Department of Dentistry
Βιβλιοθήκη Οδοντιατρικής

2022-08-06

2022

Γώγου Ευγενία

Τζάκης Μιχαήλ, Ομότιμος Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Χαλαζωνίτης Δημήτριος, Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Ψάρρας Βασίλειος, Επίκουρος Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Κανελλοπούλου Αντωνία, Επίκουρη Καθηγήτρια, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Γιαννακόπουλος Νικόλαος-Νικήτας, Αναπληρωτής Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Κούρτης Στέφανος, Αναπληρωτής Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Δρούκας Βύρων, Ομότιμος Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ

Η επίδραση της χρήσης των ενδοστοματικών συσκευών σε ασθενείς με αποφρακτική άπνοια ύπνου και ροχαλητό

Greek

The effect of mandibular advancement device in the management of obstructive sleep apnea and snoring

Background: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by repetitive episodes of upper-airway obstructions and disruptive snoring during sleep. Studies have indicated that OSA may progress and contribute to more severe morbidities such as neurologic impairments, systemic hypertension, daytime tiredness and concentration difficulties. Continuous positive airway pressure (CPAP) is considered an effective treatment for patients with OSA. Although advances in technology have led to improvements in CPAP design, such as quitter pumps, softer masks, and portable travel-size devices, non-adherence to CPAP has nonetheless been reported in 46–83% of patients; consequently, low individual adherence to CPAP limits its clinical effectiveness. Mandibular advancement devices (MAD) have been suggested in the literature as an alternative treatment modality for OSA. Mechanical advancement of the mandible relative to the maxilla with the use of a MAD has been found to increase the antero-posterior dimensions of the oropharyngeal airway space and prevent pharyngeal upper airway collapsibility, thus improving patient’s sleep-related respiratory function.
Aim: The aim of the present study is to evaluate the effects on patients’ OSA indices after their use of a MAD for eight weeks and to estimate the effects on patients’ stomatognathic systems and general health.
Methods: Fifty-nine patients with mild, moderate and severe OSA (mean age 52.35±9.61 years; nine women [15%]) were assigned to two parallel groups. Thirty patients were treated with a MAD (experimental group) and 29 patients were treated with CPAP (control group) for eight weeks. Objective (polysomnography [PSG]) and self-reported (Epworth Sleepiness Scale [ESS], Short Form Health Survey [SF-36]) data were used to assess participants’ apnea–hypopnea index (AHI), mean capillary oxygen saturation (SpO2), and self-reported sleepiness and health-related quality of life. Before the initiation of the treatment, experimental group of patients underwent drug-induced sleep endoscopy (DISE) as a useful method to identify the location of upper-airway obstruction and to calculate the mandibular protrusion needed for the construction of MAD, thus to achieve the optimal therapeutic outcome. Control group of patients, in a later date, performed laboratory manual titration of positive airway pressure in order to attain the ideal pressure setting for the elimination of apnea-hypopnea episodes and restoration of hypoxemia. CPAP was manually titrated in sleep laboratory under full PSG monitoring that included electroencephalogram, electrooculogram, submental electromyogram, airflow from a thermistor, snoring, body position, thoracic and abdominal movements, and oxygen saturation. Most of the patients who were treated with CPAP device used nasal masks that covered the nose and were fixed over a solid base covering the areas from the base of the nose down to the upper lip. The mask had a good contact with the skin from different directions, thus making it considerably stable. Patients with nasal obstruction used an oronasal mask (which covered the nose and the mouth) as it also allowed ventilation through the mouth. In the experimental group, a custom-made, adjustable mandibular advancement device was fabricated for each patient, to keep the mandible in a protruded position during sleep hours. The MADs used in the present study consist of a two-piece, adjustable mechanism which was fabricated individually for each patient. The maxillary and mandibular full coverage plates were connected bilaterally with the use of telescopic Herbst attachments, consisting of a piston that slides within a tube, on each side, thereby making it possible to vary the degree of mandibular protrusion. The range of mandibular advancement was set at 4.44±0.89 mm anteriorly (46% of the patient’s maximum mandibular protrusion capacity) with a mandibular opening of 2mm-4mm between the incisal edges of the upper and lower central incisors. PSG follow-up with MAD in situ and CPAP smart card were used to assess and compare the effect of the two treatments on OSA severity, eight weeks after the initiation of the treatment. The Helkimo Clinical Dysfunction index (Di) was used during the examination of the patients’ stomatognathic systems at the beginning of the treatment (baseline) and eight weeks after the patients had been using (follow-up) a MAD (experimental group) and a CPAP device (control group), nightly. The index facilitated the collection of standardized measurements of the functional status of each patient’s masticatory system, including the range of mandibular motion, TMJ function impairment, muscle and/or TMJ tenderness or pain during mandibular movements, and clicking or grating sounds. The dysfunction of the stomatognathic system (Di 0 = no dysfunction, Di I = mild dysfunction, Di II = moderate dysfunction, Di III = severe dysfunction) was defined as the presence of any of these symptoms. The Epworth Sleepiness Scale (ESS) and the Short Form Health Survey (SF-36) questionnaire was used to measure changes in day time sleepiness and health-related quality of life before the initiation of the treatment and eight weeks after the experimental group had been using a MAD and the control group of patients had been using a CPAP device, nightly.
Results: The change in the mean apnea-hypopnea index (AHI) score between baseline and therapy evaluation differed significantly in both therapy groups. A statistically significant reduction in AHI score was found in both therapy groups eight weeks after the initiation of the treatment as the mean AHI score decreased from 35.14/h to 6.82/h in patients treated with MAD and from 35.22/h to 3.01/h in patients treated with CPAP device (p<0.001). No significant differences between the two therapy groups were found in the mean blood oxygen saturation (SpO2) values (p=0.571) after an eight week treatment period. The changes in the domains of the Short Form Health Survey (SF-36) (p<0.197) and day time sleepiness (ESS) (p<0.422) were not significantly different between the two therapy groups while statistical analysis data showed a significant improvement in quality of life within the two therapy groups (p<0.001) eight weeks after the initiation of the treatment. There were no significant differences within both the experimental and control groups regarding clinical function of the stomatognathic systems as measured by Helkimo’s Clinical Dysfunction index (Di) (p=0.789).
Conclusions: Ιn the short term, mandibular advancement devices after DISE should be considered as effective as continuous positive airway pressure in the management of patients with snoring and mild, moderate and severe obstructive sleep apnea. CPAP yielded better polysomnography outcomes especially in reducing AHI. However, similar beneficial results from MAD and CPAP treatment in terms of clinical outcomes were found regarding daytime sleepiness and quality of life. No significant changes in the patients’ stomatognathic systems function were detected eight weeks after the initiation of the treatment.

Health Sciences

Dentistry

Obstructive sleep apnea, Mandibular advancement device, Drug-induced sleep endoscopy, Polysomnography

No

0

Yes

354

306

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https://pergamos.lib.uoa.gr/uoa/dl/object/3228796