A mandibular advancement device associated with lingual control: a new treatment option for obstructive sleep apnea?

PURPOSE: Oral appliances (OA) have become the main alternative to positive pressure airway devices (PAP) for the control of obstructive sleep apnea (OSA). Despite literature support, controversies about the mode of action and the effectiveness of these devices persist. The aim of this study was to evaluate the efficacy of modified mandibular advancement devices (MAD) in patients with OSA who failed treatment with MAD and to evaluate the role of the tongue as a factor in patients who failed treatment with MAD. MATERIALS AND METHODS: Patients unable to control the apnea-hypopnea index (AHI) using a MAD were subsequently treated with a modified version that included a tongue trimming accessory. The objective was to stabilize the tongue by preventing it from sliding with the consequent collapse of the upper airway (UA). New polysomnography (PSG) was performed with the modified MAD in place. RESULTS: A total of 20 patients who failed MAD therapy were studied including 15 men (75%) with mean age (± standard deviation) of 58.5 ± 13.1 years and BMI 29.6 ± 5.0 Kg/m2. After installing the tongue trimmer, the number of patients who achieved complete success with the new MAD (AHI < 5) went from 0 to 30% and those who achieved partial success (5 < AHI < 10) went from 0 to 20%. The number of patient responders (AHI reduced by at least 50%) went from 20 to 75%. CONCLUSION: The results suggest that the tongue, even in the presence of a MAD, may be one of the contributing factors for the collapse of the UA and consequent device ineffectiveness. By stabilizing the tongue through the insertion of a tongue trimmer, the MAD became more effective in many cases.

Whole-exome identifies germline variants in families with obstructive sleep apnea syndrome.

Background: Obstructive sleep apnea syndrome (OSAS) (OMIM #107650) is characterized by complete or partial obstruction of the upper airways, resulting in periods of sleep associated apnea. OSAS increases morbidity and mortality risk from cardiovascular and cerebrovascular diseases. While heritability of OSAS is estimated at ∼40%, the precise underlying genes remain elusive. Brazilian families with OSAS that follows as seemingly autosomal dominant inheritance pattern were recruited. Methods: The study included nine individuals from two Brazilian families displaying a seemingly autosomal dominant inheritance pattern of OSAS. Whole exome sequencing of germline DNA were analyzed using Mendel, MD software. Variants selected were analyzed using Varstation® with subsequent analyses that included validation by Sanger sequencing, pathogenic score assessment by ACMG criteria, co-segregation analyses (when possible) allele frequency, tissue expression patterns, pathway analyses, effect on protein folding modeling using Swiss-Model and RaptorX. Results: Two families (six affected patients and three unaffected controls) were analyzed. A comprehensive multistep analysis yielded variants in COX20 (rs946982087) (family A), PTPDC1 (rs61743388) and TMOD4 (rs141507115) (family B) that seemed to be strong candidate genes for being OSAS associated genes in these families. Conclusion: Sequence variants in COX20, PTPDC1 and TMOD4 seemingly are associated with OSAS phenotype in these families. Further studies in more, ethnically diverse families and non-familial OSAS cases are needed to better define the role of these variants as contributors to OSAS phenotype.

Obstructive Sleep Apnea Treatment with Oral Appliance in a Myotonic Dystrophy Type I Subject: A Case Report.

Objective to report a myotonic dystrophy type 1 (MD1) subject with obstructive sleep apnea syndrome treated with oral appliance. Methods A review of individual's history and records, associated with a photographic register of all diagnostic methods and literature research about the topic were done. Final Statements This case depicts the therapeutical choices disposable to treat subjects with obstructive sleep apnea and DM1. Although considered an uncommon treatment, the oral appliances, if well indicated in adequately selected cases, can satisfactorily improve respiratory parameters, symptoms and quality of life.

When adherence to CPAP fails, how do we treat workers with obstructive sleep apnea?

Aims: A cross-sectional study was designed to evaluate the effectiveness of a mandibular advancement device (MAD) with respect to respiratory and sleep parameters among miners with obstructive sleep apnea syndrome (OSAS) and primary snore. Methods: The target sample was composed by 102 Brazilian miners with a history of non-adherence to continuous positive airway pressure. All patients were treated with a MAD and underwent pre and post-treatment full-night polysomnography. Ethical approval and consents were obtained. Bivariate and logistic regression analyses were conducted. The level of statistical significance was set at 5%. Results: After the treatment with MAD, 71.8% of patients presented a decrease ≥ 50% in the basal apnea-hypopnea index (AHI), 51.2% presented an AHI < 5 events/h and 83.3% reached an AHI<10/h, whereas 22.5% did not show any changes and 7.5% of the sample presented an increase in the AHI (p<0.05). There was an increase in the mean SpO2 nadir (p<0.001) and in the baseline duration of the REM sleep stage (p<0.05). The MAD significantly decreased snore events (p<0.05). Multivariate analysis did not identify predictive factors related to therapy success (decrease ≥ 50% of AHI). However, basal AHI was a significant predictor related to the secondary endpoint (AHI<10/h) (OR= 1.06, IC 95%1.00-1.13, p=0.007). Conclusions: The MAD therapy showed significant improvements in AHI, minimum oxygen saturation, REM sleep and snoring.

Severe obstructive sleep apnea treatment with mandibular advancement device: A case report.

Mandibular advancement device (MAD) has been described as an alternative treatment to the severe obstructive sleep apnea (OSA), once it is not as effective as the continuous positive airway pressure therapy (CPAP) in reducing the apnea and hypopnea index (AHI). The objective of this study is to report a case using a MAD in a CPAP-intolerant patient suffering from severe OSA. Polysomnography exams were performed before and after treatment. Five months after fitting and titrating the MAD, the AHI was reduced from 80.5 events/hour to 14.6 events/hour and the minimum oxyhemoglobin saturation (SpO2) increased from 46% to 83%. A two-year assessment of therapy revealed an AHI of 8 events/hour and SpO2 of 85%.

Aparelho PLP para tratamento de ronco e apneia obstrutiva do sono / PLP appliance for treatment of snoring and obstructive sleep apnea

A síndrome da apneia obstrutiva do sono (SAOS) é um distúrbio respiratório do sono que se caracteriza por eventos recorrentes de obstrução das vias aéreas superiores durante o sono, associados aos sinais e sintomas clínicos. Os aparelhos orais são uma opção de tratamento clínico do ronco e da SAOS, que têm sido apontados, cada vez mais, como uma proposta adequada. Os aparelhos podem ter desenhos variados e mantêm a mandíbula posicionada para a anterior durante o sono, sendo os mais utilizados nos tratamentos os que têm uma maior taxa de sucesso. Objetiva-se por meio deste artigo apresentar o aparelho PLP (placas lateroprotrusivas) que consiste em um dispositivo intrabucal que possui características preconizadas para o tratamento da SAOS e do ronco, aliadas ao baixo custo e à facilidade de confecção. Recomenda-se, inicialmente, que o paciente seja avaliado para fins de diagnóstico e indicação do tratamento por médico especialista em Medicina do Sono. Para implementar a terapia com aparelho intrabucal, o profissional deve estar familiarizado com este tipo de abordagem e apresentar conhecimento sobre os aspectos relacionados aos distúrbios respiratórios do sono. A atuação deve ser multidisciplinar, envolvendo a interação da Odontologia com as especialidades da Medicina relacionadas ao problema, buscando o sucesso do tratamento e evitando-se a desvalorização da terapia com aparelhos intrabucais.

The obstructive sleep apnea syndrome (OSAS) is a sleep related breathing disorder characterized by recurrent events of upper airway obstruction during sleep, associated with clinical signs and symptoms. Oral appliances are an option for clinical treatment of snoring and sleep apnea syndrome, and have been pointed, increasingly, as a suitable treatment option. Apparatus jaw positioners may have various designs and maintain the jaw positioned protruded during sleep. These are the most commonly used treatments, and have higher success rate. The present work aims at presenting the PLP® (lateroprotrusive splints) an intraoral device with features recommended for treating OSAS and snoring, combining low cost and simple manufacture. We recommend that the patient is primarily diagnosed by a sleep medicine specialist. To implement this therapy, the dentist must be proficient and have knowledge on treatment and monitoring of sleep related breathing disorders. The approach must be interdisciplinary with dentists and physicians seeking for the success of the treatment and avoiding depreciation of oral appliance therapy.

Efetividade em Longo-Prazo de dois Aparelhos Intraorais no Tratamento da Apneia Obstrutiva do Sono: Relato de um Caso / Long-Term Effectiveness of two Oral Appliances for Obstructive Sleep Apnea: a Case Report

A síndrome da apneia obstrutiva do sono - SAOS é um distúrbio respiratório caracterizado por episódios recorrentes de obstrução das vias aéreas superiores durante o sono. Aparelhos intraorais - AIOs têm sido utilizados em pacientes com SAOS moderada ou severa que não se adaptaram ou recusam o tratamento com pressão positiva contínua nas vias aéreas - CPAP ou pacientes com impossibilidade de realização de cirurgia. Aparelhos de avanço mandibular têm sido amplamente utilizados com eficácia. Além de estabilizar a mandíbula, alguns AIOs permitem que o paciente faça movimentos mandibulares de lateralidade e verticais sem desencaixar o aparelho, reduzindo o risco de lesionar a articulação temporomandibular. O objetivo desse estudo foi avaliar a efetividade de dois tipos de AIO no tratamento da apneia. Este estudo apresenta o caso de um paciente com SAOS moderada e grave dessaturação de oxigênio (SaO2 mínima de 55%), tratado com dois tipos de aparelho intraoral: o PM PositionerTM, que não permite movimentos laterais da mandíbula, e a Placa Lateroprotrusiva (PLP®), que permite movimentos de lateralidade. O aparelho PLP ® foi mais efetivo se comparado ao PM Positioner. Através da avaliação em longo prazo observou-se que o PLP ® proporcionou mais conforto ao paciente, maior aderência ao tratamento e uma maior capacidade de avanço mandibular, quando comparado ao aparelho que não permitia movimentos mandibulares de lateralidade.

Obstructive sleep apnea syndrome (OSAS) is a breathing disorder characterized by recurrent episodes of upper airway obstruction during sleep. Oral appliances have been used in patients with moderate to severe OSAS, who cannot tolerate or refuse the therapy with continuous positive airway pressure or candidates who present impossibility of performing surgery. Oral appliances such as mandibular advancement devices (MADs) have been widely used and proven to be effective. In addition to stabilizing the mandible, some MADs allow the patient to move it laterally and vertically without disengaging the appliance, reducing the risk of injuring the temporomandibular joint. The aim of this study was to evaluate the effectiveness of two types of oral appliances in the treatment of apnea. A patient who presented moderate OSAS and severe oxygen desaturation (SaO2 minimum of 55%) was treated by two different types of MADs: the PM PositionerTM, which is a device that do not allow lateral movements of the mandible, and the Placa Lateroprotrusiva (PLP®), which allows lateral movements. The PLP® was more effective than the PM PositionerTM. Long-term assessment revealed that PLP® was more effective because it provided more comfort and a greater capacity for mandibular advancement, when compared to a device which did not allow the jaw to move laterally.

Oral appliances to prevent occupational accidents involving obstructive sleep apnea syndrome patients – a systematic review and meta-analysis / Aparelhos intraorais para prevenção de acidentes de trabalho em pacientes com apneia obstrutiva do sono - revisão sistemática e meta-análise

Studies have linked the obstructive sleep apnea syndrome with an increased risk of occupational accidents. The aim of this systematic review Cochrane format was to evaluate the effectiveness of intraoral devices to reduce these accidents. An electronic search was conducted in the databases CENTRAL (Cochrane), MEDLINE, and LILACS. Only randomized controlled trials were included. Whenever possible a meta-analysis was performed. The primary outcome was reduction of accidents involving professionals with obstructive sleep apnea. Daytime sleepiness, cognitive function, and index of apnea/hypopnea were considered secondary outcomes. To evaluate the risk of bias, we used the Cochrane Collaboration tool. From 431 articles retrieved, 13 were included. No study evaluating the effectiveness of intraoral appliance in reducing accidents at work was found. Only studies that evaluated secondary outcomes were found. Some studies showed results in favor of intraoral appliance, but when compared to continued positive pressure device (CPAP) results were in favor of the CPAP. Outcomes for excessive daytime sleepiness and cognitive performance were similar for both types of treatment.

Estudos têm associado a síndrome da apneia obstrutiva do sono com um aumento do risco de acidentes de trabalho. O objetivo desta revisão sistemática formato Cochrane foi avaliar a efetividade dos dispositivos intraorais na redução desses acidentes. Uma busca eletrônica foi realizada nas bases de dados CENTRAL (Cochrane), MEDLINE e LILACS. Foram incluídos somente ensaios controlados randomizados. Sempre que possível foi realizada a meta-análise. O desfecho primário foi redução de acidentes de trabalho em profissionais com apneia obstrutiva do sono. Sonolência diurna, função cognitiva e índice de apneia/hipopneia foram considerados desfechos secundários. Para avaliação do risco de viés, utilizou-se a ferramenta da Colaboração Cochrane. Dos 431 artigos encontrados, 13 foram incluídos. Não foi identificado nenhum estudo avaliando efetividade do aparelho intraoral sobre acidentes de trabalho. Foram encontrados apenas estudos que avaliaram os desfechos secundários. Alguns estudos mostraram resultados a favor do aparelho intraoral, mas quando comparados ao aparelho de pressão contínua positiva (CPAP), os resultados foram a favor do CPAP. Para os desfechos sonolência excessiva diurna e desempenho cognitivo, os resultados foram efetivos e semelhantes para os dois tipos de tratamento.