Remotely Controlled Mandibular Protrusion during Sleep Predicts Therapeutic Success with Oral Appliances in Patients with Obstructive Sleep Apnea

Remmers, John E.; Charkhandeh, Shouresh; Grosse, Joshua; Topor, Zbigniew L.; Brant, Rollin; Santosham, Peter; Bruehlmann, Sabina

doi:10.5665/sleep.3048

Cited by 108 publications

(141 citation statements)

References 28 publications

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“…10,[30][31][32][33] For example a single-night titration study of mandibular advancement using an available commercial remotely controlled titration device or assessment of upper airway response to mandibular advancement via nasendoscopy to observe the airway response during drug-induced sleep or even wakefulness. [34][35][36] However in CPAP failure patients with known therapeutic pressure, this information in conjunction with age and OSA severity characteristics, may be useful to give an indication of the likelihood of success with MAS as an alternative therapy.…”

Section: Discussionmentioning

confidence: 99%

CPAP Pressure for Prediction of Oral Appliance Treatment Response in Obstructive Sleep Apnea

Sutherland

Phillips

Davies

et al. 2014

Journal of Clinical Sleep Medicine

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Study Objectives: Mandibular advancement splints (MAS) are often preferred to CPAP treatment for OSA but are not always equally effi cacious. High therapeutic CPAP pressure has been associated with MAS treatment failure in a Japanese population. We sought to assess the relationship between CPAP pressure and MAS treatment response in an Australian population. Methods: Therapeutic CPAP pressure and MAS treatment response were obtained from a one-month crossover trial of both treatments. Predictive utility of CPAP pressure to identify MAS treatment response was assessed. Results: Seventy-eight OSA patients were included (age 49.3 ± 11.1 years, BMI 29.1 ± 5.8 kg/m 2 ) with predominantly moderate-severe OSA (AHI 30.0 ± 12.7/h). CPAP pressure was lower in MAS responders (MAS AHI < 10/h) 9.7 ± 1.6 vs. 11.7 ± 2.4 cm H 2 O, p < 0.01, with area under ROC curve of 0.74 (95% CI 0.63-0.86), p < 0.01. The best cutoff value of 10.5 cm H 2 O useful for discriminating MAS responders and non-responders in the previous Japanese population, was inadequate for prediction in the current population (0.47 negative predictive value [NPV] S C I E N T I F I C I N V E S T I G A T I O N SC ontinuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA). Although highly effi cacious, CPAP is often hindered by poor tolerance and suboptimal adherence, 1 limiting its effectiveness in the real world. Mandibular advancement splints (MAS) are an alternative option recommended as a fi rst-line treatment for mildmoderate OSA. 2 We have recently found that health outcome improvements, including sleepiness, are similar with MAS and CPAP treatments in patients with moderate-severe OSA. Superior patient adherence appears to offset any inferiority of MAS effi cacy, 3 and MAS may be considered a viable alternative for many patients.However despite similar health benefi ts between treatments, approximately one-third of OSA patients will not respond to MAS. [4][5][6][7] This is of signifi cant concern in terms of resource wastage and treatment delays. Much attention has been given to understanding patient phenotypes which relate to MAS response such as gender, obesity, craniofacial structure, and type and severity of OSA.8 However, none of these factors are universal, and hence there is an unresolved need for reliable indicators of MAS treatment response. A recent Japanese study has identifi ed pressure requirement in CPAP users as a predictor of MAS response. 9 In established CPAP users, a prescribed pressure of above 10.5 cm H 2 O indicated poor response to subsequent MAS therapy. This prediction method is, of course, restricted to patients who have used CPAP and wish to try MAS. However CPAP pressure would represent a simple predictor, either alone or possibly in combination with other patient characteristics to further improve BRIEF SUMMARY Current Knowledge/Study Rationale: CPAP pressure has been shown to predict oral appliance treatment response in Japanese male OSA patients and could be a simple and useful clini...

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Section: Discussionmentioning

confidence: 99%

CPAP Pressure for Prediction of Oral Appliance Treatment Response in Obstructive Sleep Apnea

Sutherland

Phillips

Davies

et al. 2014

Journal of Clinical Sleep Medicine

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“…Treatment success is commonly defined by a reduction in RDI to <5 or <10 in addition to a <50% reduction in baseline RDI. [5][6][7][8]17,18 The patient's RDI decreased from 62.7…”

Section: Discussionmentioning

confidence: 99%

“…4,[7][8][9][10][11] Although CPAP is proved to be more efficient in treatment, it is not tolerated well by patients; therefore, intraoral appliances are frequently preferred 3,5,[12][13][14][15][16] as in this patient. Treatment success is commonly defined by a reduction in RDI to <5 or <10 in addition to a <50% reduction in baseline RDI.…”

Section: Discussionmentioning

confidence: 99%

“…Obstructive sleep apnea therapy can be summarized in four main categories: Behavior modification, the use of continuous positive airway pressure (CPAP) device, the use of oral appliances, and surgical approaches. 1,3,5 With mandibular advancement device (MAD) treatment, the goal is to prevent the narrowing of the airway during sleep by positioning the mandible in a forward place. 6 When compared with other methods of treatment of OSA, oral appliances have advantages, such as being able to be better tolerated by patients, cheaper, simple, noninvasive, reversible, and reduced clinic hours.…”

Section: Introductionmentioning

confidence: 99%

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Efficiency of Mandibular Advancement Device and Bilevel Positive Airway Pressure Treatment for Severe Obstructive Sleep Apnea

Keyf¹,

Fırat²,

Çiftçi³

2017

International Journal of Experimental Dental Science

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Recently, attention to oral appliance therapy, as mandibular advancement device (MAD), has increased. Mandibular advancement device is a popular alternative treatment, particularly for mild to moderate obstructive sleep apnea (OSA). Oral appliances for treating severe OSA are recommended for patients who failed to comply with continuous positive airway pressure treatment. This clinical report presents the treatment outcome of oral appliance therapy and bilevel device in a 70-year-old man with severe OSA and also having respiratory disturbance index (RDI) of 62.7. Polysomnographic (PSG) evaluation was performed before and about 1 week after continuous use of the MAD and then with bilevel device. The results were compared, and RDI decreased 27.5 per hour with the custom MAD, whereas RDI decreased 3.1 per hour with bilevel device. Improved PSG parameters showed that bilevel device was efficient in treatment.

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“…Use of a remotely-controlled mandibular positioner (RCMP) used during sleep has been demonstrated to accurately identify such individuals. [42][43][44][45][46] This test uses temporary dental trays and is carried out in a polysomnographic setting, where a technologist advances the mandible to eliminate respiratory events (REs). Although the test appears to be safe and well tolerated, its cost and inconvenience compromise its clinical utility.…”

Section: Introductionmentioning

confidence: 99%

A Feedback-Controlled Mandibular Positioner Identifies Individuals With Sleep Apnea Who Will Respond to Oral Appliance Therapy

Remmers

Topor

Grosse³

et al. 2017

Journal of Clinical Sleep Medicine

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Study Objectives: Mandibular protruding oral appliances represent a potentially important therapy for obstructive sleep apnea (OSA). However, their clinical utility is limited by a less-than-ideal efficacy rate and uncertainty regarding an efficacious mandibular position, pointing to the need for a tool to assist in delivery of the therapy. The current study assesses the ability to prospectively identify therapeutic responders and determine an efficacious mandibular position. Methods: Individuals (n = 202) with OSA participated in a blinded, 2-part investigation. A system for identifying therapeutic responders was developed in part 1 (n = 149); the predictive accuracy of this system was prospectively evaluated on a new population in part 2 (n = 53). Each participant underwent a 2-night, in-home feedback-controlled mandibular positioner (FCMP) test, followed by treatment with a custom oral appliance and an outcome study with the oral appliance in place. A machine learning classification system was trained to predict therapeutic outcome on data obtained from FCMP studies on part 1 participants. The accuracy of this trained system was then evaluated on part 2 participants by examining the agreement between prospectively predicted outcome and observed outcome. A predicted efficacious mandibular position was derived from each FCMP study. Results: Predictive accuracy was as follows: sensitivity 85%; specificity 93%; positive predictive value 97%; and negative predictive value 72%. Of participants correctly predicted to respond to therapy, the predicted mandibular protrusive position proved efficacious in 86% of cases. Conclusions: An unattended, in-home FCMP test prospectively identifies individuals with OSA who will respond to oral appliance therapy and provides an efficacious mandibular position. Clinical Trial Registration: The trial that this study reports on is registered on www.clinicaltrials.gov, ID NCT03011762, study name: Feasibility and Predictive Accuracy of an In-Home Computer Controlled Mandibular Positioner in Identifying Favourable Candidates for Oral Appliance Therapy Keywords: home sleep test, obstructive sleep apnea, oral appliance therapy, predictive accuracy, sleep-disordered breathing Citation: Remmers JE, Topor Z, Grosse J, Vranjes N, Mosca EV, Brant R, Bruehlmann S, Charkhandeh S, Jahromi SA. A feedback-controlled mandibular positioner identifies individuals with sleep apnea who will respond to oral appliance therapy. J Clin Sleep Med. 2017;13(7):871-880. I NTRO DUCTI O NObstructive sleep apnea (OSA) is a chronic disease caused by repeated narrowing or closure of the pharynx during sleep. The disease compromises quality of life, 1,2 increases risk of accidents, [3][4][5] and is associated with an increased risk of cardiovascular events 6 and reduced survival rate. 7,8 Continuous positive airway pressure (CPAP), the standard therapy for this disease, is efficacious and benign. However, long-term compliance with CPAP is low, 9,10 and this may contribute to its ineffectiveness in preventing adverse...

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Remotely Controlled Mandibular Protrusion during Sleep Predicts Therapeutic Success with Oral Appliances in Patients with Obstructive Sleep Apnea

Cited by 108 publications

References 28 publications

CPAP Pressure for Prediction of Oral Appliance Treatment Response in Obstructive Sleep Apnea

CPAP Pressure for Prediction of Oral Appliance Treatment Response in Obstructive Sleep Apnea

Efficiency of Mandibular Advancement Device and Bilevel Positive Airway Pressure Treatment for Severe Obstructive Sleep Apnea

A Feedback-Controlled Mandibular Positioner Identifies Individuals With Sleep Apnea Who Will Respond to Oral Appliance Therapy

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