Efficacy of mandibular advancement devices in the treatment of mild to moderate obstructive sleep apnea and the usefulness of sleep endoscopy

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Domenico Viscuso, Ornella Arena | Dental Clinic, University of Cagliari, Cagliari, Italy

Abstract

Background

In mild to moderate obstructive sleep apnea (OSAS), dental treatment with a mandibular advancement device (MAD) is at least as effective as the therapy with Positive Airway Pressure (PAP or CPAP). The aim of this article is to highlight how sleep endoscopy can be useful in predicting the efficacy of the treatment.

Case report

A case is reported where sleep endoscopy, a fibroscopic examination performed under drug-induced sleep, in association with the mandibular advancement manoeuvres, proved to be very useful in predicting MAD effectiveness. Losing weight was essential for the effectiveness of the treatment.

Conclusion

MAD is as effective as CPAP in successfully treating mild to moderate OSA, as suggested in the AASM guidelines. It also shows that patients prefer MAD to CPAP, and epidemiologic data seem to confirm that the device ensures greater adherence to the treatment. Losing weight is essential for solving the pathology. MAD is often preferred by patients who are often more inclined to comply with the treatment.

Keywords: Excessive daytime sleepiness, Mandibular Advancement Device, Obstructive Sleep Apnea, Sleep endoscopy.

Introduction

Scientific literature and international guidelines report that, in mild to moderate obstructive sleep apnea (OSA) cases, dental therapy with a mandibular advancement device (MAD) is at least as effective as the therapy with Positive Airway Pressure (PAP or CPAP). Sleep endoscopy, a fibroscopic examination performed under drug-induced sleep, may be very useful in predicting MAD effectiveness. MAD is often preferred by patients who are often more inclined to comply with the treatment.

In the present work, a case is described that summarizes all these aspects.

A 55-year-old woman, habitual chronic snorer, decided to undergo cardiorespiratory monitoring after the onset of excessive daily sleepiness (EDS). The examination revealed moderate OSA. The use of CPAP was recommended. The woman decided to undergo a therapy with (MAD), reported in the guidelines of the American Association Sleep Medicine (AASM) as being equally effective for disorders of this type.

Sleep endoscopy consists of investigating the airways by means of fibroscopy under drug-induced sleep; during the snoring or apnea phases, the examiner can move the mandible forward by a manual manoeuvre called mandibular pull-up or using devices provided by the dentist, mimicking the position that the mandible will take when using the MAD. If in this situation the patient stops snoring or the apnea ends, it is highly probable that this will happen also when using the MAD.

The aim of this article is to highlight how sometimes sleep endoscopy can be useful in predicting the real effectiveness of dental therapy in the individual patient.

Case report

The patient underwent cardiorespiratory monitoring in December 2014. Table 1 shows the examination outcomes. The medical report stated she suffered from moderate OSA with deep desaturations. Indication: overnight CPAP therapy + 6.5 cm H20 in symptomatic patient.

Table 1
Table 1

After evaluating all the features of the CPAP therapy, the patient opted instead for the MAD therapy, reported as equally effective for moderate OSA in AASM guidelines.

The patient was presented to our clinic in March 2015. She scored 10 points in the Epworth test for the assessment of daily sleepiness. Her body mass index (BMI) was 31.2. The patient reported habitual, persistent snoring and excessive daily sleepiness (EDS).

The stomatognathic examination revealed good oral health, presence of all teeth and good occlusion. The patient reported having undergone an orthodontic treatment with a fixed appliance in the recent past for aesthetic reasons. The mouth opening was 43 mm, no signs or symptoms ascribable to TMJ disorders were present (Fig. 1).

cr-fig-1
Figure 1 The patient’s mouth opening

There were therefore all the pointers for MAD therapy and no contraindications.

In order to assess the probability of MAD’s effectiveness, a sleep endoscopy was prescribed.

This examination was performed in June 2015 with endoscopic recording of the upper aerodigestive tract under deep sedation using Propofol (10 mg/ml; Diprivan, AstraZeneca Co.) and with electrophysiological monitoring of brain activity (BIS).

Snoring at palate/tonsil level with circular pattern, circular obstructive site at palate/tonsil level and at the base of tongue/hypopharinx level were detected. Mandibular pull-up was effective and solved the problems at both levels. Therapeutic options prescribed were: CPAP or MAD application and weight loss.

Impression taking and bite registration were carried out using George Gauge devices (Fig. 2), in order to prepare for the application of MAD (type Odontoapneia).

Figure 2a bite registration for the fabrication of MAD
Figure 2A Bite registration for the fabrication of MAD
Figure 2 bite registration for the fabrication of MAD
Figure 2B Bite registration for the fabrication of MAD

This appliance consists of two (upper and lower) occlusal plates, linked by a frontal adjustable system, allowing sufficient freedom for mandibular movements, both in opening and in lateral excursions during use (Fig. 3).

Figure 3a The MAD appliance
Figure 3A The MAD appliance
Figure 3b The MAD appliance
Figure 3B The MAD appliance

The appliance is adjustable and can be progressively advanced, as prescribed by the AASM guidelines.

The appliance’s initial position, based on the bite registration, corresponds to 60% of the mandibular maximal protrusion.

The MAD was applied in July 2015. The patient was instructed on how to use and maintain the appliance correctly. She was informed about possible initial soreness in the face in the morning due to the necessary adjustment of the chewing muscles. The patient was asked to report any experience of problems in joints or continuing soreness.

Follow up

The patient came for the first check up in September 2015. This time the Epworth test score was 2 points. The woman reported that her daily sleepiness had disappeared while the snoring had firstly disappeared but had come back sporadically in the last two weeks, but at about 10% the level of the past, according to her husband. She did not report any particular problem in her chewing muscles nor the TMJ. The mouth opening was unchanged. The occlusion examination did not reveal any teeth displacement or changes to the contacts between the two dental arches.

The mandibular position was advanced by 1.5 mm activating the MAD advancement system.

The patient had lost weight and her BMI had decreased to 28.52.

In the meanwhile, as a first assessment of the MAD effectiveness, an overnight monitoring of blood oxygen saturation was performed; this examination is less accurate than cardio-respiratory monitoring but quicker to obtain at her local health facility. This examination was carried out in October 2015 and it showed no phasic desaturations which could lead to suspecting apneic events.

Meanwhile the patient reported the complete disappearance of snoring.

In January 2016, a new cardiorespiratory monitoring was performed with the same equipment used for the first monitoring, using the MAD.

Data are shown in Table 2. The medical report stated that the patient no longer suffered from OSA.

Table 2 Values of initial cardiorespiratory monitoring with MAD
Table 2 Values of initial cardiorespiratory monitoring with MAD

At the check up in the same month, the patient reported absence of snoring and daily sleepiness. The condition of the appliance was excellent and it showed no signs of deterioration. There were no changes in dentition, dental occlusion and chewing function compared to the initial situation.

In July 2016 the patient’s conditions were still stable, without snoring or sleepiness.

Conclusion

The case reported shows that MAD is as effective as CPAP in successfully treating mild to moderate OSA, as suggested in the AASM guidelines. It also shows that patients prefer MAD to CPAP, and epidemiologic data seem to confirm that this device ensures greater adherence to the treatment.

This case particularly reveals how sleep endoscopy, in association with the mandibular advancement manoeuvres, is an excellent prediction tool about the effectiveness of the MAD therapy.

References

1. Li DH, Yang XH, Zhou J, Zhang LP, Shu W. Radiographic study on the efficacy of mandibular advancement in patients with obstructive sleep apnea syndrome [Article in Chinese]. Shanghai Kou Qiang Yi Xue 2016 Apr;25(2):208-11.

2. Denolf PL, Vanderveken OM, Marklund ME, Braem MJ. The status of cephalometry in the prediction of non-CPAP treatment outcome in obstructive sleep apnea patients. Sleep Med Rev 2016 Jun;27:56-73.

3. Raunio A, Mattila P, Huuskonen U, Oikarinen K, Sándor GK. The influence of a mandibular advancement plate on polysomnography in different grades of obstructive sleep apnea. J Oral Maxillofac Res 2015 Mar 30;6(1):e4.

4. Serra-Torres S, Bellot-Arcís C1, Montiel-Company JM, Marco-Algarra J, Almerich-Silla JM. Effectiveness of mandibular advancement appliances in treating obstructive sleep apnea syndrome: A systematic review. Laryngoscope 2016 Feb;126(2):507-14.

5. Jaiswal M, Srivastava GN, Pratap CB, Sharma VK, Chaturvedi TP. Effect of oral appliance for snoring and obstructive sleep apnea. Int J Orthod Milwaukee 2015 Fall;26(3):67-71.

6. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. An American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine Clinical Practice Guideline. J Clinical Sleep Medicine 2015; 7 (11): 773-827.

7. Sutherland K, Takaya H, Qian J, Petocz P, Ng AT, Cistulli PA. Oral appliance treatment response and polysomnographic phenotypes of obstructive sleep apnea. J Clin Sleep Med 2015 Aug 15;11(8):861-8.

8. Guimarães TM, Colen S, Cunali PA, Rossi R, Dal-Fabbro C, Ferraz O, Tufik S, Bittencourt L. Treatment of obstructive sleep apnea with mandibular advancement appliance over prostheses: A case report. Sleep Sci 2015 Apr-Jun;8(2):103-6.

9. Tripathi A, Gupta A, Sarkar S, Tripathi S, Gupta N. Changes in upper airway volume in edentulous obstructive sleep apnea patients treated with modified mandibular advancement device. J Prosthodont 2015 Sep 30. [Epub ahead of print]

10. Mohan A, Henderson J, Mador MJ. Mandibular advancement device-emergent central sleep apnea can resolve spontaneously: A case report. J Clin Sleep Med 2016 Jan;12(1):137-8.

11. Galic T, Bozic J, Pecotic R, Ivkovic N, Valic M, Dogas Z. Improvement of cognitive and psychomotor performance in patients with mild to moderate obstructive sleep apnea treated with mandibular advancement device: a prospective 1-year study. J Clin Sleep Med 2016 Feb; 12(2): 177-86.

12. Prescinotto R, Haddad FL, Fukuchi I, Gregório LC, Cunali PA, Tufik S, Bittencourt LR. Impact of upper airway abnormalities on the success and adherence to mandibular advancement device treatment in patients with Obstructive Sleep Apnea Syndrome. Braz J Otorhinolaryngol 2015 Nov-Dec;81(6):663-70.

13. Durán-Cantolla J, Crovetto-Martínez R, Alkhraisat MH, Crovetto M, Municio A, Kutz R, Aizpuru F, Miranda E, Anitua E. Efficacy of mandibular advancement device in the treatment of obstructive sleep apnea syndrome: A randomized controlled crossover clinical trial. Med Oral Patol Oral Cir Bucal 2015 Sep 1;20(5):e605-15.

14. Jayesh SR, Bhat WM. Mandibular advancement device for obstructive sleep apnea: An overview. J Pharm Bioallied Sci 2015 Apr;7(Suppl 1):S223-5.

15. Wang L, Liu YH. Comparison of the efficacy of 2 types of mandibular advancement device in severe obstructive sleep apnea hypopnea syndrome [Article in Chinese]. Shanghai Kou Qiang Yi Xue. 2014 Dec;23(6):713-7.

16. Galic T, Bozic J, Ivkovic N, Gunjaca G, Ticinovic TK, Dogas Z. Effects of mandibular advancement device treatment on arterial stiffness and glucose metabolism in patients with mild to moderate obstructive sleep apnea: a prospective 1 year study. Sleep Breat. 2016 Mar; 20(1): 69-77.

17. De Corso E, Bastanza G, Della Marca G, Grippaudo C, Rizzotto G, Marchese MR, Fiorita A, Sergi B, Meucci D, Di Nardo W, Paludetti G, Scarano E. Drug-induced sleep endoscopy as a selection tool for mandibular advancement therapy by oral device in patients with mild to moderate obstructive sleep apnoea. Acta Otorhinolaryngol Ital 2015 Dec; 35(6): 426-32.

18. Vroegop AV, Vanderveken OM, Dieltjens M, Wouters K, Saldien V, Braem MJ, Van de Heyning PH. Sleep endoscopy with simulation bite for prediction of oral appliance treatment outcome. J Sleep Res 2013 Jun;22(3):348-55.