Prognostic predictors on the efficacy of oral appliance therapy for obstructive sleep apnea syndrome

Tadashi Iwamoto, Yoshiyuki Takata, Nobutaka Kitamura, Daichi Hasebe, Tadaharu Kobayashi, Chikara Saito

Division of Information Science and Biostatistics, Department of Imformatics and Pharmaceutics, Course for Community Disease Control, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
Division of Reconstructive Surgery for Oral and Maxillofacial Region, Department of Tissue Regeneration and Reconstruction, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.

DOI: 10.4236/ojst.2012.23038                

Abstract

Objectives: The aim of this study was to identify independent prognostic predictors of the efficacy of oral appliance (OA) therapy for obstructive sleep apnea syndrome (OSAS). Materials and methods: The subjects consisted of 89 patients (77 males and 12 females) in whom OSAS had been treated with an OA. The mean age of the subjects was 52.4 years (range: 20 to 78 years) and mean body mass index (BMI) was 23.9 kg/m2 (range: 17.3 to 32.2 kg/m2). Lateral cephalograms were taken and 15 angle, 15 distance and 5 area measurements were calculated by means of a computerized program. Overnight polysomnography (PSG) was performed before treatment and several months after titration of OA therapy. OA therapy was considered effective if the apnea-hypopnea index several months after titration was under 15 events/h and was reduced to at least 50% of that before treatment. The examined data such as patient age, sex, BMI, data from cephalometric analyses, Epworth sleepiness scale, and data for pretreatment PSG were analyzed statistically, and multivariate logistic regression analysis was performed to clarify predictive variables for treatment outcome. Results: LFH (OR = 0.350; p = 0.035) and McN-A (OR = 0.276; p = 0.057) were selected as independent predictors from the explanatory variables. The predictive accuracy of the calculated logistic regression model was 74.2%. Conclusion: This results show that OA therapy for OSAS is more effective in patients with large anteroposterior diameter of the maxilla and large lower facial height.

Keywords

Obstructive Sleep Apnea Syndrome; Oral Appliance Therapy; Predictors of Response

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Bixler, E.O., Vgontzas, A.N., Lin, H.-M., et al. (2000) Association of hypertension and sleep-disordered breathing. Archives of Internal Medicine, 160, 2289-2295. doi:10.1001/archinte.160.15.2289
[2]	Kieiy, J.L. and McNicholas, W.T. (2000) Cardiovascular risk factors in patients with obstructive sleep apnoea syndrome. European Respiratory Journal, 16, 128-133. doi:10.1034/j.1399-3003.2000.16a23.x
[3]	Findley, L.J., Unverzagt, M.E. and Suratt, P.M. (1988) Automobile accidents involving patients with obstructive sleep apnea. The American Review of Respiratory Disease, 138, 337-340.
[4]	Strohl, K., Bonnie, R., Findly, L., et al. (1994) Sleep apnea, sleepiness, and driving risk. American Journal of Respiratory and Critical Care Medicine, 150, 1463-1473.
[5]	Clark, G.T., Blumenfeld, I., Yoffe, N., et al. (1996) A crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest, 109, 1477-1483. doi:10.1378/chest.109.6.1477
[6]	Ferguson, K.A., Ono, T., Lowe, A.A., et al. (1996) A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest, 109, 1269- 1275. doi:10.1378/chest.109.5.1269
[7]	Ferguson, K.A., Ono, T., Lowe, A.A., et al. (1997) A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax, 52, 362-368. doi:10.1136/thx.52.4.362
[8]	Randerath, W.J., Heise, M., Hinz, R., et al. (2002) An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Chest, 122, 569-575. doi:10.1378/chest.122.2.569
[9]	Tan, Y.K., L’Estrange, PR., Luo, Y.-M., et al. (2002) Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: A randomized cross-over trial. European Journal of Ortho- dontics, 24, 239-249. doi:10.1093/ejo/24.3.239
[10]	American Sleep Disorders Association (1995) Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Sleep, 18, 511-513.
[11]	Krieger, J. (1998) New frontiers in the management of obstructive sleep apnoea syndrome. Monaldi Archives for Chest Disease, 53, 515-519.
[12]	Schmidt-Nowara, W., Lowe, A., Wiegand, L., et al. (1995) Oral appliances for the treatment of snoring and obstructive sleep apnea: A review. Sleep, 18, 501-510.
[13]	Cistulli, P.A., Gotsopoulos, H., Marklund, M., et al. (2004) Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Medicine Reviews, 8, 443-457. doi:10.1016/j.smrv.2004.04.002
[14]	Dort, L.C., Hadjuk, E. and Remmers, J.E. (2006) Man- dibular advancement and obstructive sleep apnoea: A method for determining effective mandibular protrusion. The European Respiratory Journal, 27, 1003-1009.
[15]	Johns, M.W. (1991) A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545.
[16]	Ohta, Y., Kawakami, Y., Takishima, T., et al. (1993) Sleep-disordered breathing in Japan: An overview. The Japanese Journal of Thoracic Diseases, 31, 12-18.
[17]	Pracharktam, N., Nelson, S., Hans, M.G., et al. (1996) Cephalometric assessment in obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics, 109, 410-419. doi:10.1016/S0889-5406(96)70123-3
[18]	Lowe, A.A., Ono, T., Ferguson, K.A., et al. (1996) Cephalometric comparisons of craniofacial and upper airway structure by skeletal subtype and gender in patients with obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics, 110, 653-664. doi:10.1016/S0889-5406(96)80043-6
[19]	Baik, U.B., Suzuki, M., Ikeda, K., et al. (2002) Relationship Between cephalometric characteristics and obstructive site in obstructive sleep apnea syndrome. The Angle Orthodontist, 72, 124-134.
[20]	Ohdaira, F., Nakamura, K., Nakayama, H., et al. (2007) Demographic characteristics of 3659 Japanese patients with obstructive sleep apnea-hypopnea syndrome diagnosed by full polysomnography: Associations with apnea-hypopnea index. Sleep and Breathing, 11, 93-101. doi:10.1007/s11325-006-0087-5
[21]	Ishiguro, K., Kobayashi, T., Kitamura, N., et al. (2009) Relationship between severity of sleep-disordered breath- ing and craniofacial morphology in Japanese male patients. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics, 107, 343-349. doi:10.1016/j.tripleo.2008.08.021
[22]	Tegelberg, A., Wilhelmsson, B., Walker-Engstr?m, M.L., et al. (1992) Effects and adverse events of a dental appli- ance for treatment of obstructive sleep apnoea. Swedish Dental Journal, 23, 117-126.
[23]	Liu, Y.H., Zeng, X.L., Fu, M.K., et al. (2000) Effects of a mandibular repositioner on obstructive sleep apnea. A- merican Journal of Orthodontics and Dentofacial Orthopedics, 118, 248-256. doi:10.1067/mod.2000.104831
[24]	Isono, S., Tanaka, A., Sho, Y., et al. (1995) Advancement of the mandible improves velopharyngeal airway patency. Journal of Applied Physiology, 79, 2132-2138.
[25]	Ryan, C.F., Love, L.L., Peat, D., et al. (1999) Mandibular advancement oral appliance therapy for obstructive sleep apnoea: Effect on awake calibre of the velopharynx. Thorax, 54, 972-977. doi:10.1136/thx.54.11.972
[26]	Lowe, A.A., Sj?holm, T.T., Ryan, C.F., et al. (2000) Treat- ment, airway and compliance effects of a titratable oral appliance. Sleep, 23, S172-S178.
[27]	Menn, S.J., Loube, D.I., Morgan, T.D., et al. (1996) The mandibular repositioning device: Role in the treatment of obstructive sleep apnea. Sleep, 19, 794-800.
[28]	Rose, E., Staats, R., Virchow, C., et al. (2002) A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnoea. European Journal of Orthodontics, 24, 191-198. doi:10.1093/ejo/24.2.191
[29]	Pancer, J., Al-Faifi, S., Al-Faifi, M., et al. (1999) Evaluation of variable mandibular advancement appliance for treatment of snoring and sleep apnea. Chest, 116, 1511- 1518. doi:10.1378/chest.116.6.1511
[30]	Ferguson, K.A., Ono, T., Lowe, A.A., et al. (1997) A short term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax, 52, 362-368. doi:10.1136/thx.52.4.362
[31]	Eveloff, S.E., Rosenberg, C.L., Carlisle, C.C., et al. (1994) Efficacy of a Herbst mandibular advancement device in obstructive sleep apnea. American Journal of Respiratory and Critical Care Medicine, 149, 905-909.
[32]	Yoshida, K. (1994) Prosthetic therapy for sleep apnea syndrome. Journal of Prosthetic Dentistry, 72, 296-302. doi:10.1016/0022-3913(94)90343-3
[33]	Mayer, G. and Meier-Ewert, K. (1995) Cephalometric pre- dictors for orthopaedic mandibular advancement in obstructive sleep apnoea. European Journal of Orthodontics, 17, 35-43.
[34]	Marklund, M., Franklin, K.A., Stenlund, H., et al. (1998) Mandibular morphology and the efficacy of a mandibular advancement device in patients with sleep apnoea. European Journal of Oral Sciences, 106, 914-921. doi:10.1046/j.0909-8836.1998.eos106503.x
[35]	Rose, E., Lehner, M., Staats, R., et al. (2002) Cepha- lometric analysis in patients with obstructive aleep apnea. Part 2: Prognostic value in treatment with a mandibular advancement device. Journal of Orofacial Orthopedics, 63, 315-324. doi:10.1007/s00056-002-0058-9
[36]	Mehta, A., Qian, J., Petocz, P., et al. (2001) A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. American Journal of Respiratory and Critical Care Medicine, 163, 1457-1461.
[37]	Liu, Y., Lowe, A.A., Fleetham, J.A., et al. (2001) Ce-phalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics, 120, 639-647. doi:10.1067/mod.2001.118782
[38]	Hoekema, A., Doff, M.H.J., De Bont, L.G.M., et al. (2007) Predictors of obstructive sleep apnea-hypopnea treatment outcome. Journal of Dental Research, 86, 1181-1186. doi:10.1177/154405910708601208
[39]	Ng, A.T., Darendeliler, M.A., Petocz, P., et al. (2012) Cephalometry and prediction of oral appliance treatment outcome. Sleep and Breathing, 16, 47-58. doi:10.1007/s11325-011-0484-2
[40]	Skinner, M.A., Robertson, C.J., Kingshott, R.N., et al. (2002) The efficacy of a mandibular advancement splint in relation to cephalometric variables. Sleep and Breathing, 6, 115-124. doi:10.1055/s-2002-34313