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PURPOSE: The effect of mandibular advancement device therapy on daytime sleepiness remains unclear. Here, we evaluate the effect of a mandibular advancement device on daytime sleepiness using the Karolinska Sleepiness Scale.

METHODS: We randomized 88 snoring patients with an apnea-hypopnea index < 30 and daytime sleepiness to a mandibular advancement device or a sham device for four months. The Karolinska Sleepiness Scale, which measures grades of sleepiness from 1 (very alert) to 9 (very sleepy), was used for seven consecutive days, four times each day. The results were analyzed with quantile regression at quartiles controlling for baseline, age, body mass index (kg/m²), sex, apnea-hypopnea index, and full-time work.

RESULTS: The Karolinska Sleepiness Scale score was lower with the mandibular advancement device than with the sham device at specific time intervals. The positive effect of mandibular advancement device therapy occurred at wake up and before lunch during the whole week and before lunch on weekdays at the middle quartile. The adjusted differences between the interventions favored mandibular advancement device therapy by almost one unit and normalized the Karolinska Sleepiness Scale scores at wake up and before lunch. In addition, there were positive effects of mandibular advancement device therapy before dinner at the highest quartile during the whole week, on weekdays, and on the weekend.

CONCLUSION: Mandibular advancement devices used for snoring and sleep apnea reduce daytime sleepiness, particularly at wake up and before lunch, but provide some benefit before dinner.

Sleep medicine is a multidisciplinary field, with patients referred to specialising physicians from all areas of medicine. The new edition of the ERS Handbook of Respiratory Sleep Medicine is truly reflective of this diversity, covering everything from neurobiology to digital health. Broad in scope but easy to use, the book is broken down into 17 sections, including diagnosis and management, neuromuscular disorders, hypoventilation syndromes, nonrespiratory sleep disorders, and paediatrics. The Editors have brought together expert authors to create a book that focuses on practical aspects, with tips and advice based on clinical practice and the latest guidelines. This book will be invaluable to experienced sleep specialists, trainees and nurses alike.

Objective: Discomfort has been related to the poor acceptance of a mandibular advancement device (MAD) in patients with obstructive sleep apnea. The present study compared severe initial side effects between a smaller and a larger degree of mandibular advancement in patients with a good protrusive capacity.

Methods: Consecutive patients with obstructive sleep apnea and a good protrusive capacity (≥8 mm) were randomized to start treatment with the mandible advanced by either 70% of maximum protrusion (Adv70%) or by 4 mm (Adv4mm) in a pilot study with a parallel design. The main outcome was tenderness or pain in the teeth or jaws using a 0-10 visual analogue scale (VAS) (from “not at all” to “very extensive”) or excluded use because of side effects during the first week of treatment. Secondary outcomes included salivation problems and bite changes.

Results: Eighteen patients were randomly selected and 17 patients fulfilled the study protocol. Four patients in the Adv70% group and none in the Adv4mm group reported severe tenderness or pain (VAS ≥7) on five or more of the seven days (p=0.03). The degree of mandibular advancement measured in millimeters correlated with the number of days with severe side effects, r=0.64 (p=0.006). The secondary side effects were minor.

Conclusion: Starting MAD treatment with 70% mandibular advancement was related to more severe side effects during the first week of treatment compared with a smaller fixed millimeter value in patients with a good protrusive capacity in this pilot study.

There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the "gold standard" in nonsurgical OSA management, OAT remains the recognised alternative treatment.This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.

Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy.

Guidelines for the evaluation and management of sleep disorders from national societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society's (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Taskforce reviewed the American Academy of Sleep Medicine's Clinical Practice Guideline on the Treatment of Adult Obstructive Sleep Apnea (OSA) with Positive Airway Pressure with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. To improve the evaluation of the guideline, surveys were sent by the senior author and the WSS to approximately 800 sleep doctors around the world to query the availability of OSA treatments in their respective region. The task force and the WSS guidelines committee endorsed the AASM's CPAP guidelines with respect to the indications for PAP therapy, utilization of different PAP modalities, and concurrent strategies to improve outcomes, noting appropriate caveats for universal applicability.

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear-nose-throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

Purpose: Occlusal changes are common during long-term treatment with oral appliances (OAs) for sleep apnea. The aim of the present study was to compare subjectively reported bite changes with objective findings.

Methods: Consecutive adherent treated patients were asked to participate in this study. The patients responded to two questionnaires using numeric visual analogue scales (VAS), ranging from 0 (not at all) to 10 (very much). The first questionnaire included open questions and the second questionnaire comprised specific questions about side effects. Measurements of overjet, overbite, and space for the teeth were made on plaster casts taken before treatment start and at follow-up.

Results: Thirty-eight (12 women) patients with a median age of 64 years (interquartile range (IQR) 57 to 69 years) and a median treatment time of 9.5 years (IQR 5.8 to 14.3 years) were included. Overjet, overbite, the molar relationship, and the irregularity of the lower front teeth had changed significantly during treatment. There were no associations between any of the patients’ responses and the objectively measured bite changes. Younger patients, those with a small baseline overjet or overbite and those who developed an anterior crossbite were more likely to report bite changes.

Conclusions: Patients who choose to continue long-term treatment with oral appliances for sleep apnea are unaware of various types of bite changes. Such changes will, however, progressively increase in magnitude and be more difficult to take care of, if needed. It is therefore important continuously to follow up patients in regard to bite changes.

Obstructive sleep apnea (OSA) is characterized by repetitive obstruction of the upper airway during sleep, resulting in sleep fragmentation and nocturnal oxygen desaturation. As a result, patients may present with signs and symptoms of daytime sleepiness, neurocognitive impairment, and cardiovascular morbidity and mortality. Mandibular advancement appliances (oral appliance mandibular, OAm) are recommended for patients with mild-to-moderate OSA, and for those with severe OSA, where continuous positive airway pressure is refused or not tolerated. The mechanism of action of OAm is based on holding the mandible in a protrusive position and hence reducing pharyngeal collapsibility during sleep. Two-thirds of patients show a minimum of 50% reduction in the apnea-hypopnea index (AHI) with OAm treatment. Further, OAm have been shown to have a positive effect on blood pressure and endothelial function that are markers of cardiovascular health. Despite OAm being inferior in therapeutic efficacy to CPAP in reducing the AHI, its higher compliance might translate to similar adjusted AHI and clinical effectiveness. There are side effects with OAm use, such as bite changes and jaw pain; however, most side effects are transient and rarely significant in the long term.