Orthodontic and Facial Characteristics of Craniofacial Syndromic Children with Obstructive Sleep Apnea.

Introduction: Obstructive sleep apnea (OSA) is a disorder in which ventilation becomes disrupted due to a complete or partial upper airway obstruction Altered craniofacial morphology is one of the most important anatomical factors associated with obstructive sleep apnea (OSA). Studies have assessed craniofacial features in the non-syndromic pediatric population. The aim of this study was to analyze the orthodontic and facial characteristic of craniofacial syndromic children referred for polysomnography (PSG) and to assess the correlation with the apnea-hypopnea index (AHI). Methods: In the current cross-sectional study, consecutive syndromic patients referred for PSG were invited to participate. A systematic clinical examination including extra- and intra-oral orthodontic examination was performed by calibrated orthodontists. Standardized frontal and profile photographs with reference points were taken and analyzed using ImageJ® software to study the craniofacial morphology. PSG data were analyzed for correlation with craniofacial features. STROBE guidelines were strictly adopted during the research presentation. Results: The sample included 52 syndromic patients (50% females, mean age 9.38 ± 3.36 years) diagnosed with 17 different syndromes, of which 24 patients had craniofacial photography analysis carried out. Most of the sample (40%) had severe OSA, while only 5.8% had no OSA. Down's syndrome (DS) was the most common syndrome (40%) followed by Goldenhar syndrome (5%), Pierre Robin Sequence (5%), and other syndromes. The severity of AHI was significantly correlated with decreased midfacial height. increased thyromental angle and cervicomental angle, decreased mandibular angle, and decreased upper facial height. All patients with DS were diagnosed with OSA (57% severe OSA), and their ODI was significantly correlated with increased intercanthal distance. Obesity was not correlated to the severity of AHI for syndromic patients. Conclusions: Decreased midfacial height and obtuse thyromental angle were correlated with increased AHI for syndromic patients. Increased intercanthal distance of DS patients could be a major predictor of OSA severity. Obesity does not seem to play a major role in the severity of OSA for syndromic patients. Further studies with larger samples are necessary to confirm these findings.

The role of oral appliance therapy in obstructive sleep apnoea.

There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the "gold standard" in nonsurgical OSA management, OAT remains the recognised alternative treatment.This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.

Socioeconomic inequalities in pediatric obstructive sleep apnea.

STUDY OBJECTIVES: To examine the association between multiple measures of socioeconomic status (SES) and objectively measured obstructive sleep apnea (OSA) in a Canadian pediatric population. METHODS: This was a cross-sectional study of 188 children (4-17 years, mean age 9.3 ± 3.5 years) prospectively recruited from two hospital sleep clinics in Canada, using multivariable-adjusted linear and logistic regression of five measures of SES including parental education, income, social class, geographic location, and perceived SES based on the MacArthur Scale of Subjective Social Status, assessed in relation to four polysomnographic OSA variables including apnea-hypopnea index, apnea index, mean oxygen saturation level, and oxygen desaturation index. RESULTS: Overall, low household-level SES appeared to be associated with both frequency (apnea index ≥ 1 events/h) and severity (apnea-hypopnea index ≥ 5 events/h) of OSA in children, with maternal education showing the most consistent and significant associations. Specifically, children with mothers reporting less than high school education had nearly three times the odds of having OSA after controlling factors including body mass index (odds ratio 2.96 [95% confidence interval, 1.05-8.37]), compared to university-educated participants. Consistent associations were also observed for geographic location with less frequency and severity of OSA among nonurban children. Perceived SES was minimally inversely associated with our outcomes. CONCLUSIONS: This cross-sectional, multicenter study demonstrated that SES factors are linked to the occurrence and severity of OSA in children. Results indicated the need to incorporate the screening of SES in the diagnostic process of pediatric OSA to provide more targeted intervention and patient-centered care. CITATION: Park JW, Hamoda MM, Almeida FR, et al. Socioeconomic inequalities in pediatric obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):637-645.

Compliance and side effects of tongue stabilizing device in patients with obstructive sleep apnea.

Objective: To evaluate the long-term effectiveness, compliance, and side effects of tongue stabilizing devices (TSDs).Methods: Thirty-nine patients were followed up after 12 and 30 months. The subjective effectiveness was assessed using the Epworth Sleepiness Scale (ESS), the Functional Outcomes Sleep Questionnaire (FOSQ-10), the Chalder Fatigue Scale (CFQ), and a sleep-related quality of life questionnaire (QoL). Compliance and side effects were assessed.Results: At 12-months, 35.9% of patients confirmed continuing the therapy, compared to only 15.4% of patients at 30 months. At 30 months, a significant average improvement of ESS (2.0 ± 2.8) was observed compared to baseline levels in six patients. Six patients demonstrated an average increase in blood pressure. The most frequently reported side effects were mouth dryness and excessive salivation. The 3D analysis revealed small tooth movements.Conclusion: The TSD therapy demonstrated a good long-term subjective effectiveness against OSA but had a relatively low treatment acceptance rate.

The efficacy of a titrated tongue-stabilizing device on obstructive sleep apnea: a quasi-experimental study.

STUDY OBJECTIVES: To evaluate the short-term efficacy and self-reported outcomes of tongue-stabilizing device (TSD) therapy as compared to those of mandibular advancement device (MAD) therapy in an adult population diagnosed with obstructive sleep apnea. METHODS: This study is a parallel, nonrandomized clinical trial of the TSD and MAD therapies. The efficacy of both interventions was evaluated objectively by level 3 home sleep apnea testing and by self-report using the Epworth Sleepiness Scale, the Functional Outcomes of Sleep Questionnaire, the Chalder Fatigue Scale, and the 36-Item Short-Form Health Survey. Adherence and adverse effects were self-reported. RESULTS: Of the 39 patients who received TSD therapy, 27 managed to adapt and complete the trial and were matched with 26 patients who received MAD therapy. At the 2-month follow-up, the acceptance rate of the TSD therapy was 53.8%. Both patients receiving TSD therapy and patients receiving MAD therapy showed significant improvements in their respiratory event index (P < .05), with no difference between the treatments (P > .05). In those receiving TSD therapy (n = 27), the only self-reported efficacy measure that significantly improved with TSD therapy was the Chalder Fatigue Scale (P < .05). In contrast, all 4 self-reported measures (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, 36-Item Short-Form Health Survey, and Chalder Fatigue Scale) showed a significant improvement with MAD therapy. CONCLUSIONS: This study revealed similar improvements in apneas and oxygen saturation between TSD and MAD therapies. Whereas MAD therapy was a better treatment for obstructive sleep apnea in terms of daytime sleepiness and quality-of-life improvements, TSD therapy had a low treatment acceptance rate. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: The Efficacy of Tongue Stabilizing Device in Patients with Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02329925; Identifier: NCT02329925; and Registry: ClinicalTrials.gov; Name: Adherence and Preference of Continuous Positive Airway Pressure vs Mandibular Advancement Splints in Obstructive Sleep Apnea Patients: A Randomized Trial (CHOICE); URL: https://clinicaltrials.gov/ct2/show/NCT02242617; Identifier: NCT02242617. CITATION: Alshhrani WM, Hamoda MM, Okuno K, et al. The efficacy of a titrated tongue-stabilizing device on obstructive sleep apnea: a quasi-experimental study. J Clin Sleep Med. 2021;17(8):1607-1618.

Long-term side effects of sleep apnea treatment with oral appliances: nature, magnitude and predictors of long-term changes.

OBJECTIVES: Oral appliances for the treatment of obstructive sleep apnea (OSA) reduce upper airway collapse by advancing the mandible (OAm) and associated soft tissues. OAm are well tolerated but have side effects, mainly dental movement. It is not yet clear whether there are irreversible skeletal changes associated with treatment. As oral appliance treatment for OSA is a life-long therapy, careful and extended follow-up of patients is required. The objectives of this study were to evaluate the magnitude and progression of the dental and skeletal changes associated with long-term treatment, in addition to determining the predictors of the changes. METHODS: Lateral cephalograms of adults treated for primary snoring or mild to severe OSA with a custom-made titratable OAm for a minimum of eight years were retrospectively studied. The magnitude and rate of progression of any changes over time was determined and initial patient and dental characteristics were investigated as possible predictors of the observed side effects. RESULTS: Records of 62 patients with an average treatment time of 12.6 years (range:8-21 years) were included. Cephalometric analysis revealed significant (p < 0.001) maxillary incisor retroclination (mean of ≈6°) and mandibular incisor proclination (mean of ≈8°) over the observation period. Maxillary incisors demonstrated a constant rate of retroclination -0.5°/year, the rate of mandibular incisors proclination was variable. The number of treatment years was significantly associated with these variables (p < 0.001). A greater body mass index (BMI) and Subspinale, Nasion, Supramentale angle (ANB) were associated with more maxillary and mandibular incisor proclination respectively. Although statistically significant (p < 0.001) skeletal changes were noted over this extended observation period, the difference in the Sella, Nasion, Supramentale point B (SNB) and mandibular plane angles were approximately 1° and were deemed not clinically significant. CONCLUSIONS: This study represents the longest observation period to date examining OAm side effects with up to 21 years of follow up for some patients. It confirms that there are significant and progressive dental changes with prolonged OAm use. Conversely, over the same time period skeletal or postural changes were negligible. Additionally, treatment duration was the predictor consistently associated with the magnitude of the observed side effects.

Oral Appliances for the Management of OSA: An Updated Review of the Literature.

Oral appliances (OAs) are becoming increasingly recognized not only as an alternative to but also possibly as an adjunct treatment modality for OSA. Compared with CPAP, the gold standard therapy, OAs are less efficacious but are more accepted and tolerated by patients, which, in turn, may lead to a comparable level of therapeutic effectiveness. Different OA designs currently exist, and more are constantly emerging. Additionally, state-of-the-art technologies are being used in the fabrication of many; however, all the currently available OAs employ the same mechanism of action by targeting the anatomical component involved in the pathogenesis of the disease. Furthermore, the scope of use of OAs is expanding to include patients who are edentulous. For patients with OAs, the dentist is a member of an interdisciplinary team managing OSA, and constant communication and follow-up with the sleep physician and other team members is necessary for disease management.