Skip to main content

Advertisement

SpringerLink
Log in

A mandibular advancement device associated with lingual control: a new treatment option for obstructive sleep apnea?

  • Sleep Breathing Physiology and Disorders • Original Article
  • Published:
Sleep and Breathing Aims and scope Submit manuscript

Abstract

Purpose

Oral appliances (OA) have become the main alternative to positive pressure airway devices (PAP) for the control of obstructive sleep apnea (OSA). Despite literature support, controversies about the mode of action and the effectiveness of these devices persist. The aim of this study was to evaluate the efficacy of modified mandibular advancement devices (MAD) in patients with OSA who failed treatment with MAD and to evaluate the role of the tongue as a factor in patients who failed treatment with MAD.

Materials and methods

Patients unable to control the apnea-hypopnea index (AHI) using a MAD were subsequently treated with a modified version that included a tongue trimming accessory. The objective was to stabilize the tongue by preventing it from sliding with the consequent collapse of the upper airway (UA). New polysomnography (PSG) was performed with the modified MAD in place.

Results

A total of 20 patients who failed MAD therapy were studied including 15 men (75%) with mean age (± standard deviation) of 58.5 ± 13.1 years and BMI 29.6 ± 5.0 Kg/m2. After installing the tongue trimmer, the number of patients who achieved complete success with the new MAD (AHI < 5) went from 0 to 30% and those who achieved partial success (5 < AHI < 10) went from 0 to 20%. The number of patient responders (AHI reduced by at least 50%) went from 20 to 75%.

Conclusion

The results suggest that the tongue, even in the presence of a MAD, may be one of the contributing factors for the collapse of the UA and consequent device ineffectiveness. By stabilizing the tongue through the insertion of a tongue trimmer, the MAD became more effective in many cases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

The data that support the findings of this study are available on request from the corresponding author (MLRG).

References

  1. Vanek J, Prasko J, Genzor S, Ociskova M, Kantor K, Holubova M, Slepecky M, Nesnidal V, Kolek A, Sova M (2020) Obstructive sleep apnea, depression and cognitive impairment. Sleep Med 72:50–58. https://doi.org/10.1016/j.sleep.2020.03.017

    Article  PubMed  Google Scholar 

  2. Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T, American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, American Heart Association Stroke Council, American Heart Association Council on Cardiovascular Nursing, American College of Cardiology Foundation (2008) Sleep apnea and cardiovascular disease: an American Heart Association/American College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation 118(10):1080–1111. https://doi.org/10.1161/CIRCULATIONAHA.107.189375

    Article  PubMed  Google Scholar 

  3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328(17):1230–5. https://doi.org/10.1056/NEJM199304293281704

    Article  CAS  PubMed  Google Scholar 

  4. Hafner M, Stepanek M, Taylor J, Troxel WM, van Stolk C (2017) Why sleep matters: the economic costs of insufficient sleep: a cross-country comparative analysis. Rand Health Q 6(4):11

    PubMed  PubMed Central  Google Scholar 

  5. Narciso FV, Mello MT (2017) Safety and health of professional drivers who drive on Brazilian highways. Rev Saude Publica 51:26. https://doi.org/10.1590/S1518-8787.2017051006761

    Article  PubMed  PubMed Central  Google Scholar 

  6. Benjafield AV, Ayas NT, Eastwood PR, Heinzer R, Ip MSM, Morrell MJ, Nunez CM, Patel SR, Penzel T, Pépin JL, Peppard PE, Sinha S, Tufik S, Valentine K, Malhotra A (2019) Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med 8:687–698. https://doi.org/10.1016/S2213-2600(19)30198-5

    Article  Google Scholar 

  7. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD (2015) Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 11(7):773–827. https://doi.org/10.5664/jcsm.4858

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ng JH (2019) Yow M Oral appliances in the management of obstructive sleep apnea. Sleep Med Clin 14(1):109–118. https://doi.org/10.1016/j.jsmc.2018.10.012

    Article  PubMed  Google Scholar 

  9. Scherr SC, Dort LC, Almeida FR, Bennett KM, Blumenstock NT, Demko BG, Essick GK, Katz SG, McLornan PM, Phillips KS, Prehn RS, Rogers RR, Schell TG, Sheats RD, Sreshta FP (2014) Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep Medicine. J Dent Sleep Med 1(1):39–50

    Google Scholar 

  10. Sutherland K, Deane SA, Chan AS, Schwab RJ, Ng AT, Darendeliler MA, Cistulli PA (2011) Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea. Sleep 34(4):469–77. https://doi.org/10.1093/sleep/34.4.469

    Article  PubMed  PubMed Central  Google Scholar 

  11. Brown EC, Cheng S, McKenzie DK, Butler JE, Gandevia SC, Bilston LE (2015) Tongue stiffness is lower in patients with obstructive sleep apnea during wakefulness compared with matched control subjects. Sleep 38(4):537–44. https://doi.org/10.5665/sleep.4566

    Article  PubMed  PubMed Central  Google Scholar 

  12. Wang W, Di C, Mona S, Wang L, Hans M (2018) Tongue function: an underrecognized component in the treatment of obstructive sleep apnea with mandibular repositioning appliance. Can Respir J 6(2018):2157974. https://doi.org/10.1155/2018/2157974

    Article  Google Scholar 

  13. Brown EC, Cheng S, McKenzie DK, Butler JE, Gandevia SC, Bilston LE (2013) Tongue and lateral upper airway movement with mandibular advancement. Sleep 36(3):397–404. https://doi.org/10.5665/sleep.2458

    Article  PubMed  PubMed Central  Google Scholar 

  14. Mediano O, Romero-Peralta S, Resano P, Cano-Pumarega I, Sánchez-de-la-Torre M, Castillo-García M, Martínez-Sánchez AB, Ortigado A, García-Río F (2019) Obstructive sleep apnea: emerging treatments targeting the genioglossus muscle. J Clin Med 8(10):1754. https://doi.org/10.3390/jcm8101754

    Article  PubMed  PubMed Central  Google Scholar 

  15. Caram JM, de Quintela MM (2013) A órtese lingual - uma nova proposta de aparelho intraoral para apneia do sono grave – relato de casos / The lingual orthosis - a new proposed oral appliance for severe sleep apnea - case reports. Ortho Sci Orthod Sci Pract 6(21):110–117

    Google Scholar 

  16. Berry RB, Brooks R, Gamaldo CE, Harding SM, Lloyd RM, Marcus CL, Vaughn BV (2015) For the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, Version 2.2. Darien, Illinois: American Academy of Sleep Medicine. www.aasmnet.org

  17. de LourdesRabeloGuimarães M, Hermont AP, de Azevedo PG, Bastos PL, de Oliveira MTP, de Melo IM, Ottoboni GS, Vedolin G, Caram JM (2018) Severe obstructive sleep apnea treatment with oral appliance: the impact on obstructive, central and mixed events. Sleep Breath 22(1):91–98. https://doi.org/10.1007/s11325-017-1535-0

    Article  Google Scholar 

  18. Okuno K, Furuhashi A, Nakamura S, Suzuki H, Arisaka T, Taga H, Tamura M, Katahira H, Furuhata M, Iida C (2020) The success rate of oral appliances based on multiple criteria according to obstructive sleep apnoea severity, BMI and age: a large multicentre study. J Oral Rehabil 47(9):1178–1183. https://doi.org/10.1111/joor.13046

    Article  PubMed  Google Scholar 

  19. Zar HJ (2009) Biostatistical Analysis. 947f, p. 72–74, 103, 220–224, 277–280. 5ª ed. Pearson, New Jersey

  20. De Corso E, Bastanza G, Della Marca G, Grippaudo C, Rizzotto G, Marchese MR, Fiorita A, Sergi B, Meucci D, Di Nardo W, Paludetti G, Scarano E (2015) Drug-induced sleep endoscopy as a selection tool for mandibular advancement therapy by oral device in patients with mild to moderate obstructive sleep apnoea. Acta Otorhinolaryngol Ital 35(6):426–432. https://doi.org/10.14639/0392-100X-959

    Article  PubMed  Google Scholar 

  21. Marques M, Genta PR, Azarbarzin A, Taranto-Montemurro L, Messineo L, Hess LB, Demko G, White DP, Sands SA, Wellman A (2019) Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea. J Physiol 597(22):5399–5410. https://doi.org/10.1113/JP278164

    Article  CAS  PubMed  Google Scholar 

  22. Turek G (2019) A novel device for passive restraint of the tongue as an adjunct to mandibular advancement therapy in incomplete responders. J Dent Sleep Med 6(2)

  23. Dort L, Remmers J (2012) A combination appliance for obstructive sleep apnea: the effectiveness of mandibular advancement and tongue retention. J Clin Sleep Med 8(3):265–269. https://doi.org/10.5664/jcsm.1910

    Article  PubMed  PubMed Central  Google Scholar 

  24. Edwards BA, Eckert DJ, Jordan AS (2017) Obstructive sleep apnoea pathogenesis from mild to severe: is it all the same? Respirology 22(1):33–42. https://doi.org/10.1111/resp.12913

    Article  PubMed  Google Scholar 

  25. Van der Wal RJ (2007) Treatment of patients with sleep disorders as snoring and obstructive apnea-hypopnea by a palatum molle supporting tongue retaining device: study of efficacy and patient comfort

  26. Singh GD, Keropian B, Pillar G (2009) Effects of the full breath solution appliance for the treatment of obstructive sleep apnea: a preliminary study. Cranio 27(2):109–117. https://doi.org/10.1179/crn.2009.017

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery and Ophthalmology, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

    Jorge Machado Caram & Vivian Resende

  2. Center for Technology in Molecular Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Benvinda de Carvalho, 105/101, Santo Antônio, Belo Horizonte, Minas Gerais, 30330-180, Brazil

    Maria de Lourdes Rabelo Guimarães & Pedro Guimarães de Azevedo

  3. Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

    Ana Luiza Cosme Silva

Authors
  1. Jorge Machado Caram
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Maria de Lourdes Rabelo Guimarães
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pedro Guimarães de Azevedo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ana Luiza Cosme Silva
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vivian Resende
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Maria de Lourdes Rabelo Guimarães.

Ethics declarations

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Caram, J.M., Guimarães, M.R., de Azevedo, P.G. et al. A mandibular advancement device associated with lingual control: a new treatment option for obstructive sleep apnea?. Sleep Breath (2023). https://doi.org/10.1007/s11325-023-02938-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11325-023-02938-6

Keywords

Search

Navigation