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Dental Tribune Middle East & Africa Edition No.2, 2016

Lateralviewverticaldimensionopening Lateral view relevant jaw advancement with competent, comfortable lipsseal Frontalviewinitialopening,visiblescrew Frontalviewwithlateralexcursionforpatient comfort Table1 Table2 Table3 Table4 Dental Tribune Middle East & Africa Edition | 2/2016 29 research ◊Page28 suffer from the noisy consequences causing problems in the partner- ships. 3. Disordered breathing by sleep is very habitual and, therefore, a con- stant source of problems regarding health and economic impacts. Poor sleep habits aggravate the impair- ments of health and quality of life causing countless traffic accidents, labor accidents and accidental home injuries. The majority of these disor- ders lead to drowsiness in its clini- cal description, disabling affected patients to drive. In all countries the number of fatal accidents increases constantly. It s the first cause in men aged be- tween16and25. 4. The access to diagnosis possibili- ties is the major problem facing the specialists, as only about 6 to 9% of the population with relevant OSA is diagnosed. Clinical researchers seek for diagnostic alternatives to the costly polysomnography that is currently the first diagnosis com- mendation (6). The OSAS is rarely known to the public. The lack of di- agnosisisthemainmedicalproblem to solve. Recent studies show that in only 7% of medical examinations of primary care, explicit references re- garding possible sleep disorders are included. This incorrect diagnosis involves fatal consequences because the pathology is ignored by patients that, without being diagnosed, do not know how to justify and cope with the symptoms that they face daybyday. To conclude, school and work ab- sence and the reduced capacity at workalsocauseeconomicdamages. Objectivesandhypotheses Hypothesis Mandibular advancement devices (MAD)areefficientforthetreatment of snoring and mild to moderate sleepapnea. Objectives 1. Applying a nocturnal cardio-res- piratory and pulse oximetry moni- toring (“ApneaLink”) in a qualified “snorer” population evaluating the OSA grade (mild/moderate) and if the patient is a candidate for MAD treatment. 2. Describe the clinical findings of the situation before and after treat- ment with two types of mandibular advancement devices in a series of adultpatients. 3. Comparative analysis of the ef- fectiveness of mandibular advance- ment devices by means of objective andsubjectivecriteria. 4. Evaluating the possibility of im- plementing this system as an effi- cient method for the treatment of mildormoderateOSAandcasesthat donottolerateCPAP. Methodology Descriptionandsubjectgroup selection The study group consists of 30 snor- ing adults, with mild/moderate sleep apnea, aged between 36 and 68 years, 8 women and 22 men, who were treated with a mandibular ad- vancementdevice(MAD). A complete dental examination was performed to get more detailed information about TMJ and dental and bone structure. It included: peri- odontal and dental examination, panoramic radiography and lateral cephalometry, evaluation of the tongue and soft tissues and, finally, possibleocclusiondefects. InclusionCriteria -Snorers - The patient should have the abil- ity to advance the mandible forward and open it without significant limi- tations. DAM 1 DAM 2 P AGE Median (Standar Deviation) 49.1 (10.5) 48.2 (9.2) 0.644 SATISFACTION Median (Standar Deviation) 4.5 (0.7) 4.6 (0.6) 0.983 SEX (% women) 27 27 0 Before DAM 2 After DAM 2 P (Wilcoxom) IAM 7.7 5.17 0.002 IR 9.17 8.23 0.001 IDO 3.93 2.93 0.01 EPW 8.6 6.07 0.006 Before DAM 2 After DAM 2 P (Wilcoxom) IAM 12.3 7.12 0.001 IR 14.23 10.67 0.001 IDO 6.43 4.47 0.003 EPW 11.63 6.73 0.001 Before DAM 2 After DAM 2 P (Wilcoxom) IAM 7.7 5.17 0.002 IR 9.17 8.23 0.001 IDO 3.93 2.93 0.01 EPW 8.6 6.07 0.006 Before DAM 2 After DAM 2 P (Wilcoxom) IAM 12.3 7.12 0.001 IR 14.23 10.67 0.001 IDO 6.43 4.47 0.003 EPW 11.63 6.73 0.001 DAM 1 DAM 2 P Difference IAH -3.43 -4.17 -0.333 Difference IR -4.23 -4.57 -0.783 DrLuisGavin. Stomatologist, Oral & Maxillo Fa- cial Surgeon; Med. Consultant (Span- ish&UAEBoard). Areas of Exper- tise: Oral & Facial Surgery; Top Den- tistry; TMJoint; Sleep Medicine; Med Wellness and Special Medical Needs. Contact: info@;; Facilities:AbuDhabi;Dubai;Marbella ExclusionCriteria -PatientswithsevereOSAS - Patients with rhino-pharyngeal pa- thology - Inappropriately dentition, peri- odontaldiseaseswithouttreatment - Serious problems in the temporo- mandibularjoint(TMJ) -Insufficientprotrusioncapacity Methods 1.Cardio-respiratorypolygraphy 2.Epworthtest 3.Dentalimpressions 4. Appointment for adaptation and userinstructions Useddevices Although there exist over three hundred systems of mandibular ad- vancement devices, we have tested two devices that have, in our opin- ion, a greater international presence placing them randomly among our study group. The used devices were intraoral with lateral excursion, opening and protusion appliance andtheTAPappliance(Figs.1and2). Procedures The study and evaluation were per- formed by the same professional with over 20 years of experience in the treatment of mandibular ad- vancement devices. Objective and subjective assessments were per- formed prior to placement and after onemonthoftreatment. The study subjects had to fill in the Epworth test and undergo the Ap- neaLink after one month of treat- ment; they underwent also a ques- tionnaire of satisfaction that the subjects answered in collaboration with their partners. This test evalu- ates the satisfaction of both regard- ingabetterqualityoflifeandnoise. Theanalyzedvariableswere:age,sex, MAD type, AHI before and after the MAD therapy, risk index before and after MAD therapy, Epworth index before and after MAD therapy and thelevelofsatisfactionofthepatient andhispartnerafterMADtherapy. Analyticstudy In table 2 the mean values of the re- ceived indices before and after using MAD1 during one month are com- pared. The comparison of the param- eters was taken by the Wilcoxon test, as it is about paired and small quan- tity data. In table 3 the same analysis forMAD2isrepeated. As reported in table 2, MAD1 has decreased the mean value of all in- dices, this diminution is statistically significant(p<0.005)inallindices. Also in the use of MAD2 ap- peared a statistically significant (p<0.005) diminution of all indices. To compare both MADs we calcu- lated the mean values of the differ- ences between the indices before and after using each MAD. In table 4 the mean values of the differences (index after MAD – index before MAD) for each type of MAD and its comparison through the test of the U of Mann-Whitney is reported, as it isabouttwodifferentsamplegroups andthegroupsizeisrelativelysmall. It can be evaluated that MAD2 achieves a greater reduction of all in- dices than MAD1, although the only statistically significant parameter (p<0.005)istheEPW. Conclusions 1) With regards to the medical com- plications of snoring and OSA and the social restrictions and the nega- tive effects on the quality of life the physician should identify the patients that need support. It is a public health problem that can be easy diagnosed and treated. Recent studies even demonstrated that the consumption of public resources is 2-3timeshigherinpatientswithnon treated snoring and OSA than in the populationwithoutOSA. 2) Totally advisable for all patients to obtain an objective valuation of the multidisciplinary diagnosis re- sults. The specialist should perform a clinical diagnosis, a prior nocturnal monitoring and, after a period of adaptation, a new clinical valuation and objective and subjective exami- nations. The experienced specialist dentist in the treatment of sleep apnoea with MADs should select adequate cases, perform design and adaption of the devices and control possible side effects through a regu- larfollowup. 3) We prove the efficiency of the mandibular advancement devices was proven. In both cases the mean values of all indices decreased and this diminution is statistically sig- nificant(p<0.05)inallindices. 4) Analysis of the efficiency between both types of MADs shows that the screw Lateral excursion, opening and protusion appliance achieves a greater reduction of all indices, although the only statistically sig- nificant index was the Epworth test result(p<0.05). 5) Our medical trial should be per- formedthroughacostandefficiency analysis, as the basic advantages of the treatment, like the decrease of the morbidity rate in the long and shortterm,areveryevident. 6) This study support the use of cardio respiratory polygraph moni- toring for the evaluation of sleep apnea detection in subjects of high probability of disease suspicion and a high prevalence or in populations ofhighprevalenceofsleepbreathing disorders. Although the controlled PSGisthestandarddiagnosistoolfor sleep apnea, not all patients have ac- cess to such a study in the sleep unit. The sleep unit installations could differfromthepatientssleepsstand- ards, there exist long waiting lists in the neumology services, the sleep study is connected with high costs and the patient’s willingness to sleep one night in a sleep unit undergoing a nocturnal PSG without confirmed OSAS could be very low. This results show that the cardio respiratory pol- ygraphy is a useful complementary technology for the diagnosis of sleep apnea,duetothesensibility,specific- ity, and simple use of the device and the resulting low costs of the sleep study. The cardio respiratory pol- ygraphy can be useful in situations where the PSG is a practical principle or in populations with high preva- lence of sleep apnea supporting the optionsofdiagnosisandtreatment. This could lead to a timely evalua- tion of sleep apnea and a better at- tention to the patient causing a bet- terhealthstatusandlifestyle. 7) Can be conclude that the adjusta- ble mandibular repositioning device is an efficient treatment alternative for patients with snoring and sleep apnea. The severity of the OSAS mo- tivates the specialist to get a better knowledge about it and makes him aware of the importance of its mul- tidisciplinary character. Including the participation of a dentist that is well experienced in the treatment of OSAS patients through the use of MAD, a treatment alternative with a highpatients’acceptance,becauseof its low treatment costs and high effi- ciency being an individualised treat- ment option or in combination with othertreatments. 8) It s a good recommendation that the public health authorities formu- lateavalidpreventivedentistryplan, asitwasdemonstratedthatthesleep apnea problem is a sanitary priority of high relevance because the effi- ciency of mandibular advancement devices for the treatment of snoring and mild and moderate sleep apnea- hypoapnea. “Badsleepisthreaten- ingtheoverstimulated, overworkedmasses withdiseaseandeven anearlydeath” Dental Tribune Middle East & Africa Edition | 2/201629 SEX (% women) 27270 IAM IR IDO 3.932.930.01 EPW IAM IR 14.2310.670.001 IDO 6.434.470.003 EPW 11.636.730.001 IAM IR IDO 3.932.930.01 EPW IAM IR 14.2310.670.001 IDO 6.434.470.003 EPW 11.636.730.001

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