under ideal, controlled conditions. Effectiveness is a measure of how well the treatment works under real-world, non-controlled conditions. In chronic disease management (e.g., OSA) effectiveness of treatment is of primary concern. In randomized controlled trials comparing CPAP to OA treatment, CPAP has been shown to be superior in terms of eliminating obstructive breathing events and improving nocturnal oxygen saturation. In other words, CPAP consistently demonstrates normalization of the AHI, compared with OA therapy, in which the average AHI remains in the mild OSA range. However, the superiority of CPAP in treatment efficacy does not translate into superior health outcomes – including less sleepiness, as well as better quality of life, driving performance, and blood pressure – compared with OA. This situation results from the greater effectiveness of OA treatment, which is a reflection of longer usage during sleep. Gjerde, Lehmann, Berge, Johansson, and Johansson (2016) examined whether oral appliances are a valid OSA treatment alternative for patients who are non-adherent to CPAP. One hundred six patients with either moderate or severe OSA were provided with individually adjusted OAs. After an average follow-up time of 12 months, the overall treatment success rate was 75% (success being defined as at least a 50% reduction in baseline AHI). No significant difference in success rates was seen between patients in the moderate and severe OSA categories. OAs were comparable to CPAP for patients with mild OSA but CPAP was superior in cases of moderate to severe disease. The use of OA is a consideration for patients who cannot tolerate CPAP therapy or for cases that are refractory to CPAP therapy (Shrivastava, et al., 2018). 5. Multilevel (e.g., maxillomandibular advancement – a bilateral, sagittal, mandibular split osteotomy performed concurrently with a Le Fort I maxillary osteotomy). (Hsieh, et al., 2020) Patients presenting with discrete anatomic irregularities that are amenable to surgery (e.g., enlarged palatine tonsils, bone and / or soft tissue irregularities) are good candidates for sleep apnea surgery (American Dental Association, 2021). Updated practice parameters for OSA surgery, approved by the AASM, were published several years ago (Kent, et al, 2021). Modafinil and armodafinil are the only drugs approved by the U.S. Food and Drug Administration that are currently indicated for this purpose. Both are central nervous system stimulants (Mehra, et al., 2021). Based on a thorough review of the literature, the American Academy of Pediatrics issued revised clinical guidelines for the management of childhood OSA syndrome (American Academy of Pediatric Dentistry, 2021). The following are some of the recommendations: ● All children should be screened for snoring. ● Polysomnography should be performed on children or adolescents with snoring and symptoms of OSA. ● An adenotonsillectomy (AT) is recommended as the first-line treatment of young patients with adenotonsillar hypertrophy. ● CPAP is recommended as treatment for children or adolescents if an AT is not performed or if OSA persists after AT. ● Weight loss is recommended in addition to other therapy in young patients who are overweight or obese. ● Intranasal corticosteroids are an option for children with mild OSA if AT is contraindicated or if mild OSA persists after AT. Recognize craniofacial abnormalities which may contribute to the development of OSA.
Sharples and colleagues (2016) reviewed 77 randomized controlled trials of OSA treatment comparing MAD with conservative management (CM), MAD with CPAP, or CPAP with CM. In direct comparisons, mean AHI and ESS scores were lower (i.e., showing greater improvement) for CPAP. The authors concluded that, for patients who cannot tolerate CPAP, MAD is an appropriate treatment and may be comparable to CPAP in mild sleep apnea cases. A comparison among CPAP therapy, MAD, and inactive control groups (placebo or no treatment) and their influence upon systolic and diastolic BP in patients with OSA were associated with reductions in both systolic and diastolic BP except in the placebo or treatment groups (Marklund, et al., 2019). No statistically significant differences were found between the two treatment modalities. In general, CPAP has been shown to improve objective measures of OSA (e.g., polysomnographic indices, AHI, and oxygen saturation) to a greater degree than OAs. The success of treating OSA patients with CPAP therapy approximates 80%-90% while that of OA approximates 50- 70% as measured by a reduction of the initial AHI values (Larratta, et al., 2017). However, these superior outcomes for CPAP do not translate into improved objective or subjective health outcomes, which are generally equivalent between the two therapies. Greater patient compliance with OAs, resulting in more usage time during sleep, appears to account for this equivalence (Summer and Vyas, 2022). Compliance with OSA treatment directly affects the efficacy versus the effectiveness of therapy (Dieltjens and Vanderveken, 2019). Treatment efficacy refers to how well a treatment works Surgical procedures According to Poss (2016), surgery for OSA “is considered the last resort and reserved for patients who have not responded to other available treatment options (e.g., CPAP, oral appliance”; [p. 160]. The following is a partial list of upper airway surgical procedures for OSA: 1. Nasal or nasopharyngeal (e.g., septoplasty, inferior turbinate reduction, and nasal valve repair). 2. Oropharyngeal (e.g., uvulopalatopharyngoplasty). 3. Hypopharyngeal (e.g., partial glossectomy and lingual tonsillectomy). 4. Neck (e.g., hyoid suspension and tracheotomy). Pharmacological management No effective pharmacotherapy exists for the treatment of OSA (Panahi, et al., 2021; Gottlieb and Punjabi, 2020). Still, medications are available that can reduce residual daytime sleepiness in OSA patients who are being treated with CPAP.
Treatment of obstructive sleep apnea in children and adolescents Obstructive sleep apnea is prevalent in up to 5.8% of children and adolescents as determined by objective indicators such as polysomnography or pulse oximetry (Tsukada, et al., 2018). As is the case with adult patients, obesity is an independent risk factor. In this age group, OSA is associated with cardiovascular,
growth, and neurobehavioral abnormalities, and possibly inflammation. Adenotonsillar hypertrophy and obesity are the major risk factors for OSA in otherwise healthy children (Paruthi, 2018). Adenoid hypertrophy is the most common cause of nasopharyngeal obstruction in children and the predominant etiology of pediatric sleep-disordered breathing (Wilkerson, 2018). Dental agenesis (congenitally missing teeth resulting from a failure of tooth development) and early dental extractions can result in a smaller oral cavity. This, in turn, can predispose the upper airway to collapse during sleep, resulting in children with clinical complaints and signs of obstructive sleep apnea (Guilleminault, Abad, Chiu, Peters, & Quo, 2016).
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