Austin, Texas - Dentist
Cosmetic & Family Dentistry
Snoring and Sleep Apnea
7800 N. MoPac, #300
Austin, TX 78759
512-338-8120
SNORING & APNEA
AN INTRODUCTION
Oral Appliance Therapy
FAQ
Sleep Questionnaire
Good Sleep Habits
Research Articles
Martin A. Denbar, D.D.S.
Cosmetic Dentistry
Snoring and Sleep Apnea
Austin, Texas
Dental Office Location
7800 N. MoPac, #300
Austin, TX 78759
512-338-8120
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The following excerpts are taken from recent research articles about positional sleep therapy.
A prospective randomized study of a dental appliance compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnoea.
Acta Otolaryngol 999; 9(4):503-9.
WILHELMSSON B, TEGELBERG A, WALKER-ENGSTROM ML, RINGQVIST M ANDERSSON L, KREKMANOV L, RINGQVIST 1.
Department of Otorhinolaryngology, Central Hospital, Vasteras, Sweden
The enthusiasm for uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnoea (OSA) has declined in recent years, partly because of a lower success rate over time and partly because of adverse effects. Reports on the beneficial effects of dental appliances exist, but only one prospective randomized study has been published comparing dental appliances with nasal continuous positive airway pressure (CPAP)-treatment. No study has been published comparing dental appliance treatment with UPPP. Ninety-five male patients with confirmed OSA, subjective daytime sleepiness and an apnoea index (Al) > 5 were randomized for subsequent treatment with either a dental appliance or UPPP. There were 49 patients in the dental appliance group and 46 in the UPPP group. Thirty-seven patients in the dental appliance group and 43 in the UPPP group completed the I 2-month follow-up. The success rate (rate of patients with at least a 50% reduction in Al) for the dental appliance group was 95%, which was significantly higher (p < 0.01) than the 70% success rate for the UPPP group. According to the criteria for OSA (apnoea index > or = 5 or apnoea/hypopnoea index > or = I 0), 78% of the dental appliance group and 5 1 % of the UPPP group were normalized after 12 months. The difference between the groups was significant (p < 0.05). These findings suggest that the dental appliance technique is useful in the treatment of mild to moderate OSA.
Summary: Oral Appliance therapy had a better success rate in treating Sleep Apnea than did UPPP.
A crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea.
Chest 1996-109(6)-.1477-83 7
CLARK GT, BLUMENFELD 1, YOFFE N, PELED E, LAVIE P
Department of Diagnostic Sciences and Orofacial Pain, School of Dentistry, University of California, Los Angeles, USA
OBJECTIVE: This study compared the efficacy of a removable anterior mandibular positioning (AMP) device to continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) using a fully balanced crossover design. DESIGN-. Twenty-three male subjects with confirmed OSA were recruited from the Technion Sleep Laboratory in Haifa, Israel, from February 18, 1991 to December 17, 1992. Twenty-one of the 23 subjects enrolled completed all aspects of the study. RESULTS: The mean apnea-hypopnea index (AHI) before treatment was 33.86 +/- 14.30. The mean AHI decreased with CPAP to 59.50%, but decreased only 38.91 % With the AMP device. The lowest mean recorded oxygen saturation level for the 21 subjects was 84.30 before treatment, 91.1 0 after CPAP treatment, and 90.20 after AMP treatment. Sleep data revealed a significant decrease in stage I and 2 (p=0.0088) and an increase in rapid eye movement percent (p=0.0066) for both treatments when compared with baseline. Three- to I 0-month posttreatment phone interviews showed that I subject was not using either device, I subject was using CPAP, and 2 subjects were using the AMP device intermittently due to occasional temporomandibular joint pain symptoms. The remaining 17 subjects were all using the AMP device nightly. The symptoms of excessive daytime sleepiness also decreased significantly by both AMP and CPAP. CONCLUSIONS: The AMP device achieved substantial success in most cases, but was less effective than
CPAP, especially for the more severe cases. In general, the AMP device was strongly preferred over the CPAP by the subjects of this study.
Snoring, obstructive sleep apnea, and surgery.
Medical Clinics of North America 1999;83(l):85-96
BARTHEL SW, STROME M
Department of Otolaryngology and Communicative Disorders, Cleveland Clinic Foundation, Ohio, USA
Snoring and OSA syndrome are prevalent and important causes of sleep disturbance. Snoring, historically considered to be only a habitual annoyance, has significant physical and social consequences. OSA is now considered to be a major public health concern with significant morbidity and mortality. CPAP is considered the treatment of choice for OSA syndrome, but poor patient acceptance and compliance remain problematic. Surgical procedures have been developed to alter the offending anatomic abnormalities responsible for OSA. Identification of the offending anatomic site with application of the most appropriate surgical procedure is essential for effective surgical treatment of OSA. When the region of the retropalate is correctly identified as the site of obstruction, UPPP can effectively treat OSA in a majority of patients. Surgical correction of nasal obstruction is advocated in conjunction with sleep apnea surgery when nasal obstruction exists. In OSA patients with retrolingual airway obstruction, a number of surgical procedures have been performed, \Mth or without UPPP, with some improvement over UPPP alone. MMO has been effective in the treatment of OSA in patients with significant retrolingual airway obstruction \Mth contributing skeletal abnormalities and in patients who have failed multiple other surgical procedures. MMO, however, is a procedure of considerable magnitude, requiring extensive oromaxillofacial surgical expertise. MMO is likely appropriate only in a limited number of patients. Tracheostomy is completely effective in the treatment of OSA syndrome but is undesirable to patients and is associated with significant physical and emotional morbidity. Nonetheless, tracheostomy can be lifesaving and remains an option for patients with severe OSA with serious associated cardiovascular complications, who cannot tolerate CPAP, and for whom other interventions are ineffective or unacceptable. Effective surgical treatment of snoring has been accomplished with UPPP and LAUP. LAUP is less invasive, less morbid, more cost-effective, and better tolerated and is likely the most appropriate procedure for debilitating symptomatic snoring. Currently, LAUP is not recommended for the treatment of OSA, despite some efficacy in patients with mild OSA. Exclusion of OSA in patients undergoing LAUP for snoring is important.
Laser assisted uvulopalatoplasty: six and eighteen month results.
J Laryngol Otol 1998; 1 12(7):639-41.
WAREING MJ, CALLANAN VP, MITCHELL DB.
Department of Otolaryngology-Head & Neck Surgery, Kent and Canterbury Hospital, U.K.
Our ongoing evaluation of the results of laser assisted uvulopalatoplasty (LAUP) for snoring is presented. Follow-up between 18 and 24 months post-treatment completion, of patients with a successful result at six months, reveals that 22 % of these patients suffer failure of snoring control between these two evaluation points. This equates to an overall success rate at this time of 55%. LAUP, like other surgical remedies for snoring, has a continued relapse rate. This must be considered when counselling patients
Surgical treatment for obstructive sleep apnoea.
Sleep Medicine Reviews 1997;1(2):77-86.
DOUGLAS NJ.
Surgical therapy of the sleep apnoea/hypopnoea syndrome is an attractive option to many patients as it avoids using therapy nightly for the remainder of one's life. This article reviews the outcomes of the surgical options available. The role of uvulopalatopharyngoplasty is not yet clear. It may be useful second line therapy for some patients but cannot at present be advocated as first-line therapy. Mandibular maxillary osteotomy and advancement is an effective therapy of value in a minority of patients. Other procedures such as partial glossectomy and genioglossal advancement may also be of value in some patients. There is an urgent need for more randomized controlled trials examining the outcomes of surgical therapy for the sleep apnoea/hypopnoea syndrome in comparison to continuous positive airway pressure therapy. Copyright 1997 W. B. Saunders Company Ltd.
Enuresis and obstructive sleep apnea in adults.
Chest 1998;114(2):634-7.
KRAMER NR, BONITATI AE, MILLMAN RP.
Division of Pulmonary, Sleep, and Critical Care Medicine, Rhode Island Hospital and Brown University School of Medicine, Providence, RI 02go3, USA
-Adult enuresis is an unusual symptom of obstructive sleep apnea (OSA). Although it is described as a classic symptom of childhood OSA, enuresis is encountered infrequently in adult sleep medicine. Five adults with enuresis associated with sleep apnea presented to our Sleep Disorders Center. In all five cases, the onset of enuresis was associated with the progression of sleep apnea symptoms. In each case, the enuresis resolved with treatment with nasal continuous positive airway pressure. Current medical literature on the postulated mechanisms of nocturia and enuresis in sleep apnea is reviewed. Based on the experience of the authors and review of the medical literature, one may conclude that severe OSA may
lead to new-onset enuresis in adults and that effective treatment of OSA is associated with resolution of enuresis.
Prevalence of ischemic heart disease among patients with sleep apnea syndrome.
Psychiatry and Clinical Neurosciences 1998;52(2):219- 20.
MAEKAWA M, SHIOMI T, USUI & SASANABE R, KOBAYASHI T.
The Third Department of Internal Medicine, Aichi Medical University, Japan
We investigated the prevalence of ischemic heart disease (IHD) in sleep apnea syndrome (SAS) and the presence of coronary risk factors involved in the onset of IHD in 386 subjects with suspected SAS due to heavy snoring. The prevalence of IHD among patients with untreated SAS was found to be 23.8%, and the percentage of patients having SAS complicated with IHD was high among those with moderate or severe SAS. Sleep apnea syndrome patients with IHD also showed high prevalences of hypertension and hyperlipideniia. It appears that sleep apnea aggravates the factors that cause coronary vascular disorders, and is involved in the onset of IHD.
A non-urologic cause of nocturia and enuresis--osbtructive sleep apnea syndrome (OSAS)
Scandinavian Journal of Urology and Nephrology
1996-30(2)-.135-7. 1
ULFBERG J, THUMAN R
Department of Internal Medicine, Avesta Hospital, Sweden
Three case reports describe nocturia and enuresis as complications of the obstructive sleep apnea syndrome (OSAS). It is important to recognize the causal relationship since these troublesome symptoms are easily treated by treating the sleep apnea.
The effect of body posture on sleep-related breathing disorders: facts and therapeutic implications.
Sleep Medicine Reviews 1998;2(3):139-162
OKSENBERG A, SILVERBERG DS,
The aggravating effect of the supine body position on breathing abnormalities during sleep was recognized from the earliest studies on sleep breathing disorders. Most of the anatomical and physiological correlates of this phenomenon appear to be due to the effect of gravity on the upper airway. Although few articles have been published on this topic, it has been shown in a large population of obstructive sleep apnoea (OSA) patients that more than half of them are Positional Patients, i.e. they have at least twice as many apnoeas/hypopnoeas during sleep in the supine posture as in the lateral position. This positional phenomenon is influenced by factors such as Respiratory Disturbances Index (RDI), Body Mass Index (BMI), age and sleep stages. The sleep supine posture not only increases the frequency of the abnormal breathing events but also their severity. This sleep posture also has a detrimental effect on snoring, -as well as on the optimal CPAP pressure. Positional Therapy, i.e. the avoidance of the supine posture during sleep, is a simple behavioural therapy for many mild to moderate OSA patients. Unfortunately, only a few studies, including only a few patients, have investigated this form of therapy. Although the results of these studies are promising, the lack of a reliable long-term evaluation of its efficacy is perhaps an important reason why this form of therapy has not been widely accepted. Since mild to moderate OSA patients are the majority of the OSA patients and since without treatment, a large percentage of them will develop a more severe form of the disease, a thorough evaluation with a major emphasis on the long-term effectiveness of this form of therapy is urgently needed. Copyright 1998 W. B. Saunders Company Ltd. All rights reserved.
Obstructive sleep apnea: oral appliance therapy and severity of condition.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodonties 1998;85(4):388-92.
COHEN R.
Harvard University School of Dental Medicine, Boston, MA 02115-5888, USA
OBJECTIVE: The purpose of this study was to determine whether an oral appliance can effectively treat severe obstructive sleep apnea. DESIGN: The study was conducted at a tertiary care military facility with an accredited sleep laboratory. Results of the treatment of the first 25 patients with obstructive sleep apnea referred for oral appliance therapy were retrospectively analyzed. Each patient received a mandibular advancement appliance and underwent polysomnography 2 weeks after delivery of the appliance. Patients were divided into two groups: those with slight-to-mild obstructive sleep apnea who had a respiratory disturbance index less than 21, and those with more severe disease. Treatment was considered to be successful if the posttreatment respiratory disturbance index was less than S. RESULTS: Nine (90%) of the 10 patients with slight-to-moderate disease were successfully managed with the oral appliance. Of the 15 patients in the moderate-to-severe group, 9 (60%) were successfully managed. CONCLUSION: Oral appliances have
commonly been recommended only for mild obstructive sleep apnea. This study indicates that they may also have a role to play in selected cases in which the condition is more severe. There is a paucity of information about long-term success. This short-term (2-week) study should be followed by others evaluating the effect over longer periods.
[Dental appliances for the treatment of obstructive sleep apnea syndrome]
Chung-Hua Kou Chiang i Hsueh Tsa Chih Chinese Journal of Stomatology 1996;31(1)-12-5.
LIU Y, ZENG X, FU M.
School of Stomatology, Beijing Medical University
This study combined the use of cephalometrics and overnight polysomnographic monitoring to analyze the effects of a dental appliance on airway, sleep and respiratory conditions in 1 0 patients with obstructive sleep apnea. The findings indicated that horizontal and vertical mean changes in mandibular position while the appliance was worn were 1.73 mm and 9.30 mm, respectively, the mean superior airway space increased by 2.80 mm (P < 0.01), while the mean middle airway space increased by 6.75 mm (P = 0.01), the inferior airway space, however, didn't change significantly when the appliance was %urn. The average Apnea Index decreased by 15.98 events per hour when the appliance was worn (P < 0.01), the average Respiratory Disturbance Index decreased from 39.43 to 6.62 events per hour in 9 of IO patients (P < 0.01, one patient didn't have recording of hypoventilation). the lowest SaO2 value increased from 73.87% to 85.50% (P < 0.01). The reduction in the rate of airway obstructive events is attributed to the effect of appliance on the orophargneal structures. The dental appliance is a conservative, successful treatment alternative that could benefit patients with obstructive sleep apnea syndrome.
Evaluation of Variable Mandibular Advancement Appliance for Treatment of Snoring and Sleep Apnea*
(Chest. 1999;1 16:1511-1518.)
@ 1999 American College of Chest Physicians
JEFFREY PANCER, DDS; SALEM AL-FAIFI, MD; MOHAMED AL-FAIFI, MD AND VICTOR HOFFSTEIN, PhD, MD, FCCP
* From the Department of Medicine, Respiratory Division, St. Michael's Hospital, University of Toronto, Ontario, Canada.
Correspondence to: Victor Hoffstein, PhD, MD, FCCP, St. Michael's Hospital, 30 Bond St, Toronto, Ontario, Canada M 5 B I W8; e-mail: victor.hoffstein@utoronto.ca
Objective: To evaluate an adjustable mandibular positioning appliance for treatment of snoring and sleep apnea.
Methods: One hundred thirty-four patients with baseline apnea/hypopnea index (AHI) of 37 ± 28 events/h (mean ± SD) received the appliance. The efficacy of the appliance was assessed by the following investigations, performed at baseline
and with the appliance: polysomnography, Epworth sleepiness scale, bedpartners' assessment of snoring severity, patients' assessment of side effects, and overall satisfaction.
Results: Thirteen patients were lost to follow-up. An additional 46 patients had no follow-up polysomnography, but answered the questionnaires. A total of 75 patients had polysomnography at baseline and with the appliance. We found a significant reduction in AHI from 44 ± 28 events/h to 1 2 ± 1 5 events/h (p <
0.0005) and a reduction in the arousal index from 37 ± 27 events/h to 1 6 ± 1 3 events/h (p < 0.05). epworth scores fell from ii ± 5 to 7 ± 3 (p < 0.0005). bedpartners' assessment revealed marked improvement in snoring. For example, at baseline 96% of patients were judged to snore loudly "often" or "always" by their bedpartners, whereas only 2% were judged so while using dental appliance. The most frequent side effect was teeth discomfort, present "sometimes" or often" in up to 32% of patients. Follow-up clinical assessment in 1 21 patients conducted on the average 350 days after the insertion of the appliance revealed that 86% of patients continued to use the appliance nightly; 60% were very satisfied with the appliance, 27% were moderately satisfied, I I% were moderately dissatisfied, and 2% were very dissatisfied.
Conclusion: We conclude that the adjustable mandibular positioning appliance is an effective treatment alternative for some patients with snoring and sleep apnea.
Nonsurgical Management of the Obstructive Sleep Apnea Patient.
J. Oral Maxillofac. Surg. 54:1103-1108, 1996.
W. KEITH THORNTON, DDS, AND D. HEATH ROBERTS, DDS.
Sleep Position
Both snoring and sleep apnea are usually worse while sleeping in the supine position. The contribution of sleep position has been recognized as more than a trivial matter in the manifestation of OSA. One study has shown that in a group of 24 unselected patients with a diagnosis of OSA, the Apnea + Hypopnea Index (AHI) was twice as high when the patients slept in the supine position as it was when they slept in the lateral decubitus position. This finding of a substantial positional effect has lead to home and commercial remedies intended to train apneic patients who have a marked worsening of their condition while in the supine position to avoid this sleep posture. The two most common home devices are a tennis ball placed in a sock and sewn in the midline of the pajama top, and a pillow attached to the sleeper's back by a belt around the waist. whenever the patient becomes supine, the tennis ball causes enough discomfort to make them reposition, whereas the pillow, if large enough, completely prevents the supine position. an example of a more technical approach would be a gravity-activated position monitor/alarm worn on the chest that emits an auditory signal when the patient remains in the supine position for more than 15 seconds. a study using this device on 10 male patients diagnosed with osa associated with the supine sleep position showed a significant decrease in the number of apneic events as well as the number of episodes of significant oxygen desaturations. while wearing the alarm, the apnea index of seven patients remained within or near normal limits. data from this as well as other studies also suggested that a treatment based on changing sleep position might be selectively effective for those who were close to their ideal weight. it appears that training patients to avoid the supine position may have some validity as a noninvasive treatment when considered as a single therapy or in combination with others.
Positional Vs Nonpositional Obstructive Sleep Apnea Patients: Anthropomorphic, Nocturnal Polysomnographic, and Multiple Sleep Latency Test Data.
Chest 1997; 112(3): 629-39
OKSENBERG A, SILVERBERG DS, ARONS E, RADWAN H.
Sleep Disorders Unit, Lowenstein Hospital Rehabilitation Center, Raanana, Israel.
Conclusions: In a large population of OSA patients, most were found to have at least twice as many apneas/hypopneas in the supine than in the lateral position. These so-called "positional patients" are on the average thinner and younger than "nonpositional patients." They had fewer and less severe breathing abnormalities than the nonpositional group. Consequently their nocturnal sleep quality was better preserved and according to MSLT data, they were less sleepy during daytime hours. RDI was the most dominant factor that could predict the positional dependency followed by BMI and age. RDI showed a threshold effect, the prevalence of positional patients in those with severe RDI(RDI > or = 40) was significantly lower than in those OSA patients with mild-moderate RDI. BMI showed a major significant inverse relationship with positional dependency, while age had only a minor although significant inverse relationship with it. Body position during sleep has a profound effect on the frequency and severity of breathing abnormalities in OSA patients.
Effects of Body Position on the Upper Airway of Patients with Obstructive Sleep Apnea.
Am. J Respir. Crit. Care Med. Vol. 152. pp.179-185, 1995.
PEVERNAGIE, ANTHONY W. STANSON, PATRICK F. SHEEDY II, BRUCE K. DANIEL, JOHN W. SHEPHARD, JR.
Fast-CT scanning was used to study the effects of changes in body position on upper airway(UA) size and shape in 11 awake subjects with obstructive sleep apnea(OSA). Six patients with position(P) dependent OSA were compared with five patients with nonposition(NP) dependent OSA. Scans were repeated in the prone(PRN), right side(RS), and supine(SUP) body positions at both functional residual capacity and end-inspiratory tidal volume. Significant group, group by position, and borderline group by respiration effects were detected for minimum but not mean UA dimension data. Significant differences between groups were noted in minimum cross-sectional area and minimum lateral distance but not in minimum anteroposterior distance in the RS and SUP positions. Turning from the PRN to the RS or SUP tended to decrease the UA size in the NP group by decreasing the lateral distance, while the opposite effect was found in the P group. The results indicate that changes in body position during wakefulness affect the lateral but not the anteriorposterior dimensions of the UA, and the UA behaves differently in patients with NP and P OSA in response to changes in body position.
The Effect of Polysomnography on Sleep Position: Possible Implications on the Diagnosis of Positional Obstructive Sleep Apnea.
Respiration 1996; 63(5): 283-7.
METERSKY ML, CASTRIOTTA RJ.
This prospective study was designed to determine if physical constraint due to the polysomnography (PSG) apparatus affects PSG results by inducing subjects to sleep in the supine position. Twelve patients found to have positional obstructive sleep apnea (OSA) during standard PSG, returned for two additional nights of study which no PSG leads were attached. The time spent supine was 56% greater during the PSG night than the non-PSG nights, 195+/-88.6 min. during the baseline PSG and 125+/- 84.6 min. during the non-PSG nights (p< 0.05). therefore, psg may overestimate the severity of osa in some patients with positional osa.
Avoiding the Supine Position During Sleep Lowers 24 Hour Blood Pressure in Obstructive Sleep Apnea (OSA) Patients.
Journal of Human Hypertension 1997; 11(10): 657-64.
BERGER M, OKSENBERG A, SILVERBERG DS, ARONS E, RADWAN H, IAINA A.
Obstructive sleep apnea (OSA), is a common clinical condition affecting at least 2-4% of the adult population. Hypertension is found in about half of all OSA patients, and about one-third of all patients with essential hypertension have OSA. There is growing evidence that successful treatment of OSA can reduce systemic blood pressure (BP). Body position appears to have an important influence on the incidence and severity of these sleep-related breathing disturbances. We have investigated the effect of avoiding the supine position during sleep for a 1 month period on systemic BP in 13 OSA patients (six hypertensives and seven normotensives) who by polysomnography (PSG) were found to have there sleep-related breathing disturbances mainly in the supine position. BP monitoring was performed by 24-hour ambulatory BP measurements before and after a 1 month intervention period. We used a simple, inexpensive method for avoiding the supine posture during sleep, namely the tennis ball technique. Of the 13 patients, all had a reduction in 24-h mean BP (MBP). The mean 24-h systolic/diastolic (SBP/DBP) fell by 6.4/2.9 mm Hg, the mean wake SBP/DBP fell by 6.6/3.3 mm Hg and the mean sleeping SBP/DBP fell by 6.5/2.7 mm Hg, respectively. All these reductions were significant (at least P< 0.05) except for the sleeping dbp. the magnitude of the fall in sbp was significantly greater in the hypertensive than in the normotensive group for the 24 hour period and for the awake hours. in addition, a significant reduction in bp variability and load were found. since the majority of osa patients have supine-related breathing abnormalities, and since about a third of all hypertensive patients have osa, avoiding the supine position during sleep, if confirmed by future studies, could become a new non-pharmacological form of treatment for many hypertensive patients.
The following excerpts are taken from recent research articles about oral appliance therapy.
1. The Mandibular Repositioning Device: Role in the Treatment of Obstructive Sleep Apnea.. Stuart J. Menn, Daniel I. Loube, Todd D. Morgan, Merrill M. Miller, Joel S. Berger and Milton K Erman. Division of Sleep Disorders, Scripps Clinic and Research Foundation, Pulmonary Service, Walter Reed Army Medical Center. 1996, Sleep, 19(10): 794-800
The role of oral appliances in the routine treatment of obstructive sleep apnea (OSA) is not well defined. This prospective study attempts to clarify the clinical role of a specific oral appliance, the mandibular repositioning device (MRD). This study evaluated the demographic, polysomnographic, and cephalometric radiographic findings predictive of treatment success or failure with the MRD. Twenty-nine patients were diagnosed with mild to severe OSA by nocturnal polysomnography. The majority of these patients were intolerant to nasal continuous positive airway pressure (C-PAP) and all were fitted with a MRD. Twenty-three of these patients were compliant initially with MRD use and received post-treatment nocturnal polysomnography at a mean of 104 days after receiving the device. The respiratory disturbance index (RDI) decreased with the MRD use (37+or - 23 versus 18+or- 20 events/hour, p< 0.001), and 16 of the 23 patients (69%) were considered responders (decrease in rdi <or = 50% and posttreatment RDI <or = 20). measurements of subjective and objective daytime sleepiness, nocturnal oxygen desaturation, and snoring were all improved with mrd use. a pre-treatment rdi > 40 was present in four of the seven (67%) non-responders. Age, body mass index, and cephlometric radiographic measurements were not predictive of treatment outcome. Sixteen of 23 patients (70%) continue to use the MRD after 3.4 + or - 0.7 years. This study suggest that the MRD is useful in the long-term treatment of patients with OSA of mild to moderate severity.
2. Oral Appliances for Obstructive Sleep Apnea (OA for OSA). Wolfgang Schmidt-Noware, M.D. Pulmary Division, University of New Mexico. Chest, in press, May 1996.
The advent of oral appliance therapy and the significance of this study need to be placed in a broad perspective. Of the 8 million men and women in this country age 30 and older with OSA (subject with RDI >or = 15, prevalence from Young,et.al., reference 6), most have relatively mild disease. OA therapy provides an important treatment choice in this group, and may be the preferred initial treatment. Clinicians caring for OSA patients should add OA to their vocabulary and OA therapy to their repertoire.
3. Effect of Jaw Position and Posture on Forced Inspiratory Airflow in Normal Subjects and Patients with Obstructive Sleep Apnea. Shin-ichi Masumi, DDS, PHD; Keisuke Nishigawa, DDS, PHD; Adrian J. Williams, MD, FCCP; Frisca L. Yan-Go, MD; and Glenn T. Clark, DDS,MS. Chest 1996; 109: 1484-89.
Objective: This study evaluated whether substantial airflow changes occur by changing both body posture and jaw position in normal subjects and patients with obstructive sleep apnea (OSA).
Results: Both groups had a significant decrease in their forced inspiratory flow25-75 upon reclining, and there were no significant group differences regarding the magnitude of this change. Both groups also had a nearly full recovery of their forced inspiratory flow25-75 airflow when their jaws were positioned forward while reclining.
Conclusions: These data document that when a patient is in a supine position, a 100% protrusive jaw position allows significantly more inspiratory airflow to occur.
4. Evaluation of Anterior Mandibular Positioning Appliances for Treatment of Obstructive Sleep Apnea. J. Pancer and V. Hoffstien. Center for Sleep and Chronobiology, University of Toronto.
Dental appliances are presently the only non-invasive alternative approach for treatment of sleep apnea. Although this treatment modality is not new, it has been somewhat neglected, mainly because of the uncertainties regarding efficacy, acceptance by patients, and dramatic success afforded by treatment with continuous positive airway pressure (C-PAP) devices. However, there are many patients with sleep apnea who for various reasons cannot use C-PAP. The purpose of this invell patients with sleep apnea or upper airway resistance syndrome presenting to our sleep disorders center. There were 23 patients (22 males and 1 female) who accepted to be fitted for the appliance and subsequently used it at home. All patients had standard nocturnal polysomnography. They were assessed by one dentist (JP) who constructed the TAP appliance for them. They started using it at home, and if there was any discomfort or continued snoring, the appliance was adjusted accordingly, until the patients were able to tolerate it. Prior to treatment patients' bedpartner was asked to fill out a questionnaire dealing with their bedmates snoring. After the appliance was used at home for several weeks, the bedpartner once again filled out the same questionnaire. At the same time the patients filled out a questionnaire dealing with 1) overall comfort of the appliance, 2) possible side affects involving the jaw, teeth, tongue, and gums, and 3)excessive salivation. Nocturnal polysomnography was repeated with the appliance in place throughout the night. The results were analyzed by comparing the apnea/hypopnea indices without and with the appliance using paired t-test, comparing replies of the bedpartners regarding snoring before and with the appliance using chi-square test, and tabulating the replies of the patients dealing with the comfort of the appliance.
Patients ranged in age from 25 to 72 (mean SD = 47+ or - 12 yrs.). Their body mass index was 31 + or - 5 km/m2. We found that apnea/hypopnea index was reduced from 44 + or - 24 without the appliance to 14 + or - 9 with the appliance (p<0.005). bedpartners reported that without the appliance 83% of their bedmates snored either always or often, and 17% snored sometimes. with the appliance, 80% either did not snore or snored only rarely, and 20% snored sometimes. 71% of all patients were very satisfied with the appliance, and 21% were moderately satisfied. teeth discomfort was reported often by 25%, and never, rarely, or sometimes by the remaining 75%. similarly, jaw discomfort was reported often by 25%, and rarely or sometimes by 75%. most patients (75%) reported no tongue discomfort at all, and only 13% reported frequent gum discomfort.
We are encouraged by the subjective and objective efficacy of the appliance, its relatively high acceptance rate, and relatively low incidence of side affects. However, we must be cautious in recommending oral appliances as an initial treatment of sleep apnea in all patients, pending proper evaluation (i.e. efficacy and acceptability) of this appliance in a large group of patients with different severity of sleep apnea.
5. Dental Appliances for the Treatment of Obstructive Sleep Apnea Syndrome. Chung-Hua Chiang i Hsueh Tse Chih. Chinese Journal of Stomatology 1996;31(1):12-5.
This study combined the use of cephalomtrics and overnight polysomnographic monitoring to analyze the effects of a dental appliance on the airway, sleep, and respiratory conditions in 10 patients with obstructive sleep apnea. The findings indicated that horizonal and vertical mean changes in mandibular postion while the appliance was worn were 1.73mm and 9.30 mmm, respectively. The mean superior airway space increased by 2.80 mm (P<0.01), while the mean middle airway space increased by 6.75 mm(p=0.01), the inferior airway space, however, didn't change significantly when the appliance was worn. The average Apnea Index decreased by 15.98 events per hour when the appliance was worn (P<0.01), the average Respiratory Disturbance Index decreased from 39.42 to 6.62 events per hour in 9 of 10 patients (P<0.01, one patient didn't have recording of hypoventilation). the lowest sao2 value increased from 73.87% to 85.50% (p<0.01). the reduction in the rate of airway obstruction events is attributable to the effect of appliance on the orophargneal structures.
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