Marie Marklund

Non-CPAP therapies in obstructive sleep apnoea

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

Oral Appliance Treatment for Obstructive Sleep Apnea: An Update

Oral appliances (OA) have emerged as an alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) treatment. The most commonly used OA reduces upper airway collapse by advancing the mandible (OAm). There is a strong evidence base demonstrating OAm improve OSA in the majority of patients, including some with more severe disease. However OAm are not efficacious for all, with approximately one-third of patients experiencing no therapeutic benefit. OAm are generally well tolerated, although short-term adverse effects during acclimatization are common. Long-term dental changes do occur, but these are for the most part subclinical and do not preclude continued use. Patients often prefer OAm to gold-standard CPAP treatment. Head-to-head trials confirm CPAP is superior in reducing OSA parameters on polysomnography; however, this greater efficacy does not necessarily translate into better health outcomes in clinical practice. Comparable effectiveness of OAm and CPAP has been attributed to higher reported nightly use of OAm, suggesting that inferiority in reducing apneic events may be counteracted by greater treatment adherence. Recently, significant advances in commercially available OAm technologies have been made. Remotely controlled mandibular positioners have the potential to identify treatment responders and the level of therapeutic advancement required in single night titration polysomnography. Objective monitoring of OAm adherence using small embedded temperature sensing data loggers is now available and will enhance clinical practice and research. These technologies will further enhance efficacy and effectiveness of OAm treatment for OSA.

Non-CPAP therapies in obstructive sleep apnoea mandibular advancement device therapy

Mandibular advancement devices (MADs) represent the main non-continuous positive airway pressure (non-CPAP) therapy for patients with obstructive sleep apnoea (OSA). The aim of the European Respiratory Society Task Force was to review the evidence in favour of MAD therapy. Effects of tongue-retaining devices are not included in this report. Custom-made MADs reduce apnoea/hypopnoea index (AHI) and daytime sleepiness compared with placebo devices. CPAP more effectively diminishes AHI, while increasing data suggest fairly similar outcomes in relation to symptoms and cardiovascular health from these treatments. Patients often prefer MADs to CPAP. Milder cases and patients with a proven increase in upper airway size as a result of mandibular advancement are most likely to experience treatment success with MADs. A custom-made device titrated from an initial 50% of maximum mandibular advancement has been recommended. More research is needed to define the patients who will benefit from MAD treatment compared with CPAP, in terms of the effects on sleep-disordered breathing and on other diseases related to OSA. In conclusion, MADs are recommended for patients with mild to moderate OSA (Recommendation Level A) and for those who do not tolerate CPAP. The treatment must be followed up and the device adjusted or exchanged in relation to the outcome.

Long-term effects of mandibular repositioning appliances on symptoms of sleep apnoea

Mandibular repositioning appliances (MRAs) reduce symptoms of obstructive sleep apnoea in the short term, but the long‐term effects are unknown. Our objective was to evaluate the long‐term symptomatic effects of custom‐made MRAs and to identify the patients who will experience subjective benefits from treatment. A cohort of 260 consecutive patients treated with appliances for non‐apnoeic snoring or sleep apnoea was followed up by a questionnaire and examination after an average of 5.4 years. The subjective effect was defined as good when complaints of daytime sleepiness occurred less than once a week. A total of 185 patients (71%) responded to the questionnaires. Of the respondents, 96 reported frequent use, 33 reported infrequent use, 26 reported discontinued treatment and 30 reported modified treatment. Mild cases (apnoea–hypopnoea index [AHI] < 15) were likelier than more severe cases to continue treatment. Patients who had used MRAs reported fewer complaints of sleepiness, headaches and daytime naps. Frequent use (P = 0.001), few night‐time awakenings before start of treatment (P = 0.02) and effective apnoea reduction during treatment of more severe cases (P = 0.02) correlated with a good subjective effect at long‐term follow‐up. Our conclusion is that custom‐made MRAs reduce sleep apnoea symptoms in the long term. The mildest cases will experience the greatest long‐term benefit. The reason is that non‐apnoeic snorers and patients with a mild disease are more likely to continue treatment and that their long‐term results with regard to excessive sleepiness are similar to patients with a more severe disease.

Physical findings in the upper airways related to obstructive sleep apnea in men and women.

Conclusions. There are gender differences when it comes to the risk factors for sleep apnea. Large tonsils, a high tongue and a wide uvula are risk factors for sleep apnea in men, while large tonsils and a retrognathic mandible are risk factors in women. Upper airway abnormalities including mandibular retrognathia are, however, unable to predict sleep apnea among snorers being investigated for suspected sleep apnea. Objectives. To identify gender-specific risk factors for obstructive sleep apnea and the diagnostic performance from physical upper airway examinations among snoring men and women investigated because of suspected sleep apnea. Patients and methods. The dimensions of the uvula, tonsils, velopharynx and tongue, and nasal septal deviation, mandibular position, neck circumference, weight, and height were systematically scored in 801 consecutive snoring patients (596 men and 205 women), who had been referred for a primary sleep apnea recording. Results. In men, large tonsils, a high tongue, and a wide uvula were independent factors associated with an apnea-hypopnea index of >15. In women, large tonsils and mandibular retrognathia were independent factors associated with an apnea-hypopnea index of >15. The positive predictive values for upper airway abnormalities ranged between 0.20 and 0.25 in men and between 0.09 and 0.15 in women.

An orthodontic oral appliance

OBJECTIVE This pilot study was performed to test the hypothesis that an orthodontic oral appliance (OA) that is designed to work against the backwardly directed forces on the upper incisors may counteract the reduction in overjet from these devices. MATERIALS AND METHODS Thirty patients with normal bites, good oral health, and milder sleep apnea were randomized to treatment with either OAs or orthodontic OAs. Bite changes were evaluated on plaster casts and radiographs and by questionnaires after a mean of 2.4 years in 19 frequent users. RESULTS Four of nine patients in the orthodontic OA group increased their overjet by > or =0.4 mm, while none of the 10 patients in the OA group experienced that effect. CONCLUSION Only the orthodontic OA increases the overjet; this design may therefore be beneficial to patients at risk of negative effects on their bite during OA treatment.

The relationship between mandibular morphology and apical root curvature in man

Two samples of individuals, a low-angle group and a high-angle group, were selected on the basis of the inclination of the lower border of their mandible, defined by the mandibular plane angle (ML/SNL) in profile radiographs. Apical root curvature of mandibular first and second premolars and molars on panoramic radiographs was compared between the two groups and related to mandibular morphology. In the low-angle group most teeth had more distally curved roots than in the high-angle group. Significant differences were found for the first premolars on both sides (p less than 0.001, p less than 0.05), the right second premolars (p less than 0.05) and the distal root of left first molars (p less than 0.05). Correlations were calculated between root curvature and two variables reflecting mandibular morphology, the mandibular plane angle and the gonial angle. The strongest associations were found between the first premolar roots and the gonial angle (rs = -0.75, p less than 0.001 and rs = -0.56, p less than 0.01, for right and left sides respectively). The association between mandibular morphology and root curvature is probably indirect, caused by tooth migration during root formation.

Report from the first conference of the European Dental Sleep Medicine Academy.

On 5 October 2004, the very first conference of the European Dental Sleep Medicine Academy (EdeSA) was held in Prague at the Prague Conference Centre. It was organised as a satellite program of the 17th congress of the European Sleep Research Society (ESRS). EdeSA is a new association for dentists and physicians who are involved in the treatment of patients with sleep apnea, snoring or other sleep-related conditions with dental implications. The first EdeSA president, Dr. Miche De Meyer from Ghent, Belgium, who is also a founder member of this society, welcomed the ESRS president Prof. Dr. Irene Tobler and 27 attendants from ten nations to a whole-day program of lectures. President Irene Tobler held the opening ceremony and wished the new society good luck. She discussed the need for new societies with specific interests in sleep medicine, like EdeSA, representing dental sleep medicine. EdeSA’s first meeting focussed on the diagnosis of sleep apnea and evidence for treatment with mandibular advancement devices, as well as other sleep-related conditions, such as sleep-related bruxism. Prof. Dr. Dirk Pevernagie from Ghent, Belgium, who is an affiliated medical advisor of EdeSA, was the first lecturer with the task of discussing evidence-based diagnosis for sleep apnea. The audience learnt about the criteria for apneas, hypopneas and sleep arousals. Prof. Pevernagie also talked about flow limitations and the need for oesophageal pressure measurements, physical examinations and questionnaires to complement the results from the polysomnographic sleep recordings. Ass. Prof. Marie Marklund from Umeå, Sweden then talked about predictors of treatment success with mandibular advancement devices in obstructive sleep apnea and described her findings that women and men with supine-dependent sleep apneas have a high chance of treatment success with an oral device. She also presented data from a study which shows that a deep bite, the use of a soft elastomeric device and a small mandibular opening by the device reduces the orthodontic side effects from the device. EdeSAwas happy to welcome Prof. Dr. Gilles Lavigne from Montreal, Canada, who talked about obstructive sleep apnea syndrome (OSAS) and sleep-related bruxism. He emphasised that sleep-related bruxism is not the same as daytime clenching. Sleeprelated bruxism has been recently classified as a movement disorder, but the condition is also recognised as an arousal disorder. Eight percent of adults are aware of tooth grinding, which may give rise to tooth damage, headache, temporomandibular joint (TMJ) problems and bed partner complaints. The treatment for this disorder is still a subject of investiM. Marklund Umeå University, Umeå, Sweden

Nocturnal Blood Pressure Is Reduced by a Mandibular Advancement Device for Sleep Apnea in Women: Findings From Secondary Analyses of a Randomized Trial

Background Obstructive sleep apnea is associated with high blood pressure. The magnitude of blood pressure effects from sleep apnea treatment is unclear. We aimed to determine the effect of mandibular advancement device therapy on ambulatory nighttime and daytime blood pressure in women and men with daytime sleepiness and snoring or mild to moderate sleep apnea (apnea‐hypopnea index, <30). Methods and Results In this 4‐month, double‐blind, randomized controlled trial comprising 96 untreated patients, 27 women and 58 men, aged 31 to 70 years, completed the study. The active group received individually made adjustable mandibular advancement devices, and the control group was given individually made sham devices, to be used during sleep. Polysomnographic sleep recordings and ambulatory 24‐hour blood pressure measurements were performed at baseline and at follow‐up. In women with mandibular advancement devices, the mean nighttime systolic blood pressure was 10.8 mm Hg (95% confidence interval, 4.0–17.7 mm Hg; P=0.004) lower than in the women in the sham group, adjusted for baseline blood pressure, age, body mass index, and the apnea‐hypopnea index. The mean nighttime adjusted diastolic blood pressure was 6.6 mm Hg (95% confidence interval, 2.7–10.4 mm Hg; P=0.002) lower in the mandibular advancement device group. In men, there were no significant differences in blood pressure at night or during the daytime between the intervention groups. Conclusions A mandibular advancement device for obstructive sleep apnea reduces nocturnal blood pressure in women. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00477009.