Abstract Objective In the treatment of obstructive sleep apnea (OSA) with an oral appliance (OA), there is no gold standard method to fine-tune the mandibular advancement. This study aimed to analyze ...the effect of gradual increment of mandibular advancement on the evolution of the apnea-hypopnea index (AHI). Methods OSA patients were recruited from a sleep unit. All treatments started with an oral appliance without mandibular advancement. After two weeks, the AHI was assessed with respiratory polygraphy. Mandibular advancement was initiated with a step size of 1 mm and evolution in the AHI was assessed. The target protrusion was the one that achieved the highest reduction in AHI and the least side effects. Anthropometric data, sleep questionnaire and Epworth sleepiness scale score were obtained. Results Thirty six patients (22 men) participated in this study. The patient's mean age was 57 ± 12 years and the body mass index was 25.4 ± 4.1 Kg/m2 . The oral appliance reduced the AHI from 20.8 ± 12.9/h to 8.4 ± 5.1/h ( p =0.000). Ten of the 26 patients with ≥50% reduction in AHI (39%) had zero advancement. The mean mandibular advancement was 1.7 ± 1.5 mm achieving ≥ 50% reduction in AHI in 72% of the patients. Twenty seven patients had an AHI < 10/h. Of the 21 patients with moderate-severe OSA, 17 had the highest decrease in the AHI in a manibular advancement ≤ 3 mm. Conclusions Monitoring the subjective symptoms of the patient and objective evolution in the AHI could minimize the mandibular advancement needed for the treatment of OSA.
Prototyping is a core activity in developing new products, processes, and organisations alike. This paper describes the prototyping activities of 31 engineering design professionals in a ...high-technology industrial company, examining the distribution of different types of activities across different phases of development based on thematic interviews. Examining 62 prototyping and testing pathways, we found that most prototyping paths started with the practitioners’ own activities, which was also more likely to lead to paths with more prototyping steps than if the first prototyping activity took place with a stakeholder. Overall, the paths were short, indicating a lack of iteration. Both internal and external stakeholders were involved in collaborative prototyping. This collaboration was enabled by personal and unit level relationships, and different stakeholders were involved in different phases of development. Taken together, our results suggest that practitioner attention in prototyping may focus on latter development phases and demonstrate less iteration than what literature might suggest, with opportunities for prototyping highly dependent on personal networks in the high-technology context in the absence of flexible prototyping budgets.
The mechanisms by which mandibular advancement splints (MAS) improve obstructive sleep apnoea (OSA) are not well understood. This study aimed to evaluate the mechanism of action of MAS by assessing ...their effect on upper airway structure in patients with OSA.
Patients were recruited from a sleep disorders clinic for treatment with a custom-made MAS. MRI of the upper airway was performed during wakefulness in the supine position, with and without the MAS.
Sixty-nine patients with OSA were recruited. Treatment with the MAS reduced the apnoea-hypopnoea index (AHI) from 27.0+/-14.7 events/h to 12.2+/-12.5 events/h (p<0.001). There was an increase in the total airway volume with mandibular advancement (16.5+/-0.7 cm(3) vs 18.1+/-0.8 cm(3); p<0.01) that occurred predominantly because of an increase in the volume of the velopharynx (5.7+/-0.3 cm(3) vs 6.5+/-0.3 cm(3); p<0.001). This increase in airway calibre was associated with an increase in the lower anterior facial height (6.8+/-0.1 cm vs 7.5+/-0.1 cm; p<0.001), reduction in the distance between the hyoid and posterior nasal spine (7.4+/-0.1 cm vs 7.2+/-0.1 cm; p<0.001), lateral displacement of the parapharyngeal fat pads away from the airway (right parapharyngeal fat pad 0.17+/-0.02 cm; left parapharyngeal fat pad 0.22+/-0.02 cm) and anterior movement of the tongue base muscles (0.33+/-0.03 cm). Subanalyses in responders and non-responders to MAS treatment showed that the increase in upper airway calibre with mandibular advancement occurred only in responders.
These results suggest that the mechanism of action of MAS is to increase the volume of the upper airway, predominantly by increasing the volume of the velopharynx, and this increased volume is associated with changes in the surrounding bony and soft tissue structures.
Summary Obstructive sleep apnea syndrome (OSAS) is the most common sleep disordered breathing disorder (SDB) in adults and is characterized by a recurrent partial or complete collapse of the upper ...airway during sleep. This can be caused by many factors, sometimes interacting, such as skeletal malformations, soft tissue crowding, respiratory instability and the various effects of aging, obesity and gender that dictate craniofacial and upper airway anatomy. Research has demonstrated that the majority of patients exhibit at least one anatomical component such as retrognathia or a narrow posterior airway space that predisposes to the development of OSAS. Within the predisposing elements for OSAS many seem to point to anatomical characteristics. A standardized and relatively simple radiologic technique to evaluate anatomical craniofacial relationships is cephalometry. This has been used already for a long time in orthodontics, but is now gradually being introduced in OSAS treatment to envisage optimal treatment selection as well as to predict treatment outcomes. The purpose of the present review is to evaluate the contribution of cephalometry in the prediction of outcomes from OSAS treatments that depend on the upper airway morphology in their mechanisms of action such as oral appliances that advance the mandible as well as various surgical methods. In addition, an overview of imaging modalities and methods that currently are being used in cephalometric analysis in OSAS patients is provided. The findings indicate that isolated cephalometric parameters cannot be used to reliably predict treatment outcomes from mandibular advancement devices and surgical methods for OSAS. Extreme or outlying values of cephalometric parameters may rather be used as contra-indicators or ‘red flags’ instead of predictors.
Purpose
To compare the efficacy of twin‐block (i.e., allows mouth opening) and fixed (i.e., maintains mouth closure) mandibular advancement splints (MASs) for the treatment of obstructive sleep ...apnea–hypopnea syndrome (OSA).
Materials and Methods
From 2011 to 2013, 23 patients with OSA in the twin‐block group, and from 2013 to 2015, 29 patients in the fixed MAS group were included. All patients underwent polysomnography before and after 3 months of treatment. The two sets of polysomnographic and cephalometric variables were compared.
Results
A significant difference (p < 0.001) was observed in the apnea–hypopnea index before and after MAS treatment in both groups (twin‐block group: 20.6 ± 11.5 vs. 14.7 ± 9.4; fixed group: 21.4 ± 15.2 vs. 11.2 ± 9.7). In the twin‐block group, 5 patients (21.7%) were complete responders, 9 (39.1%) were fair responders, and 9 (39.1%) were nonresponders; the corresponding figures for the fixed group were 14 (48.3%), 9 (31.0%), and 6 (20.7%) patients. A significant between‐group difference was observed in the distribution of responders (p = 0.046). The fixed group showed a significant improvement in the snoring index (p = 0.003), arousal index (p = 0.036), and desaturation rate (p = 0.012). Finally, the change in incisal overjet was larger in the fixed group than in the twin‐block group (p < 0.001).
Conclusions
These results suggest that fixed oral appliances are superior in treating OSA, based on their ability to prevent mouth opening and reduce incisal overjet.
The liposomes have continued to be well-recognized as an important nano-sized drug delivery system with attractive properties, such a characteristic bilayer structure assembling the cellular ...membrane, easy-to-prepare and high bio-compatibility. Extensive effort has been devoted to the development of liposome-based drug delivery systems during the past few decades. Many drug candidates have been encapsulated in liposomes and investigated for reduced toxicity and extended duration of therapeutic effect. The liposomal encapsulation of hydrophilic and hydrophobic small molecule therapeutics as well as other large molecule biologics have been established among different academic and industrial research groups. To date, there has been an increasing number of FDA-approved liposomal-based therapeutics together with more and more undergoing clinical trials, which involve a wide range of applications in anticancer, antibacterial, and antiviral therapies. In order to meet the continuing demand for new drugs in clinics, more recent advancements have been investigated for optimizing liposomal-based drug delivery system with more reproducible preparation technique and a broadened application to novel modalities, including nucleic acid therapies, CRISPR/Cas9 therapies and immunotherapies. This review focuses on the recent liposome’ preparation techniques, the excipients of liposomal formulations used in various novel studies and the routes of administration used to deliver liposomes to targeted areas of disease. It aims to update the research in liposomal delivery and highlights future nanotechnological approaches.
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Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clinical outcomes. ...The purpose of this new guideline is to replace the previous and update recommendations for the use of OAs in the treatment of obstructive sleep apnea (OSA) and snoring.
The American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) commissioned a seven-member task force. A systematic review of the literature was performed and a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the quality of evidence. The task force developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms. The AASM and AADSM Board of Directors approved the final guideline recommendations.
1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD) 2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE) 3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD) 4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE) 5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE) 6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE).
The AASM and AADSM expect these guidelines to have a positive impact on professional behavior, patient outcomes, and, possibly, health care costs. This guideline reflects the state of knowledge at the time of publication and will require updates if new evidence warrants significant changes to the current recommendations.
Mandibular advancement devices (MADs) represent the main non-continuous positive airway pressure (non-CPAP) therapy for patients with obstructive sleep apnoea (OSA). The aim of the European ...Respiratory Society Task Force was to review the evidence in favour of MAD therapy. Effects of tongue-retaining devices are not included in this report. Custom-made MADs reduce apnoea/hypopnoea index (AHI) and daytime sleepiness compared with placebo devices. CPAP more effectively diminishes AHI, while increasing data suggest fairly similar outcomes in relation to symptoms and cardiovascular health from these treatments. Patients often prefer MADs to CPAP. Milder cases and patients with a proven increase in upper airway size as a result of mandibular advancement are most likely to experience treatment success with MADs. A custom-made device titrated from an initial 50% of maximum mandibular advancement has been recommended. More research is needed to define the patients who will benefit from MAD treatment compared with CPAP, in terms of the effects on sleep-disordered breathing and on other diseases related to OSA. In conclusion, MADs are recommended for patients with mild to moderate OSA (Recommendation Level A) and for those who do not tolerate CPAP. The treatment must be followed up and the device adjusted or exchanged in relation to the outcome.
Weaving national narratives from stories of the daily lives and familiar places of local residents, Francoise Hamlin chronicles the slow struggle for black freedom through the history of Clarksdale, ...Mississippi. Hamlin paints a full picture of the town over fifty years, recognizing the accomplishments of its diverse African American community and strong NAACP branch, and examining the extreme brutality of entrenched power there. The Clarksdale story defies triumphant narratives of dramatic change, and presents instead a layered, contentious, untidy, and often disappointingly unresolved civil rights movement.Following the black freedom struggle in Clarksdale from World War II through the first decade of the twenty-first century allows Hamlin to tell multiple, interwoven stories about the town's people, their choices, and the extent of political change. She shows how members of civil rights organizations--especially local leaders Vera Pigee and Aaron Henry--worked to challenge Jim Crow through fights against inequality, police brutality, segregation, and, later, economic injustice. With Clarksdale still at a crossroads today, Hamlin explores how to evaluate success when poverty and inequality persist.
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