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and other cardiovascular outcomes, however, longterm evidence-based studies are required in this
respect. In a randomized controlled study, snoring
frequency and intensity reduced substantially;
snoring frequency reduced by 40 to 60% and
mean reduction of snoring intensity was 3 decibels.20
Factors in Oral
Appliance Therapy Success
Four factors are attributed to oral appliance effectiveness but the extent to which each factor is
involved is unclear: (1) mild to moderate OSA
severity (AHI 30), (2) large mandibular advancement, (3) supine AHI, and (4) low body
mass index (BMI). Patients with lower values in
baseline AHI and have greater supine than lateral AHI readings demonstrate better outcomes
with oral appliance use. Optimal AHI reductions
with oral appliances are variable in patients with
severe OSA (AHI 30). Fourteen-61% of severe
OSA cases compared with 57-81% of patients
with mild-to-moderate OSA were successfully
treated (AHI 5). There is no significant difference in efficacy with greater or lesser vertical mandibular opening in reducing AHI. Similarly, differences in efficacy of 1-piece or
2-piece mandibular advancement splints were
not demonstrated. A small proportion of patients developed increased AHI after shortterm (6 weeks) and long-term (4 years) use of
oral appliances.21,22 Follow-up sleep studies
are recommended to detect suboptimal reductions of AHI for OSA patients treated with oral
appliances.
Methods for determining treatment predictors and the effective amount of mandibular
advancement for optimal AHI reduction include
sleep nasoendoscopy and overnight polysomnographic titration with remote-controlled mandibular advancement of oral appliances. Sleep
nasoendoscopy identifies the level of and the degree
of obstruction when the patient is asleep. Obstructions are classified as palatal, multilevel, or tonguebased with a grading system: Grade 1palatal snoring; Grade 2palatal level obstruction; Grade
3multisegmental involvement with intermittent
oro- and hypopharyngeal collapse; Grade
4sustained multilevel collapse; and Grade
5tongue base obstruction. Patients with Grade 5 or
tongue base obstruction are likely to benefit from
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patients reported gingival soreness. Temporomandibular joint discomfort and noises were experienced by 12.5-33% of patients, and 12.5% reported headaches and bruxism.
Changes in occlusion are commonly reported
in the first few hours of waking. These changes are
transient and disappear with use. Long-term side
effects develop after 6 to 30 months of treatment
with oral appliances. Intraoral changes affect the
occlusion and positions of teeth: overjet and overbite reduced (mean 1-3 mm) with retroclination
of upper incisors (mean 1.9) and proclination
of lower incisors (mean 2.8).
Long-term users may experience dislodged or
fractured fillings, cracked or fractured teeth and
periodontal disease with mobile teeth. Skeletal
changes affect the mandible; it is relocated downwards and forwards, with increased lower anterior
face height. The occurrence of skeletal changes is
largely attributed to a greater mandibular advancement.30-33
Patient-Reported
Outcomes, Tolerance, and Compliance
In this study,19 it was reported that nCPAP and
oral appliance therapy as were effective in reducing subjective daytime sleepiness (EES). However,
there was no improvement in maintenance of
wakefulness test for both nCPAP and oral appliance treatment groups.
Compared with a placebo appliance, the oral
appliance improved quality of life for OSA patients measured by the FOSQ in mean score and
social outcome domain. nCPAP treatment improved overall score and activity level of the
FOSQ as well as mean score and well-being as
assessed by the Medical Outcomes Study Short
Form-36 (SF-36).
Patient-groups using the 1-piece or 2-piece
oral appliance indicated a preference for the
1-piece appliance.34 The compliant patient-population decreased to 82% after a year and to
62% after 4 years of oral appliance use.35 Compliance with patients using oral appliances with
either tongue retaining or soft palate lifting
components is even lower because of poor tolerance. Some factors need to be studied in order
to foster optimal long-term compliance; they are
appliance design, side-effects from oral appliance usage, attenuation in efficacy of treatment
over time, frequency and types of follow-up pro-
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Acknowledgments
The author thanks Dr. C.T. Kwa and Dr. Eric K.W. Lye for their
constructive suggestions in the preparation of this article. Special thanks are also due to Ms Roslinda bte Sabani for her
efficiency and help in sourcing the reference material.
References
1. Robin P: Glossoptosis due to atresia and hypotrophy of
the mandible. Am J Dis Child 48:541-547, 1934
2. Graber TM, Rakosi T, Petrovic AG (eds): Dentofacial
Orthopedics with Functional Appliances. St. Louis, CV
Mosby Company, 1985
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