time. Another commercially available OA compliance device (ProSomnus Sleep Technologies, Pleasanton, CA) was used in an eight-patient pilot study (Hu & Liptak, 2018). All of the patients were successfully using OAs without compliance recorders. The addition of the compliance chip (which is inserted into a predesigned pocket in the OA) did not adversely affect patient use of the OA. The mean usage time, objectively recorded in this study, was 7.4 hours per night. Once appliance efficacy has been established, follow-up visits with the dentist should be every 6 months for the first year and at least annually thereafter. At follow-up visits, the dentist should monitor patient compliance, evaluate the appliance, and assess the patient’s oral health, including the occlusion (American Dental Association, 2021). Ongoing, long-term management is recommended for all OSA patients on OA therapy. effects in a group of 104 patients being treated for OSA with MADs, who were also taking statin medication. In total, 22.1% of the patients experienced muscular side effects (including pain, which was referred, spontaneous, or induced with palpation). In patients taking statins, 57.1% had muscular side effects, compared with 16.7% who were not on this medication. The authors concluded that muscular side effects experienced by OA patients taking statins may result in part from use of the medication rather than the oral appliance. In 2016, Essick, Blank, Spencer, and Parker published a comprehensive article on the fabrication, delivery, and follow- up of OAs. Charkhandeh, Kuhns, and Kim reported on a fully digital workflow and manufacturing process for OSA mandibular repositioning devices in 2017. and functional outcomes). The researchers found no statistically significant difference in the post-treatment quality of life or mental health (measured with SF-36 surveys) between patients using CPAP therapy compared with MAD users. Furthermore, no differences were found in sleepiness or excessive daytime sleepiness between patients who used CPAP or MAD (measured with the ESS). However, there was a significantly greater improvement in the post-treatment AHI for patients using CPAP therapy as compared with the oral appliance group. Compliance with using CPAP was less than with MAD (1.1 hours less use per night); according to the authors, this difference in compliance could explain why, although CPAP is significantly more efficient in reducing AHI, no differences were seen between the use of CPAP and MAD in quality of life or cognitive or functional outcomes. Another meta-analysis of 67 studies with 6,873 patients reached somewhat different conclusions regarding the effectiveness of CPAP versus MAD in OSA-related daytime sleepiness (Bratton, Gaisl, Schlatzer, & Kohler, 2015). Compared with an inactive control, use of CPAP resulted in a reduction of 2.5 points in the ESS score, and use of MAD brought a reduction of 1.7 points. The researchers concluded that both therapies are effective in reducing excessive daytime sleepiness, with CPAP conferring a greater benefit for patients with more severe symptoms. In a study by Glos and colleagues (2016), 40 OSA patients were treated with MAD and CPAP for 12 weeks each. At baseline and after each treatment period, patients were assessed by polysomnography as well as by daytime cardiac autonomic function tests. Both CPAP and MAD therapy substantially eliminated apneas and hypopneas, with CPAP being more effective. Both MAD and CPAP resulted in similar beneficial changes in cardiac autonomic function during daytime, especially in lowering diastolic blood pressure.
purposes) to objectively measure patient compliance in using the OA. When the temperature measured is higher than 35 °C, patient use is assumed (Gjerde, et al., 2017). These thermosensor devices are not included in all OA so compliance with the use of these devices cannot be verified for all patients who utilize them (Pavwoski and Shelgikar, 2017). The device measures various parameters of use, such as temperature and three-dimensional rotation to determine OA wearing Follow-up Patients treated with OAs such as the TAP appliance generally should be seen every 1 to 2 weeks following delivery, in order to assess the fit and to titrate the degree of mandibular advancement. To monitor the therapeutic efficacy of OA therapy, patients should undergo a follow-up overnight PSG (Shrivastava, et al., 2018; Patil et al., 2019). Complications of oral appliance treatment The use of mandibular OAs may be associated with the development of symptoms of TMD (Schell, 2018). These symptoms include muscle pain, particularly myofascial pain; temporomandibular joint (TMJ) tenderness; TMJ sounds; and headaches. It is important to ascertain whether any of these TMD symptoms were present before initiation of OA therapy. Occlusal changes may occur with MAD use. These may be either temporary or more permanent and can include decreases in bite force and occlusal contact area (Marklund, et al., 2019). Such changes underscore the need for regular follow-up of OA patients. The use of statins to control lipid levels is associated with muscular side effects, which might be misinterpreted as being caused by OA use. González and colleagues (2016) conducted a prospective study to investigate the incidence of muscular side Effects on health outcomes The beneficial effects of OAs in reducing the severity of OSA and, consequently, improving health outcomes have been shown in numerous research studies. Randomized controlled studies have established the efficacy of MAD compared with that of inactive appliances (i.e., no mandibular protrusion). The use of CPAP therapy for the treatment of OSA has a higher degree of therapeutic effectiveness compared to oral appliances yet the former also has less patient compliance which results in a similar clinical outcome (Dieltjens and Vanderveken, 2019). The use of oral appliances for the treatment of OSA featured a modest improvement in blood pressure however their effect on other aspects of cardiovascular disease has not been established (Laratta, et al., 2017). Comprehensive systematic reviews of the utilization and effectiveness of OA therapy for OSA have also been published. Numerous studies have also compared CPAP with OAs in the treatment of OSA using various outcome measures. A systematic review of the effectiveness of MAD in treating obstructive sleep apnea syndrome was published by Serra- Torres, Bellot-Arcís, Montiel-Company, Marco-Algarra, and Almerich-Silla in 2016. Twenty-two articles were included in their review, which concluded that (a) using MAD while sleeping helps to prevent snoring and excessive daytime sleepiness, significantly reduces the AHI, and results in beneficial changes (increase in area) to the upper airway; (b) adjustable and custom-made appliances are more effective than fixed and prefabricated appliances; and (c) monoblock devices cause more complications, but these complications are generally mild and transient. Schwartz and colleagues (2017) conducted a systematic review and meta-analysis comparing the results of CPAP versus mandibular advancement devices (MAD) in adult patients with OSA. The review included 12 studies, which focused on improvements in the quality of life (sleepiness and cognitive
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