HSC Section 3 - Trauma, Critical Care and Sleep Medicine

TABLE III. Adverse Effects and Changes as a Result of Using MADs.

Follow-up Time, mo (Losses)

Type of Study

No. and Type of MAD

BMI, kg/m 2 2

Author

Adverse Effects

Q

Lawton 2005 3

H

P 16 Twin Block 1 Herbst

29.2

1–1.5 (0)

Short term (2–3 days) vs. long term (1–1.5 months); Herbst: muscular discomfort, 56% vs. 25%; TMJ discomfort, 69% vs. 31%; dry mouth: 63% vs. 56%; excessive salivation, 31% vs. 19%; Twin Block: muscular discomfort, 50% vs. 19%; TMJ discomfort, 38% vs. 19%; dry mouth, 75% vs. 63%; excessive salivation, 44% vs. 31%; abnormal bite, 56% vs. 25%

Marklund &

M

P 260 fixed monobloc 28

64 (105)

Frequent users vs. infrequent users; 56% vs. 35% occlusal

Franklin 2007 42

changes; 32% vs. 19% bad taste; 34% vs. 25% increased salivation; 30% vs. 25% dry mouth; 22% vs. 28% dry lips; 11% vs. 21% TMJ sounds

Martinez-Gomis 2010 43

P 40 adjustable duobloc —

60 (25)

Reduced overjet, overbite, and No. of occlusal contact points Ulcers: 12.5%; TMJ: 25%; muscular discomfort: 18.75%; tooth discomfort: 25%

H

Zhou & Llu 2012 39

26.67 6 3.22 6.5 (0)

H

P 16 custom-made adjustable monobloc 1 custom-made

adjustable duobloc*

Doff 2013 44

P 29 adjustable †

31.4 6 5.7 24 (0)

Overbite: 2 1.2 6 1.1 mm; overjet: 2 1.5 6 1.5 mm; anteroposterior movement: 2 1.3 6 1.5 mm; decrease in No. of posterior occlusal contact points

M

*SILENT NITE. † Thornton Adjustable Positioner. BMI 5 body mass index; H 5 high; M 5 medium; MAD 5 mandibular advancement device; P 5 prospective study; Q 5 quality; TMJ 5 temporomandibular joint.

were excluded. A critical reading of the titles and abstracts eliminated 132 articles, leaving 51 articles of possible interest. After reading the full text of these articles, 26 were excluded because they did not meet the inclusion cri- teria. Of the remaining 25, three were excluded because they were considered of low quality (Fig. 1). Of the 22 articles selected, 21 reported on prospec- tive studies and one on a retrospective study. Their qual- ity was high in 16 cases and medium in six. The effectiveness of MADs in reducing sleep AHI was studied in 18 articles, which showed significant per- centages of reduction ranging from 21% to 80%. Of the 18 articles, 16 reported a 50% reduction in AHI or a change in AHI level from severe or moderate to mild (Table I). Regarding the differences between the various types of MAD, the studies that compared adjustable with fixed or custom-made with prefabricated devices showed that in both cases the former were more effec- tive. Oxygen saturation was assessed in 12 articles, most of which reported improvements (Table I). The effectiveness of MADs in decreasing snoring and daytime sleepiness, measured by the ESS, was measured by 11 studies. Almost all of these found signif- icant reductions. The size of the velopharynx was meas- ured in five studies, all of which showed an increase in the dimensions of the upper airway (Table II). Table III shows the adverse effects caused by the use of MADs to treat sleep apnea. The main adverse

The search strategy included a combination of eight MeSH terms: “obstructive sleep apnea,” “sleep apnea syndrome,” “sleep hypopnea,” “sleep disordered breathing,” “mandibular advance- ment splints,” “mandibular advancement appliance,” “oral appli- ances,” and “mandibular advancement device.” Two reviewers independently assessed the titles and abstracts of all the articles. In the event of disagreement they reached a consensus, but if they continued to disagree they con- sulted a third reviewer. If the abstract did not provide sufficient information for a definite decision on inclusion or exclusion, the full article was obtained and reviewed before taking the final decision. Data Extraction The following variables were recorded: author, year of pub- lication, sample size, demographic variables (gender and age), follow-up time, losses to follow-up, body mass index, type of MAD used, and indices employed to measure OSAHS. The suc- cess criteria considered were a 50% reduction in AHI or a change in AHI level from severe or moderate to mild. 26 The articles were classified as being of high, medium, or low quality according to the CONSORT criteria 25 as adapted by Mattos et al. 27 RESULTS The search identified 241 articles in Medline, three in Cochrane Library Plus, and 149 in Scopus, making a total of 393 articles. Of these, 210 were duplicate references and

Laryngoscope 126: February 2016

Serra-Torres et al.: Oral Appliances for Sleep Apnea

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