Effect of a Titration Polysomnogram on Treatment Success with a Mandibular Repositioning Appliance

Abstract

Scientific inveStigAtionSStudy Objectives: Mandibular repositioning appliance (MRA) therapy is a treatment option for patients with mild to moderate sleep apnea and for patients who do not tolerate continuous positive airway pressure. Titration of MRAs consists of sequential mandibular advancement guided by symptom improvement. The goal of the study was to determine if patients with an elevated apnea hypopnea index (AHI), despite the use of a subjectively optimized MRA, could achieve better results with additional titration during polysomnography (PSG). Methods: Patients were enrolled if they had an AHI ≥ 15/h and were referred for MRA therapy. The MRA was advanced until symptoms improved. During the PSG, the technologist monitored the patient's sleep and increased mandibular protrusion until the AHI was improved. Results: There was a significant improvement in AHI, minimum oxygen saturation, and total sleep time with the MRA before further advance-ment. At the final PSG, 65.2% of patients had an AHI ≤ 10 associated with at least a 50% reduction in AHI. The incomplete responders had their appliance further titrated, and this improved the results of MRA therapy by 30.4% to a total success rate of 95.6%. Conclusions: This study shows that it is possible to improve the results of MRA therapy by further advancing the appliance during a titration PSG in patients with an incomplete response. The titration night improved the results of the usual clinical advancement of the MRA with substantially more patients achieving a successful outcome.

Impact of an oral appliance on obstructive sleep apnea severity, quality of life, and biomarkers

“…Our results are similar to those of other studies, 28,34,36,38,42,52 although there are authors who have reported worse results than ours, 35,37,39,40 perhaps because the sample size, BMI, and AHI were higher in these studies, and because of a certain degree of retrognathia in some patients. Better results than ours have been shown in other studies, 26,41,43,53 in our opinion due to a shorter follow-up, irregular use of a MAD, a larger sample, and inclusion of mild OSA in these studies.…”

Assessment of oral appliance for obstructive sleep apnea patients

“…Apnea index (AI), apnea‐hypopnea index (AHI), minimum hemoglobin oxygen saturation measured by pulse oximetry (minimum SpO 2 ), and arousal index from overnight PSG data before and after treatment were used to evaluate treatment effects of the OA. In addition, treatment efficacy was evaluated based on goals of AHI < 10/h and a percentage reduction in AHI of more than 50% compared with baseline (Almeida et al ; Krishnan et al ; Kuna et al ).…”

Oral Appliances in the Management of Obstructive Sleep Apnea

“…24 A nonlinear dose-dependent relationship with degree of advancement is reported. [25][26][27][28][29][30] The efficacy of CPAP over MAD in reducing AHI is well established and has been consistently reported by meta-analyses comparing the 2, 4,31-34 even with increasing numbers of primary studies. According to the AASM/American Academy of Dental Sleep Medicine (AADSM) task force, CPAP is significantly better than MAD at reducing AHI scores (difference of 6.24 events per hour).…”

“…After a clinical titration period, overnight MAD titration with PSG using the final MAD increased treatment response by an additional 9.9% to 30.4% of study subjects. 28,75 Disappointing outcomes were reported, however, using an interim MAD without a period of clinical titration because efficacy of the interim MAD was not translated to the final MAD. 76 Overnight MAD titration with PSG may require large single-night mandibular advancements to relieve respiratory events, in contrast to slow titration with conventional protocols.…”

“…Significant jaw discomfort was noted with PSG titration without prior MAD use 76 but was not reported by patients who had an adaptation period with conventional clinical MAD titration. 28 Remote-controlled mandibular positioners Using remote-controlled mandibular positioners (RCMPs) for single-night titration of MADs is similar to overnight MAD titration with PSG, with the advantage of adjustment done remotely without waking the patient or removing the appliance. Sleep architecture is maintained while protruding the mandible progressively until respiratory events are eliminated.…”