IRUCAA@TDC : Review of systematic reviews on mandibular advancement oral appliance for obstructive sleep apnea: The importance of long-term follow-up.

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Title

Review of systematic reviews on mandibular

advancement oral appliance for obstructive sleep

apnea: The importance of long-term follow-up.

Author(s)

Alternative

Sato, K; Nakajima, T

Journal

The Japanese dental science review, 56(1): 32-37

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http://hdl.handle.net/10130/5099

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This is an open access article distributed under

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Description

JapaneseDentalScienceReview56(2020)32–37

Contents lists available atScienceDirect

Japanese

Dental

Science

Review

j o u r n a l h o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / j d s r

Review

Article

Review

of

systematic

reviews

on

mandibular

advancement

oral

appliance

for

obstructive

sleep

apnea:

The

importance

of

long-term

follow-up

Kazumichi

Sato

_,

_Tsuneya

_Nakajima

a_{DepartmentofOralMedicine,OralandMaxillofacialSurgery,TokyoDentalCollege,Chiba,272-8513,Japan} b_{DivisionofOtorhinolaryngology,IchikawaGeneralHospital,TokyoDentalCollege,Chiba,272-8513,Japan}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received20May2019

Receivedinrevisedform23May2019 Accepted27October2019

Keywords: Oralappliance Obstructivesleepapnea

Mandibularadvancementoralappliance Systematicreview

Clinic-baseddentists

s

u

m

m

a

r

y

Thepurposeofthisreviewwastopresentthecurrentlyavailableinformationonoralappliance(OA) therapyfordentists,especiallyclinic-baseddentists,toaidtheminperformingthistreatmentforthe managementofsymptomsofobstructivesleepapnea(OSA).Theclinicalresearchevidencecomprised ofsystematicreviewsconcernedwiththemandibularadvancementoralappliance(OAm).Continuous positiveairwaypressure(CPAP)issuperiortoOAtherapyinimprovingOSAsymptoms.Itisnecessary tosurveytheadherenceofpatientswhostoppedCPAPtherapytoOAmtherapy.Thereislittleevidence supportingthetheorythatOAmtherapypreventscardiovasculardiseaseorimprovesprognosis.There isstillroomtoinvestigatethetypesofOAm.OAmtherapyhascleardentalandskeletalsideeffects withlong-termuse,andtheseareimportantfordentists.However,acertainpercentageofpatients discontinueconsultations.Regardingconsultationrateforfollow-upandrepair/adjustmentsofOAm, thereareadvantagesfortheclinic-baseddentiststreatingOSAwithOAm.Webelievethatenhancing under-graduateandpost-graduateeducationonsleepmedicine,andestablishingaspecialistsystem couldbethestrategiesforenablingthedentiststohandleOAmtherapyindentalclinics.

©2019TheAuthors.PublishedbyElsevierLtdonbehalfofTheJapaneseAssociationforDental Science.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

1. Introduction

Oralappliance(OA)therapyforobstructivesleepapnea(OSA) attractedattentionintheWesterncountriesintheearly1990s.In Japan,OAbecameanacceptedtreatmentoptionforOSAinthe mid-1990s,andwasintroducedintotheNationalHealthInsurancein 2004.OSAisnormallydiagnosedbydoctors.Thisisbecausemany sleepdisordersexistasadifferentialdiagnosis.Whendoctorsselect OAasthemodeoftreatment,theyrequestthedentistto fabri-catethedevice.Ifthepatientsreportwithareferralfromadoctor, theyareeligibletoreceiveOAtherapythroughtheNationalHealth Insurance.

Thedentistswhocollaboratewithspecialistsinsleepmedicine performOAtherapy.Theseareusuallydentistsworkingatgeneral hospitalsordentalhospitals.DentalstudentsinJapanalsohave receivedsufficienteducationonOAtherapyforOSA.Some text-booksonOAtherapyforOSAhavebeenpublished,andscientific

∗ Correspondingauthor.

E-mailaddress:[email protected](K.Sato).

organizationsofsleepdentalmedicinehavebeeninauguratedin manycountriesincludingJapan.Therewillnowbemore oppor-tunities for clinic-based dentists to handle OA therapy. Hence, wereviewedthecurrentlyavailableevidenceonOAtherapyand providethe information usefulfor clinic-based dentiststo per-formOAtherapy.Inparticular,wehavefocusedonanddiscussed theimportance offollow-up monitoring.Regarding thetype of OA,mandibularadvancementoralappliance(OAm)hasbeen con-sidered more mainstream. The clinical research evidence used systematicreviews(SR)onOAmforthisstudy.

2. ReviewofSRs

2.1. Searchresults

The primary database used was Medline (via PubMed). No limits were applied to the year of study, but only studies published in the English language were included. A thorough literature search was conducted, and was completed on April 11, 2019. The search strategy used: (”Sleep apnea”[TIAB] OR “Sleep apnoea” OR ¨Sleep Apnea Syndromes¨[MeSH] OR “Sleep

https://doi.org/10.1016/j.jdsr.2019.10.002

1882-7616/©2019TheAuthors.PublishedbyElsevierLtdonbehalfofTheJapaneseAssociationforDentalScience.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

K. Sato, T. Nakajima / Japanese Dental Science Review 56 (2020) 32–37 33

Descriptionsofincludedsystematicreviews.

Firstauthor,

year

Journal AimsofSR:evaluationitems(primary

outcomes)

Numberof

includedstudies

SummaryofConclusions

Hoekema,2004 CritRevOralBiol

Med.

EfficacyandsideeffectsofOAm 13(respectively) OAmtherapyisaviabletreatmentespeciallyformildtomoderateOSA.

Lim,2006 CochraneDatabase

SystRev.

ComparisonbetweenOAmandother

treatments(daytimesleepiness,AHI)

17 ThereisincreasingevidencesuggestingthatOAmimprovessubjectivesleepinessandsleep

disorderedbreathing.CPAPappearstobemoreeffectiveinimprovingsleepdisorderedbreathing

thanOAm.

Ahrens,2010 AmJOrthod

DentofacialOrthop.

EfficacyofdifferentOAms(thesubjective

patient-centeredoutcome)

14 ThereisnospecificOAmdesignthatmosteffectivelyinfluencesthesubjectivelyperceived

treatmentefficacy

Ahrens,2011 EurJOrthod. EfficacyofdifferentOAms

(polysomnographicindices)

14 ThereisnospecificOAmdesignthatmosteffectivelyimprovespolysomnographicindices

Alsufyani,2013 SleepBreath. Changesintheupperairwayaftertherapy 3onOAm TheavailablepublishedstudiesprovideevidenceutilizingCBCTtomeasureanatomicairway

changespostsurgicalanddentalappliancetreatmentforOSA.

Iftikhar,2013 JClinSleepMed. EfficacyofOAm(bloodpressure) 7 ThepooledestimateshowsafavorableeffectofOAmonbloodpressure.

Okuno,2014 JOralRehabil. ComparisonbetweenOAmandCPAP

(AHI,ESS,arousalindexlowestSpO2,

SF-36)

5 OAmimprovesOSAwhencomparedwithuntreatedcontrols.CPAPappearstobemoreeffectivein

improvingOSAthanOAm.

Guarda-Nardini, 2015

JClinSleepMed. Predictivemethodsfortheefficacyof

OAm

13 Themandibularplaneangleandthedistancebetweenhyoidboneandmandibularplanewerefound

tohaveapredictivevalueforOAmeffectivenessinOSApatients.

Saffer,2015 IntArch

Otorhinolaryngol.

Predictivemethodsfortheefficacyof

OAm

14 Itremainsunclearwhichpredictivefactorcanbeusedwithconfidencetoselectpatientssuitablefor

treatmentwithOAm.

Bratton,2015 LancetRespirMed. ComparisonbetweenOAmandCPAP

(ESS)[networkmeta-analysis]

13onOAm CPAPseemedtobeamoreeffectivetreatmentthanOAm,andhadanincreasinglylargereffecton

moresevereorsleepierOSApatientswhencomparedwithinactivecontrols.

Sharples,2016 SleepMedRev. ComparisonbetweenOAmandCPAP

(AHI,ESS)

22onOAm CPAPisthemostclinicallyeffectivetreatmentinreducingAHIinmoderatetosevereOSA.

Serra-Torres, 2016

Laryngoscope. EfficacyofdifferentOAms 22 Adjustableandcustom-madeOAmsgivebetterresultsthanfixedandprefabricatedappliances.

Monoblocappliancescausemoreadverseeffects.

Okuno,2016 SleepMedRev. Predictivemethodsfortheefficacyof

OAm

17 Thepredictiveaccuracyvarieddependingonthedefinitionsoftreatmentsuccessusedaswellasthe

typeofindextest.

Bartolucci,2016 SleepBreath. Efficacyofdifferentamountsof

mandibularadvancement

13 TheAHIimprovementwasnotproportionaltothemandibularadvancementincrease.

Kastoer,2016 JClinSleepMed. Efficacyofremotelycontrolled

mandibularpositioner

4 RemotelycontrolledmandibularpositionermightbeapromisinginstrumentforpredictingOAm

treatmentoutcomeandtargetingthedegreeofmandibularadvancementneeded.

Kuhn,2017 Chest. ComparisonbetweenOAmandCPAP

(SF-36)

23 CPAPiseffectiveinimprovinghealth-relatedQOLinOSA,andOAmmaybejustaseffective,but

furtherRCTscomparingthetwotreatmentsarerequired.

Iftikhar,2017 SleepMed. ComparisonbetweenOAmandother

treatments(AHI,ESS)

Total80 CPAPisthemostefficaciousincompleteresolutionofsleepapneaandinimprovingtheindicesof

saturationduringsleep.

Cammaroto, 2017

MedOralPatolOral

CirBucal.

ComparisonbetweenOAmandCPAP

(AHI,ESS,lowestSpO2)

6 CPAPstillmustbeconsideredthegoldstandardtreatmentforOSAand,therefore,OAmmaybe

includedinthelistofalternativeoptions.

Sivaramakrishnan, 2017

JIndianProsthodont

Soc.

EfficacyofdifferentOAms 5 Theresultsfromthissystematicreviewdidnotshowsignificantadvantagesinusingtitratable

appliances

Schwartz,2018 SleepBreath. ComparisonbetweenOAmandCPAP

(Sleepiness,AHI,QOL,usagecompliance)

12 ThoughCPAPissignificantlymoreefficientinreducingAHI(moderatequalityofevidence),ithasa

significantlylowercomplianceresultinginnodifferencesinQOLwithOAm,andnocognitiveor

functionaloutcomes.

deVries,2018 SleepMedRev. EfficacyofOAm(cardiovascular

outcomes)

11 ItcouldbespeculatedthatOAmmayleadtoareductioninlong-termcardiovascularmorbidityand

mortalityinOSApatients.

Gao,2018 JFormosMedAssoc. ComparisonbetweenOAmandother

minimallyinvasivetreatments(AHI,ESS)

Total89 ConsideringtheeffectivenessinreducingbothAHIandESS,CPAPwasrankedthebest,followedby

OAmandpositionaltherapy,whilelifestylemodificationalonewastheleasteffectiveintervention.

Chen,2018 JOralMaxillofac

Surg.

Changesintheupperairwayaftertherapy

(computationalfluiddynamicsanalysis)

2onAm IntheresponderstoOAmtherapy,thevelocity,wallstaticpressure,andairwayresistanceofthe

upperairwaydecreased.InnonresponderstoOAmtherapy,thewallstaticpressureandairway

resistanceoftheupperairwayincreased.

Araie,2018 SleepMedRev. SideeffectsofOAm 21 SignificantchangeofOJ,OB,andL1-MPwasobservedinpatientswithlong-termOAuse,whilethere

werenosignificantchangesofskeletalindicesormandibularrotation.

Zhang,2018 Cranio. ComparisonbetweenOAmandCPAP

(AHI,lowestSpO2)

14 EventhoughCPAPcanbetterdecreasetheseverityofOSA,morepatientsoptedforOAm,which

showedbetterresultsinseverepatients,especiallyadjustableOAm.

Martins,2018 DentalPressJ

Orthod.

SideeffectsofOAm 6 ThelimitedavailableevidencesuggeststhatOAmtherapyforsnoringandOSAresultsinchangesin

craniofacialmorphologythatarepredominantlydentalinnature,especiallyonalong-termbasis.

Bartolucci,2019 EurJOrthod. SideeffectsofOAm 6 OAmtherapyproducestime-relateddentalandskeletalsideeffects.

AHI:apneahypopneaindex,CBCT:conebeamcomputedtomography,CPAP:nasalcontinuouspositiveairwaypressure,ESS:EpworthSleepinessScale,OAm:mandibularadvancementoralappliance,OSA:obstructivesleep apnea(includingobstructivesleepapnea-hypopneasyndrome),OJ:overjet,OB:overbite,QOL:qualityoflife,RCT:randomizedcontrolledtrial.

34 K.Sato,T.Nakajima/JapaneseDentalScienceReview56(2020)32–37

apnea syndrome”[TIAB] OR “Sleep apnoea syndrome”[TIAB] OR “Sleepapnea hypopneasyndrome”[TIAB]“Sleepapnea, Obstruc-tive”[MeSH]OR“Obstructivesleepapnea”[TIAB]OR“Obstructive sleepapnoea”OR“Obstructivesleepapneasyndrome”[TIAB]OR “Obstructivesleepapnoeasyndrome”[TIAB]OR“Obstructivesleep apneahypopneasyndrome”[TIAB] OR“Sleepdisordered breath-ing”[TIAB]OR“Sleeprelatedrespiratorydisorder”[TIAB]OR“Sleep respiratorydisorder”[TIAB])AND(“Oralappliance”[TIAB]OR“Oral device”[TIAB]OR“Oralsplint”[TIAB]OR“Mandibularadvancement appliance”[TIAB] OR “Mandibular advancement device”[TIAB] OR “Mandibular advancement splint”[TIAB] OR “Dental appli-ance”[TIAB]OR“Dentaldevice”[TIAB]OR“Dentalsplint¨[TIAB]OR “Mandibularrepositioningappliance”[TIAB]OR“Mandibular repo-sitioningdevice”[TIAB]OR“Mandibularrepositioningsplint”[TIAB] OR“Prostheticmandibularadvancement”[TIAB]OR“Mandibular Advancement/instrumentation¨[MeSH])AND (( ¨Meta-Analysis¨[PT] OR ¨meta-analysis¨[TIAB])OR( ¨CochraneDatabaseSystRev¨[TA]or ¨systematicreview¨[TIAB])).Wesearchedthrough50articles,and excluded articles on pediatric subjects, treatments other than OA,andthosewritteninlanguagesotherthanEnglish.Wealso excluded the articles, such as short communications, evidence reports,andclinicalpracticeguidelines.ThereweresomeCochrane reviewsbyLimJetal.,andanSRin2006[1]wasnotsearchedin thissearchstrategy.However,weincludedthisSR.Zhuetal.[2] includedstudiesonOA,butnotOAm.Liuetal.[3]didnotdescribe thetypesofOA,andhencethoseSRswereexcluded.Ultimately,27 articleswereincluded[1,4–29].DescriptionsoftheincludedSRs areshowninTable1.In2016,Al-Jewairetal.[30]examinedthe methodologicalqualityoftheSRsandthemeta-analyses(MA)on OAtherapy.TheyconcludedthattheSRsonOAtherapyforadult andpediatricsleep-disorderedbreathing’wereconductedwithan overallacceptablemethodologicalquality.

Breakdown of the content of the 27 SRs is as follows: there were 10 articles on comparison with other treatments [1,9,12,13,18–20,22,24,27], five articles on the types of OAm [5,6,14,16,21],andsixarticlesontheeffectofOAmandthe associ-atedsideeffects[4,8,23,26,28,29].Therewerealsothreearticleson predictingthetherapeuticeffectofOAm[10,11,15],twoarticleson changesintheupperrespiratorytractcausedbythistherapy[7,25], andone articleona remotelycontrolledmandibularpositioner [17].TheSRbyOkunoetal.[15]basedonpredictingthetherapeutic effectsofOAmwasthelatest.Theyconcludedthatthepredictive accuracyvarieddependingonthedefinitionsoftreatmentsuccess used,aswellasthetypeofindextest.

2.2. Comparisonwithothertreatments

TheSRsoncomparisonofOAmwithothertreatmentsalways includednasalcontinuouspositiveairwaypressure (CPAP).OSA symptomsweresetasstudyoutcomes,andtheseincludedApnea HypopneaIndex(AHI),EpworthSleepinessScale,andQualityof Life.Cross-overstudieswerealsoincluded;andhence,therewere alargenumberofshort-termstudies.AlltheSRsstatedthatthe CPAPwasmoreeffectivethanOAmwithrespecttothe aforemen-tionedoutcomes.Cammarotoetal.[20]concludedthatCPAPstill mustbeconsideredthegoldstandardtreatmentforOSA,andOAm maybeincludedinthelistofalternativeoptions.Kuhnetal.[18] examinedtheQualityofLifeindexandcommentedthatCPAPwas effectiveinachievingthisoutcome.Theyalsocarefullycommented thatinvestigationwitharandomizedcontrolledtrial(RCT)was needed.Schwartzetal.[22]examinedadherence,and analyzed thattheusagetimeofCPAPisaroundonehourshorterthanthat ofOAm.However,theseresultsdemonstrated a highdegreeof heterogeneitybetweenstudies.

CPAP and OAm are the two major conservative treatment optionsforOSA.WealsoreachedthefinalconclusionthatCPAPis

superiortoOAmintermsofimprovingOSAsymptoms,astypified bytheAHI.Thereisstillroomtoinvestigateadherence.Itis par-ticularlyessentialtomonitortheadherenceofpatientswhohave withdrawnfromCPAPtherapy,whentheyuseOAm.Ontheother hand,inclinicalpractice,itisimportanttopursuethereasonwhy patientsareunabletouseCPAPorOAmcontinuously,and take actiontoexcludetherespectivecauses.Goodadherencecanbe achievedwithinafewmonths.

2.3. TypesofOAm

TherearevarioustypesofOAm.OAmarebroadlydividedinto twotypes:typeswithupperandlowerjawsseparatedandtypes withfixedjaws.InJapan,whenOAtherapyisprovidedthrough theNationalHealthInsurance,thefixedtypesofOAmareoften used tobalancethe costsof the technician.In this review, we searchedthroughfiveSRsontypesofOAm.Ahrensinvestigatedthe subjectivepatient-centeredoutcomes[5]andpolysomnographic indices[6].Theyconcludedthattheywereunabletodemonstrate themosteffectivetypeofOAthroughbothinvestigations. Serra-Torresetal.[14]concludedthatadjustableandcustom-madeOAms givebetterresultsthan fixedand prefabricatedappliances;and monoblocappliancescausemore adverseeffects. However,this conclusionwastheirinterpretationoftheincludedobservational studies.SivaramakrishnanandSridharan[21]comparedthe titrat-able OAmwiththe fixednon-titratable OAm.He includedfive studies.Fourofthefivestudieswereobservational,andonewas ashort-termcross-overrandomizedtrial.Therewasahighdegree ofheterogeneitybetweenthestudyresults,sotheydidnotconduct ameta-analysis.Therefore,theyconcludedthat“ThisSRdoesnot demonstratesignificantadvantagesinusingtitratableappliances”. Thisfieldhasmanyunresolvedquestions.Itisessentialto inves-tigateadherenceinadditiontoimprovementofOSAsymptoms, typifiedbytheAHI.Itisalsonecessarytoinvestigatethelong-term dentalandskeletalsideeffects.

OAmpositions the lower jaw anteriorly,thereby improving upperrespiratorytractobstruction.Bartoluccietal.[16] investi-gatedtheanteriorpositioningofthelowerjaw.TheyincludedRCT datatoanalyzetheratioofthemaximumpossibledistanceof ante-riormovementandimprovementrateofAHI,usingabubbleplot. TheyconcludedthattheimprovementintheAHIwasnot propor-tionaltotheincreaseinmandibularadvancement.Wealsofound thattheappropriatepositionofthelowerjawisnotuniform,and itdiffersdependingupontheindividual.However,inJapan,where thefixedOAm(non-titratable,butadjustableOAm)ismainstream, itisworthwhiletoprovidedentistswithanindicationoftheinitial positionofthemandible.

2.4. EffectofOAmandsideeffects

An important outcome of OSA treatment is prevention of complicationstypifiedbycardiovasculardisease,andreducingthe mortalityassociated with thesecomplications. This outcome is moreimportantforseverecasesofOSA.Mildcasesalsorequire cautionwithincreaseinthebaselineofAHIcausedbyagingand weightgain.TherearetwoSRsonimprovementofcardiovascular disease [8,23]. Iftikhar et al. [8] evaluated blood pressure, and concludedthat thepooledestimateshows a favorable effectof OAmonbloodpressure.However,healsostatedthatalmostall the data came from observational studies. Five years later, de Vriesetal.[23]evaluatedthecardiovasculareffects.AlltheRCTs hadafollow-upperiodofthreemonths,whichwasconsideredto betooshort.DeVriesetal.[23]alsocommentedthatonestudy [31]showedthatOAmwasaseffectiveasCPAPinreducingdeath fromacardiovascularcause,butthatstudywasnotanRCT,andit probablyhadselectionbias.Webelieveusingapropensityscore

andconductingalong-termobservationalstudywithacarefully designedOAmcouldresolvethisquestion.

TheSRbyHoekemaetal.[4]wasthefirstoneonOAm.They comparedOAmwithothertreatments,conductedameta-analysis onevaluationofthetypeofdevice,andalsoevaluatedsideeffects. Afterthat,therewerenoSRspublishedonsideeffectsforsome time.Patientscantoleratemanyshort-termsideeffects.However, thereareirreversiblesideeffectsamongthosethatoccuroverthe long-term.Therehasbeenanincreaseinthenumberofstudieswith longerstudyperiods.AnSRonlong-termsideeffectshasrecently beenpublished[26,28,29].Thereweredifferencesinthenumberof studiesincludedinthethreeSRs.ThereasonforthisisthatMartins etal.[28]includedRCTsonly.Thereweredifferencesinthe stud-iesincludedbyAraieetal.[26]andBartoluccietal.[29]because ofthesearchdate,andBartoluccietal.[29]onlytargetedstudies whereOAmwasusedfortwoormoreyears.Theinterpretationof thestudiesdifferedamongthethreeSRs.Forexample,thestudy byRingqvistetal.[32]wasincludedasanRCTbyMartinsetal. [28],andasanon-randomizedstudybyAraieetal.[26].However, itwasnotincludedatallbyBartoluccietal.[29].Eitherway, mor-phologicalchangesintheteethandskeletonwereseenoverthe long-term(Araieetal.[26]statedthattherewerenochangesin skeletalindicesormandibularrotation).Bartoluccietal.[29]used abubble plot,and concludedthatOAmtherapyproduces time-relateddentalandskeletalsideeffects.

Araieetal.[26],statedtheimportanceofcliniciansbeingaware ofthesideeffects.Wealsoemphasizeonthedutyofdentiststo explainthelong-termsideeffectstopatientsattheirinitialvisit totheclinic.Itisvitaltodealwiththesesideeffectsatanearly stage.One of the long-termside effects is posterior openbite. Reportsindicatethat70%ofthepatientsareunawareofthis symp-tom[33].Theextentofawarenessofmasticatorydisturbancesand cosmeticdisturbancescausedbydentalandskeletalsideeffects differsdependingonthepatient.Dentistsmustrespondtothese long-termsideeffectsonacase-by-casebasis.Regularpersistent follow-upmonitoringisimportant.AmongtheSRsincludedinthis study,noneinvestigatedlong-termadherence.Weconfirmedthis situationinourhospitalandalsoinvestigatedthesituationinthe studiesincludedintheSRs.Inparticular,weinvestigatedthe exam-inationsconductedbydentists,namelyfollow-upmonitoring.

3. Consultationrateforfollow-up:atourhospitalandin literature

3.1. Currentsituationinourhospital

Herewereportthecurrentsituationinourhospital(Ichikawa GeneralHospital,TokyoDentalCollege).Thedentistsinthis hospi-talhavebeentreatingpatientsdiagnosedwithOSAbythedivision ofotolaryngologyofthishospitaloranotherhospitalwithfixed OAmsince1999.Thepositionofthelowerjawwasadjusted refer-encingsubjectivesymptomsorsleeptests.Follow-upmonitoring wasstartedoncethepatientwasfreeofdiscomfort,andtheeffectof thedevicehasbeenconfirmedusingsleeptests.Thelongest dura-tionoffollow-upmonitoringwassetassixmonths.Themedical consultationsituationwascheckedeverytwomonths,andwe con-tactedpatientswhohaddiscontinuedconsultationsbytelephone. Patientswhohadnothadamedicalconsultationforoneyearor more,despiterepeatedtelephonecalls,wereconsideredtohave discontinuedtreatment(dropoutcase).

WesurveyedpatientswhohadreceivedOAmtherapyinthe one-yearperiod betweenJune 2015and May2016(in-hospital ethicsreviewnumber:I16–48).Theconsultationsituationofthe patientsduringthisperiodwascheckeduptoFebruary2019.There were46patientsintotal.Fivepatientswereunabletocontinueuse

duetoinabilitytogetusedtothedeviceorjawpain.Twopatients discontinuedtreatmentduetorelocation,andonepatientswitched toCPAP.OAmtherapywasstartedintheremaining38patients,but eightpatientsstoppedreportingforconsultationsbeforethesleep test.Approximately20%ofthepatientsrefusedtoundergothetest toconfirmtheeffect.Onepatientwasfoundnottohaveanyeffect fromthesleeptest.Finally,29patientshadtheeffectofthe treat-mentconfirmedwithasleeptest,andfollow-upmonitoringwas startedforthem.Sevenofthesepatientsdiscontinued consulta-tions.Duringtheapproximatethreeyearsoffollow-upmonitoring, oneinfourpatientsdiscontinuedconsultations.Somepatientswho discontinuedconsultationsarestillusingOAm.Hence,thisvalueis thepercentageofpatientswhocontinuedconsultation,andnotthe percentageofthosewhocontinuedtouseOAm.

3.2. Consultationrateintheliterature

WeusedthestudiesincludedintheSRsthatinvestigated long-termsideeffects[26,28,29].Doffetal.conductedanRCTcomparing OAmwithCPAP,andreportedtheresultsinmultiplearticles.We checked theFlow diagram by Doff et al. [34]. Sevenof the 51 patientswhoswitchedtoCPAPpartwaythroughthestudy;hence, 44 patientsweretreated withOAm. Twopatientswerelost to follow-up in thefirsttwo months,and one patientwaslost to follow-upbytheendofthestudy,twoyearslater.Thisgoodresult achievedintheirstudydemonstratesabiasofthecases participat-ingintheRCT.Weexaminedtheprospectiveobservationalstudies includedbyAraieetal.[26] andBartoluccietal.[29].Fransson etal.[35]reportedthat12outof77patients(15.6%) discontin-uedtreatmentoftheirownaccordduringthetwo-yearobservation period.Houetal.[36]reportedthat27outof151patients(17.9%) failedtoattendfollow-upappointmentsinthethree-year observa-tionperiod.Martínez-Gomisetal.[37]reportedthatnineoutof40 patients(22.5%)discontinuedtreatmentoftheirownaccordduring thefive-yearobservationperiod.Sharplesetal.[38]summarizedan investigativereportonclinicaleffectivenessandcost-effectiveness. Thiswasoneofthearticlesexcludedfromthisreview.They intro-ducedaFrenchcohortwitha76%usagerate(notconsultationrate) over2.75years[39].

Theaforementioneddataarefromthefacilitiesthatconducted theresearch.Weestimatethat20–25%ofpatientsstopcoming forconsultations(includingpatientsstillusingthedevice)when OAmtherapyiscontinuedforapproximatelythreeyearsinthese facilities.

4. Conclusions

4.1. Summarytodate

• CPAPissuperiortoOAinimprovingOSAsymptoms.

• ItisnecessarytosurveytheadherencetoOAmtherapyofpatients whostoppedCPAPtherapy.

• ThereislittleevidencesupportingthetheorythatOAmtherapy preventscardiovasculardiseaseorimproveslifeprognosis. • OAmtherapyhasdentalandskeletalsideeffectswithlong-term

use.

• ThereisstillroomtoinvestigatethetypesofOAm.Itis partic-ularlyessentialtoinvestigateadherenceandsideeffects after startingfollow-upmonitoring(oncetheeffectofOAmhasbeen confirmed).

36 K.Sato,T.Nakajima/JapaneseDentalScienceReview56(2020)32–37

4.2. Expectationsfromclinic-baseddentistsinvolvedinOAm therapy

Theclearresultsare:superiorityofCPAPanddentalandskeletal sideeffectsofOAm.Thelatterisespeciallyimportantfordentists. Long-termfollow-upmonitoringbydentistsisimportanttodeal withthissideeffectsofOAmandworseningoftheOSAbaseline. Thisreviewhasreiteratedtheimportancenotonlyoflong-term useofthedevicebypatients,butalsotheimportanceofreporting forconsultationsatamedicalinstitution,andbeingexaminedby dentists.However,thereareacertainnumberofpatientswho hesi-tatetovisitgeneralhospitalsordentalhospitals.Oneofthereasons forthisisthatalargenumberofthepatientsaremiddle-agedmen whoworkduringtheday.Clinicsareeasiertoattendthanhospitals. WebelievethatprovidingOAmtherapyinacliniccouldimprove thecontinuingconsultationrate.OAmrequiresadjustmentwhen patientsaretreatedwithdentalprosthetics.Fromthisperspective, thereareadvantagesintheclinic-baseddentiststreatingpatients withOAm.Themaintenanceintervalforperiodontitisisalsothe idealinterval forfollow-upmonitoringofOAtherapy.Although thepurposeofthisreviewwastoprovidethecurrentevidenceof OAmforclinic-baseddentists,thisreviewalsoprovesthebenefit ofdentalclinic-basedOAmtherapy.

Ontheotherhand,theAmericanAcademyofSleepMedicine andtheAmericanAcademyofDentalSleepMedicinecreateda clin-icalpracticeguidelinein2015[40].Thisclinicalpracticeguideline recommendsthatfollow-upmonitoringistobecontinued appro-priatelybysleepphysiciansandqualifieddentists.Itisimportant tofosterdentistswhoareabletodealwithsleepmedicine,which includesconductingmedicalexaminationsincollaborationwith sleep physicians. Enhancing under-graduate and post-graduate educationonsleepmedicine,andestablishingaspecialistsystem arestrategiesforfosteringtheabilityofdentiststohandleOAm therapyindentalclinics.Ontheotherhand,OAmplacesaburden ontheteethandthejaws.Searchingforanalternativetherapyis thedutyofdentists.Weanticipatethatincreasingthenumberof dentistsinvolvedinsleepmedicinewillresultinthecreationof newideasforanalternativetherapy.

Conflictsofinterestandsourceoffunding

Therearenoconflictsof interesttodeclare.No fundingwas acquiredforthisstudy.

Acknowledgments

Wewouldliketothanktheclinicalfellowsandstaffdoctorsof theDepartmentofOralMedicine,OralandMaxillofacialSurgery, TokyoDentalCollege,whohavetreatedthepatientswithOSAusing OAm.

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