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Evolution of apnea–hypopnea index (AHI) in comparison to baseline AHI in three different titration methods for 10 subjects. A few patients did not undergo a follow-up PSG after one or more titration method
Source publication
Study objectives
The aim of this pilot study was to evaluate the clinical effectiveness of subjective titration versus objectively guided titration during polysomnography (PSG) and drug-induced sleep endoscopy (DISE) in mandibular advancement device (MAD) therapy for patients with obstructive sleep apnea (OSA).
Methods
In this pilot cross-over stu...
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Objective
Discomfort has been related to the poor acceptance of a mandibular advancement device (MAD) in patients with obstructive sleep apnea. The present study compared severe initial side effects between a smaller and a larger degree of mandibular advancement in patients with a good protrusive capacity.
Methods
Consecutive patients with obstruc...
Citations
... Studies generally rely on subjective titration wherein the degree of mandibular advancement is progressively increased over several weeks (5-40 weeks) until an improvement or a resolution of symptoms occurs or until the patient cannot tolerate any further advancement. Studies have also used objective guided titration, which means selecting the mandibular position that has determined the abolishment of respiratory events or nonphysiologic parameters during the diagnostic instruments/ procedures (DISE, PSG, oximetry) [99,100]. Objective-guided titration is more reproducible and could avoid the overextension of mandibular protrusion, which may occur with subjective titration, and that can generate discomfort and consequently less adherence to the treatment. ...
Obstructive sleep apnea (OSA) syndrome is characterized by repeated airway collapse during sleep. It determines cardiovascular, pulmonary, and neurocognitive consequences and is associated with several daytime and nighttime symptoms that influence the patient’s quality of life. The contribution of the dental specialist in the clinical management of OSA patients entails participating in the screening process as diagnostic sentinels and providing adequate treatment using mandibular advancement devices (MADs). Since the treatment of OSA requires a multidisciplinary approach, including different medical specialists, dentists should have a comprehensive understanding of medical and dental factors that influence the strategy and effectiveness of OSA treatment with MAD. Such expertise is crucial in determining the appropriate treatment indications and helps clinicians establish a consolidated position within the multidisciplinary OSA team. In this regard, this review summarizes the evidence of the clinical indications for MAD treatment and provides the dental specialist with helpful information about medical, functional, and other relevant factors that should be considered during diagnosis, treatment plan, and follow-up stages. Information retrieved was organized and discussed, generating specific domains/queries oriented to the clinical management of OSA patients from the clinical perspective of dental specialists.
... YEAR n MANEUVER Johal et al. [34] 2005 19 Manual advancement maneuver and mad in situ Johal et al. [35] 2007 120 4-5 mm advancement maneuver performed by the anesthesiologist Vroegop et al. and Vanderveken et al. [36] 2013 200 Simulation bite De Corso et al. [37] 2015 65 Less than 5 mm manual advancement maneuver Huntley et al. [38] 2018 20 Manual advancement maneuver Beelen et al. [39] 2018 200 Manual advancement maneuver (jaw thrust) Kastoer et al. [40] 2018 10 Remotely controlled mandibular positioner Park et al. [41] 2019 40 Modified mandibular advancemen maneuver. 50-75% manual advancement Carrasco et al. [42] 2019 -Modified Esmarch maneuver Vonk et al. [43] 2020 63 Manual advancement maneuver and boil and bite mad Cavaliere et al. [44] 2020 66 Simulation bite Koutsourelakis et al. [45] 2021 49 Manual advancement maneuver Veugen et al. [46] 2021 70 Manual advancement maneuver Kazemeini et al. [47] 2022 10 Remotely controlled mandibular positioner Bosschieter et al. [48] 2022 94 Manual advancement maneuver and boil and bite mad Fernández-Sanjuán et al. [49] 2022 161 Mandibular titratable positioner (SAM) Van den Bossche et al. [50] 2023 56 Manual advancement maneuver and mad in situ According to some publications [36,41,50], performing manual maneuvers is not considered an appropriate technique for selecting patients eligible for MAD therapy, as it may lead to awakenings during the DISE and may not accurately replicate the real effect of a MAD. ...
Background:
Mandibular advancement devices (MADs) are an effective treatment for patients with sleep-related breathing disorders, with variable response. Increasingly more research points to the predictive value of Drug-Induced Sleep Endoscopy (DISE) in patient selection. This study aims to analyze the changes in upper airway collapsibility using a titratable MAD simulator during DISE.
Methods:
This study included 104 patients with simple snoring and obstructive sleep apnea (OSA). The VOTE scale was used to assess the presence of collapses during the DISE both without and with the MAD simulator.
Results:
In snorers, there was a decrease in collapses at the level of the soft palate and oropharynx when the advancement was achieved. Patients with mild OSA also showed a decrease in collapses at the base of the tongue. Patients with moderate/severe OSA exhibited significant amelioration at all levels. The levels at which there were residual collapses despite the maneuver were, in order, the velopharynx, oropharynx, epiglottis, and tongue.
Conclusions:
The MAD simulator reduces collapsibility at all levels and in all severity groups. Residual collapses suitable for combined treatments were able to be identified. This highlights the need for individualized patient selection, as upper airway collapsibility exhibits variable improvement or worsening with the MAD simulator regardless of the severity of the condition.
... A recent study by Kazemeini et al has evaluated clinical effectiveness of subjective titration vs objectively guided titration during polysomnography and DISE in OAT for patients with OSA and found no differences in optimal mandibular positioning and corresponding efficacy. 46 Additionally, Ma et al has shown that OAT reaches a plateau stage after reaching approximately 70% of protrusion, suggesting that more protrusion does not always yield a decrease in AHI. 47 ...
Study objectives:
To prospectively validate drug-induced sleep endoscopy with mandibular advancement maneuvers as a prediction tool for treatment success of oral appliance treatment (OAT).
Methods:
Seventy-seven patients diagnosed with moderate obstructive sleep apnea were included and underwent drug-induced sleep endoscopy. The upper airway collapse was assessed using the VOTE classification. Additionally, three mandibular advancement maneuvers were performed to predict treatment success of OAT. If the maneuver was negative, the level and degree and configuration of the persistent collapse was described according to the VOTE classification. All patients were treated with OAT and completed a follow-up sleep study with OAT in situ without regard to their anticipated response to treatment.
Results:
Sixty-four patients completed 6-month follow up. A positive jaw thrust maneuver proved to be significantly associated with favorable OAT response, whereas the chin lift maneuver and the vertical chin lift maneuver were not. Additionally, a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver was significantly associated with unfavorable OAT response.
Conclusions:
The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting OAT response. Patients with a positive jaw thrust maneuver should be counseled toward favorable OAT response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of unfavorable OAT response. A negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing drug-induced sleep endoscopy solely for predicting the efficacy of OAT. However, the results of the current study could be influenced by heterogeneity in the assessment of respiratory parameters, variability in the performance of the mandibular advancement maneuvers, and the instability of bolus technique sedation.
Clinical trial registration:
Registry: Netherlands Trial Register; Name: Drug-induced Sleep Endoscopy: a prediction tool for success rate of oral appliance treatment; Identifier: NL8425; URL: https://www.onderzoekmetmensen.nl/en/trial/20741.
Citation:
Veugen CCAFM, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2024;20(3): 353-361.
... Millimeter and percentage values of mandibular advancement were utilized in this study. Kazemeini et al. 15 conducted a comparison of personalized titration procedures and found no differences regarding final mandibular positioning or final AHI between them. One method started treatment in the maximally comfortable mandibular position followed by subjectively *Statistical significance p<0.05. ...
Objective
Discomfort has been related to the poor acceptance of a mandibular advancement device (MAD) in patients with obstructive sleep apnea. The present study compared severe initial side effects between a smaller and a larger degree of mandibular advancement in patients with a good protrusive capacity.
Methods
Consecutive patients with obstructive sleep apnea and a good protrusive capacity (≥8 mm) were randomized to start treatment with the mandible advanced by either 70% of maximum protrusion (Adv70%) or by 4 mm (Adv4mm) in a pilot study with a parallel design. The main outcome was tenderness or pain in the teeth or jaws using a 0-10 visual analogue scale (VAS) (from “not at all” to “very extensive”) or excluded use because of side effects during the first week of treatment. Secondary outcomes included salivation problems and bite changes.
Results
Eighteen patients were randomly selected and 17 patients fulfilled the study protocol. Four patients in the Adv70% group and none in the Adv4mm group reported severe tenderness or pain (VAS ≥7) on five or more of the seven days (p=0.03). The degree of mandibular advancement measured in millimeters correlated with the number of days with severe side effects, r=0.64 (p=0.006). The secondary side effects were minor.
Conclusion
Starting MAD treatment with 70% mandibular advancement was related to more severe side effects during the first week of treatment compared with a smaller fixed millimeter value in patients with a good protrusive capacity in this pilot study.
... On this basis, current appliances can be classified into first-, second-or third-generation OAT (table 1). Whilst there is evidence from an experimental setting, in which a dose-dependent effect is achieved by mandibular titration using a remote advancement activation, this is yet unpractised in routine patient care with OAT [39]. Thus, clinicians routinely advise patients to use subjective criteria, such as symptomatic improvement in determining the amount of mandibular titration required to achieve maximum therapeutic effect. ...
... It will also become necessary to define treatment success from a wider perspective and use new grading systems that consider a number of variables beyond AHI to identify OAT responders [136,137]. Improved appliance design including easier and more precise ways to measure and identify the therapeutic mandibular position are also important developments for the future [39,138,139]. For the longer-term outcomes, the use of appliances that continuously measure adherence [44] and efficacy would equalise the follow-up regimes with those for CPAP. ...
There is now widespread recognition within the world of sleep medicine of the increasing importance of dental sleep medicine and, in particular, the role of oral appliance therapy (OAT) in the management of adults with obstructive sleep apnoea (OSA). For the purpose of this review, the term OAT refers to a custom-made intra-oral appliance, which acts to posture the mandible in a forward and downward direction, away from its natural resting position. Whilst nasally applied continuous positive airway pressure remains the “gold standard” in nonsurgical OSA management, OAT remains the recognised alternative treatment.
This review of OAT aims to provide an evidence-based update on our current understanding of their mode of action, exploring the potential anatomical and physiological impact of their use in preventing collapse of the upper airway; the current clinical practice guidelines, including the recently published National Institute of Clinical Excellence 2021 guidance, in conjunction with the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine; optimal design features, comparing the role of custom-made versus noncustom OAT devices and the importance of titration in achieving a dose-dependent effect; patient predictors, preference and adherence to OAT; its impact on a range of both patient- and clinician-centred health outcomes, with a comparison with CPAP; the limitations and side-effects of providing OAT; and, finally, a look at future considerations to help optimise the delivery and outcomes of OAT.
... Additional research has focused on whether temporary appliances can play a role in helping to determine the therapeutic position of an appliance 9-12 and predicting which patients are likely to respond or not respond to OAT. [13][14][15][16][17][18] Dentists considering the use of a temporary appliance for a patient should be aware that these studies have limitations. None are long-term studies, and the literature yields few data about the use of temporary appliances selected and fit by patients themselves without the supervision of a qualified dentist per the American Academy of Dental Sleep Medicine (AADSM); 19 therefore, the conclusions that can be drawn from the evidence to date are also limited. ...
... If residual or worse collapse remained under DISE þ SAM, OA would not be recommended [58]. Apart from the SAM device for OAT titration, another device (MATRx) could also be used to perform OAT titrations during DISE [59]. Jaw thrust was a simple way to mimic the OAT. ...
Background and Objective: Obstructive sleep apnoea (OSA) is characterized by nocturnal repetitive upper airway (UA) collapse. For sleep physicians, the recognition of UA collapse characteristics is critical for understanding OSA mechanisms and developing individualized treatment plans. Drug-induced sleep endoscopy (DISE) is an exam during simulated sleep that allows the dynamic assessment of the UA of individuals with OSA. The initial recognition of DISE was to locate the sites of UA obstruction and direct the surgical selection of OSA since it was introduced in the 1990s. After approximately 30 years of studies, based on advances in endoscopic operative techniques and innovative treatments of OSA, DISE had been performed to explore mechanisms and comprehensive treatments related to UA collapse.
Methods: This article reviewed contemporary DISE advances, including indications and contraindications, technique of induced sleep, endoscopic operation, UA characteristics classification.
Results and Conclusions: Precise selection based on the association between collapse patterns and treatment modalities, such as continuous positive airway pressure, oral appliance, positional therapy, robotic surgery and neurostimulator implanting, is the future research prospect based on DISE.
Key messages
DISE provides sleep physicians with valuable information about the upper airway collapse characteristics and dynamic changes during sleep.
The studies based on DISE findings improve the selectivity and efficiency of treatment modalities, including classical therapies such as continuous positive airway pressure, oral appliance, positional therapy, and innovative therapies such as neurostimulator implanting and robotic surgery, promote the advancement of OSA precision medicine
... Therefore, relying on objective criteria in the titration process should be advantageous. In analogy with CPAP, titration of the most optimal mandibular protrusion could be performed using a remotely controlled mandibular positioner (RCMP) during an overnight titration polysomnography [36,37]. Recently, it was shown that titration under direct visualisation of upper airway patency and collapsibility is feasible using the RCMP during DISE [38]. ...
Treatment of obstructive sleep apnoea in adults is evolving, from a "one treatment fits all" to a more individualised approach. The spectrum of treatment options is broad and heterogeneous, including conservative, technological and pharmaceutical modalities. This raises the questions of which patients these modalities might be useful for, and if there are specific criteria for single or combined treatment. The most commonly used non-CPAP treatment is a mandibular advancement device. Furthermore, it appears from the available evidence that upper airway surgery, bariatric surgery, and maxillomandibular advancement can be effective in particular patient groups and should be indicated more readily in clinical practice. Technically, a tracheotomy is the most effective surgical treatment, but is not socially acceptable and is associated with major side-effects. Other treatment options are emerging, like positional therapy, hypoglossal nerve stimulation, and myofunctional exercises. Drug therapy is also promising when pathophysiological traits are considered. The range of currently available treatment options will be discussed in this review, with emphasis on the selection of appropriate patients, therapeutic efficacy and compliance, and reference to recent guidelines. In the selection process, routine application of drug-induced sleep endoscopy to assess the site(s) of collapse during sleep can increase the success rate of both surgical interventions and oral appliance therapy.
Educational aims:
To outline recommendations concerning the proper management of obstructive sleep apnoea (OSA) patients that cannot be treated adequately with continuous positive airway pressure (CPAP) due to intolerance, poor adherence or compliance, or CPAP refusal.To provide information about the selection of appropriate patients for alternative non-CPAP treatment options.To better understand the different aspects of OSA treatment with noninvasive approaches, such as oral appliances, positional therapy, drug treatment and myofunctional therapy, including indications, contraindications, and expected short- and long-term results.To discuss the different surgical options for the treatment of OSA and to provide information on the important issue of proper patient selection for surgery, as most OSA surgical outcomes are associated with the pre-operative assessment of the level(s) of upper airway collapse.
... Thereafter, the device was put in at bedtime and worn throughout the night. Advancement (titration protocol) was progressively activated by the dentist until clinical resolution of subjective symptoms [11]. ...
This study was conducted to determine the efficacy of a customized mandibular advancement device (MAD) in the treatment of obstructive sleep apnea (OSA). Eight patients (M = 3; F = 5; mean age = 56.3 ± 9.4) with a diagnosis of OSA confirmed by polysomnography (PSG) were recruited on the basis of the following inclusion criteria: apnea-hypopnea index (AHI) > 5, age between 18 and 75 years, body mass index (BMI) < 25, and PSG data available at baseline (T0). All were treated with the new NOA® MAD by OrthoApnea (NOA®) for at least 3 months; PSG with NOA in situ was performed after 3 months of treatment (T1). The following parameters were calculated at T0 and T1: AHI, supine AHI, oxygen desaturation index (ODI), percentage of recording time spent with oxygen saturation <90% (SpO2 < 90%), and mean oxygen desaturation (MeanSpO2%). Data were submitted for statistical analysis. The baseline values were AHI = 21.33 ± 14.79, supine AHI = 35.64 ± 12.80, ODI = 17.51 ± 13.5, SpO2 < 90% = 7.82 ± 17.08, and MeanSpO2% = 93.45 ± 1.86. Four patients had mild OSA (5 > AHI < 15), one moderate OSA (15 > AHI < 30), and three severe OSA (AHI > 30). After treatment with NOA®, statistically significant improvements in AHI (8.6 ± 4.21) and supine AHI (11.21 ± 7.26) were recorded. OrthoApnea NOA® could be an effective alternative in the treatment of OSA: the device improved the PSG parameters assessed.
