Preliminary short-term outcomes of rapid maxillary expansion on periodic limb movements during sleep in pediatric sleep-disordered breathing.

OBJECTIVE: To assess the short-term outcome of rapid maxillary expansion (RME) on periodic limb movement disorder (PLMD) in children with residual snoring after late adenotonsillectomy (AT). METHODS: This prospective clinical trial included 24 patients treated with rapid maxillary expansion (RME). Participants' inclusion criteria were children with maxillary constriction aged 5-12 years who had AT for more than two years and those whose parents/guardians reported that they still snored ≥4 nights per week. Of which 13 had primary snoring, and 11 had OSA. All patients underwent laryngeal nasofibroscopy evaluation and complete polysomnography. The Quality of life (QOL) Questionnaire (OSA-18), the Pediatric Sleep Questionnaire (PSQ), the Conners Abbreviated Scale (CAE), and the Epworth Sleep Scale (ESS) were applied before and after palatal expansion. RESULTS: The OSA 18 domain, PSQ total, CAE, and ESS scores were significantly reduced in both groups (p < 0.001). There was a decrease in PLMS indices. In the total sample, the mean decreased significantly from 4.15 to 1.08. In the Primary Snoring group, the mean decreased from 2.64 to 0.99; in the OSA group, the average decreased significantly from 5.95 to 1.19. CONCLUSION: This preliminary study suggests that the improvement of PLMS in the OSA group with maxillary constriction is correlated with a favorable neurological impact of the treatment. We suggest a multi-professional approach to the treatment of sleep disorders in children.

Australasian Sleep Association position statement on consensus and evidence based treatment for primary snoring.

Primary snoring impacts a significant portion of the adult population and has the potential to significantly impair quality of life. The purpose of these guidelines is to provide evidence-based recommendations to assist Australasian practitioners in the management of adult patients who present with primary snoring without significant obstructive sleep apnoea. The Timetable, Methodology and Standards by which this Position Statement has been established is outlined in the Appendix S1. The main recommendations are: Weight loss, and reduced alcohol consumption should be recommended, where appropriate If clinical judgement dictates, benzodiazepine and opioid reduction or avoidance may be advised Positional therapy should be considered in supine dominant snorers In dentate patients, Mandibular advancement devices (MAD) should be recommended as a first line treatment following assessment by both an appropriate Dentist and Sleep physician Continuous positive airway pressure (CPAP) devices may be recommended in patients with primary snoring in those already committed to their use or willing to try Surgical treatment of primary snoring by an appropriately credentialled surgeon may be advised and includes nasal (adjunctive), palatal and other interventions This position statement has been designed based on the best available current evidence and our combined expert clinical experience to facilitate the management of patients who present with primary snoring. It provides clinicians with a series of both non-surgical and surgical options with the aim of achieving optimal symptom control and patient outcomes. This is the first such set of recommendations to be established within Australasia and has also been reviewed and endorsed by the Australasian Sleep Association.

Orofacial Pain and Snoring/Obstructive Sleep Apnea in Individuals with Head and Neck Cancer: A Critical Review.

AIMS: (1) To summarize current knowledge on the prevalence, intensity, and descriptors of orofacial pain and snoring/obstructive sleep apnea (OSA) before and after head and neck cancer (HNC) treatment; and (2) to propose future directions for research. METHODS: The median prevalence for each condition was estimated from the most recent systematic reviews (SRs) and updated with new findings retrieved from the PubMed, Web of Science, Embase, and Cochrane databases up to December 2021. RESULTS: The prevalence of HNC pain seems relatively stable over time, with a median of 31% before treatment in three studies to a median of 39% at 1 month to 16 years after treatment in six studies. HNC pain intensity remains mild to moderate. There was a threefold increase in temporomandibular pain prevalence after surgery (median 7.25% before to 21.3% after). The data for snoring prevalence are unreliable. The OSA/HNC prevalence seems relatively stable over time, with a median of 72% before treatment in three studies to 77% after treatment in 14 studies. CONCLUSION: With the exception of temporomandibular pain, the prevalence of HNC pain and OSA seems to be stable over time. Future studies should: (1) compare the trajectory of change over time according to each treatment; (2) compare individuals with HNC to healthy subjects; (3) use a standardized and comparable method of data collection; and (4) assess tolerance to oral or breathing devices, since HNC individuals may have mucosal sensitivity or pain.

El paciente roncador: evaluación y alternativas terapéuticas / The snoring patient: evaluation and therapeutic alternatives

El ronquido es un problema altamente prevalente, que afecta a millones de personas a nivel mundial. Impacta negativamente en la calidad de vida al afectar la relación de pareja y la calidad de sueño, además de constituir un factor de riesgo cardiovascular. El objetivo de esta revisión es analizar y discutir los aspectos más relevantes de esta condición, desde su etiopatogenia hasta las diferentes alternativas terapéuticas disponibles. En la evaluación del paciente roncador se debe realizar un minucioso examen de nariz, boca, faringe, cuello y esqueleto facial, además de estimar el riesgo de que exista una apnea obstructiva del sueño asociada. Son de utilidad una serie de cuestionarios que permiten asignar puntaje a la sintomatología del paciente y evaluar su impacto en la vida diaria. En general, el estudio deberá incluir exámenes radiológicos, endoscopías de la vía aérea superior (con el paciente despierto y bajo sueño inducido por medicamentos) y estudios del sueño, que se pueden realizar tanto en forma ambulatoria como hospitalizado. Existe una amplia gama de tratamientos disponibles para el ronquido, los que han demostrado una alta efectividad en diferentes subgrupos de pacientes: bajar de peso, dejar de fumar, medicamentos antialérgicos, terapia postural, ejercicios faríngeos, dispositivos de avance mandibular y procedimientos quirúrgicos que van desde intervenciones mínimamente invasivas hasta procedimientos avanzados como cirugía robótica, avances máxilo-mandibulares y la estimulación del nervio hipogloso. Es clave para manejar exitosamente el ronquido el realizar una evaluación detallada del paciente y establecer un plan terapéutico personalizado.

Snoring is a highly prevalent problem, affecting millions of people worldwide. It negatively impacts quality of life by affecting couple relationships and sleep quality, as well as being a cardiovascular risk factor. The aim of this review article is to analyze and discuss the most relevant aspects of this condition, ranging from its etiology and pathogenesis to the different available therapeutic options. When evaluating a snoring patient, a thorough examination of the nose, mouth, pharynx, neck and facial skeleton should be performed, and the risk of having an associated obstructive sleep apnea must be estimated. A series of questionnaires are useful to assign scores to the patient's symptoms and assess their impact on daily life. In general terms, patient evaluation should include radiological examinations, upper airway endoscopies (awake and under drug-induced sleep) and sleep studies, which can be performed both on an outpatient or inpatient basis. There is a wide range of treatments available for snoring, which have shown high effectiveness in different patient subgroups: weight loss, quitting smoking, anti-allergic medications, postural therapy, pharyngeal exercises, mandibular-advancement devices and surgical procedures ranging from minimally invasive interventions to advanced procedures such as robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. The cornerstone for a successful snoring management is to perform a detailed patient evaluation and to establish a personalized therapeutic plan.

Effect of position therapy and oral devices on sleep parameters in patients with obstructive sleep apnea.

PURPOSE: The purpose of this study was to elucidate the effect of a neck-worn position therapy device (PTD) and oral appliance (OA) on sleep parameters in patients with obstructive sleep apnea (OSA). METHODS: Patients with an apnea hypopnea index (AHI) of 5/h or more at baseline polysomnography were divided into a PTD group and an OA group randomly. All participants underwent a type 1 polysomnography for diagnosis and device-set outcome measurements. RESULTS: The PTD decreased the AHI from a mean of 24.2/h to 16.7/h, and the OA decreased the AHI from 20.8/h to 10.3/h. Snoring duration decreased from 31.1% to 16.9% in the PTD group, and from 41.2% to 30.7% in the OA group. There were no significant differences in these decreases between the two groups. The PTD decreased sleep-time percentage in the supine position from a mean of 67.4% to 4.5%, despite five patients who were unable to avoid the supine position. There were no significant differences in improvement in sleep efficiency, percentage of stage wake, stage N1, stage N2, and stage REM, and overall arousal and respiratory arousal indices between the two groups. However, the spontaneous arousal index worsened in the OA responders but remained unchanged in the PTD responders. Percentage of stage N3 sleep (%N3) was improved in the PTD responders but not in the OA responders. There were significant differences in spontaneous arousal index and %N3 between the two groups. CONCLUSION: PTDs are a potential treatment modality that does not disturb sleep in patients with OSA.

Adherence to oral appliance treatment and its determinants in obstructive sleep apnoea patients.

BACKGROUND AND OBJECTIVES: Treatment effectiveness, in terms of health benefits, is a composite of efficacy and adherence. Oral appliance (OA) usage is mainly based on self-reports, but nowadays, objective adherence monitoring for OAs is available. This study investigated the objective OA adherence and its determinants in obstructive sleep apnoea (OSA) patients. MATERIALS AND METHODS: There were 29 subjects who were treated with OA; mean [SD] age 51.4 [11.1]; mean apnoea-hypopnoea index (AHI) [SD] 19.5 [10.0]. Anthropometric and sociodemographic parameters, AHI, daytime sleepiness, snoring, and adverse effects of OA as potential determinants were evaluated. Patients were classified as regular users if they wore OA at least 4 hours nightly 5-7 nights a week. Statistical analyses included the chi-square test, t-test, Mann-Whitney U-test, and linear regression analyses. RESULTS: At the 3-month follow-up, 68% of subjects were regular users and at 12-month follow-up, 64%. AHI, sociodemographic parameters, or adverse effects were not associated with OA adherence. Snoring seemed to improve weakly adherence, whereas mandibular retrusion reduced the weekly use, and smoking the nightly use of OAs. LIMITATIONS: The follow-up time was short, and there were a relatively small number of patients with obtainable adherence data, therefore it is difficult to establish if OA therapy alone is a successful long-term treatment option for OSA patients. CONCLUSIONS/IMPLICATIONS: Adherence to OA therapy is mainly the outcome of patients' subjective comfort in everyday life through eliminating social disturbance of snoring. To best meet a subject's individual treatment need and to prevent suboptimal use of OA, a patient-tailored therapy including digital wear-time documentation is recommended.

Surgical solutions to orofacial problems.

BACKGROUND: Orofacial problems present frequently to primary care providers. Many of these problems have a surgical solution. Some may require minor procedures, while others require major maxillofacial surgery. OBJECTIVE: The purpose of this article is to illustrate how some common orofacial presentations can be investigated and solutions found in conjunction with oral and maxillofacial surgeons. DISCUSSION: This article outlines a method of approach for some of the issues with which patients present to their primary healthcare provider that may be resolved using skills and techniques of maxillofacial surgery.

Comparison of the efficacy of two surgical procedures on adenoidal hypertrophy in children.

OBJECTIVE: The aim of this study was to explore the treatment effects of two surgical procedures, performed with nasal endoscopy, on treating adenoidal hypertrophy in children. METHODS: A total of 100 children diagnosed with adenoidal hypertrophy were treated with curettage combined with microwave thermocoagulation and with low-temperature plasma radiofrequency ablation under nasal endoscopic guidance; 6 months after surgery, the effects on snoring, nasal congestion, hearing loss, and gland residue were retrospectively analyzed. RESULTS: Differences in snoring and hearing loss between the two groups were not statistically significant (P>0.05), but the differences in nasal congestion and gland residue between the two groups were statistically significant (P<0.05); the therapeutic effect was superior in the low-temperature plasma radiofrequency ablation group than in the curettage combined with microwave thermocoagulation group. CONCLUSION: Low-temperature plasma radiofrequency ablation with nasal endoscopy can achieve a better comprehensive effect on treating adenoidal hypertrophy in children than curettage combined with microwave thermocoagulation.

El paciente ortodóncico en dentición mixta y los trastornos del sueño / The orthodontic patient with mixed dentition and sleep disorders

Los desórdenes respiratorios del sueño (DRS) y, principalmente, roncopatías y apneas obstructivas afectan aproximadamente al 7% de los pacientes ortodóncicos. Los DRS no solo son importantes por la cantidad de pacientes afectados, sino por la gravedad de los posibles efectos secundarios a nivel de la salud general del paciente. La obstrucción de las vías aéreas superiores (VAS) provoca alteraciones del crecimiento y deformaciones craneofaciales importantes, por lo que el tratamiento temprano y la prevención de la respiración oral es muy importante.El papel del ortodoncista es muy importante en el diagnóstico y en el tratamiento de los DRS, pero también en su prevención, realizando tratamientos que aumenten la dimensión y la permeabilidad de las VAS. El protocolo de exploración interdisciplinar en niños y adolescentes y la cefalometría de vías aéreas son importantes en el diagnóstico y deben ser tenidos en cuenta en el plan de tratamiento. Pero las pruebas más significativas, el CBCT de vías aéreas y la polisomnografía no son pruebas rutinarias por la dificultad logística y el precio de estas pruebas. En este artículo también se recomiendan los tratamientos de ortodoncia más indicados en estos casos y que tienden al aumento de la dimensión de las VAS (AU)

Sleep breathing disorders (SBD) and in the first place, roncopathy and obstructive apnea, affect approximately 7% of orthodontic patients. The SBD are not only important for the number of affected patients, but also for the severity of the possible side effects at the level of general health of a patient. The upper air ways (UAW) obstruction provokes important alterations in growth and craniofacial deformations, and this is why the early treatment and prevention of mouth breathing are very important. The role of an orthodontist in diagnosis and treatment of SBD is very important, but it is also in its prevention, carrying out the treatments which increase the dimension and permeability of UAW. The protocol of interdisciplinary examination.In children and adolescents and the air ways cephalometry analysis have an important role in diagnosis and they should be taken into account in treatment planning. But the most important tests, the air ways CBCT and polysomnography, are not routine tests due to the complicated logistics and their cost. In this article, the orthodontic treatments most indicated in these cases are recommended, because they tend to increase the UAW dimension (AU)

Oral appliance for Obstructive Sleep Apnea: Prototyping and Optimization of the Mandibular Protrusion Device.

Obstructive Sleep apnea is a public health problem. This disease is associated with daytime sleepiness, increased motor vehicle accidents, heart failure and stroke. Treatment options include weight loss, positive airway pressure, pharyngeal and orthognatic surgery. However, selected patients have good response to oral appliances devices that intended to protrude and stabilize the mandible mechanically during the night in order to reduce the collapsibility of the upper airway. Selection of patients includes primary snoring, mild, moderate and positional apnea. The perfect mandibular advance device has not yet been designed. For these reasons, the objective of this paper is to present a new thermoadjustable chair-side oral appliance. Device integrates the best characteristics of custom made and boils and bite previous designs and minimizes inconveniences and possible side effects. The device is a titratable mandibular advancement appliance. It consists of two independent prefabricated trays adaptable to the shape of adult dental arch and linked to each other by a protrusion mechanism. Each tray contains a hard outer shell and a soft thermoplastic resin inner body. The position of the jaw can be adjusted by moving an aluminum rack into, or out from, the guide so the ratchet may get locked into a certain position ensuring the length of the mechanism. The protrusion mechanism is fixed to the splint using small rings that are articulated over a "t" button. Our prototype satisfies the requirements of an effective oral appliance, in terms of retention, comfort, safety and efficacy. It is easy to fit, durable, low cost, quickly titratable, not bulky and easy cleaning. Thermoplastic appliances are specially used like a predictor of treatment response in apnea patients. The device described is a cost-effective introduction to mandibular advancement technology. A qualified dentist or trained sleep doctor could mitigate dental side effects and reduce their incidence.

A prospective, non-randomized evaluation of a novel low energy radiofrequency treatment for nasal obstruction and snoring.

BACKGROUND: Weak or inward-bent cartilage of the nasal sidewall at the level of the internal nasal valve (INV) can produce narrowness or collapse of the nasal valve. This is a common cause of impaired nasal breathing during daily activities and there is also an established connection between nasal obstruction and snoring. The condition is often difficult to treat, although even a small enlargement of the lumen at the nasal valve can lead to a significant improvement in the ease of nasal breathing. METHODS: The primary objective of this prospective study was to evaluate the safety and efficacy of the Vivaer system for the treatment of narrowed nasal valves and to measure changes in the symptoms of nasal obstruction and snoring. The Vivaer system uses low energy radiofrequency to remodel the nasal sidewall in order to improve airflow. RESULTS: The study involved 31 patients presenting from 1st September 2017 to 1st May 2018 with symptoms of nasal obstruction and snoring. In all patients, an improvement was observed in nasal breathing measured by NOSE score, sleep quality by SOS questionnaire and quality of life as measured by EQ-5D and SNOT-22. CONCLUSION: Vivaer intranasal remodeling can provide a durable and well-tolerated non-invasive treatment for those patients who are suffering congestion due to narrowness or collapse of the INV.

Side effects of mandibular advancement splints for the treatment of snoring and obstructive sleep apnea: a systematic review

ABSTRACT Introduction: Occlusal side effects or development of pain and/or functional impairment of the temporomandibular complex are potential reasons for poor compliance or abandonment of mandibular advancement splints treatment for snoring and obstructive sleep apnea. Objective: This study aimed at providing a comprehensive review evaluating the craniofacial side effects of oral appliance therapy for snoring and obstructive sleep apnea. Methods: An electronic search was systematically conducted in PubMed and Virtual Health Library from their inception until October 2016. Only Randomized Controlled Trials whose primary aim was to measure objectively identified side effects on craniofacial complex of a custom-made oral appliance for treating primary snoring or obstructive sleep apnea were included. Studied patients should be aged 20 or older. The risk of bias in the trials was assessed in accordance with the recommendations of The Cochrane Risk of Bias criteria. Results: A total of 62 full-text articles were assessed for eligibility. After the review process, only 6 met all the inclusion criteria. All studies were rated as having a high risk of bias. The most uniformly reported mandibular advancement splint side effects were predominantly of dental nature and included a decrease in overjet and overbite. The risk of developing pain and function impairment of the temporomandibular complex appeared limited with long-term mandibular advancement splint use. Conclusion: The limited available evidence suggests that mandibular advancement splint therapy for snoring and obstructive sleep apnea results in changes in craniofacial morphology that are predominantly dental in nature, specially on a long-term basis. Considering the chronic nature of obstructive sleep apnea and that oral appliance use might be a lifelong treatment, a thorough customized follow-up should therefore be undertaken to detect possible side effects on craniofacial complex. It is also important to provide adequate information to the patients regarding these possible changes, especially to those in whom larger occlusal changes are to be expected or in whom they are unfavorable. Long-term assessments of adverse effects of oral appliance therapy, with larger study samples and recruitment of homogenous patient population are still required.

RESUMO Introdução: efeitos colaterais oclusais e o desenvolvimento de dor e/ou disfunção do complexo temporomandibular podem levar à baixa adesão ou ao abandono do tratamento do ronco e da apneia obstrutiva do sono com aparelhos de avanço mandibular. Objetivo: fornecer uma revisão abrangente da literatura sobre os efeitos colaterais craniofaciais do tratamento do ronco e da apneia obstrutiva do sono com aparelhos de avanço mandibular. Métodos: foram realizadas buscas eletrônicas sistematicamente no PubMed e na Biblioteca Virtual em Saúde até outubro de 2016. Foram incluídos apenas Ensaios Controlados Randomizados, com o objetivo primário de mensurar objetivamente os efeitos colaterais no complexo craniofacial associados ao uso de aparelhos de avanço mandibular no tratamento do ronco e da apneia obstrutiva do sono. Os pacientes estudados deveriam ter 20 anos de idade ou mais. A avaliação do risco de viés dos trabalhos selecionados seguiu as recomendações do The Cochrane Risk of Bias. Resultados: no total, 62 artigos completos foram avaliados em relação à elegibilidade. Após o processo de revisão, apenas 6 atenderam aos critérios de inclusão. Todos os estudos foram julgados como tendo alto risco de viés. Os efeitos colaterais mais frequentemente encontrados foram de natureza dentária e incluíram uma diminuição do overjet e do overbite. O risco de desenvolvimento de dor ou disfunção do complexo temporomandibular pareceu limitado na avaliação de longo prazo do uso do aparelho de avanço mandibular. Conclusão: as evidências disponíveis são limitadas e sugerem que o tratamento do ronco e da apneia obstrutiva do sono com aparelhos de avanço mandibular resulta em alterações craniofaciais predominantemente dentárias, especialmente nas avaliações de longo prazo. Considerando-se que a apneia obstrutiva do sono é crônica e que os aparelho intrabucais se constituem em uma forma de tratamento contínuo e por tempo indefinido, é necessário um acompanhamento individualizado para monitorar possíveis efeitos colaterais no complexo craniofacial. Também é importante informar aos pacientes sobre esses possíveis efeitos, especialmente àqueles nos quais são esperadas maiores alterações oclusais ou nos quais elas sejam desfavoráveis. Ainda são necessárias avaliações de longo prazo dos efeitos colaterais do tratamento com aparelhos intrabucais, com amostras maiores e mais homogêneas.

Effectiveness of a mandibular advancement device in obstructive sleep apnea patients: a prospective clinical trial.

PURPOSE: This study aimed to determine the effectiveness of a mandibular advancement device in a sample of obstructive sleep apnea syndrome patients by the evaluation of respiratory and neurophysiologic parameters and clinical symptoms. Second, the influence of certain predictor factors related with the patient and the intraoral device, were considered in the final response with this treatment option. METHODS: Forty-one patients constituted the final sample. Outcomes were measured using polysomnography, Epworth sleepiness scale and an analogue visual snoring scale, before treatment and once the device was properly titrated. RESULTS: Mean apnea-hypopnea index decreased from 22.5 ± 16.8 to 9.1 ± 11.6 (p ≤ 0.05), influencing only gender and Fujita index as predictor factors. The oxygen saturation, arousal index, percentages of sleep stages and sleep efficiency significantly improved with the mandibular advancement device (MAD) placement. The snoring index improved in absolute terms in 6.1 units and the excessive daytime sleepiness was reduced from 12.2 ± 4.7 to 8.5 ± 3.8 (p ≤ 0.00). CONCLUSIONS: The successful treatment rate with the MAD was 65.8%. The placement and posterior regulation of the intraoral appliance efficiently reduced the apnea-hypopnea index, improved the sleep quality and the clinical symptomatology associated. Obstructive sleep apnea syndrome is a highly prevalent disease. and dentists should be aware of the benefits enhanced by this prosthetic device, considered the first treatment option by certain physicians.

Repercusiones del uso de Dispositivos de Avance Mandibular como Terapia para el Síndrome de Apnea Obstructiva del Sueño en el Complejo Temporomandibular. Revisión Narrativa / Repercussions of the use of Mandibular Advancement Devices as Therapy for Obstructive Sleep Apnea Syndrome in the Temporomandibular Complex. Narrative Review

RESUMEN: El objetivo de este trabajo fue escribir, según la literatura científica disponible más actual, los efectos que inducen el uso de dispositivos de avance mandibular, como terapia para el SAHOS, en el sistema temporomandibular de los pacientes. Se realizó una revisión de la literatura más actual (últimos 10 años; 2006-2016) a partir de la búsqueda electrónica en las bases de datos PubMed, TripData Base, Epistemonikos, The Cochrane Library y las revistas especializadas Journal of Clinical Sleep Medicine y SLEEP. Con el uso de las palabras clave: "Mandibular advancement device", "orthodonthic appliances", "sleep apnea syndroms", "sleep apnea obstructive", "Temporomandibular joints disorder", los operadores booleanos AND y OR. Se realizó un análisis crítico de la literatura evaluando nivel de evidencia, grado de recomendación y riesgo de sesgo de cada publicación. La búsqueda en las distintas bases de datos arrojó un total de 242 documentos, de los cuales 60 fueron seleccionados por título y abstract. Luego 8 estudios fueron descartados por estar repetidos. Se aplicaron los criterios de inclusión y exclusión quedando un total de 20 artículos; se eliminaron 8 por no responder a la pregunta de investigación y se añadió 1 título mediante la búsqueda manual. Finalmente, se analizaron 13 artículos; 2 revisiones sistemáticas, 2 ensayos clínicos aleatorizados y 6 series de casos. La mayoría de los documentos incluidos concuerda en que los efectos inducidos por los DAM, sobre el complejo temporomandibular son mínimos y reversibles, sin explicitar ningún diagnóstico de TTM en particular. Sin embargo, esta evidencia viene en su mayoría de estudios recomendables, pero no concluyentes. Se necesitan más y mejores estudios para realizar un análisis y abstraer conclusiones más certeras. Estos deben ser homogéneos a la hora de clasificar TTM y definir un protocolo óptimo de avance mandibular.

ABSTRACT: The aim of this study was to describe, based on the most recent scientific literature available, the effects produced by the mandibular advance appliances (MAA) as a therapy for obstructive sleep apnea-hypopnea syndrome (OSAHS) in the temporomandibular system. We carried out a review of the most current literature published in the last 10 years, based on an electronic search in PubMed, TripData Base, Epistemonikos, The Cochrane Library and the specialized magazines Journal of Clinical Sleep Medicine and SLEEP. The key words used for each search were "MANDIBULAR ADVANCEMENT DEVICE", "ORTHODONTIC APPLIANCES", "SLEEP APNEA SYNDROMS", "SLEEP APNEA, OBSTRUCTIVE", and "TEMPOROMANDIBULAR JOINT DISORDERS" combined with boolean operators AND and OR. A critical analysis of the literature was evaluated based on the level of evidence, degree of recommendation and risk of bias of each publication. We obtained 242 articles and 60 of these were selected by title and abstract. Inclusion and exclusion criteria were applied, obtaining 20 articles of which 8 were excluded because they did not answer the investigation question. One article was obtained by manual search. Of this number, 13 articles, 2 systematic reviews, 2 randomized clinical trial and 6 cases series were analyzed. Most of the articles analyzed agreed that the effects produced by the MAA in the temporomandibular complex are minimal and reversible, and they did not specify any TMD diagnosis in particular. However, this evidence comes mostly from recommended but inconclusive studies. More and better designed studies are needed, with homogeneous classification of TMD diagnostic criteria that allows to define an optimal protocol for mandibular advancement as a therapy.

Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis.

PURPOSE: Oropharyngeal and tongue exercises (myofunctional therapy) have been shown to improve obstructive sleep apnea. However, to our knowledge, a systematic review has not been performed for snoring. The study objective is to perform a systematic review, with a meta-analysis, dedicated to snoring outcomes after myofunctional therapy. METHODS: PubMed/MEDLINE and three other databases were searched through November 25, 2017. Two authors independently searched the literature. Eligibility (1) patients: children or adults with snoring, (2) intervention: oropharyngeal and/or tongue exercises, (3) comparison: pre and post-treatment data for snoring, (4) outcomes: snoring frequency and snoring intensity, (5) study design: publications of all study designs. RESULTS: A total of 483 articles were screened, 56 were downloaded in their full text form, and nine studies reported outcomes related to snoring. There were a total of 211 patients (all adults) in these studies. The snoring intensity was reduced by 51% in 80 patients from pre-therapy to post-therapy visual analog scale values of 8.2 ± 2.1 (95% CI 7.7, 8.7) to 4.0 ± 3.7 (95% CI 3.2, 4.8). Berlin questionnaire snoring intensity reduced by 36% in 34 patients from 2.5 ± 1.0 (95% CI 2.2, 2.8) to 1.6 ± 0.8 (95% CI 1.3, 1.9). Finally, time spent snoring during sleep was reduced by 31% in 60 patients from 26.3 ± 18.7% (95% CI 21.6, 31.0) to 18.1 ± 20.5% (95% CI 12.9, 23.3) of total sleep time. CONCLUSIONS: This systematic review demonstrated that myofunctional therapy has reduced snoring in adults based on both subjective questionnaires and objective sleep studies.

Apnea en niños: diagnóstico y tratamiento / Apnea in children: diagnosis and treatment

El síndrome de apnea-hipoapnea del sueño en niños es una patología de alta prevalencia en la población infantil. Afecta entre el 2-4 por ciento de los niños de edades entre 2 a 6 años. La comorbilidad asociada determina serias consecuencias fisiológicas entre las que se encuentran: alteraciones cardiovasculares, neuroconductuales, neurocognitivas y anomalías en elcrecimiento. Las alteraciones bucocraneofaciales y de la oclusión asociadas a este síndrome son significativas. El rol del odontólogo /odontopediatra/ortodoncista es importante para realizar un diagnóstico y un tratamiento precoz de la oclusión e integrarse al equipo de salud. En este artículo pretendemos participar a los colegas odontólogos, odontopediatras y ortodoncistas deuna visión actualizada de la apnea infantil.

Sleep apnea-hypoapnea syndrome in childrenis a pathology with a high prevalence in children, affecting 2-4% of children aged 2-6 years.The associated comorbidity determines serious physiological consequences among whichthey are: cardiovascular, neuroconductual, neurocognitive alterations and growth anomalies.The bucco-cranial and occlusion alterations associated with this syndrome are significant. Therole of the dentist-odontopediatrician-orthodontistis important to perform a diagnosis and early treatment of the occlusion and integrate to the health team.In this article, we intend to involve our dental colleagues, odontopediatricians and orthodontists with anup-to-date view of childhood apnea.

Women with symptoms of sleep-disordered breathing are less likely to be diagnosed and treated for sleep apnea than men.

BACKGROUND: Women are often underrepresented at sleep clinics evaluating sleep-disordered breathing (SDB). The aim of the present study was to analyze gender differences in sleep apnea diagnosis and treatment in men and women with similar symptoms of SDB. METHODS: Respiratory Health in Northern Europe (RHINE) provided information about snoring, excessive daytime sleepiness (EDS), BMI and somatic diseases at baseline (1999-2001) and follow-up (2010-2012) from 4962 men and 5892 women. At follow-up participants were asked whether they had a diagnosis of and/or treatment for sleep apnea. RESULTS: Among those with symptoms of SDB (snoring and EDS), more men than women had been given the diagnosis of sleep apnea (25% vs. 14%, p < 0.001), any treatment (17% vs. 11%, p = 0.05) and CPAP (6% vs. 3%, p = 0.04) at follow-up. Predictors of receiving treatment were age, BMI, SDB symptoms at baseline and weight gain, while female gender was related to a lower probability of receiving treatment (adj. OR 0.3, 95% CI 0.3-0.5). In both genders, the symptoms of SDB increased the risk of developing hypertension (adj OR, 95% CI: 1.5, 1.2-1.8) and diabetes (1.5, 1.05-2.3), independent of age, BMI, smoking and weight gain. CONCLUSIONS: Snoring females with daytime sleepiness may be under-diagnosed and under-treated for sleep apnea compared with males, despite running a similar risk of developing hypertension and diabetes.

Upper Airway Stimulation for Obstructive Sleep Apnea: Patient-Reported Outcomes after 48 Months of Follow-up.

Objective To assess patient-based outcomes of participants in a large cohort study-the STAR trial (Stimulation Therapy for Apnea Reduction)-48 months after implantation with an upper airway stimulation system for moderate to severe obstructive sleep apnea. Study Design A multicenter prospective cohort study. Setting Industry-supported multicenter academic and clinical setting. Subjects Participants (n = 91) at 48 months from a cohort of 126 implanted participants. Methods A total of 126 participants received an implanted upper airway stimulation system in a prospective phase III trial. Patient-reported outcomes at 48 months, including Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), and snoring level, were compared with preimplantation baseline. Results A total of 91 subjects completed the 48-month visit. Daytime sleepiness as measured by ESS was significantly reduced ( P = .01), and sleep-related quality of life as measured by FOSQ significantly improved ( P = .01) when compared with baseline. Soft to no snoring was reported by 85% of bed partners. Two patients required additional surgery without complication for lead malfunction. Conclusion Upper airway stimulation maintained a sustained benefit on patient-reported outcomes (ESS, FOSQ, snoring) at 48 months in select patients with moderate to severe obstructive sleep apnea.

A prospective 10-year follow-up dental cast study of patients with obstructive sleep apnoea/snoring who use a mandibular protruding device.

OBJECTIVES: This 10-year prospective study aimed to measure and evaluate the teeth position and occlusion following 10-year nocturnal use of a mandibular protruding device (MPD) in subjects with obstructive sleep apnoea (OSA) or snoring. MATERIALS AND METHODS: Seventy-seven consecutive patients diagnosed with OSA/snoring were treated with an MPD. Fabrication of dental casts with jaw registration indexes in the intercuspal position was carried out at baseline and at follow-up, a construction bite was made, and an MPD was fitted. At the 10-year follow-up, all subjects (n = 74) were invited to participate. The dental casts were analysed in a series of measurements. RESULTS: Sixty subjects were included in the follow-up examination-41 were still using the device and 19 had ceased using the MPD. The MPD users showed significant changes in all analysed variables-decrease of overjet (-1.8 mm), overbite (-1.5 mm)-except the mandibular intercanine width and the maxillary anteroposterior relationship. Subjects who had ceased using their MPD retained their initial values, with the exception of a decreased overbite. The MPD users also showed an increased number of subjects with mesio-occlusion and posterior infra-occlusion; those who had ceased using their MPD mostly retained their initial status. CONCLUSIONS: Long-term nocturnal use of an MPD may cause both favourable and unfavourable occlusion changes, such as a decrease of the overjet and overbite or posterior infra-occlusion, and these changes may continue to develop during treatment with an MPD. Subjects with a Class III relationship may not be a suitable group for treatment with an MPD due to the mesial drift of the mandibular teeth.

When and why to treat the child who snores?

Obstructive sleep-disordered breathing (SDB) can result in cardiovascular and neurocognitive morbidity as well as adversely affect behavior, growth, quality of life, and nocturnal continence. This article summarizes the latest evidence regarding the morbidity related to obstructive SDB, commenting on the impact of severity of obstruction, that is, the difference in effects seen of moderate to severe obstructive sleep apnea syndrome (OSAS) compared to those of mild OSAS or primary snoring. The impact of therapy is discussed, focusing on which children are likely to benefit from treatment interventions; namely those with moderate or severe OSAS irrespective of the presence of morbidity, children with mild OSAS with associated morbidity or predictors of SDB persistence such as obesity, and children with complex conditions accompanied by upper airway obstruction like craniosynostosis and Prader-Willi syndrome. The co-existing conditions which may improve when treatment for obstructive SDB is offered are reviewed, while the clinical parameters associated with spontaneous improvement or resolution of obstructive SDB are discussed. The intention being to enable clinicians to make informed decisions on who should be treated, when and why. Pediatr Pulmonol. 2017;52:399-412. © 2016 Wiley Periodicals, Inc.