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JID: PULMOE ARTICLE IN PRESS [mSP6P;July 13, 2024;2:30] Pulmonology 000 (xxxx) 1 11 w...

JID: PULMOE ARTICLE IN PRESS [mSP6P;July 13, 2024;2:30] Pulmonology 000 (xxxx) 1 11 www.journalpulmonology.org REVIEW Treatment of obstructive sleep apnea syndrome (OSAS) with mandibular advancement devices—A statement of the Portuguese society of pulmonology, the Portuguese society of stomatology and dental medicine, the Portuguese dental association, and the Portuguese society of temporomandibular disorders, orofacial pain and sleep
Mariz de Almeidaa,f,g, Gabriela Videirag,h, Susana Sousaa,b,c,*, Sílvia Correiad,e, Andre Ricardo Diasi,j, Susana Falardo Ramosk,l, Ju
lio Fonsecag,m a CUF Tejo Hospital, Lisbon, Portugal b CUF Descobertas Hospital, Lisbon, Portugal c Nova Medical School, Lisbon, Portugal d Hospital da Boa Nova, Matosinhos, Portugal e Hospital Privado de Braga, Braga, Portugal f ~o Interdisciplinar Egas Moniz (CiiEM), Egas Moniz School of Health and Science, Instituto Universita Centro de Investigaç a
rio Egas Moniz (IUEM), Almada, Portugal g Portuguese Society of Temporomandibular Disorders, Orofacial Pain and Sleep h Luz Lisbon Hospital, Lisbon, Portugal i Portuguese Society of Stomatology and Dental Medicine j Faculty of Medicine, University of Coimbra, Coimbra, Portugal k Portuguese Dental Association, Portugal l Universidade Cato
lica Portuguesa, Faculty of Dental Medicine, Centre for Interdisciplinary Research in Health, Viseu, Portugal m ORISCLINIC, Coimbra, Portugal Received 24 March 2023; accepted 27 May 2024 Available online xxx KEYWORDS Abstract With the purpose of establishing a consensus around clinical orientations for profes- Sleep breathing sionals involved in managing patients with sleep breathing disorders (SBD), an interdisciplinary disorders; group of scientific societies involved in this field discussed and reviewed all the published inter- Obstructive sleep national guidelines from the American Dental Association, American Academy of Sleep Medicine, apnea; American Academy of Dental Sleep Medicine and the European counterparts. Treatment of SBD * Corresponding author. E-mail address: [email protected] (S. Sousa). https://doi.org/10.1016/j.pulmoe.2024.05.006 2531-0437/© 2024 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC- ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: S. Sousa, S. Correia, A.M. de Almeida et al., Treatment of obstructive sleep apnea syndrome (OSAS) with mandibular advancement devices—A statement of the Portuguese society of pulmonology, the Portuguese society of stomatology and dental medicine, the Portuguese dental association, and the Portuguese society of JID: PULMOE ARTICLE IN PRESS [mSP6P;July 13, 2024;2:30] S. Sousa, S. Correia, A.M. de Almeida et al. Snoring; is multidisciplinary and should be made in concert with the patient, the sleep physician, and the Guidelines; qualified dentist to solve the individual, social, and economic burden of the disease,. This con- Oral appliance; sensus document represents the current thinking of a team of Portuguese experts on managing Mandibular advance- patients with SBD based on the available evidence. ment devices © 2024 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). Introduction available, depending on the case severity, patient compli- ance, and other factors subject to medical evaluation, such Snoring and obstructive sleep apnea (OSA) are common in as oral appliance therapy (OAT) with intraoral devices (OA) - clinical practice. Snoring is the sound caused by the vibra- custom-made and titrable - and surgery.7,17,18 tion of soft tissues of the upper airway and has an extremely OAs are indicated for patients with mild to moderate high prevalence in the general population, estimated to be OSA, with no comorbidities and primary snoring, and are around 40 % in adult men and 20 % in adult women.1 How- accepted as an alternative therapy for patients with severe ever, snoring is not only a sound problem; several studies OSA who do not respond to or are unable or unwilling to tol- associate it with damaging effects, namely erate positive airway pressure (PAP) therapies.19 atherosclerosis,2,3 and with nervous lesions on the upper air- The most effective OA are mandibular advancement devi- way muscles.4,5 Roncopathy is often associated with OSA, ces (MAD) that stabilize the lower jaw in a forward and and an objective measurement of snoring severity consti- downward position, maintaining airway patency during tutes a strong predictor for concomitant OSA after adjusting sleep.7,19 MAD were shown to decrease the frequency and/ for specific risk factors.6 or duration of apneas, hypopneas, respiratory effort-related OSA is a sleep-breathing disorder that involves complete arousals (RERA), and/or snoring events, as well as to or partial cessation of breathing while sleeping due to com- improve nocturnal oxygenation.19 They also reduce daytime plete or partial pharyngeal obstruction.7 9 If OSA is associ- sleepiness and improve quality of life measures in OSA, with ated with frequent arousal during sleep, excessive daytime a better adherence comparing to CPAP.7,20 sleepiness and other symptoms, it is termed OSA syndrome.8 There are some contraindications for MAD that include Epidemiological data suggests that, globally, 936 million severe periodontal disease, severe pre-existing temporo- adults between 30 and 69 years have mild to severe OSA and mandibular disorders (TMD), lack of adequate retention 425 million have moderate to severe OSA.10 The prevalence (inadequate dentition or implants), and severe gag reflex. of OSA in the United States adult population is estimated to Poor dexterity or hand function can also compromise device be around 12 %, with nearly 80 % of patients undiagnosed, handling.21 Despite these contraindications, depending on which represents a massive economic impact.11,12 Data from the status of the implants and adjoining tissues, MAD can be the HypnoLaus study from Switzerland, showed a prevalence used with implant patients without edentulous dental of moderate-to-severe sleep-disordered breathing of 23.4 % arches, or in unrehabilitated completely edentulous (95 % CI 20.9 26.0) in women and 49.7 % (46.6 52.8) in patients, considering the upper dental arch. men.13 When considering the prevalence of sleep apnea syn- Dilator muscles of the upper airway play a critical role in drome, i.e., OSA associated with symptoms, the prevalence maintaining an open airway during sleep.22 Therefore, exer- is considerably lower (43 cm in men, >40 cm in women), body mass index (BMI) >30 kg/m2, a Modified Mallampati score of 3 or 4, lateral The role of dentists peritonsillar narrowing, macroglossia, tonsillar hypertrophy, elongated/enlarged uvula, high arched/narrow hard palate According to the 2021 Oral Health Barometer, released by and nasal abnormalities.24 The presence of retrognathia the Portuguese Dental Association, it is estimated that 61 % and/or overjet should be noticed23.In some cases, the of Portuguese visit a dental doctor at least once a year for patient should be referred for an ear, nose, and throat evalu- professional oral hygiene procedures or other therapies,17,25 ation.23 When OA can be indicated, it should be noticed that in accordance with the published data. These conditions set the number of teeth included in the appliance framework dentists in an ideal position to perform OSA screening. can compromise the retention and efficacy of the device or A medical dentist can participate in screening, treating, even the loss of teeth in the future.23 Also, the location and and managing adults with SBD7,17,18,23,26 and can provide a morphological integrity of teeth and periodontal health more streamlined and cost-effective model of care.18,23 Spe- should be accessed to orientate OA selection. TMD and oro- cial training or experience is required to deliver informed facial pain should be screened. Occlusal analysis and intrao- care. Dentists should be educated according to the AADSM- ral and extraoral photographs are mandatory and defined requirements to be a “Qualified Dentist” in dental recommended to access any future variations. A retro- sleep medicine.7 AADSM advocates that dentists should gnathic mandible, shorter soft palate, and low positioning of have a valid state license and proof of liability coverage and hyoid bone have all been associated with favorable out- possess additional training or experience in this area comes. However, these associations are weak and, again, of care.7 Dentists should use objective data according to cannot be relied on for clinical decision-making.21 A cepha- their scope of practice and as defined by their state dental lometric evaluation is not always required for patients who practice acts.27 will use an OA, although it is recognized that appropriately In Portugal, the competence in dental sleep medicine was trained professionals should perform this examination.24 framed in December 2021 in the Regulation Document for This evaluation is considered as an option, and not as a Sectorial Competences.28 However, the specific criteria to guideline, for physical examination.32 be recognized as a dentist qualified in dental sleep medicine in Portugal are not well defined yet. SBD diagnosis Screening SBD diagnosis should always be made in a multidisciplinary team including the qualified dentist, the sleep unit and the When faced with a patient with snoring, the dentist must sleep doctor, as recommended by the international guide- investigate whether it is isolated snoring or associated with lines. As for screening the role of dentists, family doctors, other symptoms that suggest sleep-related respiratory pulmonologists and ear nose throat (ENT) doctors as well pathology.19,23,29 Dentists should screen patients for SBD, as others healthcare professionals that compose the multi- starting with the partner’s perception of both sleep and disciplinary seep team including the qualified dentist, the awake symptoms (snoring, witnessed apneas, gasping, sleep- sleep unit and the sleep doctor, as recommended by the iness) and by evaluating the upper airway.23,26 Clinical international guidelines.24 3 JID: PULMOE ARTICLE IN PRESS [mSP6P;July 13, 2024;2:30] S. Sousa, S. Correia, A.M. de Almeida et al. Overnight polysomnography (PSG) or a home sleep apnea severe symptomatic OSA (OSA syndrome) is CPAP therapy, test (HSAT) should be prescribed, aimed at collecting objec- considered the gold-standard treatment.18,37 This therapy tive data to determine if the patient suffers from an SBD. should be used considering OSA risk factors and, therefore HSAT portable monitors may be indicated for the diagnosis regarding behavioral and positional therapies.37,38 of OSA in patients for whom in-laboratory PSG is not avail- Behavioral treatment options include weight loss, ideally able or possible due to immobility, safety, or critical ill- to a BMI of 25 kg/m2 or less; weight reduction surgery in ness.32 Sleep tests can be divided into four types:32 selected cases; physical exercise; positional therapy when Type 1: in laboratory full attended PSG ( 7 channels) in a indicated; and avoidance of alcohol and sedatives before laboratory setting bedtime.24,37 The patient should be aware that weight Type 2: ambulatory full unattended PSG ( 7 channels) reduction in obese patients with OSA is associated with a Type 3 (HSAT): limited channel devices (usually using 4 7 trend of improvement in breathing pattern, quality of sleep channels) and daytime sleepiness, and that is recommended to reduce Type 4: 1 or 2 channels usually using oximetry as one of these important risk factors.16,24 the parameters Supine position can also affect airway size and patency A PSG (type 1 or 2) uses a 7 channel minimum recording with a decrease in the area of the upper airway, particularly system with an electroencephalogram (EEG), electrooculo- in the lateral dimension.24 Positional therapy can be initi- gram (EOG), chin electromyogram, airflow, oxygen satura- ated by positioning devices (e.g., alarm, pillow, backpack, tion, respiratory effort, and electrocardiogram (ECG) or tennis ball) and keeping the patient in a non-supine position, heart rate.24 A type 3 HSAT includes, at a minimum, the with better patency, which can improve AHI.32,37 record of airflow, respiratory effort, and blood oxygenation. In selected adult patients, hypoglossal nerve stimulation The type of biosensors used to monitor these parameters for and myofunctional therapy can be considered for specific in-laboratory PSG are also recommended to use in type 3 cases seeking alternative treatments, although both consti- HSAT and include an oronasal thermal sensor to detect tute conditional recommendations.37 apnea, a nasal pressure transducer to measure hypopneas, Videotapes, handouts, websites, and brochures can be oximetry, and, if possible, calibrated or uncalibrated induc- used as resources for patient education.24 Medical treat- tance plethysmography for respiratory effort.24 ment of ENT diseases with pharmacological treatment PSG can provide the Apnea Hypopnea Index (AHI) and should also be considered. respiratory disturbance index (RDI). AHI can be fixed as the For specific cases, other treatment options include sur- number of apnea and hypopneas per hour of sleep.7 RDI gery, such as maxillofacial surgery (maxillo-mandibular measures the number of apnea, hypopneas and RERA.33 The advancement) or otolaryngologic surgery.23,26,39 severity of OSA can be determined using the AHI: mild OSA Treatment options should always be discussed by a multi- (5AHI