) were evaluated at three time intervals (2, 4, and 12 weeks). In the membrane groups the defects were covered; in the control group the defects were left uncovered. Data were analysed using a multiple regression model. RESULTS: New bone formation could be detected by post-mortem microradiography in 130 samples and by muCT imaging in 112 samples. Bone formation was progressive in 12 weeks, when the mandibular defect was covered with a membrane. Overall, more bone formation was observed underneath the collagen and ePTFE membranes than the PDLLCL membranes. CONCLUSIONS: In contrast to uncovered mandibular defects, substantial bone healing was observed in defects covered with a PDLLCL membrane. However, bone formation in PDLLCL-covered defects tended to be less than in the defects covered with collagen or ePTFE. The high variation in the PDLLCL samples at 12 weeks may be caused by the moderate adherence of this membrane to bone compared with collagen. These results indicate that further study is needed to optimize the properties of PDLLCL membranes.

A comparison of micro-CT, microradiography and histomorphometry in bone research.

OBJECTIVE: Intraobserver reliability and agreement were determined for microradiography (MR), micro-computed tomography (microCT) and histomorphometry (HM). These three modalities were compared for quantitative measurements of bone formation and graft modelling in rat mandibular defects and grafts. DESIGN: Twelve rats were randomly selected from a larger experiment, evaluating bone formation in rat mandibular defects and bone modelling in grafts. Twelve lateral microradiographs were taken of the grafts. microCT images were obtained from all defects and grafts (24 specimens). Defects and grafts were cut perpendicularly through their centre. Microradiographs, microCT images and histological sections were obtained from the resulting 48 specimens. New bone volume and graft volume were measured using image analysis software on MR and microCT images. Defect width and graft width were measured using images from HM, MR and microCT. The results were compared to each other. RESULTS: The intraobserver reliabilities for the measurements of new bone volume by microCT, and the measurement of graft modelling by MR and graft volume by microCT were high. The differences between MR, HM and microCT were larger in defect width measurements than in graft width measurement. MR measured smaller defects than HM and microCT. The 95% confidence interval was larger in defect width measurements compared to graft width measurements. CONCLUSIONS: The methods of MR and microCT image analysis are reliable but preferably should be used in combination as to obtain valid conclusions. HM, MR and microCT for graft widths measurements showed more agreement than for defect width measurements. MR appears to overestimate bone formation.

Cost Effectiveness of Arthrocentesis Compared to Conservative Therapy for Arthralgia of the Temporomandibular Joint: A Randomized Controlled Trial.

AIMS: To determine the cost effectiveness and cost utility of arthrocentesis as an initial treatment for temporomandibular joint (TMJ) arthralgia compared to usual care. METHODS: A two-armed, parallel-design, randomized controlled trial (RCT) was conducted in the Netherlands from January 2009 to June 2012 that included patients with TMJ arthralgia. Patients were randomly allocated to arthrocentesis (n = 40) or usual care (n = 40) for initial treatment. Arthrocentesis consisted of rinsing the intra-articular space with isotonic saline, and usual care included a soft diet, physical therapy, and splint therapy. The duration of the usual care program was 6 weeks, and follow-up was conducted 3, 12, and 26 weeks after its completion. Generalized estimated equation multivariate models were assessed in order to correct for the dependency of repeated measurements in the longitudinal data analysis. An independent samples t test was used to compare the arthrocentesis group with the usual care group for TMJ pain after 26 weeks. Cost effectiveness (total cost from a societal view) was related to TMJ pain (as measured on a visual analog scale [0 to 100 mm]) and to cost utility (quality-adjusted life years). RESULTS: TMJ pain declined more quickly in the arthrocentesis group (n = 36) than in the usual care group (n = 36) (regression coefficient ß = -10.76; 95% confidence interval [CI] = -17.75 to -3.77; P = .003). The estimated mean total (ie, societal) cost over 26 weeks was €589 (US $795) in the arthrocentesis group and €1,680 (US $2,266) in the usual care group. Arthrocentesis was associated with a lower mean cost and better health outcomes than usual care in 98% and 95% of the bootstrap simulations, respectively. CONCLUSION: The results of this study suggest that, from an economical perspective, arthrocentesis may be superior to usual care for the initial treatment of TMJ pain, as it had better health outcomes and lower costs than usual care.

Reasons That Dutch Dentists and Dental Hygienists Oppose or Support an Extended Scope of Practice for Dental Hygienists.

BACKGROUND: In the Netherlands, the scope of dental hygiene practice was expanded in 2006. The objective of this study was to explore reasons among dentists and dental hygienists for supporting or opposing an extended scope of practice and to find explanatory factors. METHODS: A questionnaire containing pre-defined reasons and an open-ended question was distributed among 1,674 randomly selected members of two Dutch professional associations (874 dentists, 800 dental hygienists). Data were analyzed with binary logistic regression with Bayesian information criterion (BIC) model selection. RESULTS: Response were obtained from 541 practitioners (32.3%): i.e., 233 dentists (43.1%) and 308 dental hygienists (56.9%). Non-response analysis revealed no differences, and representativeness analysis showed similarities between samples and target populations. Most often, dentists reported flexible collaboration (50.2%) and dental hygienists indicated task variation (71.1%) as supportive reasons. As opposing reasons, dentists generally reported quality of care (41.2%) and dental hygienists' self-competence (22.7%). Reasons were explained by profession, gender, and new-style practitioners. CONCLUSION: Dentists and dental hygienists conveyed different reasons for supporting or opposing an extended scope of dental hygiene practice. Outcomes can be categorized as reasons related to economic, professional status, quality, job satisfaction, and flexible collaboration and are not only explained by profession.