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Obstructive Sleep Apnea
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Watermark Medical (ARES™)
Assessing Treatment Outcomes:

In-Home Evaluation of Efficacy and Titration of a Mandibular Advancement Device for Obstructive Sleep Apnea;
Levendowski D, Morgan T, Patrickus J, et al. Sleep Breath 2007 11(3):139-147.

In a study of 30 patients (25 being CPAP failures) mandibular advancement devices (MAD) provided a 96% efficacy, reducing the AHI by at least 50% and in most cases reduced the AHI below 10 events/hour.

Impact of Time on the Treatment Efficacy of Mandibular Repositioning Devices (MRD).
Levendowski D, Morgan T, Montague J et al. Sleep 2009 32: 203.

Twenty-patients completed ARES sleep studies pre-treatment and at one-, two- three- and six-months subsequent to initiation of MRD therapy. Repeated ANOVA found a significant reduction in both AHI and RDI as a result of therapy, paired t-tests found no differences in the sleep disordered breathing (SDB) measures across treatment time points. No significant difference in the percent of time snoring pre- or post-treatment suggested it is not a reliable measure for assessing efficacious MRD outcomes.

Benefit of Mandibular Repositioning Device (MRD) Therapy in Patients with Moderate and Severe OSA.
Levendowski D, Morgan T, Melzer V et al. Sleep 2009 32:203.

Fifty-nine patients identified with Moderate (AHI 15-29) or Severe (AHI > 30) OSA based on an ARES in-home sleep study were retested to assess outcomes as a result of MRD therapy. Based on an AHI reduction > 50%, 83% of the moderate and 96% of the severe OSA patients received an efficacious outcome. The percent of time SpO2 < 90% was significantly reduced in both severity groups. Post-treatment changes in Epworth Scores, and Beck Depression and Comfort and Efficacy Indexes as well as the number of patients with normalized Epworth and Beck Depression scores resulting from therapy were significant.

Predicting Changes in AHI Resulting from Mandibular Repositioning Device Therapy.
Gagne R, Levendowski D, Scarfeo D, Westbrook P. Sleep Breath 2009, in-press.

A comparison was made between pre- and post-treatment AHI and RDI values from 84 males and 38 females treated with a Tap or Herbst oral appliance. There is a strong positional component associated with the pre-treatment AHI and RDI and the overall post-treatment values. Neck size and Epworth scores for females were associated with the post-treatment values but not with males. The pre-treatment supine AHI and RDI were correlated with post-treatment values in males but not females, however the ratio between the supine and non-supine AHI was alternatively predictive only in females. A simple equation (divide the pre-treatment AHI by 5 and add 2) correctly predicted the post-treatment AHI resulting from MRD therapy within + 6 event/hour in 89% of the 122 cases.

Predicted Prevalence of OSA in a Population of Dental Patients Undergoing Moderate Sedation Compared to a Cohort of General Dentistry Patients.
Gagne R, Levendowski D, Scarfeo D, Westbrook P. Sleep Breath 2009, in-press.

A study of 98 consecutive cases found that females constituted a greater percentage of those who under parenteral sedation (62% vs. 38% for males). The prevalence of predicted OSA using the ARES Screener in the female sedation patient group was 46%, more than 60% greater than a comparable female cohort from a general dentistry population. None of the ‘at-risk’ sedation females had been previously diagnosed with OSA. There was no difference in the predicted OSA prevalence in sedation vs. general dentistry males (>60%). The estimated prevalence in both females and males suggests that parenteral sedation practitioners should be aware of OSA prevalence and consider screening for OSA as a normal part of their pre-sedation work-up.

Assessing Change in OSA Severity During a Non-Treatment Wash-Out Period
Levendowski D, Morgan T, Popovic D et al. Sleep Breath 2009, in-press.

Seventeen males and eight females, having completed three months of Mandibular Repositioning Device Therapy, were enrolled in a follow-up study to assess the change in AHI and RDI resulting from treatment with custom made Tap III appliance. Two lower trays were fabricated to provide either 7mm or 10mm VDO with approximately the same mandibular advancement. For males, the AHI and RDI trended toward improved efficacy or no change with increased VDO (94% and 84% respectively). With females, the opposite occurred with 100% showing an increase in AHI and RDI or no change as a result of 10mm VDO.

Assessing Changes in the AHI Resulting from Increased Vertical Dimension of Occlusion (VDO) of Mandibular Repositioning Devices.
Levendowski D, Popovic D, Morgan T et al. Sleep Breath 2009, in-press.

Seventeen males and eight females, having completed three months of Mandibular Repositioning Device Therapy, were enrolled in a follow-up study to assess the change in AHI and RDI resulting from treatment with custom made Tap III appliance. Two lower trays were fabricated to provide either 7mm or 10mm VDO with approximately the same mandibular advancement. For males, the AHI and RDI trended toward improved efficacy or no change with increased VDO (94% and 84% respectively). With females, the opposite occurred with 100% showing an increase in AHI and RDI or no change as a result of 10mm VDO.

Factors Impacting Mandibular Repositioning Device Therapy at One-Month.
Morgan T, Montague J, Melzer V et al. Sleep Breath 2009, in-press

A dentist with 18-years experience fitted 20 patients with a Tap III and 26 patients with a Herbst oral appliance. A dentist with no prior experience in dental sleep medicine fitted 46 patients with the Tap III and using the expert’s training manual. No differences in treatment efficacy were noted between the Tap III and the Herbst oral appliances or between a novice and expert dentist based on the AHI values. With a more subtle measure of sleep disordered breathing the TAP provided improved efficacy compared to the Herbst. The study showed that more consistent follow-up and coaching with the patient improved outcomes at one-month, and that a novice dentist can manage MRD complications without assistance with an appropriate training manual.

Oral Appliance Efficacy in Positional and Non-Positional OSA Patients.
Chung J, Enciso R, Levendowski D et al. Sleep Breath 2009, in-press

Seventy-nine patients treated with the Tap III or Herbst oral appliances were stratified into positional (n=44) and non-positional (n=35) OSA categories based on the supine to non-supine AHI ratio > 2.0. The percentage of patients with > 50% reduction in AHI was 89% for the positional group and 57% for the non-positional group. The percent time supine significantly increased in the positional group even as the AHI decreased. Oral appliances are more effective in positional OSA than non-positional OSA patients.

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