A Prospective Randomized Study Comparing Two Different Degrees of Mandibular Advancement with a Dental Appliance in Treatment of Severe Obstructive Sleep Apnea Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial. Can psychological factors help us to determine adherence to CPAP? A prospective study Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea Mandibular advancement splint improves indices of obstructive sleep apnoea and snoring but side effects are common. A prospective randomized study of a dental appliance compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnoea. The occurrence of sleep-disordered breathing among middle-aged adults. Prospective evaluation of an oral appliance in the treatment of obstructive sleep apnea syndrome Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial. Effects and adverse events of a dental appliance for treatment of obstructive sleep apnoea. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial. A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised prospective parallel trial The effect of a mandibular advancement device on apneas and sleep in patients with obstructive sleep apnea. 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Dental and skeletal changes after 4 years of obstructive sleep apnea treatment with a mandibular advancement device: a prospective, randomized study. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Obligatory nasal breathing: effects on snoring and sleep apnoea. Quality of life assessment of treatment with dental appliance or UPPP in patients with mild to moderate obstructive sleep apnoea. A prospective randomized 1-year follow-up study. The mandibular repositioning device: role in the treatment of obstructive sleep apnea. An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea.
The objective of this study was to compare the effect of two different degrees of m and ibular advancement ( MA ) , 75 % versus 50 % , on somnographic variables after 6 months of dental appliance treatment in patients with severe obstructive sleep apnea ( OSA ) . A further purpose was to compare the number of adverse events on the stomatognathic system and the effects of dental appliance treatment on the presence of daytime sleepiness . Eighty-six males with severe OSA ( apnea index ≥ 20 ) were r and omly allocated to either 75 % or 50 % MA . Forty patients in the 75 % MA group and 37 patients in the 50 % MA group completed the 6-month follow-up . The effectiveness of treatment in terms of normalization ( apnea index < 5 and apnea/hypopnea index < 10 ) with 75 % MA was 52 % , which was significantly higher ( p = 0.04 ) than the 31 % achieved with 50 % MA . The dental appliance had few adverse events on the stomatognathic system regardless of group , and the number of adverse events did not differ between the two groups . Finally , the mean value of Epworth Sleepiness Scale scores decreased significantly from 11.6 at baseline to 8.0 at follow-up ( p < 0.001 ) . No significant difference was observed between the two groups . The results indicate that a dental appliance could be an alternative treatment for some patients with severe OSA The aim of this study was to evaluate the effect of a m and ibular advancement splint ( MAS ) on daytime sleepiness and a range of other symptoms in obstructive sleep apnea ( OSA ) .  Using a r and omized crossover design , patients received 4 weeks of treatment with MAS and a control device ( inactive oral appliance ) , with an intervening 1-week washout . At the end of each treatment period , patients were reassessed by question naire , polysomnography , and multiple sleep latency test .  Fifty-nine men and 14 women with a mean ( + /- SD ) age of 48 + /- 11 years and proven OSA experienced a significantly improved mean ( + /- SEM ) sleep latency on the multiple sleep latency test ( 10.3 + /- 0.5 versus 9.1 + /- 0.5 minutes , p = 0.01 ) and Epworth sleepiness scale score ( 7 + /- 1 versus 9 + /- 1 , p < 0.0001 ) with the MAS compared with the control device after 4 weeks . The proportion of patients with normal subjective sleepiness was significantly higher with the MAS than with the control device ( 82 versus 62 % , p < 0.01 ) , but this was not so for objective sleepiness ( 48 versus 34 % , p = 0.08 ) . Other OSA symptoms were controlled in significantly more patients with the MAS than with the control device . MAS therapy improves a range of symptoms associated with OSA The present study objective was to establish whether pretreatment social cognitive variables may contribute to the explanation of variance in adherence to continuous positive airway pressure ( CPAP ) treatment for patients with obstructive sleep apnoea/hypopnoea syndrome ( OSAHS ) . A total of 119 of 180 consecutive OSAHS patients were recruited to the study prior to initial CPAP titration . Patients completed psychological measures of health value , health locus of control ( incorporating internality , chance , powerful others ) and self-efficacy prior to CPAP titration . Objective adherence data were measured by CPAP unit time clocks and collected at 3-month follow-up . Average nightly use was calculated over this period . Logistic regression of prospect i ve predictors of adherence produced a model comprising psychological ( health value , internality , powerful others ) , as well as clinical variables ( Epworth score , body mass index , apnoea/hypopnoea index , CPAP pressure ) . This model explained 24 % of the variance in CPAP use , and correctly identified 75 % of adherers and 53 % of nonadherers . Although the psychological variables explained only a small amount of the overall variance in adherence behaviour , this result provides further support for the hypothesis that psychological variables contribute , in part , to continuous positive airway pressure adherence . Future research should focus on highlighting discrete variables , which may helpfully inform psychologically based interventions aim ed at improving the use of continuous positive airway pressure by patients with obstructive sleep apnoea/hypopnoea syndrome at risk of discontinuance M and ibular repositioning splints ( MRSs ) and continuous positive airway pressure ( CPAP ) are used to treat the sleep apnea/hypopnea syndrome ( SAHS ) . There are some data suggesting that patients with milder symptoms prefer MRS , but there are few comparative data on outcomes . Therefore , we performed a r and omized crossover trial of 8 weeks of CPAP and 8 weeks of MRS treatment in consecutive new out patients diagnosed with SAHS ( apnea/hypopnea index [ AHI ] > or= 5/hour , and > or= 2 symptoms including sleepiness ) . Assessment s at the end of both limbs comprised home sleep study , subjective ratings of treatment value , sleepiness , symptoms , and well-being , and objective tests of sleepiness and cognition .  Forty-eight of 51 recruited patients completed the trial ( 12 women ; age [ mean + /- SD ] , 46 + /- 9 years ; Epworth 14 + /- 4 ; median AHI , 22/hour ; interquartile ratio [ IQR ] , 11 - 43/hour ) . Significant ( p < or= 0.01 ) differences between MRS and CPAP were observed for 7 of 21 variables ( effect sizes , 0.3 - 0.6 SDs ) , all favoring CPAP , including AHI ( 15 + /- 16 and 8 + /- 6/hour , respectively ) , effectiveness rating , symptoms , Epworth ( 12 + /- 5 and 8 + /- 5 , respectively ) , functional outcomes of sleepiness question naire , short-form 36 health survey mental component , and health transition scores . Objective sleepiness , cognitive performance , and preference for treatments were not different . In patients experiencing a mild form of the syndrome ( AHI < 15 , n = 18 ) , symptoms , treatment efficacy and satisfaction , and subjective sleepiness were also better with CPAP than with MRS ( effect sizes , 0.7 - 1.1 SDs ) . These results do not support these MRS devices as first-line treatment for sleepy patients with SAHS Background : Patients with mild to moderate obstructive sleep apnoea ( OSA ) may be managed with different treatment options . This study compared the effectiveness of three commonly used non-surgical treatment modalities . Methods : Subjects with mild to moderate OSA were r and omised to one of three treatment groups for 10 weeks : conservative measures ( sleep hygiene ) only , continuous positive airways pressure ( CPAP ) in addition to conservative measures or an oral appliance in addition to conservative measures .  All overweight subjects were referred to a weight-reduction class . OSA  was assessed by polysomnography .  Blood pressure was recorded in the morning and evening in the sleep laboratory . Daytime sleepiness was assessed with the Epworth Sleepiness Scale . Health-related quality of life ( HRQOL ) was assessed with the 36-Item Short-Form Health Survey ( SF-36 ) and Sleep Apnoea Quality of Life Index ( SAQLI ) . Results : 101 subjects with a mean ( SEM ) apnoea – hypopnoea index ( AHI ) of 21.4 ( 1.1 ) were r and omised to one of the three groups . The severity of sleep-disordered breathing was decreased in the CPAP and oral appliance groups compared with the conservative measures group , and the CPAP group was significantly better than the oral appliance group . Relief from sleepiness was significantly better in the CPAP group . CPAP was also better than the oral appliance or conservative measures in improving the “ bodily pain ” domain , and better than conservative measures in improving the “ physical function ” domain of SF-36 . Both CPAP and the oral appliance were more effective than conservative measures in improving the SAQLI , although no difference was detected between the CPAP and oral appliance groups . CPAP and the oral appliance significantly lowered the morning diastolic blood pressure compared with baseline values , but there was no difference in the changes in blood pressure between the groups . There was also a linear relationship between the changes in AHI and body weight . Conclusion : CPAP produced the best improvement in terms of physiological , symptomatic and HRQOL measures , while the oral appliance was slightly less effective . Weight loss , if achieved , result ed in an improvement in sleep parameters , but weight control alone was not uniformly effective AIM To assess the efficacy of a m and ibular advancement splint ( MAS ) in the treatment of  obstructive sleep apnoea syndrome ( OSAS ) .  METHODS Nineteen patients using a MAS for symptomatic OSAS underwent  polysomnography  , with MAS use r and omised to one half of the night . Indices of snoring and OSAS  were compared . Side effects , compliance and treatment response were evaluated by question naire . RESULTS Use of the MAS improved total respiratory disturbance index ( RDI ) from 22.2 + /- 19.8 ( SD ) events per hour to 16.5 + /- 21.4/hr ( p = 0.03 ) , supine RDI ( 30.8 + /- 23.8/hr to 18.8 + /- 22.1/hr , p = 0.01 ) , arousal index ( 25.2 + /- 18.9/hr to 19.3 + /- 14.2/hr , p = 0.01 ) and snoring intensity ( 52.7 + /- 4.1 to 50.7 + /- 2.7 dB , p = 0.02 ) but not total snore frequency ( p > 0.05 ) . Using polysomnographic criteria , MAS treatment was completely successful in four ( 21 % ) patients , partially successful in ten ( 52.6 % ) and a failure in five ( 26.3 % ) . Treatment over a median of 6.5 weeks ( range 2 - 48 ) was perceived as beneficial by ten of eleven partners . Fifteen patients ( 79 % ) reported side effects , 9 ( 46 % ) did not use the device every night and four ( 21 % ) used the device less than three nights per week . CONCLUSION The use of the MAS result ed in significant reductions in indices of OSAS and snoring . However , a significant number of patients had difficulty tolerating and regularly using the device The enthusiasm for uvulopalatopharyngoplasty ( UPPP ) in the treatment of obstructive sleep apnoea ( OSA ) has declined in recent years , partly because of a lower success rate over time and partly because of adverse effects . Reports on the beneficial effects of dental appliances exist , but only one prospect i ve r and omized study has been published comparing dental appliances with nasal continuous positive airway pressure ( CPAP ) treatment . No study has been published comparing dental appliance treatment with UPPP .  Ninety-five male patients with confirmed OSA , subjective daytime sleepiness and an apnoea index ( AI ) > 5 were r and omized for subsequent treatment with either a dental appliance or UPPP . There were 49 patients in the dental appliance group and 46 in the UPPP group . Thirty-seven patients in the dental appliance group and 43 in the UPPP group completed the 12-month follow-up . The success rate ( rate of patients with at least a 50 % reduction in AI ) for the dental appliance group was 95 % , which was significantly higher ( p < 0.01 ) than the 70 % success rate for the UPPP group . According to the criteria for OSA ( apnoea index > or = 5 or apnoea/hypopnoea index > or = 10 ) , 78 % of the dental appliance group and 51 % of the UPPP group were normalized after 12 months . The difference between the groups was significant ( p < 0.05 ) . These findings suggest that the dental appliance technique is useful in the treatment of mild to moderate OSA BACKGROUND Limited data have suggested that sleep-disordered breathing , a condition of repeated episodes of apnea and hypopnea during sleep , is prevalent among adults . Data from the Wisconsin Sleep Cohort Study , a longitudinal study of the natural history of cardiopulmonary disorders of sleep , were used to estimate the prevalence of undiagnosed sleep-disordered breathing among adults and address its importance to the public health . METHODS A r and om sample of 602 employed men and women 30 to 60 years old were studied by overnight polysomnography to determine the frequency of episodes of apnea and hypopnea per hour of sleep ( the apnea-hypopnea score ) . We measured the age- and sex-specific prevalence of sleep-disordered breathing in this group using three cutoff points for the apnea-hypopnea score ( > or = 5 , > or = 10 , and > or = 15 ) ; we used logistic regression to investigate risk factors . RESULTS The estimated prevalence of sleep-disordered breathing , defined as an apnea-hypopnea score of 5 or higher , was 9 percent for women and 24 percent for men . We estimated that 2 percent of women and 4 percent of men in the middle-aged work force meet the minimal diagnostic criteria for the sleep apnea syndrome ( an apnea-hypopnea score of 5 or higher and daytime hypersomnolence ) . Male sex and obesity were strongly associated with the presence of sleep-disordered breathing . Habitual snorers , both men and women , tended to have a higher prevalence of apnea-hypopnea scores of 15 or higher . CONCLUSIONS The prevalence of undiagnosed sleep-disordered breathing is high among men and is much higher than previously suspected among women . Undiagnosed sleep-disordered breathing is associated with daytime hypersomnolence The purpose of this study was to investigate the effects of an oral appliance ( OA ) , with and without m and ible advance , in the treatment of  obstructive sleep apnea syndrome ( OSA ) . Twenty-four patients diagnosed with OSA agreed to participate in this study . The patients were treated for 3 months ( with a removable soft elastic silicone positioner customized with thermoplastic silicone and with a 5-mm opening ) . Patients were selected , using a r and omized design , to receive an OA model either with ( 12 patients ) or without advance ( 12 patients ) . Before treatment , a snoring question naire , the Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) , the Functional Outcomes of Sleep Question naire ( FOSQ ) , the Epworth Sleepiness Scale ( ESS ) , and polysomnography  were completed . Fifteen subjects completed the protocol ( 13 men , two women ) . With respect to basal values , the m and ible-advanced OA group presented a decrease in the mean apnea – hypopnea index ( AHI ) ( 33.8±4.7 versus 9.6±2.1 ; p<0.01 ) , number of arousals per hour ( 33.8±13.9 versus 16.0±1.5 ; p<0.05 ) , ESS score ( 14.7±5.1 versus 5.1±1.9 ; p<0.05 ) , snoring score ( 15.4±1.9 versus 10.1±3.2 ; p<0.05 ) , and total FOSQ score ( 78.1±22.6 versus 99.3±14.4 ; p<0.05 ) . After treatment , the non-advanced group presented a decrease in the mean AHI ( 24.0±12.2 versus . 11.7±7.9 ; p<0.05 ) . However , no significant differences were found in the number of arousals per hour , ESS score , snoring , and total FOSQ score in the non-advanced group . Neither study group showed significant difference in mean SF36 scores . Oral appliances , especially those that advance the m and ible , offer an effective treatment for OSA STUDY OBJECTIVE To investigate the short-term effect ( 4 weeks ) of oral appliance therapy for obstructive sleep apnea on blood pressure .  DESIGN R and omized , controlled , crossover trial . SETTING Multidisciplinary sleep disorders clinic in a university teaching hospital . PATIENTS Sixty-one patients diagnosed with obstructive sleep apnea on polysomnography ( apnea hypopnea index > or = 10 per hour and at least 2 of the following symptoms -- daytime sleepiness , snoring , witnessed apneas , fragmented sleep ; age > 20 years ; and minimum m and ibular protrusion of 3 mm ) . INTERVENTION A m and ibular advancement splint ( MAS ) and control oral appliance for 4 weeks each . MEASUREMENTS AND RESULTS Polysomnography and 24-hour ambulatory blood pressure monitoring were carried out at baseline and following each 4-week intervention period . Patients showed a 50 % reduction in mean apnea hypopnea index with MAS compared with the control and a significant improvement in both minimum oxygen saturation and arousal index . There was a significant reduction with the MAS in mean ( + /- SEM ) 24-hour diastolic blood pressure ( 1.8 + /- 0.5 mmHg ) compared with the control ( P = .001 ) but not in 24-hour systolic blood pressure . Awake blood-pressure variables were reduced with the MAS by an estimated mean ( + /- SEM ) of 3.3 + /- 1.1 mmHg for systolic blood pressure ( P = .003 ) and 3.4 + /- 0.9 mmHg for diastolic blood pressure ( P < .0001 ) . There was no significant difference in blood pressure measured asleep . CONCLUSION Oral appliance therapy for obstructive sleep apnea over 4 weeks results in a reduction in blood pressure , similar to that reported with continuous positive airway pressure therapy In a prospect i ve study , 95 patients with mild to moderate obstructive sleep apnoea ( OSA ) were r and omised to receive either surgical treatment , uvulopalatopharyngoplasty , ( 4 - 6 patients ) or treatment with a nocturnal dental appliance for m and ibular advancement  ( 49 patients ) . Of the 49 dental appliance patients , 37 completed the 12-month follow-up . The aim of this study was to evaluate the effects and adverse events of dental appliance treatment from a one-year perspective . Somnography was employed to measure treatment effects before and 12 months post-treatment . At the 12-month control , somnography was performed twice : the first time with the dental appliance and the second time without it . Adverse events were recorded 2 weeks and 3 , 6 , and 12 months after treatment was initiated . The patients used the dental appliance on average 6 nights/week . After 12 months of treatment , the apnoea , apnoea/hypopnoea , oxygen desaturation , and snoring indices decreased significantly . Ninety-five per cent of the patients reduced their apnoea index by > or = 50 % and 78 % of the patients were normalised following treatment . At the somnographic registration without the dental appliance , the values were found comparable to what they were before treatment . M and ibular mobility and occlusion were constant throughout the study . The adverse events result ing from using the dental appliance were relatively minor and infrequent , and no serious complications were observed except for two patients who reported pain from the temporom and ibular joint . In conclusion , the dental appliance has been shown to be a valuable treatment method for mild to moderate OSA with few adverse events in the stomatognathic system or other complications STUDY OBJECTIVES This study aim ed to assess the efficacy of a custom-made m and ibular advancement splint for the treatment of obstructive sleep apnea with respect to neuropsychological functioning and mood state . METHODS A r and omized controlled crossover design was used in which 73 participants ( mean age = 48.4 , SD = 11.0 , % men = 80.8 ) with at least 2 symptoms of obstructive sleep apnea and an apnea hypopnea index > or = 10 per hour underwent treatment with both m and ibular advancement splint and an inactive oral device .  Polysomnographic , neuropsychological and self-report measures were conducted at baseline and repeated after each of the two 4-week treatment phases . RESULTS MAS treatment was associated with improvements on the somatic component of the Beck Depression Inventory and the Vigor-Activity and Fatigue-Inertia scales of the Profile of Mood States . While there were no improvements within the neuropsychological domains of attention/working memory , verbal memory , visuospatial or executive functioning , treatment with the m and ibular advancement splint was associated with faster performance on a test of vigilance/psychomotor speed . These changes , however , did not correspond to the improved subjective sleepiness or apnea-hypopnea index during treatment . CONCLUSIONS Treatment with the m and ibular advancement splint results in improvements in self-reported sleepiness , fatigue/energy levels and vigilance/psychomotor speed in patients with obstructive sleep apnea Although there is increasing interest in the use of oral appliances to treat obstructive sleep apnea ( OSA ) , the evidence base for this is weak . Furthermore , the precise mechanisms of action are uncertain . We aim ed to systematic ally investigate the efficacy of a novel m and ibular advancement splint ( MAS ) in patients with OSA . The sample consisted of 28 patients with proven OSA . A r and omized , controlled three-period ( ABB/BAA ) crossover study design was used . After an acclimatization period , patients underwent three polysomnographs with either a control oral plate , which did not advance the m and ible ( A ) , or MAS ( B ) , 1 wk apart , in either the ABB or BAA sequence . Complete response ( CR ) was defined as a resolution of symptoms and a reduction in Apnea/Hypopnea Index ( AHI ) to < 5/h , and partial response ( PR ) as a > or = 50 % reduction in AHI , but remaining > or = 5/h . Twenty-four patients ( 19 men , 5 women ) completed the protocol . Subjective improvements with the  MAS  were reported by the majority of patients ( 96 % ) . There were significant improvements in AHI ( 30 + /- 2/h versus 14 + /- 2/h , p < 0.0001 ) , MinSa(O(2 ) ) ( 87 + /- 1 % versus 91 + /- 1 % , p < 0.0001 ) , and arousal index ( 41 + /- 2/h versus 27 + /- 2/h , p < 0.0001 ) with MAS , compared with the control . The control plate had no significant effect on AHI and MinSa(O(2 ) ) . CR ( n = 9 ) or PR ( n = 6 ) was achieved in 62.5 % of patients . The MAS is an effective treatment in some patients with OSA , including those patients with moderate or severe OSA BACKGROUND Nasal continuous positive airway pressure ( NCPAP ) is widely used as a treatment for obstructive sleep apnoea . However , to date there are no r and omised controlled trials of this therapy against a well-matched control . We undertook a r and omised prospect i ve parallel trial of therapeutic NCPAP for obstructive sleep apnoea compared with a control group on subtherapeutic NCPAP . METHODS Men with obstructive sleep apnoea , defined as an Epworth sleepiness score of 10 or more and ten or more dips per h of more than 4 % SaO2 caused by obstructive sleep apnoea on overnight sleep study , were r and omly assigned therapeutic NCPAP or subtherapeutic NCPAP ( about 1 cm H2O ) for 1 month . Primary outcomes were subjective sleepiness ( Epworth sleepiness score ) , objective sleepiness ( maintenance of wakefulness test ) , and SF-36 question naire measurements of self-reported functioning and well-being . FINDINGS 107 men entered the study : 53 received subtherapeutic NCPAP and 54 therapeutic NCPAP . Use of NCPAP by the two treatment groups was similar : 5.4 h ( therapeutic ) and 4.6 h ( subtherapeutic ) per night . Subtherapeutic NCPAP did not alter the overnight number of SaO2 dips per h compared with baseline , and thus acted as a control . Therapeutic NCPAP was superior to subtherapeutic NCPAP in all primary outcome measures . The Epworth score was decreased from a median of 15.5 to 7.0 on therapeutic NCPAP , and from 15.0 to 13.0 on subtherapeutic NCPAP ( between treatments , p<0.0001 ) . Mean maintenance-of-wakefulness time increased from 22.5 to 32.9 min on therapeutic NCPAP and , not significantly , from 20.0 to 23.5 min on subtherapeutic NCPAP ( between treatments p<0.005 ) . Effect sizes for SF-36 measures of energy and vitality were 1.68 ( therapeutic ) and 0.97 ( subtherapeutic ) NCPAP ( between treatments p<0.0001 ) . For mental summary score , the corresponding values were 1.02 and 0.4 ( between treatments p=0.002 ) . INTERPRETATION Therapeutic NCPAP reduces excessive daytime sleepiness and improves self-reported health status compared with a subtherapeutic control . Compared with controls , the effects of therapeutic NCPAP are large and confirm previous uncontrolled clinical observations and the results of controlled trials that used an oral placebo OBJECTIVE To evaluate the effects of a m and ibular advancement device on  apneas and sleep in mild , moderate , and severe obstructive sleep apnea . DESIGN Prospect i ve study . SUBJECTS Forty-four of 47 patients included . INTERVENTION Individually adjusted m and ibular advancement devices . MEASUREMENTS Polysomnographic sleep recordings for 1 night without the device and 1 night with it , with a median of 1 day and no changes in weight , medication , or sleep position between the recordings . RESULTS The device reduced the median obstructive apnea-hypopnea index from 11 ( range , 7 to 19 ) to 5 ( range , 0 to 17 ) ( p<0.001 ) in 21 patients with mild sleep apnea , from 27 ( range , 20 to 38 ) to 7 ( range , 1 to 19 ) ( p<0.001 ) in 15 patients with moderate sleep apnea , and from 53 ( range , 44 to 66 ) to 14 ( range , 2 to 32 ) ( p<0.05 ) in 8 patients with severe sleep apnea . The arousal index decreased and the sleep stage patterns improved in all severity groups . Twenty-eight of 44 patients were successfully treated with an obstructive apnea-hypopnea index of below 10 and a subjective reduction in snoring . Nine of 16 patients with treatment failure still reported a reduction in snoring . The success rate correlated inversely to the disease severity ( r=-0.41 ; p<0.01 ) . CONCLUSIONS A m and ibular advancement device reduces apneas and improves sleep quality in patients with obstructive sleep apnea , especially in those with mild and moderate disease . A follow-up sleep recording during treatment is necessary because of the risk of silent obstructive apneas without subjective snoring with the device Impaired simulated driving performance has been demonstrated in obstructive sleep apnoea – hypopnoea syndrome ( OSAHS ) patients . Although continuous positive airway pressure ( CPAP ) generally improves simulated driving performance , the effects of oral-appliance ( OA ) therapy are unknown . The aims of this study were to determine to what extent OSAHS patients have more difficulty with a monotonous simulated driving test when compared with control subjects and to compare the effects of OA with CPAP therapy .  Simulated driving performance was evaluated in 20 OSAHS patients and 16 control subjects during a 25-min driving test . After r and omization , ten patients started OA and CPAP therapy , respectively . After 2 to 3 months of treatment , patients repeated the driving test . At baseline , the total number of lapses of attention during driving was significantly higher in OSAHS patients as compared with control subjects . As a result of treatment , the total number of lapses of attention was significantly decreased in both the OA and CPAP group . When comparing driving performance between the OA and CPAP group , no significant differences were noted . OSAHS patients  perform worse on a simulated driving test when compared with control subjects . When evaluating the effects of treatment , adequate OSAHS management with either OA or CPAP therapy usually result ed in substantial improvements of simulated driving . Conclusions beyond both treatments improving simulated driving performance are , however , not justified by the data in the present study BACKGROUND Although oral appliances are effective in some patients with obstructive sleep apnoea ( OSA ) , they are not universally effective . A novel anterior m and ibular positioner ( AMP ) has been developed with an adjustable hinge that allows progressive advancement of the m and ible . The objective of this prospect i ve crossover study was to compare efficacy , side effects , patient compliance , and preference between AMP and nasal continuous positive airway pressure ( nCPAP ) in patients with symptomatic mild to moderate OSA . METHODS Twenty four patients of mean ( SD ) age 44.0 ( 10.6 ) years were recruited with a mean ( SD ) body mass index of 32.0 ( 8.2 ) kg/m2 , Epworth sleepiness score 10.7 ( 3.4 ) , and apnoea/hypopnoea index 26.8 (11.9)/hour . There was a two week wash-in and a two week wash-out period and two treatment periods ( AMP and nCPAP ) each of four months . Efficacy , side effects , compliance , and preference were evaluated by a question naire and home sleep monitoring . RESULTS One patient dropped out early in the study and three refused to cross over so treatment results are presented on the remaining 20 patients . The apnoea/hypopnoea index ( AHI ) was lower with nasal CPAP 4.2 (2.2)/hour than with the AMP 13.6 (14.5)/hour ( p < 0.01 ) . Eleven of the 20 patients ( 55 % ) who used the AMP were treatment successes ( reduction of AHI to < 10/hour and relief of symptoms ) , one ( 5 % ) was a compliance failure ( unable or unwilling to use the treatment ) , and eight ( 40 % ) were treatment failures ( failure to reduce AHI to < 10/hour and /or failure to relieve symptoms ) . Fourteen of the 20 patients ( 70 % ) who used nCPAP were treatment successes , six ( 30 % ) were compliance failures , and there were no treatment failures . There was greater patient satisfaction with the AMP ( p < 0.01 ) than with nCPAP but no difference in reported side effects or compliance . CONCLUSIONS AMP is an effective treatment in some patients with mild to moderate OSA and is associated with greater patient satisfaction than nCPAP This r and omized placebo-controlled cross-over trial assessed the effectiveness of a m and ibular advancement appliance ( MAA ) in managing  obstructive sleep apnoea ( OSA ) . Twenty-one adults , with confirmed OSA , were provided with a maxillary placebo appliance and a MAA for 4 - 6 weeks each , in a r and omized order . Question naires at baseline and after each appliance assessed bed-partners ' reports of snoring severity ( loudness and number of nights per week ) , and patients ' daytime sleepiness ( Epworth Sleepiness Score , ESS ) . The Apnoea Hypopnoea Index ( AHI ) and Oxygen Desaturation Index ( ODI ) were measured at baseline and with each appliance during single night sleep studies . Seventy-nine per cent of subjects wore their MAA for at least 4 hours at night . Sixty-eight per cent of subjects wore their MAA for 6 - 7 nights per week . Excessive salivation was the most commonly reported complication . One subject was unable to tolerate the MAA and withdrew from the study . Among the remaining 20 subjects , the MAA produced significantly lower AHI and ODI values than the placebo . However , although the reported frequency and loudness of snoring and the ESS values were lower with the MAA than the placebo , these differences were not statistically significant . When wearing the MAA , 35 per cent of the OSA subjects had a reduction in the pre-treatment ODI to 10 or less , while 33 per cent had an AHI of 10 or less . The MAA was less effective in the subjects with the most severe OSA ( pre-treatment ODI > 50 and /or pre-treatment AHI > 50 ) The objective of this study was to evaluate the effect of 2 different degrees of m and ibular advancement , 50 % vs. 75 % of maximum protrusive capacity , on somnographic variables after 1 year of dental appliance treatment in patients with mild to moderate obstructive sleep apnea ( OSA ) . A further purpose was to compare the number of adverse events on the stomatognathic system . In a prospect i ve study , 74 male patients were r and omly allocated to receive a dental appliance with either 50 % ( 38 patients ) or 75 % m and ibular advancement ( 36 patients ) . After 1 year of treatment , 55 patients completed the follow‐up . Somnography was performed to measure treatment effects before and 12 months post‐treatment . The apnea , apnea/hypopnea , and oxygen desaturation indices decreased significantly in both groups after 1 year ( P<0.001 ) ; however , there were no differences between the groups . Normalization ( apnea index < 5 and apnea/hypopnea index < 10 ) was observed in 79 % in group 50 and in 73 % in group 75 . Few patients ( < 5 % ) reported symptoms from the stomatognathic system except for headache ( > once a week ) , which was reported in one‐third of the patients . Headache was significantly more infrequent after 1 year of treatment in both groups ( P<0.001 ) . No serious complications were observed except for 2 patients who reported a painful condition from the temporom and ibular joint in either group . In conclusion , m and ibular advancement with a dental appliance effectively reduces the sleep‐breathing disorder measured as frequency of apneas , and a pronounced m and ibular advancement did not show a greater improvement of the medical problem compared to less advancement for patients with mild to moderate OSA . On the basis of few adverse events in the stomatognathic system or other complications we can recommend dental appliance treatment and , for patients with mild to moderate obstructive sleep apnea , not starting treatment by more than 50 % m and ibular advancement Our purpose was to compare the effectiveness and side effects of a novel , single-piece m and ibular advancement device ( OSA-Monobloc ) for sleep apnea therapy with those of a two-piece appliance with lateral Herbst attachments ( OSA-Herbst ) as used in previous studies . An OSA-Monobloc and an OSA-Herbst with equal protrusion were fitted in 24 obstructive sleep apnea patients unable to use continuous positive airway pressure ( CPAP ) therapy . After an adaptation period of 156 + /- 14 d ( mean + /- SE ) , patients used the OSA-Monobloc , the OSA-Herbst , and no appliance in r and om order , using each appliance for 1 wk . Symptom scores were recorded and sleep studies were done at the end of each week . Several symptom scores were significantly improved with both appliances , but to a greater degree with the OSA-Monobloc .  Epworth Sleepiness Scale scores were 8.8 + /- 0.7 with the OSA-Herbst , and 8.6 + /- 0.8 with the OSA-Monobloc devices , and 13.1 + /- 0.9 without therapy ( p < 0.05 versus both appliances ) . The apnea/hypopnea index was 8.7 + /- 1.5/h with the OSA-Herbst and 7.9 + /- 1.6/h with the OSA-Monobloc device , and 22.6 + /- 3.1/h without therapy ( p < 0.05 versus both appliances ) . Side effects were mild and of equal prevalence with both appliances . Fifteen patients preferred the OSA-Monobloc , eight patients had no preference , and one patient preferred the OSA-Herbst device ( p < 0.008 versus OSA-Monobloc ) . We conclude that both the OSA-Herbst and the OSA-Monobloc are effective therapeutic devices for sleep apnea . The OSA-Monobloc relieved symptoms to a greater extent than the OSA-Herbst , and was preferred by the majority of patients on the basis of its simple application OBJECTIVE This study compared the efficacy of a removable anterior m and ibular positioning ( AMP ) device to continuous positive airway pressure ( CPAP ) in patients with obstructive sleep apnea ( OSA ) using a fully balanced crossover design . DESIGN Twenty-three male subjects with confirmed OSA were recruited from the Technion Sleep Laboratory in Haifa , Israel , from February 18 , 1991 to December 17 , 1992 . Twenty-one of the 23 subjects enrolled completed all aspects of the study . RESULTS The mean apnea-hypopnea index ( AHI ) before treatment was 33.86 + /- 14.30 . The mean AHI decreased with CPAP to 59.50 % , but decreased only 38.91 % with the AMP device . The lowest mean recorded oxygen saturation level for the 21 subjects was 84.30 before treatment , 91.10 after CPAP treatment , and 90.20 after AMP treatment . Sleep data revealed a significant decrease in stage 1 and 2 ( p=0.0088 ) and an increase in rapid eye movement percent ( p=0.0066 ) for both treatments when compared with baseline . Three- to 10-month posttreatment phone interviews showed that 1 subject was not using either device , 1 subject was using CPAP , and 2 subjects were using the AMP device intermittently due to occasional temporom and ibular joint pain symptoms . The remaining 17 subjects were all using the AMP device nightly . The symptoms of excessive daytime sleepiness also decreased significantly by both AMP and CPAP . CONCLUSIONS The AMP device achieved substantial success in most cases , but was less effective than CPAP , especially for the more severe cases . In general , the AMP device was strongly preferred over the CPAP by the subjects of this study This prospect i ve , r and omized , cross-over trial was design ed to compare the efficacy of a m and ibular advancement splint ( MAS ) with that of nasal continuous positive airway pressure ( nCPAP ) in patients with obstructive sleep apnoea ( OSA ) . Twenty-four patients ( 20 males and four females ) with mild to moderate OSA ( AHI between 10 and 49 events per hour ) were enrolled in the study . Each patient used both MAS and nCPAP , with the initial therapy being allocated at r and om . Treatment periods lasted for two months with a two-week wash-out interval between .  Polysomnography  was performed prior to the study and after each clinical intervention . Patient and partner question naires were used to assess changes in general health and daytime somnolence . The AHI decreased from 22.2 to 3.1 using nCPAP , and to 8.0 using the MAS ( P < 0.001 for both devices ) and there was no statistically significant difference between the two treatments . The Epworth Sleepiness Score ( ESS ) fell from 13.4 to 8.1 with nCPAP , and to 9.2 with MAS ( P < 0.001 ) , again with no differences between the use of MAS or nCPAP . The question naire data showed an improvement in general health scores ( P < 0.001 ) after both treatments , but daytime sleepiness only improved significantly using nCPAP ( P < 0.001 ) . Despite this , 17 out of the 21 subjects who completed both arms of the study preferred the MAS . The splints were well tolerated and their efficacy suggests that the MAS may be a suitable alternative to nCPAP in the management of patients with mild or moderate OSA Knowledge of how dental appliances alter upper airway muscle activity when they are used for the treatment of snoring and /or obstructive sleep apnea ( OSA ) is very limited . The purpose of this study was to define the effect of a tongue retaining device ( TRD ) on awake genioglossus ( GG ) muscle activity in 10 adult subjects with OSA and in 6 age and body mass index ( BMI ) matched symptom-free control subjects . The TRD is a custom-made appliance design ed to allow the tongue to remain in a forward position between the anterior teeth by holding the tongue in an anterior bulb with negative pressure , during sleep . This pulls the tongue forward to enlarge the volume of the upper airway and to reduce upper airway resistance . In this study , two customized TRDs were used for each subject . The TRD-A did not have an anterior bulb but incorporated lingual surface electrodes to record the GG electromyographic ( EMG ) activity . The TRD-B contained an anterior bulb and two similar electrodes . The GG EMG activity was also recorded while patients used the TRD-B but were instructed to keep their tongue at rest outside the anterior bulb ; this condition is hereafter referred to as TRD-X. The GG EMG activity and nasal airflow were simultaneously recorded while subjects used these customized TRDs during spontaneous awake breathing in both the upright and supine position . The following results were obtained and were consistent whether subjects were in the upright or the supine position . The GG EMG activity was greater with the TRD-B than with the TRD-A in control subjects ( p < 0.05 ) , whereas the GG EMG activity was less with the TRD-B than with the TRD-A in subjects with OSA ( p < 0.01 ) . Furthermore , there was no significant difference between the GG EMG activity of the TRD-A and the TRD-X in control subjects , whereas there was less activity with the TRD-X than with the TRD-A in subjects with OSA ( p < 0.05 ) . On the basis of these findings , it was concluded that the TRD has different effects on the awake GG muscle activity in control subjects and patients with OSA . The result ant change in the anatomic configuration of the upper airway caused by the TRD may be important in the treatment of OSA because such a change may alleviate the impaired upper airway function BACKGROUND Obstructive sleep apnoea is associated with raised blood pressure . If blood pressure can be reduced by nasal continuous positive airway pressure ( nCPAP ) , such treatment could reduce risk of cardiovascular disease in patients with obstructive sleep apnoea . Our aim was to see whether nCPAP for sleep apnoea reduces blood pressure compared with the most robust control intervention subtherapeutic nCPAP . METHODS We did a r and omised parallel trial to compare change in blood pressure in 118 men with obstructive sleep apnoea ( Epworth score > 9 , and a > 4 % oxygen desaturation index of > 10 per h ) who were assigned to either therapeutic ( n=59 ) or subtherapeutic ( 59 ) nCPAP ( about 1 cm H(2)O pressure ) for 1 month . The primary outcome was the change in 24-h mean blood pressure . Secondary outcomes were changes in systolic , diastolic , sleep , and wake blood pressure , and relations between blood pressure changes , baseline blood pressure , and severity of sleep apnoea . FINDINGS Therapeutic nCPAP reduced mean arterial ambulatory blood pressure by 2.5 mm Hg ( SE 0.8 ) , whereas subtherapeutic nCPAP increased blood pressure by 0.8 mm Hg ( 0.7 ) ( difference -3.3 [ 95 % CI -5.3 to -1.3 ] ; p=0.0013 , unpaired t test ) . This benefit was seen in both systolic and diastolic blood pressure , and during both sleep and wake . The benefit was larger in patients with more severe sleep apnoea than those who had less severe apnoea , but was independent of the baseline blood pressure . The benefit was especially large in patients taking drug treatment for blood pressure .  INTERPRETATION In patients with most severe sleep apnoea , nCPAP reduces blood pressure , providing significant vascular risk benefits , and substantially improving excessive daytime sleepiness and quality of life M and ibular advancement appliances ( MAAs ) are accepted as a treatment option for  snoring and mild obstructive sleep disorders .  In the present clinical study two differently design ed devices were examined for their effectiveness in treating  obstructive sleep apnoea ( OSA ) .  The study was based on an assessment of 26 patients with a polysomnographic diagnosis of mild OSA [ 22 men , four women ; mean body mass index 27.3 kg/m2 ( SD 3.1 ) ; mean age 56.8 years ( SD 5.2 ) ; mean respiratory disturbance index ( RDI ) : 16.0 events/hour ( SD 4.4 ) ] . After insertion of the first MAA and a 6 - 8-week habituation period , a cardio-respiratory home-sleep study was carried out . Following a 2 - 3-week period with no treatment , the second appliance was inserted . The sequence of the devices was r and omized . Once the patients had become accustomed to the second appliance , another somnographic registration was carried out . Daytime sleepiness , snoring , and sleep quality were assessed subjectively on a visual analogue scale . The results showed that a statistically significant improvement in the respiratory parameters was achieved with both appliances ( P < 0.01 ) . However , the activator [ RDI : 5.5 events/hour , SD 3.3 ; apnoea index ( AI ) : 3.4 events/hour , SD 2.1 ] was significantly more effective ( P < 0.01 ) than the Silencor ( RDI , 7.3 events/hour , SD 5.3 ; AI : 5.8 events/hour , SD 3.2 ) . No difference was recorded in the subjective assessment of the therapeutic effects . Both appliances reduced daytime sleepiness and snoring and improved sleep quality , and both influenced the treatment outcome To evaluate the clinical usefulness and tolerability of an oral jaw-positioning appliance in the treatment of obstructive sleep apnea syndrome in children , we studied 32 patients ( mean age , 7.1 + /- 2.6 yr ; 20 males ) with symptoms of obstructive sleep apnea , malocclusion , and a baseline apnea index > 1 event/h . A group of 19 subjects was r and omly assigned to a 6-mo trial of an oral appliance ; the remainder acted as control subjects . At baseline and after the trial all patients underwent physical examination  , a  st  and ard polysomnography , and orthodontic assessment .  A modified version of the Brouillette question naire related to obstructive sleep apnea symptoms was administered to parents before and after the trial and a clinical score was calculated . Of the 32 subjects enrolled , 4 treated subjects and 5 control subjects were lost to follow-up . Polysomnography after the trial showed that treated subjects all had significantly lower apnea index ( p < 0.001 ) and hypopnea index values ( p < 0.001 ) than before the trial , whereas in untreated control subjects these values remained almost unchanged . Clinical assessment before and after treatment showed that in 7 of the 14 subjects ( 50 % ) the oral appliance had reduced ( a fall of at least 2 points in the respiratory score ) and in 7 had resolved the main respiratory symptoms , whereas untreated patients continued to have symptoms . In conclusion , treatment of obstructive sleep apnea syndrome  with an oral appliance in children with malocclusion is effective and well tolerated Snoring and obstructive sleep apnea ( OSA ) are related to narrowing of the upper airway . A m and ibular advancement splint ( MAS ) could improve both conditions by increasing oropharyngeal and hypopharyngeal dimensions . The effects of a MAS on snoring and OSA was evaluated 3.5 + /- 2.1 ( mean + /- SD ) mo after issue in 57 subjects with habitual loud snoring , 39 of whom had an apnea-hypopnea index ( AHI ) > or = 10 . Assessment was by question naire ( all subjects ) and  polysomnography  ( 51 subjects , 47 male ) including measurement of sound intensity . Use of the MAS was r and omized to first or second half of study . Snores were scored where inspiratory noise was greater than 5 dB above background . Total sleep time , sleep efficiency , % REM sleep , and % sleep spent supine were similar ( p > 0.05 ) with and without the MAS . Snores per sleep minute , corrected for time in apnea , and sound intensity of snores ( % snores > or = 50 dB ) decreased with the MAS from 11.0 + /- 5.8 and 42.0 + /- 25.0 % to 9.0 + /- 6.0 ( p < 0.01 ) and 26.2 + /- 25.2 % ( p < 0.01 ) , respectively . Using the MAS significantly improved OSA : AHI decreased from 32.2 + /- 28.5 to 17.5 + /- 22.7 ( p < 0.01 ) and arousal index decreased from 31.4 + /- 20.6 to 19.0 + /- 14.6 ( p < 0.01 ) . AHI decreased to < 20 with the MAS in 12 of 17 subjects where untreated AHI was between 20 and 60 , and in 2 of 9 subjects where untreated AHI was > 60 . Forty-five patients continued to use the MAS regularly . ( ABSTRACT TRUNCATED AT 250 WORDS This prospect i ve , r and omized , crossover study of 16 patients with obstructive sleep apnoea ( OSA ) [ 12 males , four females ; median body mass index ( BMI ) 29.2 kg/m(2 ) ( range 23.8 - 51.1 ) ; median age 44.8 years ( range 24.0 - 68.4 ) ] analysed the efficacy of the Twin Block ( TB ) in relation to the Herbst appliance as a m and ibular advancement splint ( MAS ) . Each subject was fitted with a TB and Herbst MAS in a r and om order with a washout period of 2 weeks between appliances . Once each patient was subjectively happy with the performance of each appliance , question naires and a visual analogue scale ( VAS ) were used to determine differences in snoring , daytime sleepiness , quality of life , side-effects of the appliances and patient preference . All patients underwent overnight domiciliary sleep recordings prior to and after fitting each appliance in order to objective ly assess sleep quality in terms of the apnoea-hypopnoea index ( AHI ) , snoring frequency and arterial oxygen saturation . The results suggested that there was no difference in the treatment performance of the TB and Herbst MAS for AHI ( P = 0.71 ) , snoring frequency ( P = 0.49 ) , arterial blood oxygen saturation ( P = 0.97 ) , quality of life and side-effects . The Herbst MAS proved to be the more effective appliance for reducing daytime sleepiness ( P = 0.04 ) and was the more popular appliance among the patients . Side-effects with both appliances were minor and improved in the longer term . The TB MAS represents a viable alternative to the Herbst MAS in the treatment of patients with OSA The aim of this study was to assess the effect of bite opening induced by a m and ibular advancement splint ( MAS ) on efficacy and side effects in the treatment of obstructive sleep apnea . In a r and omized crossover fashion , 23 adult patients received either MAS-1 ( 4 mm of interincisal opening ) or MAS-2 ( 14 mm of interincisal opening )  for 2 weeks , followed by the alternate treatment for 2 weeks , with an intervening 1-week washout . Complete response was defined as a resolution of symptoms and a reduction in apnea/hypopnea index ( AHI ) to less than 5 per hour . Partial response was defined as improved symptoms and a reduction in AHI of 50 % or more , with the AHI remaining at a value of 5 or more per hour . Both MAS-1 and MAS-2 produced similar reductions in mean ( + /- SEM ) AHI from baseline : 21 + /- 2 versus 8 + /- 1/hour and 21 + /- 2 versus 10 + /- 2/hour , respectively ( p < 0.001 ) . Either complete response or partial response occurred in 74 and 61 % of patients with MAS-1 and MAS-2 , respectively . Subjective improvements were reported with both appliances by the majority of patients . Patients preferred MAS-1 ( 78 versus 22 % , p = 0.007 ) . This study suggests that the amount of bite opening induced by MAS does not have a significant impact on treatment efficacy but does have an impact on patient acceptance STUDY OBJECTIVES The effect of therapy using a cervicom and ibular support collar ( CMSC ) to manage obstructive sleep apnea ( OSA ) was compared with st and ard therapy , nasal continuous positive airway pressure ( nCPAP ) . DESIGN Subjects received treatment with CMSC or nCPAP each for 1 month in r and om order . The study was analyzed on an intention-to-treat basis . SETTING Tom McKendrick Sleep Laboratory , Dunedin Hospital . PARTICIPANTS Ten adult subjects with mild-to-moderate OSA ( apnea-hypopnea index [ AHI ] , 24 + /- 13/h slept [ mean + /- SD ] ) completed the study . INTERVENTIONS The CMSC was design ed to prevent m and ibular movement and hold the head in slight extension , thus preventing the postural changes that might contribute to OSA . Positioning of the CMSC was confirmed by an externally applied cervical range of motion ( CROM ) instrument and by cephalometry . Subjects were carefully instructed in the use of each device and completed a symptom diary . After 1 month , subjects underwent  polysomnography  with each of the allocated devices in situ , and symptom question naires were administered . MEASUREMENTS AND RESULTS Treatment success ( AHI < /= 10/h slept ) with CMSC was achieved in only 2 of 10 subjects , partial success ( AHI > 10/h to < /= 15/h slept ) was achieved in 2 subjects , and in 6 of 10 subjects there was no benefit . In contrast , treatment success was achieved in 7 of 10 subjects receiving nCPAP .  Mean AHI was 29.4 + /- 13.4/h at baseline , 26.9 + /- 17.2/h slept with CMSC , and 9.9 + /- 8.0/h slept with nCPAP ( p = 0.001 ) . No significant differences in sleep architecture or sleep efficiency were achieved using nCPAP compared to CMSC . The efficacy of the CMSC in maintaining the desired head position was confirmed by cephalometry and the CROM instrument . CONCLUSIONS Our results , although negative , provide important evidence that control of head and neck posture , perhaps adopted as a second-line treatment , is not helpful in the management of OSA . It appears that other anatomic and physiologic factors have a dynamic overriding influence on upper airway closure compared to simple skeletal relationships The precise role of maxillary constriction in the pathophysiology of obstructive sleep apnea ( OSA ) is unclear . However , it is known that subjects with maxillary constriction have increased nasal resistance and result ant mouth-breathing , features typically seen in OSA patients . Maxillary constriction is also associated with alterations in tongue posture which could result in retroglossal airway narrowing , another feature of OSA . Rapid maxillary expansion ( RME ) is an orthodontic treatment for maxillary constriction which increases the width of the maxilla and reduces nasal resistance . The aim of this pilot study was to investigate the effect of rapid maxillary expansion in OSA . We studied 10 young adults ( 8 male , 2 female , mean age 27 + /- 2 [ sem ] years ) with mild to moderate OSA ( apnea/hypopnea index-AHI 19 + /- 4 and minimum SaO2 89 + /- 1 % ) , and evidence of maxillary constriction on orthodontic evaluation . All patients underwent treatment with RME , six cases requiring elective surgical assistance . Polysomnography was repeated at the completion of treatment . Nine of the 10 patients reported improvements in snoring and hypersomnolence . There was a significant reduction in AHI ( 19 + /- 4 vs 7 + /- 4 , p < 0.05 ) in the entire group . In seven patients , the AHI returned to normal ( i.e. , = < 5 ) ; only one patient showed no improvement . These preliminary data suggest that RME may be a useful treatment alternative for selected patients with OSA The purpose of this study was to compare the effects of a modified Herbst appliance ( mHA ) and a muscle relaxation appliance ( MR ) on nocturnal breathing and body movement activity in patients with obstructive sleep apnoea syndrome ( OSAS ) . To increase the airway space posterior to the tongue base without severely affecting the craniom and ibular joint , the mHA was adjusted to anchor the m and ible at 50 % of maximum protrusion . MR producing an occlusal coverage but no protrusion served as a control appliance . All-night static charge-sensitive bed ( SCSB ) and finger oximeter recordings were done to six male patients in three conditions : first without dental device and then with mHA and with MR , in a r and om order , after a 2 month period of habituation . The oxyhaemoglobin desaturation events were 44.7 h-1 of recording observed during the control night , 29.6 h-1 with mHA ( P = 0.087 ) . The frequency of body movements decreased from 34.9 to 20.4 h-1 ( P = 0.0079 ) , respectively . MR had no significant effects either on the frequency of the desaturation events or the frequency of body movements , but the increased respiratory resistance breathing , indicating presence of partial upper airway obstruction , was reduced from 14.3 to 6.9 % of the time in bed ( P = 0.022 ) . We conclude that 50 % protrusion chosen for these experiments , produced with a mHA , brought about some alleviation of upper airway obstruction in our preselected patients , but did not lead to sufficient control of apnoea . The reduction of partial upper airway obstruction induced with a MR warrants further studies in a larger patient population STUDY OBJECTIVES To examine dose-dependent effects of m and ibular advancement on collapsibility of the passive pharynx and sleep-disordered breathing ( SDB ) . DESIGN Prospect i ve , r and omized study . SETTING University hospital . PATIENTS Thirty-seven adult patients with SDB . INTERVENTIONS Oral appliances with 2- , 4- , and 6-mm advancement of the m and ible . MEASUREMENTS AND RESULTS Overnight oximetry was performed with and without oral appliances . Each 2-mm m and ibular advancement coincided with approximately 20 % improvement in number and severity of nocturnal desaturations . Percentages of patients producing a > 50 % improvement rate of the number of desaturations were 25 % , 48 % , and 65 % with use of oral appliances with 2- , 4- , and 6-mm m and ibular advancement , respectively . Static pharyngeal mechanics were evaluated in six completely paralyzed patients with SDB under general anesthesia with and without the oral appliances . Advancement of m and ibular position was found to produce dose-dependent closing pressure reduction of all pharyngeal segments . Normalization of nocturnal oxygenation was associated with negative closing pressure , especially at the velopharynx . CONCLUSIONS We conclude that improvement of both nocturnal oxygenation and pharyngeal collapsibility significantly depends on the m and ibular position STUDY OBJECTIVE To compare efficacy , side effects , patient compliance , and preference between oral appliance ( OA ) therapy and nasal-continuous positive airway pressure ( N-CPAP ) therapy . DESIGN R and omized , prospect i ve , crossover study . SETTING University hospital and tertiary sleep referral center . PATIENTS Twenty-seven unselected patients with mild-moderate obstructive sleep apnea ( OSA ) . INTERVENTIONS There was a 2-week wash-in and a 2-week wash-out period , and 2 x 4-month treatment periods ( OA and N-CPAP ) . Efficacy , side effects , compliance , and preference were evaluated by a question naire and home sleep monitoring . MEASUREMENTS AND RESULTS Two patients dropped out early in the study and treatment results are presented on the remaining 25 patients . The apnea/hypopnea index was lower with N-CPAP ( 3.5 + /- 1.6 ) ( mean + /- SD ) than with the OA ( 9.7 + /- 7.3 ) ( p < 0.05 ) . Twelve of the 25 patients who used the OA ( 48 % ) were treatment successes ( reduction of apnea/hypopnea to < 10/h and relief of symptoms ) , 6 ( 24 % ) were compliance failures ( unable or unwilling to use the treatment ) , and 7 ( 28 % ) were treatment failures ( failure to reduce apnea/hypopnea index to < 10/h and /or failure to relieve symptoms ) . Four people refused to use N-CPAP after using the OA . Thirteen of the 21 patients who used N-CPAP were overall treatment successes ( 62 % ) , 8 were compliance failures ( 38 % ) , and there were no treatment failures . Side effects were more common and the patients were less satisfied with N-CPAP ( p < 0.005 ) . Seven patients were treatment successes with both treatments , six of these patients preferred OA , and one preferred N-CPAP as a long-term treatment . CONCLUSIONS We conclude that OA is an effective treatment in some patients with mild-moderate OSA and is associated with fewer side effects and greater patient satisfaction than N-CPAP The evidence linking sleep-disordered breathing to increased mortality and cardiovascular morbidity has been conflicting and inconclusive . We hypothesized that a potential adverse effect of disordered breathing would be more obvious in patients with established vascular disease . In a prospect i ve cohort study 408 patients aged 70 yr or younger with verified coronary disease were followed for a median period of 5.1 yr .  An apnea-hypopnea index ( AHI ) of > or = 10 and an oxygen desaturation index ( ODI ) of > or = 5 were used as the diagnostic criteria for sleep-disordered breathing . The primary end point was a composite of death , cerebrovascular events , and myocardial infa rct ion . There was a 70 % relative increase and a 10.7 % absolute increase in the primary composite end point in patients with disordered breathing defined as an ODI of > or = 5 ( risk ratio 1.70 , 95 % confidence interval [ CI ] 1.15 - 2.52 , p = 0.008 ) . Similarly , patients with an AHI of > or = 10 had a 62 % relative increase and a 10.1 % absolute increase in the composite endpoint ( risk ratio 1.62 , 95 % CI 1.09 - 2.41 , p = 0.017 ) . An ODI of > or = 5 and an AHI of > or = 10 were both independently associated with cerebrovascular events ( hazard ratio 2.62 , 95 % CI 1.26 - 5.46 , p = 0.01 , and hazard ratio 2.98 , 95 % CI 1.43 - 6.20 , p = 0.004 , respectively ) . We conclude that sleep-disordered breathing in patients with coronary artery disease is associated with a worse long-term prognosis and has an independent association with cerebrovascular events STUDY OBJECTIVES To measure the effects of a titratable anterior m and ibular repositioner on airway size and  Obstructive Sleep Apnea ( OSA )  and to evaluate its compliance . DESIGN Before and after insertion sleep studies were obtained in a total of 38 OSA patients of varying severity from three different sites . Covert compliance was measured by means of a newly-developed , miniaturized , temperature-sensitive , imbedded monitor . Validity testing was completed in six adult volunteers who wore monitors imbedded into small acrylic appliances .  MEASUREMENTS AND RESULTS The mean RDI before treatment was 32.6 ( SEM 2.1 ) and after the insertion of the appliance , the RDI was reduced to 12.1 ( SEM 1.7 , p<0.001 ) . RDI was reduced to less than 15/hour in 80 % of a group of moderate OSA patients ( RDI 15 to 30 ) and in 61 % of a group of severe OSA patients ( RDI > 30 ) with respect to baseline RDI .  Fiber optic video endoscopy  was performed on 9 OSA patients with and without the appliance . No significant differences in hypopharynx or oropharynx cross sectional areas were found , but at the level of the velopharynx , the airway size was significantly increased ( p<0.05 ) . The index of agreement was 0.99 between the monitor clock time and the subject 's log sheets . Compliance data from eight OSA subjects instructed to wear the appliance during sleep indicated that it was worn for a mean of 6.8 hours with a range of 5.6 to 7.5 hours per night . CONCLUSION The titratable adjustable m and ibular advancement appliance , made from thermoelastic acrylic , significantly reduces RDI in moderate to severe OSA patients , has a direct effect on airway size and is well worn throughout the night We studied the short-term effects and complications of the use of a dental device ( prosthetic m and ibular advancement : PMA ) in 72 patients with obstructive sleep apnea syndrome ( OSAS ) , and the compliance of these patients with this treatment . In 61 ( 84.5 % ) of the 72 patients , the apnea index decreased by more than 50 % . The lowest SaO2 and symptom scores also improved significantly . The severity of OSAS was not related to the percent reduction in apnea index . Complications of PMA use were observed in 22 patients ( 30.6 % ) , but no severe adverse effects were observed . Sixty-two of the 72 patients continued using the PMA throughout the entire study period ( overall compliance rate , 86.1 % ) . In addition , the long-term compliance rate ( more than 5 years ) was 61.5 % . We conclude that the effects of PMA in patients with OSAS are clinical ly significant , that there are no severe complications , and that compliance with treatment is good Previous case reports have indicated dental devices can be an effective nonsurgical treatment for  snoring and obstructive sleep apnea .  This pilot study evaluated the effectiveness of two intraoral devices in reducing the Respiratory Disturbance Index ( RDI ) and Epworth Sleepiness Scale ( ESS ) scores in a group of 24 adult volunteers with a history of loud snoring . Subjects were r and omly assigned to two groups . Twelve subjects were fitted with a dental device design ed to increase vertical dimension and protrude the m and ible ( device A ) . The other 12 subjects received a different device design ed to minimally increase vertical opening without protruding the m and ible ( device B ) .  Unattended home sleep monitoring ( Edentrace II Digital Recorder , Edentech Corp. ) was used to compute RDI at two time periods : ( T0 ) before using any dental device and ( T1 ) while using a dental device 2 weeks after the initial delivery date . The mean RDI and ESS scores at T0 for subjects in the device A group were 35.6 + /- 28.4 and 12.0 + /- 3.9 , respectively . Means for the same measures at T1 were 21.1 + /- 21.4 and 8.2 + /- 4.0 . For subjects in the device B group , means for RDI and ESS scores at T0 were 36.5 + /- 43.7 and 13.0 + /- 4.5 , the means at T1 were 46.8 + /- 47.0 and 12.5 + /- 5.7 . The effectiveness of the two devices was estimated by comparing the difference in RDI scores from T0 to T1 for the 10 subjects who were using device A and completed the study and the 8 subjects who were using device B and completed the study . Six subjects withdrew for various reasons . From T0 to T1 , device A reduced RDI scores in 9 of 10 subjects , with a mean reduction in RDI of 14.5 ( p < or = 0.05 ) and in ESS score of 3.8 ( p < or = 0.005 ) . Device B showed no change or an increased RDI score in 8 of 8 subjects . Seven of the eight subjects who showed no improvement in RDI with device B were then fitted with device A. Four of these seven subjects showed a reduction in RDI and five showed a reduction in ESS after using device A for 2 weeks . The mean reduction in RDI and ESS was 2.4 + /- 19.8 and 2.4 + /- 3.0 , respectively . Hence , we conclude that a dental device that advances the m and ible and increases the vertical dimension to open the upper airway is more effective in reducing the number of apneic and snoring events during sleep than one which does not The aim of this prospect i ve , r and omized study was to analyze dental and skeletal side effects after 4 years of treating obstructive sleep apnea ( OSA ) patients with a m and ibular advancement device ( MAD ) compared with uvulopalatopharyngoplasty ( UPPP ) . With the appliance in position , the m and ible was advanced 50 % of maximum protrusion capacity ( ie , 4 - 6 mm ) ; the vertical opening between the incisal edges was , on average , 3 mm . Thirty patients in the MAD group and 37 in the UPPP group completed the 4-year follow-up . There were no differences between the MAD and the UPPP groups in any of the dental or skeletal variables measured after the 4-year treatment period . In the MAD group , small but statistically significant changes were found : there was a posterior rotation of the m and ible ( m and ibular line [ML]/nasion-sella line [ NSL ] ) ( mean 0.5 degrees [ 95 % confidence interval ( CI ) 0.1 - 0.8 degrees ] ) . Correlated to the posterior rotation of the m and ible , the distances incision superius ML , incision superius-NSL , and incision inferius-NSL increased by means ( 95 % CI ) of 0.7 ( 0.5 - 1.2 ) , 0.8 ( 0.4 - 1.1 ) , and 1.3 ( 0.8 - 1.8 ) mm , respectively . Overjet and overbite did not change significantly , nor was there a significant change in the m and ibular length . The observed changes were considered clinical ly insignificant because overbite and overjet stayed within normal limits . Only the vertical position of the maxillary incisors in relation to ML changed to the extent that the 95 % CI of the mean for the change was outside that of the mean of the change in the UPPP group and measurement error . Treatment of OSA with a dental appliance is probably a lifelong process , and long-term follow-up studies should therefore be undertaken to control both the treatment effect on OSA and the side effects on the masticatory system STUDY OBJECTIVES To evaluate the effects of treatment with a dental appliance or uvulopalatopharyngoplasty ( UPPP ) on somnographic variables in patients with mild-to-moderate obstructive sleep apnea ( OSA ) followed up for 4 years , and compliance and complementary treatment . DESIGN R and omized study . SETTING Central Hospital , Västerås , Uppsala University , Sweden . PATIENTS Ninety-five male patients with confirmed mild-to-moderate OSA ( apnea index [ AI ] > 5 and < 25 ) were r and omized to treatment with a dental appliance or UPPP .  Sleep studies were performed before and 1 year and 4 years after intervention . Thirty-two patients in the dental-appliance group and 40 patients in the UPPP group completed the 4-year follow-up . RESULTS The success rate ( percentage of patients with at least 50 % reduction in AI ) in the dental-appliance group was 81 % , which was significantly higher than in the UPPP group , 53 % ( p < 0.05 ) . Normalization ( AI < 5 or apnea/hypopnea index < 10 ) was observed in 63 % of the dental-appliance group and 33 % of the UPPP group after 4 years . The difference between the groups was significant ( p < 0.05 ) . The compliance to use of the dental appliance was 62 % at the 4-year follow-up . Thirty patients ( 75 % ) in the UPPP group continued without complementary treatment . The dental appliances had few adverse effects on the stomatognathic system , and the number of adjustments and repairs of the appliances over time was moderate . Pronounced complaints of nasopharyngeal regurgitation of fluid and difficulty with swallowing after UPPP were reported by 8 % and 10 % , respectively . CONCLUSIONS The dental-appliance group showed significantly higher success and normalization rates regarding the somnographic variables compared to the UPPP group , but the effectiveness of the dental appliance was partly invali date d by the compliance of 62 % at the 4-year follow-up . However , the appliances had few adverse effects on the stomatognathic system and required only moderate adjustments . Use of a dental appliance with regular follow-up can be recommended for long-term treatment of OSA OBJECTIVE To test the effects on  snoring and sleep disordered breathing  of a dental prosthesis ( Snore-No-More ) which is design ed to decrease snoring by preventing mouth breathing during sleep . DESIGN A crossover controlled trial . Each subject was studied on two nights a week apart . There was a control ( no treatment ) night and an experimental ( treatment ) night . The order of control and experimental nights was r and omised . SETTING The Royal Adelaide Hospital Sleep Laboratory . PARTICIPANTS Fourteen male volunteers ( age range , 36 - 59 years ) were studied . All had a history of chronic snoring but denied other symptoms of obstructive sleep apnoea syndrome . INTERVENTIONS On experimental nights subjects wore the dental prosthesis for the whole study period . On control nights no device was worn . MAIN OUTCOME MEASURES Studies were conducted overnight during the subject 's normal sleep period . The following measurements were made : ( i ) frequency and loudness of snores ; ( ii ) frequency of disordered breathing events ( apnoeas and hypopnoeas ) ; ( iii ) mean and minimum arterial oxygen saturation while asleep ; and ( iv ) sleep stages . RESULTS The dental prosthesis did not change the mean frequency or mean intensity of snores . The number of sleep disordered breathing events per hour of sleep decreased by approximately one-third on experimental nights ( mean + /- SEM events/h : control , 24.7 + /- 5.3 ; experimental , 16.1 + /- 3.3 , P less than 0.05 ) . Neither sleep architecture nor arterial oxygen saturation differed between control and experimental nights . CONCLUSION Snores using the dental prosthesis Snore-No-More to produce obligatory nasal breathing are unlikely to experience clinical benefit The objectives of this study were : to evaluate the change in the three quality of life ( QOL ) dimensions of vitality , contentment and sleep before intervention and 1 year after treatment with a dental appliance or uvulopalatopharyngoplasty ( UPPP ) ; to compare the effect of treatment between these two treatment groups on these three dimensions ; and to determine the relation between the QOL scores and somnographic values . Ninety-five patients with mild to moderate obstructive sleep apnoea ( OSA ) ( AI > 5 ) were r and omly allocated to either a dental appliance or UPPP treatment group . Seven patients withdrew after r and omization but before treatment , leaving 88 patients eligible for treatment . The patients were examined using somnography and administered the Minor Symptoms Evaluation-Profile ( MSE-P ) , a QOL question naire , before and 1 year after intervention . Thirty-seven patients in the dental appliance group and 43 in the UPPP group completed the 1-year follow-up . The mean values for the three dimensions vitality , contentment and sleep improved significantly 1 year after intervention in the dental appliance and UPPP groups . No difference in the QOL scores at baseline was noted between the groups . One year after intervention the UPPP group showed significantly more contentment than the dental appliance group . In contrast , vitality and sleep dimensions did not differ between the two treatment groups . No significant correlations were observed between the QOL scores and somnographic values . In conclusion , quality of life improved significantly in the dental appliance and UPPP groups 1 year after intervention . However , the dental appliance group showed a lower level of contentment than the UPPP group , even though the somnographic values were superior in the former group The role of oral appliances in the routine treatment of obstructive sleep apnea ( OSA ) is not well defined . This prospect i ve study attempts to clarify the clinical role of a specific oral appliance , the m and ibular repositioning device ( MRD ) . This study evaluated the demographic , polysomnographic , and cephalometric radiographic findings predictive of treatment success or failure with the MRD .  Twenty-nine patients were diagnosed with mild to severe OSA by nocturnal polysomnography .  The majority of these patients were intolerant to nasal continuous positive airway pressure ( CPAP ) and all were fitted with a MRD . Twenty-three of these patients were compliant initially with MRD use and received post-treatment  nocturnal polysomnogrpahy  at a mean of 104 days after receiving the device . The respiratory disturbance index ( RDI ) decreased with MRD use ( 37 + /- 23 versus 18 + /- 20 events/hour , p < 0.001 ) , and 16 of the 23 patients ( 69 % ) were considered responders ( decrease in RDI > or = 50 % and posttreatment RDI < or = 20 ) . Measurements of subjective and objective daytime sleepiness , nocturnal oxygen desaturation , and snoring were all improved with MRD use . A pre-treatment RDI > 40 was present in four of the seven ( 67 % ) non-responders . Age , body mass index , and cephalometric radiographic measurements were not predictive of treatment outcome . Sixteen of 23 patients ( 70 % ) continue to use the MRD after 3.4 + /- 0.7 years . This study suggests that the MRD is useful in the long-term treatment of patients with OSA of mild to moderate severity BACKGROUND For the treatment of nonsevere obstructive sleep apnea syndrome ( OSAS ) , m and ibular advancement devices ( MADs ) are employed as an alternative to nasal continuous positive airway pressure ( CPAP ) therapy . However , very few specific data on the effectiveness of MADs in this group of patients are available . We therefore compared an individually adjustable intraoral sleep apnea device ( ISAD ) that permits movements of the lower jaw in three dimensions , with CPAP in the treatment of patients with an apnea/hypopnea index ( AHI ) < or = 30/h . METHODS In a r and omized crossover study , 16 men and 4 women ( mean + /- SD age , 56.5 + /- 10.2 years ; body mass index , 31.2 + /- 6.4 ; AHI , 17.5 + /- 7.7/h ) were treated for 6 weeks with each modality . RESULTS In the initial phase , a significant improvement in AHI ( baseline , 17.5 + /- 7.7/h ; ISAD , 10.5 + /- 7.5/h [ p < 0.05 ] ; CPAP , 3.5 + /- 2.9/h [ p < 0.01 ] ) and in breathing-related arousals ( baseline , 8.9 + /- 6.1/h ; ISAD , 3.7 + /- 3.3/h [ p < 0.01 ] ; CPAP , 1.4 + /- 1.6/h [ p < 0.01 ] ) was achieved with both modalities . Considering all 20 subjects , after 6 weeks of treatment , normalization of the respiratory parameters was seen only with CPAP . However , 30 % of the patients had a lasting reduction in AHI to < 10/h with the ISAD also . The patients considered the ISAD to be easier to use ( scale of 1 to 6 : ISAD , 1.8 + /- 1.1 ; CPAP , 3.1 + /- 1.5 [ p < 0.05 ] ) , and indicated greater utilization of the device in comparison with CPAP . CONCLUSION Even in patients with mild-to-moderate OSAS , CPAP is the more effective long-term treatment modality . In the individual case , the better compliance seen with the ISAD may be advantageous The efficacy of currently recommended treatments is uncertain in patients with mild to moderate obstructive sleep apnea ( apnea-hypopnea index [ AHI ] , 5 - 30 ) . A group of 114 sleep clinic patients with an AHI of 5 - 30 have participated in a r and omized controlled crossover trial of 3 months of treatment with each of nasal continuous positive airway pressure ( CPAP ) , a m and ibular advancement splint , and a placebo tablet . Outcomes were sleep fragmentation and hypoxemia , daytime sleepiness , quality of life , neurobehavioral function , and blood pressure . Both active treatments improved sleep outcomes , but positive airway pressure had a greater effect . The quality of life , symptoms , and subjective but not objective sleepiness improved to a similar degree with both treatments ; however , many of the improvements seen in neuropsychologic function and mood were not better than the placebo effect . Some aspects of nocturnal blood pressure were improved with the splint but not with CPAP . This study has shown that although both CPAP and m and ibular advancement splint effectively treated sleep-disordered breathing and sleepiness , the expected response in neurobehavioral function was incomplete . This may be due to the splint having a lesser therapeutic effect and CPAP being poorly tolerated and therefore used less in this patient group
BACKGROUND Obstructive sleep apnoea-hypopnoea is a syndrome characterised by recurrent episodes of partial or complete upper airway obstruction during sleep that are usually terminated by an arousal .
Nasal continuous positive airway pressure is the primary treatment for obstructive sleep apnoea-hypopnoea , but many patients are unable or unwilling to comply with this treatment .
Oral appliances are an alternative treatment for sleep apnoea .
OBJECTIVES The objective was to review the effects of oral appliance in the treatment of  sleep apnoea in adults .