Mandibular Advancement vs CPAP for Blood Pressure Reduction in Patients With Obstructive Sleep Apnea.

BACKGROUND: Hypertension guidelines recommend diagnosis and treatment of obstructive sleep apnea (OSA) in patients with hypertension. The mandibular advancement device (MAD) is an oral appliance therapy for patients who decline or cannot tolerate continuous positive airway pressure (CPAP). OBJECTIVES: We compared the relative effectiveness of MAD vs CPAP in reducing 24-hour ambulatory blood pressure (BP). METHODS: In an investigator-initiated, randomized, noninferiority trial (prespecified margin 1.5 mm Hg), 321 participants aged ≥40 years with hypertension and increased cardiovascular risk were recruited at 3 public hospitals for polysomnography. Of these, 220 participants with moderate-to-severe OSA (apnea-hypopnea index ≥15 events per hour) were randomized to either MAD or CPAP (1:1). The primary outcome was the difference between the 24-hour mean arterial BP at baseline and 6 months. RESULTS: Compared with baseline, the 24-hour mean arterial BP decreased by 2.5 mm Hg (P = 0.003) at 6 months in the MAD group, whereas no change was observed in the CPAP group (P = 0.374). The between-group difference was -1.6 mm Hg (95% CI: -3.51 to 0.24, noninferiority P < 0.001). The MAD group demonstrated a larger between-group reduction in all secondary ambulatory BP parameters compared with the CPAP group, with the most pronounced effects observed in the asleep BP parameters. Both the MAD and CPAP improved daytime sleepiness, with the between-group difference similar (P = 0.384). There were no between-group differences in cardiovascular biomarkers. CONCLUSIONS: MAD is noninferior to CPAP for reducing 24-hour mean arterial BP in participants with hypertension and increased cardiovascular risk. (Cardiosleep Research Program on Obstructive Sleep Apnea, Blood Pressure Control and Maladaptive Myocardial Remodeling-Non-inferiority Trial [CRESCENT]; NCT04119999).

Mandibular advancement device versus CPAP in lowering 24-hour blood pressure in patients with obstructive sleep apnoea and hypertension: the CRESCENT trial protocol.

INTRODUCTION: Although treatment of obstructive sleep apnoea (OSA) using continuous positive airway pressure (CPAP) reduces blood pressure (BP), adherence to CPAP is often suboptimal. A mandibular advancement device (MAD) is a guideline-endorsed alternative therapy for OSA. Still, there is limited evidence on the relative efficacy between MAD and CPAP on BP reduction. We evaluate whether treatment of moderate-to-severe OSA using MAD can improve BP and other health-related outcomes compared with CPAP. METHODS AND ANALYSIS: This is a randomised, controlled, non-inferiority trial conducted. We will recruit 220 Asians with a history of hypertension and high cardiovascular risk for an overnight polysomnography screening. Those with moderate-to-severe OSA (apnoea-hypopnoea index ≥15 events/hour) will be randomised to treatment with either MAD or CPAP in a 1:1 ratio. Stratified by age (60 vs <60 years old), body mass index (25 vs <25 kg/m2) and apnoea-hypopnoea index (30 vs <30 events/hour), an adaptive randomisation scheme with permuted blocks constructed in real-time is implemented to restrict imbalance. The overall study duration is 12 months. The primary endpoint is the 24-hour mean arterial BP difference between baseline and 6-month follow-up. The secondary endpoints include other measures of ambulatory BP monitoring, arrhythmia based on a 4-day electrocardiographic monitoring, biomarker and proteomic analysis, cardiovascular magnetic resonance-derived myocardial fibrosis and remodelling and quality-of-life questionnaires. Recruitment began in October 2019 and ended in December 2022. Comparison between MAD and CPAP will be performed using covariance (ANCOVA) analysis of the changes in 24-hour mean arterial BP while adjusting for the baseline 24-hour mean arterial BP. We will compare the 95% CIs around the treatment difference point estimate with the prespecified non-inferiority margin (1.5 mm Hg). If the upper limit of the 95% CI is <1.5 mm Hg and crosses 0, non-inferiority of the MAD relative to CPAP will be established. ETHICS AND DISSEMINATION: The Domain Specific Review Board-C, National Healthcare Group under approved the study protocol (NHG DSRB Ref: 2019/00359, approved on 28 August 2019). Study findings will be disseminated to various local, national, and international audiences through abstract presentations and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04119999.

Evaluation of marginal and internal fit of ceramic crown copings.

OBJECTIVES: (1) To measure the marginal and internal adaptation of different prosthetic crowns infrastructures (IS); (2) to analyze two types of methodologies (replica and weight technique) used to evaluate the adaptation of indirect restorations. METHODS: Ceramic IS were fabricated using CAD/CAM technology and slip-casting technique, and metal IS were produced by casting (n=10). For each experimental group, the adaptation was evaluated with the replica (RT) and the weight technique (WT), using an impression material (low viscosity silicon) to simulate the luting agent. Cross-sectional images of the silicon replica were obtained and analyzed with Image J software to measure the low viscosity silicon layer thickness at pre-determined points. The silicon layer was also weighted. Results were statistically analyzed with ANOVA and Tukey's test (α=0.05). Pearson correlation was used to analyze the relation between the two types of evaluation methods. RESULTS: All IS evaluated showed clinically acceptable internal and marginal adaptation. Metal IS showed the best adaptation, irrespective of the measuring technique (RT and WT). The IS produced by CAD-CAM showed greater gap values at the occlusal area than at other evaluated regions. The IS produced by the dental laboratory technician showed similar gap values at all evaluated regions. There is no correlation between RT and WT (p>0.05). SIGNIFICANCE: Different levels of adaptation were found for the different experimental groups and for the different evaluation methods. However, all IS evaluated showed clinically acceptable values of marginal and internal adaptation.

Relação diagnóstica entre folículo pericoronário e cisto dentígero / Diagnostic relationship between pericoronal follicle and dentigerous cyst

Objetivo: Relacionar os diagnósticos histopatológico e radiográfico para casos de folículo pericoronário e cisto dentígero de terceiros molares inferiores. Métodos: Foram selecionadas, em arquivos, as lâminas histológicas e as respectivas radiografias panorâmicas dos casos diagnosticados como folículo pericoronário e cisto dentígero. Obteve-se uma amostra de 62 casos elegíveis: 45 folículos pericoronários e 17 cistos dentígeros. Para confirmação do diagnóstico histopatológico foram reavaliadas as informações clínicas dos pacientes e as lâminas histológicas. No exame radiográfico foi realizada a mensuração das imagens radiolúcidas pericoronárias, sendo que medidas iguais ou maiores do que 2,5mm foram utilizadas como parâmetro para o diagnóstico de cistos dentígeros. A comparação entre os resultados dos diagnósticos histopatológico e radiográfico, atribuídos aos 62 casos apurados, foi feita pelos testes de sensibilidade, especificidade e valor preditivo. Resultados: Os resultados mostraram que a medida de 2,5mm para o halo radiolúcido pericoronário foi pouco sensível no diagnóstico de cisto dentígero. Conclusão: O diagnóstico diferencial das imagens radiolúcidas pericoronárias deve ser esclarecido pela soma de dados clínicos, radiográficos e histopatológicos.

Objective: Associate the histopathological and radiographic diagnoses of cases of pericoronal follicle and dentigerous cyst of the mandibular third molars. Methods: Histological slides and the respective panoramic radiographs of cases diagnosed as pericoronal follicle and dentigerous cyst were selected from files. A sample of 62 eligible cases was obtained: 45 pericoronal follicles and 17 dentigerous cysts. In order to confirm the histopathological diagnosis, the clinical information and histological slides of the patients were reassessed. The pericoronal radiolucent images in the radiographs were measured and those equal to or greater than 2.5 mm were used as parameter for the diagnosis of dentigerous cysts. The comparison between the results of the histopathological and radiographic diagnoses attributed to the 62 cases was done by sensitivity and specificity tests and by predictive value. Results: The results showed that a size of 2.5 mm for the pericoronal radiolucent halo was not very sensitive for the diagnosis of dentigerous cyst. Conclusion: The differential diagnosis of the pericoronal radiolucent images must be clarified by the sum of clinical, histopathological and radiographic data.