Gender differences in oral appliance treatment of obstructive sleep apnea.

PURPOSE: Although overall success rates for treating obstructive sleep apnea (OSA) with an oral appliance (OA) are high, they are significantly higher among females. To verify published data, the study's purpose was to evaluate a participant sample after one year of OA use. The primary outcome was treatment response, with responders defined as having an apnea-hypopnea index (AHI) < 10 at follow-up and/or reduced by ≥50% of baseline. Secondary measures were from standardized questionnaires. METHODS: A sample of 314 participants, predominately with moderate-to-severe OSA, were enrolled and instructed to use an OA every night. At baseline and one-year follow-up, polygraphic recordings and questionnaires, including sleepiness (measured using the Epworth sleepiness scale) and quality-of-life (measured using the Functional Outcomes of Sleep Questionnaire), were collected. RESULTS: Among the 314 participants, 192 completed the one-year evaluation: 51 females (27%) and 141 males (73%). Overall, OA treatment resulted in 78% and 77% responders among females and males, respectively. Neither the difference in improvement nor the absolute change in AHI differed significantly based on gender, at any OSA severity level. There were no significant gender differences in sleepiness or quality of life. Treatment-related adverse reactions were more common among females. CONCLUSION: Both females and males with OSA respond well to OA therapy, with nonsignificant gender differences in outcomes. Thus, the hypothesis that females respond better to OA treatment is rejected.

Identification of Swedish caries active individuals aged 30-90 years using a life course perspective and SKaPa longitudinal national registry data over a 10-year period.

OBJECTIVE: To describe the occurrence of caries disease from a life course perspective using longitudinal data from the Swedish Quality Registry for Caries and Periodontal Disease (SKaPa).  Material and Methods: Data from seven age cohorts (ages 30-90 years), each followed over 10 years, were retrieved from the SKaPa. Using a three-trajectory model, individuals were divided into three trajectories according to their caries development over time: high (15%), moderate (45%), or low (40%). Caries experience was expressed as the mean decayed, missing, and filled surfaces (DMFS) index. RESULTS: Significant differences were found for all three trajectories and in all age groups over the 10 years. The mean DMFS index increase was significantly larger for the high trajectory group than for the moderate and low trajectory groups across all age cohorts. An increase in caries experience was observed for the older cohorts across all trajectories. CONCLUSIONS: A three-trajectory model appears useful for identifying and quantifying caries experiences in longitudinal studies. Increased caries disease occurs over time, especially in the highest trajectory group and among older cohorts. These findings emphasise the need for greater attention and more efficient caries prevention methods.

Identification of caries-active individuals in longitudinal data a methodological study using a national registry.

OBJECTIVE: The aim was to identify caries active individuals among adults by using a trajectory model of longitudinal data from the Swedish national registry (SKaPa) and comparing them with published data from the Dunedin cohort. MATERIALS AND METHODS: Data from two different age groups (30- and 40-year-olds) followed for 10 years were retrieved from SKaPa and were compared with published longitudinal birth-cohort data from the Dunedin study. Using the trajectory model, the subjects were divided into three different trajectories according to their caries development over time (i.e. high, 15%; moderate, 45%; low, 40%). RESULTS: Caries experience, as measured by mean decayed, missing, and filled surfaces (DMFS) index, revealed significant differences among the three trajectories in both age groups. The patterns were similar to those observed in the Dunedin cohort. The mean increase in DMFS during the 10-year follow-up period from SKaPa was significantly higher for the high trajectories in both age groups compared with the moderate and low trajectories. CONCLUSIONS: The method using three trajectories for presentation of caries experience over time, may be a useful tool to identify subjects with different disease activities. Identification of subjects in the high caries experience trajectory may increase the possibility to explore and evaluate more effective caries prevention for this group in the future.

Oral appliance influence on jaw function in obstructive sleep apnea.

INTRODUCTION: Oral appliance (OA) therapy in obstructive sleep apnea (OSA) could be a risk factor for normal jaw function, given the prolonged effect of an OA in keeping the mandible in a protruded position away from a normal position. This study aimed to assess changes in symptoms and clinical findings related to jaw function after 1 year of treating OSA with an OA. METHODS: In this follow-up clinical trial, 302 patients with OSA were assigned to treatment with either monobloc or bibloc OA. Baseline and 1-year follow-up assessment included using the Jaw Functional Limitation Scale, self-reported symptoms and signs related to jaw function. The clinical examination of jaw function included mandibular mobility, dental occlusion, and tenderness in the temporomandibular joints and masticatory muscles. Descriptive analyses of variables are presented for the per-protocol population. To evaluate differences between the baseline and the 1-year follow-up, paired Student t tests and the McNemar change test was used. RESULTS: One-hundred and ninety-two patients completed the 1-year follow-up (male 73%, mean aged 55 ± 11 years). There was no change in the Jaw Functional Limitation Scale score at the follow-up (nonsignificant). The patients described no change in symptoms at the follow-up, except for improvements in morning headache (P <0.001) and increased frequency of difficulties in opening the mouth or chewing on awakening (P = 0.002). Subjectively reported changes in dental occlusion during biting/chewing increased significantly at the follow-up (P = 0.009). CONCLUSIONS: No changes in measurements of jaw mobility, dental occlusion, or pain on palpation of the temporomandibular joints or masticatory muscles were seen at the follow-up. Thus, using an OA in treating OSA had limited influence on jaw functions and related symptoms. Moreover, the risk of developing pain and functional impairment in the masticatory system was infrequent, indicating that this treatment is safe and can be recommended.

Effects of oral appliance treatment on inflammatory biomarkers in obstructive sleep apnea: A randomised controlled trial.

Obstructive sleep apnea (OSA) may lead to increased circulating concentrations of inflammatory biomarkers and treatment may change these. We aimed to assess the effect of oral appliance (OA) therapy on inflammatory biomarkers in a randomised controlled pilot trial. A total of 71 patients with OSA and systemic hypertension were randomly allocated to an active, mandible protruded (OAa) or a passive, mandible non-protruded device (OAp) treatment. Serum concentrations of the inflammatory biomarkers white blood cells, high-sensitivity C-reactive protein, interleukin 6, interleukin 10, and tumour necrosis factor-α were measured at baseline and after 3 months of OA treatment. The differences between treatment groups in biomarker concentration change during the treatment were presented as the Vargha and Delaney effect size and evaluated with the Wilcoxon-Mann-Whitney test. This effect size expresses the probability of a higher value in a random participant from one group compared with a random patient from the other group, and a value of 0.5 means stochastically equal groups. After 3 months of treatment, there was a significant reduction of the apnea-hypopnea index in the OAa group compared with the OAp group (effect size 0.258, 95% confidence interval 0.146-0.386, p < .001). There were no significant differences between the groups in any of the inflammatory markers' concentration changes during the treatment period (effect sizes between 0.488 and 0.524; all p values ≥.737). Thus, OA treatment for 3 months did not affect circulating concentrations of some common inflammatory markers in patients with OSA and systemic hypertension.

Respiratory outcomes after a 1-year treatment of obstructive sleep apnoea with bibloc versus monobloc oral appliances: a multicentre, randomized equivalence trial.

Objective: The benefit of bibloc over monobloc appliances in treating obstructive sleep apnoea (OSA) has not been evaluated in randomized trials. We hypothesized that these types of appliances would be equally effective.Material and methods: In this multicentre, randomized equivalence trial, patients with OSA received one type of bibloc or one type of monobloc treatment. At baseline, a 1-night polygraphy study was done, and this was repeated after 1 year. The outcome was any change in the apnoea-hypopnoea index (AHI) and the limits of equivalence between the two devices were set at ±5 AHI units.Results: Of 302 patients, 146 were randomly assigned to bibloc and 156 to monobloc appliances. In 88 and 104 patients, respectively, there were significant reductions in the AHI (p < .001) with a mean change of -16.7 (95% CI -19.4 to -14.1) in the bibloc and -11.8 (-14.9 to -8.7) in the monobloc groups. The proportions of responders defined as having an AHI <10 were 68% and 65% for the bibloc and monobloc groups, respectively. Treatment-related adverse events were mild, transient and the dropouts were more frequent in the bibloc group.Conclusions: Both types of treatments positively and significantly reduced respiratory disturbances, but at the 1-year follow-up, they were not significantly different in treating OSA, with a numerically greater reduction of the AHI value with the bibloc appliance. However, the higher proportion of treatment-related adverse events and higher proportion of dropouts among bibloc users should be balanced against the advantage of a greater reduction in the AHI.

Self-reported oral and general health related to xerostomia, hyposalivation, and quality of life among caries active younger adults.

Objective: The aim was to study prevalence of xerostomia, hyposalivation and quality of life among caries active younger adults.Materials and methods: A questionnaire regarding oral and general health, xerostomia and quality of life was mailed to 134 caries active (CA) and 40 caries inactive (CI) patients, 25-50 years of age (mean age 39.9 ± 6.2 years) treated at a Swedish Public Dental Service clinic, regarding oral and general health, xerostomia and quality of life. Caries data and unstimulated whole salivary flow rates were obtained from dental records.Results: The overall response rate was 69%. Dental records confirmed that CA patients had more decayed teeth over time than CI patients (p < .001). The CA group reported worse oral health (p < .001) and general health (p < .01), more xerostomia (p < .001) and lower salivary flow rate (p < .01) compared to CI patients. Xerostomia was inversely related to unstimulated whole salivary flow rates as well as to oral and general health (p < .01). There were no differences between groups in quality of life.Conclusion: Younger caries active adult patients reported significantly more xerostomia and hyposalivation compared to caries inactive patients. Xerostomia and hyposalivation were inversely related to perceptions of oral and general health, but not to quality of life.

Pain relief following a single-dose intra-articular injection of methylprednisolone in the temporomandibular joint arthralgia-A multicentre randomised controlled trial.

BACKGROUND: Temporomandibular joint (TMJ) arthralgia is a painful condition assumed to be associated with local inflammation. OBJECTIVE: The objective of the present study was to determine the efficacy for reducing pain of a single-dose intra-articular (IA) injection of methylprednisolone to the TMJ. The hypothesis was that methylprednisolone would effectively reduce TMJ pain. METHODS: This randomised, double-blind, parallel-group, multicentre, controlled study included visits for enrolment, treatment and 4-week follow-up. The study included patients 18 years and older who had been diagnosed with unilateral TMJ arthralgia. All participants were randomly assigned to receive 1 mL IA injections of methylprednisolone or saline. The primary outcome was change in recorded pain intensity on a visual analogue scale (VAS) at maximum jaw opening, analysed in the per protocol population. RESULTS: In total, 54 patients were randomly assigned to single-dose IA injections with methylprednisolone (n = 27) or saline (n = 27). Between baseline and the 4-week follow-up, VAS-rated pain intensity at maximum jaw opening decreased from a mean of 61.0 (95% confidence interval [CI]: 50.1; 70.7) to 33.9 (95% CI: 21.6; 46.2) in the methylprednisolone group and from 59.6 (95% CI: 50.7; 65.9) to 33.9 (95% CI: 23.8; 43.9) in the saline group. The between-group difference was not significant (P = 0.812). Treatment-related adverse events were doubled in the methylprednisolone group. CONCLUSION: Methylprednisolone provided no additional benefit for reducing pain, but caused more harm compared with saline following a single-dose IA injection in patients with TMJ arthralgia.

Use of bibloc and monobloc oral appliances in obstructive sleep apnoea: a multicentre, randomized, blinded, parallel-group equivalence trial.

Background: The clinical benefit of bibloc over monobloc appliances in treating obstructive sleep apnoea (OSA) has not been evaluated in randomized trials. We hypothesized that the two types of appliances are equally effective in treating OSA. Objective: To compare the efficacy of monobloc versus bibloc appliances in a short-term perspective. Patients and methods: In this multicentre, randomized, blinded, controlled, parallel-group equivalence trial, patients with OSA were randomly assigned to use either a bibloc or a monobloc appliance. One-night respiratory polygraphy without respiratory support was performed at baseline, and participants were re-examined with the appliance in place at short-term follow-up. The primary outcome was the change in the apnoea-hypopnea index (AHI). An independent person prepared a randomization list and sealed envelopes. Evaluating dentist and the biomedical analysts who evaluated the polygraphy were blinded to the choice of therapy. Results: Of 302 patients, 146 were randomly assigned to use the bibloc and 156 the monobloc device; 123 and 139 patients, respectively, were analysed as per protocol. The mean changes in AHI were -13.8 (95% confidence interval -16.1 to -11.5) in the bibloc group and -12.5 (-14.8 to -10.3) in the monobloc group. The difference of -1.3 (-4.5 to 1.9) was significant within the equivalence interval (P = 0.011; the greater of the two P values) and was confirmed by the intention-to-treat analysis (P = 0.001). The adverse events were of mild character and were experienced by similar percentages of patients in both groups (39 and 40 per cent for the bibloc and monobloc group, respectively). Limitations: The study shows short-term results with a median time from commencing treatment to the evaluation visit of 56 days and long-term data on efficacy and harm are needed to be fully conclusive. Conclusion: In a short-term perspective, both appliances were equivalent in terms of their positive effects for treating OSA and caused adverse events of similar magnitude. Trial registration: Registered with ClinicalTrials.gov (#NCT02148510).

Self-reportance of temporomandibular disorders in adult patients attending general dental practice in Sweden from 2011 to 2013.

OBJECTIVES: The study aim was to evaluate the prevalence of self-reported temporomandibular disorders (TMD) and acceptance or nonacceptance of such disorders in adult patients attending all public dental health services in the County of Sörmland, Sweden, during a 3-year period, 2011-2013. METHODS: Two questions were asked about TMD and the voluntary mouth-opening capacity was measured. The results were registered in a score 0-3. The registration was completed with a question about each patient's acceptance or nonacceptance of their condition. RESULTS: More than 73,000 registrations of the TMD condition were performed in general dental clinics from 2011 to 2013. The mean prevalence of a TMD score of 1-3 was 5% and was consistent over these years. Seventy percent of these patients were women. The peak prevalence of TMD was registered in patients aged 30-45 years (38%), and the frequency declined in older age groups. Reduced voluntary mouth-opening capacity (≤35 mm) was found in less than 2% of the participants. About one-fifth of the patients with a TMD-score of 1-3 did not accept their condition and wanted professional care. The frequency of nonacceptance of the condition increased with the severity of symptom score: 15%, 27%, and 49% for scores 1, 2, and 3, respectively. CONCLUSIONS: This study shows that the prevalence of self-reported TMD in adult patients was consistent from 2011 to 2013 and should be considered as a public health issue in Sweden. Patients with more severe TMD pain symptoms wanted care more frequent. The annual clinical calibrations should be continued to achieve an acceptable level of registration.

Patient-reported negative experiences related to caries and its treatment among Swedish adult patients.

BACKGROUND: It has been suggested that dental caries should be regarded as a chronic disease as many individuals repeatedly develop new caries lesions. How this is perceived by caries active patients is unclear. The aim of this study was to measure patient-reported attitudes and negative experiences related to caries and dental treatment. METHODS: A questionnaire was mailed to 134 caries active (CA) and 40 caries inactive (CI) adult patients treated at a Swedish public dental service clinic. The questionnaire included items regarding patient-reported oral health; attitudes towards caries and efforts to prevent them; and negative experiences related to caries and dental treatment. Questionnaire data were supplemented with data on caries and caries prophylaxis from patients' dental records. Exploratory factor analysis was conducted on items related to patients' perceptions of problems to see whether scales could be created. Experiences, perceptions and dental records of CA and CI patients were compared. RESULTS: The overall response rate was 69%. Dental records confirmed that CA patients had significantly more decayed teeth per year and a longer period of caries-active time than CI patients. Factor analysis resulted in 3 distinct scales measuring problems related to caries; 1) caries-related information; 2) negative experiences; and 3) negative treatment/staff attitudes. A fourth scale measuring perceived problems related to caries was also created. The CA group reported significantly more problems related to caries and dental treatment, received significantly more caries-related information, and reported significantly more negative treatment experiences compared to CI patients. CONCLUSIONS: Caries prophylaxis methods need to be improved in order to better meet the needs of caries active patients and to create a more positive experience with dental care.

Treatment of temporomandibular disorders - knowledge, attitudes and clinical experience among general practising dentists in Sweden.

OBJECTIVE: The aim of the study was to investigate the self-perceived level of knowledge, attitudes and clinical experience in treatment of temporomandibular disorders (TMD) among general practising dentists (GPDs). MATERIAL AND METHODS: A web-based questionnaire was sent to all GPDs in the public dental health service in the County of Uppsala in 2010 (n = 128) and 2014 (n = 113). The GPDs were asked to answer questions in the following categories: Demographic information, Quality assurance, Clinical experience and treatment, Need for specialist resources in the field of TMD and Attitudes. Between the two questionnaires, the GPDs were offered TMD education and an examination template including three TMD questions was introduced in the computer case files. The results were also compared with a previous questionnaire from 2001. RESULTS: The response rate was 71% (2010) and 73% (2014). The majority of the GPDs were women (70% in 2010 and 72% in 2014). The reported frequency of taking a case history of facial pain and headache increased between 2010 and 2014. In 2014, the GPDs were more secure and reported higher frequency of good clinical routines in treatment with jaw exercises and pharmacological intervention compared to 2001. Interocclusal appliance was the treatment with which most dentists felt confident and reported good clinical routines. CONCLUSIONS: The GPDs felt more insecure concerning TMD diagnostics, therapy decisions and treatment in children/adolescents compared to adults. There is a high need for orofacial pain/TMD specialists and a majority of the GPDs wants the specialists to offer continuing education in TMD.

Patient-reported outcomes of caries prophylaxis among Swedish caries active adults in a long-term perspective.

The aim of this study was to measure patient-reported outcomes of caries prophylaxis and to compare them with previously documented efforts in dental offices. A questionnaire was mailed to 134 caries active (CA) and 40 caries inactive (CI) adult patients treated at a Swedish public dental service clinic. The overall response rate was 69%. The questionnaire included items regarding patient perceived caries prophylaxis in relation to: 1) treatment and recommendations given by the dental personnel, 2) performed self-care and 3) perceived and expected effects.The responses were studied for their association to clinical data, extracted retrospectively from the patients' dental records.The mean follow up time was > 16 years. Information about caries prophylaxis (p = 0.01) and recommendations for self-care (p = 0.04) were given more often to the CA group than to the CI group. Supplementary examinations and recommendations of self-care risk treatments were more frequent in the CA group (p < 0.001). CA patients also made more frequent extra efforts at home to avoid caries by changing their eating habits (p < 0.001), improving their oral hygiene (p = 0.04) and using extra fluoride (p = 0.001). In the CA group, 60% did not considerthat the extra prophylaxis efforts had made them caries inactive, and 40% were not satisfied with the outcome. Most patients (> 90%) hoped that the outcome of caries prophylactics would be a reduced number of cavities.The patient-perceived experiences of caries prophylaxis-were in concordance with dental records. Both the dentists and the caries active middle-aged Swedish adults were aware of the need for extra prophylaxis.The caries active patients perceived having made extra home care efforts, but had not experienced that they had become free from caries.

Eating disorders - knowledge, attitudes, management and clinical experience of Norwegian dentists.

BACKGROUND: The purpose of this study was to investigate knowledge, attitudes and clinical experience with regard to patients with eating disorders (ED) among Norwegian dentists. METHODS: In 2010, a questionnaire was sent to all dentists in Norway (N = 4282) comprising 33 questions related to demographics of the participating dentists, their knowledge of ED (general and oral health aspects), clinical experience, attitudes and perceived management preferences. RESULTS: The participation rate was 40 % (47 % women and 53 % men). Their knowledge about ED was often retrieved from common media sources and the greater part of the participants reported they had seen very few patients with ED during their professional career. Female dentists reported superior knowledge about ED compared to males, but the former experienced greater difficulties to inform about the condition. Referrals of the patient to other health facilities were significantly more common among female compared to male dentists. The majority of dentists (76 %) reported a need of more education related to ED management. CONCLUSIONS: The Norwegian dentists in this study reported limited clinical experience and insufficient knowledge regarding ED. There is therefore a need to increase both undergraduate and continuing education in this field, which can improve preventive and management measures that a dentist can provide for ED patients.

Prevalence of temporomandibular dysfunction and pain in adult general practice patients.

OBJECTIVE: To analyse the prevalence of temporomandibular disorders and related pain (TMD-pain) among adult recall patients in general dental practice. MATERIALS AND METHODS: From November 2006 to September 2008, all adults attending a Swedish Public Dental Service (PDS) clinic for recall examination were asked two standardized questions about temporomandibular pain and dysfunction. Mouth-opening capacity was measured. The responses to the questions and mouth-opening capacity were combined to give a TMD-pain score, on a scale of 0-3. The patients' acceptance of their TMD condition was also noted. RESULTS: The subjects comprised 2837 adults (53% females, 47% men). Of the total sample, 4.9% reported a TMD-pain score of 1-3. The gender difference was significant: women predominated (p < 0.003). Forty-three per cent of those with TMD-pain scores of 1-3 (36% men, 47% women) considered that the condition warranted treatment, especially those registering a pain score (significant difference between pain and dysfunction groups, p < 0.000). CONCLUSIONS: The TMD-pain score shows promise as a useful instrument for detecting and recording TMD-pain. The prevalence of TMD disclosed in the study is high enough to be considered a public health concern. Most of the subjects with lower scores on the TMD-pain scale accepted their condition as not severe enough to require treatment.

Socioeconomic differences in self-rated oral health and dental care utilisation after the dental care reform in 2008 in Sweden.

BACKGROUND: The aims of this study were to determine self-rated oral health and dental attendance habits among Swedish adults, with special reference to the role of social inequalities, after the Swedish dental care reform in 2008. METHODS: The study is based on a survey questionnaire, sent to 12,235 residents of a Swedish county, in 2012. The age group was 16-84 years: 5,999 (49%) responded. Using chi-square statistics, differences in prevalence of self-rated oral health and regular dental attendance were analysed with respect to gender, age, educational level, family status, employment status and country of birth. Self-rated poor oral health was analysed by multivarite logistic regression adjusting for the different socio-demographic factors, financial security and having refrained from dental treatment for financial reasons. RESULTS: Three out of four respondents (75%) reported fairly good or very good oral health. Almost 90% claimed to be regular dental attenders. Those who were financially secure reported better oral health. The differences in oral health between those with a cash margin and those without were large whereas the differences between age groups were rather small. About 8% reported that they had refrained from dental treatment for financial reasons during the last three months. Self-rated poor oral health was most common among the unemployed, those on disability pension or on long-term sick leave, those born outside the Nordic countries and those with no cash margin (odds ratios ranging from 2.4 to 4.4). The most important factor contributing to these differences was having refrained from dental treatment for financial reasons. CONCLUSION: The results are relevant to strategies intended to reduce social inequalities in oral health, affirming the importance of the provision of equitable access to dental care.

Intravenous S-ketamine's analgesic efficacy in third molar surgery. A randomized placebo-controlled double-blind clinical trial.

Background: In most cases, a combination of paracetamol and ibuprofen are the optimal treatment for postoperative pain in third molar surgery. If stronger analgesia is required, opioids are traditionally administered. In day-case, surgery; however, opioids should be avoided. Thus, the anaesthetic agent S-ketamine in analgesic doses might be preferred. Methods: The study was designed as a randomized placebo-controlled double-blind clinical trial. The study enrolled healthy subjects according to the American Society of Anaesthesiologists classification; I or II (ASA), aged 18 to 44 years, with a body weight between 50 and 100 kg. The patients were randomized into three groups where two doses of S-ketamine were compared (high: 0.25 mg/kg or low: 0.125 mg/kg) with placebo (saline). Results: A primary outcome of the study was that VAS at 4 h postoperatively, showed no significant difference between the placebo and high-dose S-ketamine group or in the low-dose group. We found a significant difference between the groups for the first 24 h, with a lower VAS-score in the high-dose S-ketamine group. The time to when 50% had taken their first rescue medication was 12 min later in the high-dose ketamine group. Conclusions: Pre-emptive S-ketamine 0.25 mg/kg gave a global significant reduction of pain by VAS during the first 24 h postoperatively. The time from end of surgery to first rescue medication were longer in the high-dose ketamine group compared to both low-dose ketamine and placebo groups.

Comparison of the cost-effectiveness of a high- and a low-intensity smoking cessation intervention in Sweden: a randomized trial.

OBJECTIVE: To assess the relative cost-effectiveness of a high-intensity treatment (HIT) and a low-intensity treatment (LIT) for smoking cessation. METHODS: The societal and health care perspective economic evaluation was based on the reported number of quitters at 12-month follow-up (point prevalence) from a randomized controlled trial of 2 smoking cessation programs in Sweden. Future disease-related costs (in Swedish kronor [SEK] 2004; SEK7.35 = USD1) and health effects (in quality-adjusted life-years [QALYs]) were estimated via a Markov model comprising lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease including stroke with costs and QALYs discounted 3% annually. RESULTS: HIT was more effective than LIT (23% vs. 16% quitters), but at a considerably higher intervention cost: SEK26,100 versus 9,100 per quitter. The model-estimated societal costs avoided did not balance the higher intervention costs, so the incremental cost-effectiveness ratio (ICER) amounted to SEK100,000 per QALY for HIT versus LIT. All sensitivity analyses indicated an ICER below SEK300,000 and that HIT is the preferred option if the decision maker willingness-to-pay exceeds SEK50,000 per QALY. Compared with no intervention, LIT was cost saving, whereas HIT was estimated at SEK8,400 per QALY. CONCLUSIONS: Compared with no smoking cessation program, it is a societal waste not to implement the LIT as it is estimated to result in lower societal costs. The incremental cost per QALY gained of SEK100,000 for HIT is considered very cost-effective in Sweden. Thus, if smoking cessation programs are judged in the same manner as other Swedish health care measures, the high-intensity program should be chosen before the low-cost program.

Effects of treatment with oral appliance on 24-h blood pressure in patients with obstructive sleep apnea and hypertension: a randomized clinical trial.

BACKGROUND: Continuous positive airway pressure treatment has been shown to lower blood pressure (BP) in patients with obstructive sleep apnea (OSA). The aims of the present pilot study were to evaluate the potential effects of oral appliance (OA) therapy on BP, to assess various outcome BP measures, and to inform sample size calculation. METHODS: Seventy-two patients with OSA and hypertension were randomly assigned to intervention with either an OA with mandibular advancement (active group) or an OA without advancement (control group). Before and after 3 months of treatment, the patients underwent nocturnal somnographic registration and 24-h ambulatory BP monitoring. RESULTS: Among the various BP measures, the largest trend toward effect of OA treatment was seen in 24-h mean systolic BP with a 1.8 mmHg stronger BP reduction in the active group compared with controls. A stronger trend toward effect was seen in a subgroup with baseline ambulatory daytime mean systolic BP >135/85 mmHg where the mean systolic BP fell, on average, 2.6 mmHg. Additional exclusion of patients with baseline apnea hypopnea index (AHI) ≤15 gave a significant reduction in mean systolic BP of 4.4 mmHg (P = 0.044) in the active group compared with controls. CONCLUSIONS: In patients with OSA and hypertension, OA treatment had a modest trend toward effect on reducing BP. A stronger trend toward treatment effect was seen after excluding patients with normal baseline ambulatory BP. Additional exclusion of patients with baseline AHI ≤15 showed a significant treatment effect. Data to inform sample size for an adequately powered randomized study are provided.

Long-term follow-up of a high- and a low-intensity smoking cessation intervention in a dental setting--a randomized trial.

BACKGROUND: Achieving lifelong tobacco abstinence is an important public health goal. Most studies use 1-year follow-ups, but little is known about how good these are as proxies for long-term and life-long abstinence. Also, intervention intensity is an important issue for development of efficient and cost-effective cessation treatment protocols.The study aims were to assess the long-term effectiveness of a high- and a low-intensity treatment (HIT and LIT) for smoking cessation and to analyze to what extent 12-month abstinence predicted long-term abstinence. METHODS: 300 smokers attending dental or general health care were randomly assigned to HIT or LIT at the public dental clinic. Main outcome measures were self-reported point prevalence, continuous abstinence (≥6 months), and sustained abstinence. The study was a follow-up after 5-8 years of a previously performed 12-month follow-up, both by postal questionnaires. RESULTS: Response rate was 85% (n=241) of those still alive and living in Sweden. Abstinence rates were 8% higher in both programs at the long-term than at the 12-month follow-up. The difference of 7% between HIT and LIT had not change, being 31% vs. 24% for point prevalence and 26% vs. 19% for 6-month continuous abstinence, respectively. Significantly more participants in HIT (12%) than in LIT (5%) had been sustained abstinent (p=0.03). Logistic regression analyses showed that abstinence at 12-month follow-up was a strong predictor for abstinence at long-term follow-up. CONCLUSIONS: Abstinence at 12-month follow-up is a good predictor for long-term abstinence. The difference in outcome between HIT and LIT for smoking cessation remains at least 5-8 years after the intervention. TRIAL REGISTRATION NUMBER: NCT00670514.