Skip to main content

Advertisement

SpringerLink
Log in

Efficacy of Oral Appliance Therapy in the Treatment of Severe OSA in CPAP-Resistant Cases

  • Original Article
  • Published:
Sleep and Vigilance Aims and scope Submit manuscript

Abstract

Purposes

Continuous positive airway pressure (CPAP) is the current standard of care for the treatment of obstructive sleep apnea (OSA). It is known that there is a low rate of adherence in many patients. Oral appliance therapy (OAT) is effective in patients with mild-to-moderate OSA. The efficacy of OAT in severe patients is unknown. The aim of this study is to evaluate treatment using an in-laboratory titration method to determine whether OAT might be appropriate for patients with severe OSA.

Methods

This is an IRB approved, retrospective study of 41 adults (mean age 51 years; 73% male) with severe OSA who were intolerant of CPAP therapy. All patients were treated with OAT (OASYS Oral–Nasal Airway System™). The sample was sub-divided into severe [Apnea–Hypopnea Index (AHI > 30 < 50)] and very severe (AHI > 50) groups. Informed consent was obtained from all patients included in the study. The device was custom fit by a dentist. After patients reported subjective symptom improvement, titration polysomnography was performed. If obstructive events were still noted after 90 min of the sleep study, an attending sleep technologist titrated the device in vivo in 1 mm increments for a maximum of 3 mm to optimize effectiveness.

Results

For severe cases, almost half (46%) were resolved with a post-treatment AHI < 5, while two-thirds (66%) had an AHI < 10. For very severe cases, 43% were resolved with a post-treatment AHI < 5, while 64% had an AHI < 10. All findings were statistically significant (p < 0.001).

Conclusions

This preliminary study supports the notion that oral appliance therapy using the OASYS Oral–Nasal Airway System™ may be effective in severe cases of OSA.

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
Fig. 5

Similar content being viewed by others

Abbreviations

AHI:

Apnea–Hypopnea Index

AASM:

American academy of sleep medicine

BMI:

Body mass index

CPAP:

Continuous positive airway pressure

ENT:

Ear nose throat

ECG:

Electrocardiogram

EEG:

Electroencephalogram

EMG:

Electromyography

EOG:

Electrooculogram

FDA:

Food and drug administration

OSA:

Obstructive sleep apnea

OAT:

Oral appliance therapy

PSG:

Polysomnography

REM:

Rapid eye movement

RDI:

Respiratory distress index

References

  1. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136–43.

    Article  Google Scholar 

  2. Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population—a review on the epidemiology of sleep apnea. J Thorac Dis. 2015;7(8):1311–22.

    PubMed  PubMed Central  Google Scholar 

  3. Garvey JF, Pengo MF, Drakatos P, Kent BD. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis. 2015;7(5):920–9.

    PubMed  PubMed Central  Google Scholar 

  4. Martinez D, Klien C, Rahmeier L, et al. Sleep apnea is a stronger predictor for coronary heart disease than traditional risk factors. Sleep Breath. 2012;16:695–701.

    Article  Google Scholar 

  5. Dimitri H, Ng M, Brooks AF, et al. Atrial remodeling in obstructive sleep apnea and the risk of sudden cardiac death. Heart Rhythm. 2012;9:321–7.

    Article  Google Scholar 

  6. Gami AS, Olson EJ, Shen WK, et al. Obstructive sleep apnea and the risk of sudden cardiac death. J Am Coll Cardiol. 2013;62:610–6.

    Article  Google Scholar 

  7. Aronsohn RS, Whitmore H, Vauter EV, et al. impact of untreated obstructive sleep apnea on glucose control in type 2 diabetes. Am J Respirt Crit Care Med. 2010;181(5):507–13.

    Article  Google Scholar 

  8. Vgontzas AN, Papanicolaou DA, Bixler EO, et al. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, hypercytokinemia. J Clin Endocrinol Metab. 2000;85:1151–8.

    Article  CAS  Google Scholar 

  9. Redline S, Yenokyan G, Gottlieb DJ, et al. Obstructive sleep apnea-hypopnea and incident stroke. Am J Respir Crit Care Med. 2017;182:269–77.

    Article  Google Scholar 

  10. Doff MHJ, Hoekema A, Wijkstra PJ, et al. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep. 2013;36:1289–96.

    Article  Google Scholar 

  11. Karatayli-Ozgursoy S, Demireller A. Hyoid suspension surgery with UPPP for the treatment of hypopharyngeal airway obstruction in obstructive sleep apnea. Ear Nose Throat J. 2012;91:358–64.

    PubMed  Google Scholar 

  12. Hochban W, Brandendurg U, Peter JH. Surgical treatment of obstructive sleep apnea by maxillomandibular advancement. Sleep. 1994;17:624–9.

    Article  CAS  Google Scholar 

  13. Engleman HM, Asgari-Jirhandeh N, McLeod AL, et al. Self-reported use of CPAP and benefits of CPAP therapy. A patient survey. Chest. 1996;109:1470–6.

    Article  CAS  Google Scholar 

  14. Reeves-Hoché MK, Meck R, Zwillich CW. Nasal CPAP: an objective evaluation of patient compliance. Am J Respir Crit Care Med. 1994;149:149–54.

    Article  Google Scholar 

  15. Kribbs NB, Pack AI, Kline LR, et al. Effects of one night without nasal CPAP treatment on sleep and sleepiness in patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147:1162–8.

    Article  CAS  Google Scholar 

  16. Hussain SF, Irfan M, Waheed Z, et al. Compliance with continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea among privately paying patients—a cross sectional study. BMC Pulm Med. 2014;14:188. https://doi.org/10.1186/1471-2466-14-188.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Singh GD, Abramson M. Effect of an intra-oral nasal dilation appliance on 3-D nasal airway morphology in adults. Sleep Breath. 2008;12(1):69–75.

    Article  Google Scholar 

  18. Hoekema A, Stegena B, Wijkstra PJ, et al. Obstructive sleep apnea therapy. J Den Res. 2008;87:882–7.

    Article  CAS  Google Scholar 

  19. Almeida FR, Parker JA, Hodges JS, et al. Effect of a titration polysomnogram on treatment of success with a mandibular repositioning appliance. J Clin Sleep Med. 2009;5:198–204.

    PubMed  PubMed Central  Google Scholar 

  20. Holley AB, Lettieri CJ, Shah AA. Efficacy of an adjustable oral appliance and comparison with continuous positive airway pressure for the treatment of obstructive sleep apnea syndrome. Chest. 2011;140:1511–6.

    Article  Google Scholar 

  21. Berry RB, Brooks R, Gamaldo CE et al; for the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, scoring manual version 2.4. American Academy of Sleep Medicine;2017.

  22. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Dent Sleep Med. 2015;2(3):71–125.

    Google Scholar 

  23. American Sleep Disorders Association. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Sleep. 1995;18:511–3.

    Article  Google Scholar 

  24. Gulati A, Oscroft N, Chadwick R, Ali M, Smith I. The impact of changing people with sleep apnea using CPAP less than 4 h per night to a bi-level device. Respir Med. 2015;109(6):778–83.

    Article  Google Scholar 

  25. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244–62.

    Article  Google Scholar 

  26. Singh GD, Griffin TM, Cress SE. Biomimetic oral appliance therapy in adults with severe obstructive sleep apnea. J Sleep Disord Ther. 2016;5:1–5.

    Google Scholar 

  27. Kushida CA, Morgenthaler TI, Littner MR, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006;29:240–3.

    Article  Google Scholar 

  28. Liu Y, Lowe AA. Factors related to the efficacy of an adjustable oral appliance for the treatment of obstructive sleep apnea. Chin J Dent Res. 2000;3:15–23.

    CAS  PubMed  Google Scholar 

  29. Otsuka R, Almeida FR, Lowe AA, Ryan F. A comparison of responders and nonresponders to oral appliance therapy for the treatment of obstructive sleep apnea. Am J Orthod Dentofac Orthop. 2006;129:222–9.

    Article  Google Scholar 

  30. Hoffstein V. Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath. 2007;11:1–22.

    Article  Google Scholar 

  31. Ozturk O, Tuna SH, Hayri U. The efficacy of oral appliance in patients with severe obstructive sleep apnea: a cohort study. Oral Dis. 2015;21:386–92.

    Article  Google Scholar 

  32. Haviv Y, Bachar G, Aframian DJ, et al. A 2-year mean follow-up of oral appliance therapy for severe obstructive sleep apnea: a cohort study. Oral Dis. 2015;21:386–92.

    Article  CAS  Google Scholar 

  33. Vasdev S, Gill VD, Singal PK. Modulation of oxidative stress-induced changes in hypertension and atherosclerosis by antioxidants. Exp Clin Cardiol. 2006;11(3):206–16.

    CAS  PubMed  PubMed Central  Google Scholar 

  34. Kattoor AJ, Pothineni NVK, Palagiri D, Mehta JL. oxidative stress in atherosclerosis. Curr Atheroscler Rep. 2017;19(11):42. https://doi.org/10.1007/s11883-017-0678-6.

    Article  CAS  PubMed  Google Scholar 

  35. Jezovnik MK, Poredos P. Oxidative stress and atherosclerosis. E-journal Cardio Practice. [Internet]. 2007 [cited 2018 Feb 1];6(6). https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-6/Oxidative-stress-and-atherosclerosis-Title-Oxidative-stress-and-atheroscleros.

  36. Fukuda T, Tsuiki S, Kobayashi M, et al. Selection of response criteria affects the success rate of oral appliance treatment for obstructive sleep apnea. Sleep Med. 2014;15:367–70.

    Article  Google Scholar 

Download references

Acknowledgements

The authors are indebted to Richa Shrivastava, BS for statistical analysis; Dennis Bashaw, MLIS and G. Dave Singh, DMD PhD DDSc for manuscript preparation.

Author information

Authors and Affiliations

  1. SJGH Sleep Center, ACGME Accredited Sleep Medicine Fellowship Program UC Davis School of Medicine, San Joaquin General Hospital, 500 W. Hospital Road, French Camp, CA, 95231, USA

    Deepak Shrivastava & Vikrum Jain

  2. Sleep Dynamics – Center for Diagnosis of Sleep Disorders – An AASM Accredited Center, Neptune City, NJ, 07753, USA

    John K. Bixby, Douglas S. Livornese, Felix Urena & Michael J. Bixby

Authors
  1. Deepak Shrivastava
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. John K. Bixby
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Douglas S. Livornese
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Felix Urena
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael J. Bixby
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Vikrum Jain
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Deepak Shrivastava.

Ethics declarations

Conflict of interest

This study did not receive any intra- or extramural financial support. There is no conflict of interest, off label or investigational use of any product or service discussed in this article.

Additional information

Drs. John and Michael Bixby performed all the clinical work. All post-treatment sleep studies were performed at Sleep Dynamics—Center for Diagnosis of Sleep Disorders—An AASM Accredited Center. 2240 State Highway 33, Suite 114, Neptune City, NJ 07753.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shrivastava, D., Bixby, J.K., Livornese, D.S. et al. Efficacy of Oral Appliance Therapy in the Treatment of Severe OSA in CPAP-Resistant Cases. Sleep Vigilance 2, 119–125 (2018). https://doi.org/10.1007/s41782-018-0044-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s41782-018-0044-y

Keywords

Search

Navigation