Evidence-based Recommendationsfor the Treatment of Children or Adults
with Obstructive Sleep Apnea
Spyros Papageorgiou, DDS, Dr med dent
Clinic of Orthodontics and Pediatric Dentistry
University of Zurich, SwitzerlandDr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Evidence-based Recommendationsfor the Treatment of Children or Adults
with Obstructive Sleep Apnea
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
I have no conflict of interest
(personal, institutional, or professional)
with any company or entity
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Evidence-based
considerations
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Evidence-based medicine
Best
available
evidence
Clinical
situation
Patient
preference
Clinical
expertise
Patient
Patient
Doctor
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
PubMed Birdbox Challenge
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
All studies are NOT equal
Evidence-based medicine
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
All studies are NOT equal
Evidence-based medicine
SR
RCT
Cohort study
Cross-sectional study
Case series / reports
Animal studies
Lab studies
Editorials, Opinions, Narrative reviews
Internal validity
„Quality“Clinical
Studies
Non-
clinical
studies
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Retrospective 1-group
Prospective 1-group
Retrospective 2-groups
Prospective 2-groups
Randomized trial
What could be the results of treatment in a
setting +confounding +bias
What are the results of a treatment in a setting
+confounding
Which treatment could work better in a setting
+confounding +bias
Which treatment works better in a setting
+confounding
Which treatment consistently works better in a
setting
Which treatment consistently works better in
all settingsMeta-analysis
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Clinical studies
SR
RCT
Cohort study
Cross-sectional study
Case series / reports
Animal studies
Lab studies
Editorials, Opinions, Narrative reviews
Internal validity
„Quality“Clinical
Studies
Non-
clinical
studies
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Clinical studies
SR
RCT
Cohort study
Cross-sectional study
Case series / reports
Animal studies
Lab studies
Editorials, Opinions, Narrative reviews
Internal validity
„Quality“Clinical
Studies
Non-
clinical
studies
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Clinical studies
SR
RCT
Cohort study
Cross-sectional study
Case series / reports
Animal studies
Lab studies
Editorials, Opinions, Narrative reviews
Internal validity
„Quality“Clinical
Studies
Non-
clinical
studies
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Clinical studies
RCTs
Prospective
non-RCTs
Retrospective
non-RCTs
Quality criteria (not all)
Randomization (RCT)
Blinding (Outcome)
Design-Bias (retrospective studies)
Control group (historical control)
Methodological robustness
Adequate sample (Power analysis)
Statistical evaluation (Clustering)
Clinical relevance (95% CI)
Publications bias
Empirical data
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Theoretical vs empirical data
https://bit.ly/2RfxxET
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Empirical evidence of bias
For similar studies comparing the same 2 treatments on similar patients
Savović et al 2012 (PMID 22945832) / Papageorgiou et al 2015 (PMID 25910911) / Papageorgiou et al 2017 (PMID 27129869) Papageorgiou et al 2018 (PMID
29705094) / Saltaji et al 2018a (PMIDs 29776394) / Saltaji et al 2018b (PMIDs 28813182)
non-randomizedRandomized trials show smaller Tx benefits than edicine/ rthodontics
show smaller Tx benefits thanStudies w blind
outcome assessmentunblinded
edicine/ rthodontics
show smaller Tx benefits thanRegistered trials non-registeredrthodontics
show smaller Tx benefits thanProspective studies retrospectiveedicine/ rthodontics
show smaller Tx benefits thanStudies w
concurrent controls
studies w historical
controls edicine/ rthodonticsDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Bias
High
Low High
Systematic
error
(imprecision)
Low
TRUE
Result
Bias versus systematic error
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
The Thinker, Auguste Rodin, 1880
Statistically
significant
clinically
significant
≠
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Difference & 95% confidence intervals
0
B
A
Very large Large Medium Small
C
D
Statistically
significant
Clinically
relevant
Precise
No-effect line
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Not all studies are equal
Evidence-based medicine
SR
RCT
Cohort study
Cross-sectional study
Case series / reports
Animal studies
Lab studies
Editorials, Opinions, Narrative reviews
Internal validity
„Quality“Clinical
Studies
Non-
clinical
studies
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Garbage In - Garbage Out (GIGO) principle
Meta-
analysis
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Bias
High
Low High
Imp
recis
ion
Low
TRUE
Result
Single well-designed
prospective (randomized)
comparative study
Meta-analysis of
(badly-designed) before-
and-after case series
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
https://bit.ly/2S9EA6G / https://bit.ly/2Whhpqp
Randomized trials
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
I’ll stick to randomized trials, where there are
Where there’s none,…..
For this presentation
…then non-randomized ones
(preferably prospective),
but uncertainty exists….Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Methods
Synthesis of multiple trials via meta-analysisMean Difference / Relative Risk & 95% Confidence Intervals
Random-effects model (REML, not DerSimonian-Laird!)
Heterogeneity & uncertainty
95% predictions
Meta-regression / subgroup analyses
Clinical translation
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Methods
Synthesis of multiple trials via meta-analysisMean Difference / Relative Risk & 95% Confidence Intervals
Random-effects model (REML, not DerSimonian-Laird!)
Heterogeneity & uncertainty
95% predictions
Meta-regression / subgroup analyses
Clinical translation
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Treatment
of
adults
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Tx for adults with OSA: non-surgical
Images: https://bit.ly/2AYFJ7s / https://bit.ly/2T5hISZ / https://bit.ly/2FRsyIs / https://bit.ly/2AVP2EU / https://bit.ly/2Mok8d3 / https://bit.ly/2AVTpAa / https://bit.ly/2WbQYCy / https://bit.ly/2Hn8Qqw / https://bit.ly/2FMIQTP
Oxygen
therapy
Positional
therapy
Cervicomandibular
support collar
Oral pressure
therapy
Tongue stabilizing
device
Lifestyle
modification
Cont. Positive Airway
Pressure (CPAP)
Mand. Advancement
Device (MAD)
Myofunctional
therapyExercise
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Images: https://bit.ly/2NWz0DC / https://bit.ly/2sFXbZO / https://bit.ly/2AQXDJd / https://bit.ly/2HDdaST / https://mayocl.in/2W5Z9Ah
Uvulopalato-
(pharyngo)-plasty
Palate stiffening
(Pillar implants) Septoplasty
Radiofrequency
tissue ablation
Maxillomandibular
advancement
Tx for adults with OSA: surgical
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Tx for adults with OSA
Bratton et al 2015 (PMID 26497082) / Iftikhar et al 2017 (PMID 28215266) / Gao et al 2018 (PMID 29523457)
network meta-analysis
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Network meta-analysis
A B
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Network meta-analysis
C
A B
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Network meta-analysis
C
A B
D
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Network meta-analysis
D
A C
E
B
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Network meta-analysis
D
A C
F
B
E
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
No Tx
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
No Tx
13
randomized
trials
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
No Tx
12
randomized
trials
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
No Tx
9
randomized
trials
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
No Tx
7
randomized
trials
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
No Tx
4
randomized
trials
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
No Tx
3
randomized
trials
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: ranking of treatments by AHI reduction
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: ranking of treatments by AHI reduction
1
2
3
4
5
6
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: ranking of treatments by AHI reduction
1
2
3
4
5
6
+
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: ranking of treatments by ESS reduction
1
2
3
4
5
6
+1
2
3
4
5
6
AHI
ESS
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: ranking of treatments by both AHI and ESS
Ranking by AHI reduction
No Tx
Ran
kin
g b
y E
SS
red
ucti
on
Gao et al 2018 (PMID 29523457)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Tx for adults with OSA
Iftikhar et al 2017 (PMID 28215266)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: ranking of treatments (multiple outcomes)
1
2
3
4AHI
Iftikhar et al 2017 (PMID 28215266)
1
2
3
4ESS
1
2
3
4ODI
1
2
3
4Sleep efficiency
1
2
3
4O2 nadir
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: effects on blood pressure
Bratton et al 2015 (PMID 26497082)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: effects on blood pressure
Bratton et al 2015 (PMID 26497082)
CPAP and MAD have
equal effect on blood pressure
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: effects on blood pressure
Bratton et al 2015 (PMID 26497082)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults: effects on blood pressure
Bratton et al 2015 (PMID 26497082)
CPAP use blood pressure effects
Every +1 hour CPAP use:
-1.5 mm Hg systolic pressure
-0.9 mm Hg diastolic pressure
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP
or
MADDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
CPAP v MAD: AHI reduction12
Trial
with prediction
Overall (I2 = 29%)
Schutz 2013
Aarab 2011
Ferguson 1996
Gagnadoux 2009
Nikolopoulou 2017
Tan 2002
Hoekema 2008
Phillips 2013
Engleman 2002
Clark 1996
Barnes 2004
Glos 2016
Ferguson 1997
Banhiran 2017
Randerath 2002
Lam 2007
Trzepizur 2009
Dal-Fabbro 2014
Mean
Difference (95% CI)
(-11.73, -3.77)
-7.75 (-9.30, -6.21)
-2.00 (-14.58, 10.58)
-3.20 (-9.24, 2.84)
-4.00 (-10.55, 2.55)
-4.00 (-7.65, -0.35)
-4.60 (-10.99, 1.79)
-4.90 (-9.55, -0.25)
-6.30 (-16.90, 4.30)
-6.60 (-9.25, -3.95)
-7.00 (-14.39, 0.39)
-8.79 (-15.71, -1.87)
-9.20 (-12.38, -6.02)
-10.20 (-15.30, -5.10)
-10.20 (-16.65, -3.75)
-10.36 (-18.79, -1.93)
-10.60 (-15.19, -6.01)
-10.70 (-15.35, -6.05)
-12.00 (-20.13, -3.87)
-23.50 (-34.28, -12.72)
-36 -24 -12 -6 0 6 12 24 36
very large large medium small
Favors CPAP Favors MAD
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: AHI reduction12
Trial
with prediction
Overall (I2 = 29%)
Schutz 2013
Aarab 2011
Ferguson 1996
Gagnadoux 2009
Nikolopoulou 2017
Tan 2002
Hoekema 2008
Phillips 2013
Engleman 2002
Clark 1996
Barnes 2004
Glos 2016
Ferguson 1997
Banhiran 2017
Randerath 2002
Lam 2007
Trzepizur 2009
Dal-Fabbro 2014
Mean
Difference (95% CI)
(-11.73, -3.77)
-7.75 (-9.30, -6.21)
-2.00 (-14.58, 10.58)
-3.20 (-9.24, 2.84)
-4.00 (-10.55, 2.55)
-4.00 (-7.65, -0.35)
-4.60 (-10.99, 1.79)
-4.90 (-9.55, -0.25)
-6.30 (-16.90, 4.30)
-6.60 (-9.25, -3.95)
-7.00 (-14.39, 0.39)
-8.79 (-15.71, -1.87)
-9.20 (-12.38, -6.02)
-10.20 (-15.30, -5.10)
-10.20 (-16.65, -3.75)
-10.36 (-18.79, -1.93)
-10.60 (-15.19, -6.01)
-10.70 (-15.35, -6.05)
-12.00 (-20.13, -3.87)
-23.50 (-34.28, -12.72)
-36 -24 -12 -6 0 6 12 24 36
very large large medium small
Favors CPAP Favors MAD
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: AHI reduction12
Trial
with prediction
Overall (I2 = 29%)
Schutz 2013
Aarab 2011
Ferguson 1996
Gagnadoux 2009
Nikolopoulou 2017
Tan 2002
Hoekema 2008
Phillips 2013
Engleman 2002
Clark 1996
Barnes 2004
Glos 2016
Ferguson 1997
Banhiran 2017
Randerath 2002
Lam 2007
Trzepizur 2009
Dal-Fabbro 2014
Mean
Difference (95% CI)
(-11.73, -3.77)
-7.75 (-9.30, -6.21)
-2.00 (-14.58, 10.58)
-3.20 (-9.24, 2.84)
-4.00 (-10.55, 2.55)
-4.00 (-7.65, -0.35)
-4.60 (-10.99, 1.79)
-4.90 (-9.55, -0.25)
-6.30 (-16.90, 4.30)
-6.60 (-9.25, -3.95)
-7.00 (-14.39, 0.39)
-8.79 (-15.71, -1.87)
-9.20 (-12.38, -6.02)
-10.20 (-15.30, -5.10)
-10.20 (-16.65, -3.75)
-10.36 (-18.79, -1.93)
-10.60 (-15.19, -6.01)
-10.70 (-15.35, -6.05)
-12.00 (-20.13, -3.87)
-23.50 (-34.28, -12.72)
-36 -24 -12 -6 0 6 12 24 36
very large large medium small
Favors CPAP Favors MAD
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: AHI reduction12
Trial
with prediction
Overall (I2 = 29%)
Schutz 2013
Aarab 2011
Ferguson 1996
Gagnadoux 2009
Nikolopoulou 2017
Tan 2002
Hoekema 2008
Phillips 2013
Engleman 2002
Clark 1996
Barnes 2004
Glos 2016
Ferguson 1997
Banhiran 2017
Randerath 2002
Lam 2007
Trzepizur 2009
Dal-Fabbro 2014
Mean
Difference (95% CI)
(-11.73, -3.77)
-7.75 (-9.30, -6.21)
-2.00 (-14.58, 10.58)
-3.20 (-9.24, 2.84)
-4.00 (-10.55, 2.55)
-4.00 (-7.65, -0.35)
-4.60 (-10.99, 1.79)
-4.90 (-9.55, -0.25)
-6.30 (-16.90, 4.30)
-6.60 (-9.25, -3.95)
-7.00 (-14.39, 0.39)
-8.79 (-15.71, -1.87)
-9.20 (-12.38, -6.02)
-10.20 (-15.30, -5.10)
-10.20 (-16.65, -3.75)
-10.36 (-18.79, -1.93)
-10.60 (-15.19, -6.01)
-10.70 (-15.35, -6.05)
-12.00 (-20.13, -3.87)
-23.50 (-34.28, -12.72)
-36 -24 -12 -6 0 6 12 24 36
Favors CPAP Favors MAD
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: AHI reduction
Trial
with prediction
Overall (I2 = 29%)
Schutz 2013
Aarab 2011
Ferguson 1996
Gagnadoux 2009
Nikolopoulou 2017
Tan 2002
Hoekema 2008
Phillips 2013
Engleman 2002
Clark 1996
Barnes 2004
Glos 2016
Ferguson 1997
Banhiran 2017
Randerath 2002
Lam 2007
Trzepizur 2009
Dal-Fabbro 2014
Mean
Difference (95% CI)
(-11.73, -3.77)
-7.75 (-9.30, -6.21)
-2.00 (-14.58, 10.58)
-3.20 (-9.24, 2.84)
-4.00 (-10.55, 2.55)
-4.00 (-7.65, -0.35)
-4.60 (-10.99, 1.79)
-4.90 (-9.55, -0.25)
-6.30 (-16.90, 4.30)
-6.60 (-9.25, -3.95)
-7.00 (-14.39, 0.39)
-8.79 (-15.71, -1.87)
-9.20 (-12.38, -6.02)
-10.20 (-15.30, -5.10)
-10.20 (-16.65, -3.75)
-10.36 (-18.79, -1.93)
-10.60 (-15.19, -6.01)
-10.70 (-15.35, -6.05)
-12.00 (-20.13, -3.87)
-23.50 (-34.28, -12.72)
-36 -24 -12 -6 0 6 12 24 36
very large large medium small
Favors CPAP
12
Favors MAD
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: AHI reduction
Trial
with prediction
Overall (I2 = 29%)
Schutz 2013
Aarab 2011
Ferguson 1996
Gagnadoux 2009
Nikolopoulou 2017
Tan 2002
Hoekema 2008
Phillips 2013
Engleman 2002
Clark 1996
Barnes 2004
Glos 2016
Ferguson 1997
Banhiran 2017
Randerath 2002
Lam 2007
Trzepizur 2009
Dal-Fabbro 2014
Mean
Difference (95% CI)
(-11.73, -3.77)
-7.75 (-9.30, -6.21)
-2.00 (-14.58, 10.58)
-3.20 (-9.24, 2.84)
-4.00 (-10.55, 2.55)
-4.00 (-7.65, -0.35)
-4.60 (-10.99, 1.79)
-4.90 (-9.55, -0.25)
-6.30 (-16.90, 4.30)
-6.60 (-9.25, -3.95)
-7.00 (-14.39, 0.39)
-8.79 (-15.71, -1.87)
-9.20 (-12.38, -6.02)
-10.20 (-15.30, -5.10)
-10.20 (-16.65, -3.75)
-10.36 (-18.79, -1.93)
-10.60 (-15.19, -6.01)
-10.70 (-15.35, -6.05)
-12.00 (-20.13, -3.87)
-23.50 (-34.28, -12.72)
-36 -24 -12 -6 0 6 12 24 36
very large large medium small
Favors CPAP
12
Favors MAD
CPAP
lowers AHI more
than MAD (P<0.001)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: Epworth Sleepiness Scale reduction9
Trial
with prediction
Overall (I2 = 73%)
Trzepizur 2009
Gagnadoux 2009
Ferguson 1997
Philips 2013
Barnes 2004
Dal-Fabbro 2014
Tan 2002
Banhiran 2017
Lam 2007
Hoekema 2008
Schutz 2013
Engleman 2002
Mean
Difference (95% CI)
(-3.69, 2.12)
-0.79 (-1.68, 0.11)
1.00 (-2.16, 4.16)
0.50 (-0.85, 1.85)
0.40 (-1.32, 2.12)
0.31 (-0.24, 0.86)
0.00 (-0.96, 0.96)
-0.30 (-2.55, 1.95)
-0.90 (-3.17, 1.37)
-1.26 (-2.98, 0.46)
-2.00 (-4.76, 0.76)
-2.30 (-4.44, -0.16)
-2.45 (-6.62, 1.72)
-4.00 (-5.59, -2.41)
-12 -8 -4 -2 0 2 4 8 12
very large large medium small
Favors CPAP Favors MAD
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: Epworth Sleepiness Scale reduction9
Trial
with prediction
Overall (I2 = 73%)
Trzepizur 2009
Gagnadoux 2009
Ferguson 1997
Philips 2013
Barnes 2004
Dal-Fabbro 2014
Tan 2002
Banhiran 2017
Lam 2007
Hoekema 2008
Schutz 2013
Engleman 2002
Mean
Difference (95% CI)
(-3.69, 2.12)
-0.79 (-1.68, 0.11)
1.00 (-2.16, 4.16)
0.50 (-0.85, 1.85)
0.40 (-1.32, 2.12)
0.31 (-0.24, 0.86)
0.00 (-0.96, 0.96)
-0.30 (-2.55, 1.95)
-0.90 (-3.17, 1.37)
-1.26 (-2.98, 0.46)
-2.00 (-4.76, 0.76)
-2.30 (-4.44, -0.16)
-2.45 (-6.62, 1.72)
-4.00 (-5.59, -2.41)
-12 -8 -4 -2 0 2 4 8 12
very large large medium small
Favors CPAP Favors MAD
CPAP and MAD have
equal effect
on sleepiness (ESS)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: complete success (AHI<5)
Trial
with prediction
Overall (I2 = 73%)
Glos 2016
Dal-Fabbro 2014
Phillips 2013
Gagnadoux 2009
Pre-Tx
AHI
28.5
42.3
25.6
34.2
Relative
Risk (95% CI)
(0.43, 13.30)
2.39 (1.59, 3.58)
4.14 (2.21, 7.75)
3.42 (1.76, 6.66)
1.88 (1.46, 2.42)
1.72 (1.23, 2.39)
.1 .2 .5 .66 1 1.5 2 5 10
Favors MAD Favors CPAP
very large large medium small
4
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: complete success (AHI<5)
Trial
with prediction
Overall (I2 = 73%)
Glos 2016
Dal-Fabbro 2014
Phillips 2013
Gagnadoux 2009
Pre-Tx
AHI
28.5
42.3
25.6
34.2
Relative
Risk (95% CI)
(0.43, 13.30)
2.39 (1.59, 3.58)
4.14 (2.21, 7.75)
3.42 (1.76, 6.66)
1.88 (1.46, 2.42)
1.72 (1.23, 2.39)
.1 .2 .5 .66 1 1.5 2 5 10
Favors MAD Favors CPAP
very large large medium small
4
Probability of OSA cure (AHI<5)
increased by 139% with CPAP
compared to MAD
P<0.001
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Complete Tx success (AHI<5)
100
0
90
80
70
60
50
40
30
20
10
MAD
Complete success rate=32.9%
100
0
90
80
70
60
50
40
30
20
10
CPAP
Complete success rate=78.6%
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Complete Tx success (AHI<5)
100
0
90
80
70
60
50
40
30
20
10
MAD
Complete success rate=32.9%
100
0
90
80
70
60
50
40
30
20
10
CPAP
Complete success rate=78.6%
+45.7%
Number Needed to Treat: 3
To put things into context1….
Antibiotics for dog bites to avoid infection:
NNT=16
Aspirin for myocardial infarction to avoid
vascular death: NNT=40McQuay 1997 (PMID 9139558)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: partial success (…)8
Trial
with prediction
Overall (I2 = 38%)
Glos 2016
Dal-Fabbro 2014
Tan 2002
Phillips 2013
Ferguson 1996
Ferguson 1997
Gagnadoux 2009
Hoekema 2008
Pre-Tx
AHI
28.5
42.3
22.2
25.6
18.65
24.4
34.2
39.85
AHI<10
50% AHI
AHI<10 & tolerance
50% AHI
AHI<10 & no symptoms
AHI<10 & no symptoms
AHI<10
50% AHI or AHI<5
Relative
Risk (95% CI)
(1.00, 1.78)
1.34 (1.19, 1.50)
1.68 (1.25, 2.26)
1.68 (1.23, 2.30)
1.42 (1.08, 1.87)
1.36 (1.19, 1.56)
1.28 (0.76, 2.18)
1.27 (0.78, 2.08)
1.19 (0.96, 1.47)
1.08 (0.89, 1.32)
.17 .2 .5 .66 1 1.5 2 5 6
Success
description
Favors MAD Favors CPAP
very large large medium small
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: partial success (…)8
Trial
with prediction
Overall (I2 = 38%)
Glos 2016
Dal-Fabbro 2014
Tan 2002
Phillips 2013
Ferguson 1996
Ferguson 1997
Gagnadoux 2009
Hoekema 2008
Pre-Tx
AHI
28.5
42.3
22.2
25.6
18.65
24.4
34.2
39.85
AHI<10
50% AHI
AHI<10 & tolerance
50% AHI
AHI<10 & no symptoms
AHI<10 & no symptoms
AHI<10
50% AHI or AHI<5
Relative
Risk (95% CI)
(1.00, 1.78)
1.34 (1.19, 1.50)
1.68 (1.25, 2.26)
1.68 (1.23, 2.30)
1.42 (1.08, 1.87)
1.36 (1.19, 1.56)
1.28 (0.76, 2.18)
1.27 (0.78, 2.08)
1.19 (0.96, 1.47)
1.08 (0.89, 1.32)
.17 .2 .5 .66 1 1.5 2 5 6
Success
description
Favors MAD Favors CPAP
very large large medium small
Probability of OSA partial success
increased by 34% with CPAP
compared to MAD
P<0.001
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
(At least) partial Tx success (AHI<5)
100
0
90
80
70
60
50
40
30
20
10
MAD
Partial success rate=63.9%
100
0
90
80
70
60
50
40
30
20
10
CPAP
Partial success rate=85.6%
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
(At least) partial Tx success (AHI<5)
100
0
90
80
70
60
50
40
30
20
10
MAD
Partial success rate=63.9%
100
0
90
80
70
60
50
40
30
20
10
CPAP
Partial success rate=85.6%
+21.7%
Number Needed to Treat: 5
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Quality of life
SF36 – physical component
SF36 – mental component
Trial
with prediction
Subgroup (I2 = 40%)
Schutz 2013
Hoekema 2008
Phillips 2013
Engleman 2002
with prediction
Subgroup (I2 = 64%)
Schutz 2013
Hoekema 2008
Phillips 2013
Engleman 2002
Mean
Difference (95% CI)
(-11.87, 11.59)
-0.14 (-3.52, 3.24)
-8.49 (-22.60, 5.62)
4.70 (-4.04, 13.44)
-2.00 (-4.61, 0.61)
2.00 (-2.00, 6.00)
(-19.41, 18.11)
-0.65 (-5.42, 4.11)
-13.43 (-32.68, 5.82)
0.20 (-6.52, 6.92)
-3.50 (-6.69, -0.31)
4.00 (-0.19, 8.19)
-48 -32 -16 -8 0 8 16 32 48
very large large medium small4
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Quality of life
SF36 – physical component
SF36 – mental component
Trial
with prediction
Subgroup (I2 = 40%)
Schutz 2013
Hoekema 2008
Phillips 2013
Engleman 2002
with prediction
Subgroup (I2 = 64%)
Schutz 2013
Hoekema 2008
Phillips 2013
Engleman 2002
Mean
Difference (95% CI)
(-11.87, 11.59)
-0.14 (-3.52, 3.24)
-8.49 (-22.60, 5.62)
4.70 (-4.04, 13.44)
-2.00 (-4.61, 0.61)
2.00 (-2.00, 6.00)
(-19.41, 18.11)
-0.65 (-5.42, 4.11)
-13.43 (-32.68, 5.82)
0.20 (-6.52, 6.92)
-3.50 (-6.69, -0.31)
4.00 (-0.19, 8.19)
-48 -32 -16 -8 0 8 16 32 48
very large large medium small4
CPAP and MAD have
equal effect
on quality of life
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Tx success
OSA severityDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
CPAP v MAD: complete success (AHI<5)
Dal-Fabbro 2014
Dal-Fabbro 2014
Trial
Severe
Moderate
Category
11.94 (1.75, 81.51)
1.92 (1.11, 3.32)
Relative
Risk (95% CI)
.04 .2 .5 .66 1 1.5 2 5 25.03
very large large medium small
Favors MAD Favors CPAPDr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: partial success (…)
Severe
Mild/moderate
Trial
Subgroup (I2 = 67%)
Dal-Fabbro 2014
Hoekema 2008
Subgroup (I2 = 52%)
Dal-Fabbro 2014 (moderate)
Hoekema 2008 (mild)
Relative
Risk (95% CI)
1.53 (0.93, 2.51)
2.05 (1.26, 3.35)
1.23 (0.92, 1.66)
1.09 (0.80, 1.49)
1.31 (0.92, 1.86)
0.95 (0.74, 1.23)
.17 .2 .5 .66 1 1.5 2 5 6
very large large medium small
Favors MAD Favors CPAP
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: partial success (…)
Severe
Mild/moderate
Trial
Subgroup (I2 = 67%)
Dal-Fabbro 2014
Hoekema 2008
Subgroup (I2 = 52%)
Dal-Fabbro 2014 (moderate)
Hoekema 2008 (mild)
Relative
Risk (95% CI)
1.53 (0.93, 2.51)
2.05 (1.26, 3.35)
1.23 (0.92, 1.66)
1.09 (0.80, 1.49)
1.31 (0.92, 1.86)
0.95 (0.74, 1.23)
.17 .2 .5 .66 1 1.5 2 5 6
very large large medium small
Favors MAD Favors CPAP
It’s more possible for
CPAP and MAD to be
equally effective for
mild/moderate OSA
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD according to pre-Tx Epworth Sleepiness Scale
-4-2
02
4
8 10 12 14
Baseline ESS
Prediction interval
Confidence interval
Linear prediction
Mean Difference
between CPAP v MAD
MD in ESS
Between
CPAP-MAD
9
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD according to pre-Tx Epworth Sleepiness Scale
-4-2
02
4
8 10 12 14
Baseline ESS
Prediction interval
Confidence interval
Linear prediction
Mean Difference
between CPAP v MAD
MD in ESS
Between
CPAP-MAD
For milder pre-Tx sleepiness: CPAP and MAD
might be equally effective in lowering ESS
For moderate/severe pre-Tx sleepiness CPAP
is better in lowering ESS than MAD
P<0.05
9
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Reception & preference
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: reception
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
ComplaintsMAD CPAP
hypersalivation (x4) nasal congestion (x3)
sensitive/painful teeth (x4) air leaks (x2)
TMJ discomfort (x3) noise/inconvenience (x2)
jaw pain (x2) cold airstream
dental crown damage conjunctivitis
difficulty in swallowing with MAD difficulty in changing sleep position
discomfort difficulty in expiration
feeling of changed occlusion dry nose
tenderness in the masseter muscle region facial skin abrasion
inconvenience carrying device
pain/pressure on face pain/pressure on face (x4)
MAD dislodging (x2) CPAP dislodging
dry throath/airway dry throath/airway (x3)
sleep disruption sleep disruption
dry mouth dry mouth
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: Tx discontinuation due to problems
Trial
with prediction
Overall (I2 = 0%)
Lam 2007
Barnes 2004
Banhiran 2017
Dal-Fabbro 2014
Clark 1996
Ferguson 1996
Phillips 2013
Tan 2002
Aarab 2011; 2017
Nikolopoulou 2017
Glos 2016
Ferguson 1997
Schutz 2013
Relative
Risk (95% CI)
(0.39, 1.27)
0.70 (0.42, 1.19)
4.01 (0.47, 34.00)
1.95 (0.18, 21.35)
1.25 (0.36, 4.37)
1.00 (0.15, 6.69)
1.00 (0.07, 14.95)
0.75 (0.30, 1.84)
0.52 (0.05, 5.54)
0.50 (0.05, 5.17)
0.15 (0.01, 2.72)
0.15 (0.01, 2.72)
0.14 (0.01, 2.69)
0.14 (0.01, 2.59)
0.08 (0.00, 1.25)
.04 .1 .2 .5 .66 1 1.5 2 5 10 25.03
Favors MAD Favors CPAP
13
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP v MAD: Tx discontinuation due to problems
Trial
with prediction
Overall (I2 = 0%)
Lam 2007
Barnes 2004
Banhiran 2017
Dal-Fabbro 2014
Clark 1996
Ferguson 1996
Phillips 2013
Tan 2002
Aarab 2011; 2017
Nikolopoulou 2017
Glos 2016
Ferguson 1997
Schutz 2013
Relative
Risk (95% CI)
(0.39, 1.27)
0.70 (0.42, 1.19)
4.01 (0.47, 34.00)
1.95 (0.18, 21.35)
1.25 (0.36, 4.37)
1.00 (0.15, 6.69)
1.00 (0.07, 14.95)
0.75 (0.30, 1.84)
0.52 (0.05, 5.54)
0.50 (0.05, 5.17)
0.15 (0.01, 2.72)
0.15 (0.01, 2.72)
0.14 (0.01, 2.69)
0.14 (0.01, 2.59)
0.08 (0.00, 1.25)
.04 .1 .2 .5 .66 1 1.5 2 5 10 25.03
Favors MAD Favors CPAP
CPAP discontinuation: 10.1%
MAD discontinuation : 4.6%
NOT significant (p>0.05)
13
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Long-term MAD use & adverse effects
Outcome Association with duration use
Association with pre-Tx value
Lower incisor inclination (IMPA) 12 P=0.0020.6° (0.3, 1.0°)/year
P>0.05
Upper incisor inclination (1s/SN) 6 P=0.004-0.6° (-0.8, -0.3°)/year
P>0.05
Upper incisor inclination (1s/PP) 8 P=0.007-0.5° (-0.8, -0.2°)/year
P>0.05
Mandibular inclination (SM/ML) 10 P>0.05 P>0.05
Face height (N-Me) 7 P>0.05 P>0.05Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Long-term MAD use on lower incisor inclination
-50
510
15
2 4 6 8 10 12
Years after MAD administration
Confidence interval
Linear prediction
Change in IMPA
IMPA change (°)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Long-term MAD use on lower incisor inclination
-50
510
15
2 4 6 8 10 12
Years after MAD administration
Confidence interval
Linear prediction
Change in IMPA
IMPA change (°)
In 1 yr: +0.6° lower incisor proclination In 10 yrs: +6.0° lower incisor proclination
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
CPAP
or
MADDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Responders to Tx
1Tsuiki 2013 (PMID 23493981) / 2Tsuiki 2010 (PMID 19840960) / 3Sutherland 2014 (PMID 25142773)
OSA patients with BMI>24kg/m2 and oropharyngeal crowding (Mallampati score of 4) are NOT likely to respond to MADs (neg predictive value 92%)1
OSA patients with titrated optimal pressure of nCPAP(PnCPAP) > 10.5 cmH2O are NOT likely to respond to MADs (AHI<5 or 50% off; neg predictive value 93%)2
OSA patients with PnCPAP > 13.0 cmH2O are NOT likely to respond to MADs (AHI<10; neg predictive value 100%)3Dr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
https://bit.ly/2S9K9lz
Ready-made
vs
Custom-made
MADs
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Ready-made vs custom-made MADs
Johal 2018 (PMID 29405512)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Ready-made vs custom-made MADs
Johal 2018 (PMID 29405512)
Outcome P valueEffect(95% CI)
AHI reduction 3 P<0.05 MD: -3.5(-6.4 to -0.7)
ESS reduction 3 P<0.05 MD: -1.0(-2.0 to 0)
Partial or complete Tx success(AHI -50% or AHI<5)
3 P<0.001 RR: 1.5(1.2 to 1.8)
Quality of life – medical outcomes 2 P>0.05 -
Quality of life – functional outcomes 2 P<0.05 MD: 0.8(0.1 to 1.4)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Ready-made vs custom-made MADs
Johal 2018 (PMID 29405512)
Outcome P valueEffect(95% CI)
AHI reduction 3 P<0.05 MD: -3.5(-6.4 to -0.7)
ESS reduction 3 P<0.05 MD: -1.0(-2.0 to 0)
Partial or complete Tx success(AHI -50% or AHI<5)
3 P<0.001 RR: 1.5(1.2 to 1.8)
Quality of life – medical outcomes 2 P>0.05 -
Quality of life – functional outcomes 2 P<0.05 MD: 0.8(0.1 to 1.4)
Generally, custom-made appliances
perform better and are more preferred by patients
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Maxillo-
Mandibular
AdvancementDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Maxillomandibular advancement
Vicini et al 2010 (PMID 19944893)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Maxillomandibular advancement
Vicini et al 2010 (PMID 19944893)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Maxillomandibular advancement
Vicini et al 2010 (PMID 19944893)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Age BMI AHI ESS
30
40
50
60
70
80
CPAP MMA20
30
40
50
CPAP MMA
20
40
60
80
100
CPAP MMA
510
15
20
CPAP MMA
P=0.89 P=0.11 P=0.06 P=0.58
Obese AHI>60
P=0.02 P=0.04
Vicini et al 2010 (PMID 19944893)
Maxillomandibular advancement
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Age BMI AHI ESS
30
40
50
60
70
80
CPAP MMA20
30
40
50
CPAP MMA
20
40
60
80
100
CPAP MMA
510
15
20
CPAP MMA
P=0.89 P=0.11 P=0.06 P=0.58
Obese AHI>60
P=0.02 P=0.04
After controlling for confounders AHI reduction: no difference (P>0.05)
ESS reduction: CPAP greater than MMA (+1.8; P<0.001)
Complete cure (AHI<5): no difference (P>0.05)
Satisfaction >80%: no difference (P>0.05)
Vicini et al 2010 (PMID 19944893)
Maxillomandibular advancement
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Treatment
of
children
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Rapid
Maxillary
Expansion
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Rapid Maxillary Expansion for OSA children
Hoxha et al 2018 (PMID 29453640)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Rapid Maxillary Expansion for OSA children
Hoxha et al 2018 (PMID 29453640)
MATERIAL30 children with max transverse deficit; high narrow palate; Xbite
NO adenoid hypertrophy
Symptoms of OSA (AHI>1)
Randomized toRME (McNamara Hyrax)
No Tx
+ 6.6mm (M1) / 6.4mm (PM) / 4.4mm (C)
Outcome (5.2 months):Respiratory (AHI, ODI, SaO2, etc)
Pharyngeal area (LCeph), Nasal/Max width (PA Ceph)
Biomarkers
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Rapid Maxillary Expansion for OSA children
Hoxha et al 2018 (PMID 29453640)
RESULTS
Stat. significant Pre-Post increase in dental arch width, max/nasal width, and pharyngeal area in RME patients (p<0.05)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Rapid Maxillary Expansion for OSA children
Hoxha et al 2018 (PMID 29453640)
RESULTS
Stat. significant Pre-Post increase in dental arch width, max/nasal width, and pharyngeal area in RME patients (p<0.05)
….but….
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Rapid Maxillary Expansion for OSA children
Hoxha et al 2018 (PMID 29453640)
RESULTS
Stat. significant Pre-Post increase in dental arch width, max/nasal width, and pharyngeal area in RME patients (p<0.05)
….but….
NO DIFFERENCE in OSA parameters between RME-ControlAHI
ODI
O2 saturationDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Rapid Maxillary Expansion for OSA children
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Rapid Maxillary Expansion for OSA children
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Mandibular
Advancement
Devices
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Mandibular advancement for OSA children
Machado-Júnior 2016 (PMID 26946208) / Villa 2002 (PMID 11779741)
Mand retrognathism
OSA diagnosis
Tonsils not assessed
Custom/ non-titrable appliance
Mand retrognathism
OSA diagnosis
Tonsils assessed
Custom/ non-titrable applianceDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Mandibular advancement for OSA children
Machado-Júnior 2016 (PMID 26946208) / Villa 2002 (PMID 11779741)
OSA symptoms
Significantly improved in MAD group / no improvement in control group STAT. SIGN DIFFERENCE (large effect)
50% complete cure (AHI 0)
Tonsilar hypertrophy
Start: similar in MAD-control
End: concomitant REDUCTION in tons. hypertrophy
[67% in MAD vs 14% in control] STAT SIGNIFICANTDr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical
Management
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical Tx for OSA children
Marcus 2013 (PMID 23692173)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical Tx for OSA children
Marcus 2013 (PMID 23692173)
MATERIAL
464 children, 5-9 yrs, with OSA (AHI>2)
AdenotonsillectomyNo Tx
(watchful waiting)
Randomized to
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical Tx for OSA children
Marcus 2013 (PMID 23692173)
RESULTS
Treated patients: no effect on attention and executive function
Improvement in behavior, quality of life, and PSG findings(effect size: moderate-large)
PSG normalization: 79% in Treated & 46% in No-Tx
Bad response & residual OSA more often in obese children
Generally low complications (but non-predictable)Dr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Surgical Tx for OSA children
Guilleminault 2013 (PMID 23026504)
69% (20/29) still having
OSA problems
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical Tx for OSA children
Marcus 2013 (PMID 23692173)
RESULTS
Treated patients: no effect on attention and executive function
Improvement in behavior, quality of life, and PSG findings(effect size: moderate-large)
PSG normalization: 79% in Treated & 46% in No-Tx
Bad response & residual OSA more often in obese children
Generally low complications (but non-predictable)Dr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Surgical Tx for OSA children
Marcus 2013 (PMID 23692173)
RESULTS
Treated patients: no effect on attention and executive function
Improvement in behavior, quality of life, and PSG findings(effect size: moderate-large)
PSG normalization: 79% in Treated & 46% in No-Tx
Bad response & residual OSA more often in obese children
Generally low complications (but non-predictable)Dr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Spontaneously resolved OSA in children
Chervin 2015 (PMID 25811889)
100
0
90
80
70
60
50
40
30
20
10
6.5 years old
100
0
90
80
70
60
50
40
30
20
10
7.8 years old
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Spontaneously resolved OSA in children
Chervin 2015 (PMID 25811889)
100
0
90
80
70
60
50
40
30
20
10
6.5 years old
100
0
90
80
70
60
50
40
30
20
10
7.8 years old
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Spontaneously resolved OSA in children
Chervin 2015 (PMID 25811889)
100
0
90
80
70
60
50
40
30
20
10
6.5 years old
100
0
90
80
70
60
50
40
30
20
10
7.8 years old
46% resolution
Initial predictors:
AHI
Waist circumference
PSQ score (total)
PSQ score (snoring)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical Tx for OSA children
Goldstein 2004 (PMID 15231905)
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical Tx for OSA children
Goldstein 2004 (PMID 15231905)
MATERIAL
Children with clinical signs of OSA
Assessed with PSG
PSG (+): Adenoidectomy & Tonsillectomy (AT)
PSG (-) randomized to:
Either AT
No Tx
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Surgical Tx for OSA children
Goldstein 2004 (PMID 15231905)
RESULTS
Significant improvement in clinically assessed OSA
in AT patients compared to No Tx
At end: asymptomatic 82% in AT / 22% in No-Tx
Both OSA children (PSG+) and non-OSA sleep
disordered children (PSG-) might benefit from ATDr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Summary
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults with OSA
Is CPAP effective for OSA?
YES! Has been shown more effective than controls and is generally the gold standard with benefits on AHI, ESS, blood pressure, and quality of life (high-quality evidence)
High rate for partial or complete Tx success
Issues of preference / compliance among some patientsDr. S
pyros Papage
orgiou, D
DS, Dr M
ed Dent
Adults with OSA
Are MADs effective for OSA?
YES! More effective against controls (high-quality evidence). Compared to CPAP: somewhat less (AHI) or equally effective (ESS, blood pressure, quality of life) (low-quality evidence)
Have on average lower rate for Tx success than CPAP, especially for patients with severe OSA
Might be more easily acceptable than CPAP, but could lead to long-term duration-dependent intraoral (dental) changes
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults with OSA
Is surgery effective for OSA?
MMA might be equally effective in treating patients with severe OSA, but only one trial exists with spurious data (low quality evidence)
There is no (robust) evidence to support surgically assisted RME or skeletal distraction.
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Adults with OSA
What other treatments exist for OSA?
Some evidence exists for the efficacy of(i) oral pressure therapy
(ii) positional therapy
(iii) tongue stabilizing devices
(iv) lifestyle modification (weight loss)
(v) exercise, and
(vi) cervicomandibular support collars
Evidence however is meager and should be confirmed by future research
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Children with OSA
Which treatments exist for OSA children?
CPAP could be extrapolated as a good option to treat children with OSA, but evidence is limited
MADs might be effective against OSA in children (few high-quality trials) +effects on tonsils
The use of RME for children with OSA is most supported by low-quality studies. One randomized trial found no grounds for its use.
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
Children with OSA
Which treatments exist for OSA children?
Surgical interventions like adenotonsillectomy have been shown to be effective for children with OSA (few high-quality trials)
Careful identification of Tx candidates is important, since OSA might resolve spontaneously for many children
Residual OSA might persist after surgical Tx and further monitoring / Tx might be needed
Dr. Spyro
s Papageorgio
u, DDS, D
r Med Dent
