Gioia Luca. Il Ruolo dei dispositivi intraorali nella terapia dell'Osas. ASMaD 2011

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  • 1. IL RUOLODEI DISPOSITIVI INTRAORALI NELLA TERAPIA DELL’OSASDott. Luca Gioia
  • 2. ODONTOIATRIA ed OSAS1. Cenni storici sulla letteratura2. Linee guide MAS3. Panoramica e caratteristiche dispositivi MAS
  • 3. Paskow H, Paskow S. New Jersey Medicine. 1991 Nov;88(11):815-7. Dentistrys role in treating sleep apnea and snoring.Dental appliances have a place in the treatment of loud snoring and obstructive sleep apnea (OSA), and may be indicated for those patients who cannot tolerate continuous positive air pressure ventilation.Physicians and dentists must work together for the health, comfort, and well-being of patients.
  • 4. Schmidt-Nowara W, Lowe A, Sleep. 1995 Jul;18(6):501-10. Oral appliances for the treatment of snoring and obstructive sleep apnea: a review.1. The appliances modify the upper airway by changing the posture of the mandible and tongue.2. Snoring is improved and often eliminated in almost all patients who use oral appliances3. Obstructive sleep apnea improves in the majority of patients; the mean apnea-hypopnea index (AHI) in this group of patients was reduced from 47 to 19. Approximately half of treated patients achieved an AHI of < 10; however, as many as 40% of those treated were left with significantly elevated AHIs.4. Improvement in sleep quality and sleepiness reflects the effect on breathing
  • 5. Schmidt-Nowara W, Lowe A. Sleep. 1995 Jul;18(6):501-10. Oral appliances for the treatment of snoring and obstructive sleep apnea: a review.1. Compliance varies from 50% to 100% of patients2. Comparison of the risk and benefit of oral appliance therapy with the other available treatments suggests that oral appliances present a useful alternative to continuous positive airway pressure (CPAP), especially for patients with simple snoring and patients with obstructive sleep apnea who cannot tolerate CPAP therapy.
  • 6. Barsh LI. Sleep Disorders Dental Society Wexford, Pennsylvania, USA.Compend Contin Educ Dent. 1996 May;17(5):490-4, 496 passim; quiz 502.1. Responsibilities of the dental profession in recognizing and treating sleep breathing disorders.2. Oral appliance therapy has been accepted by the American Sleep Disorders Association as an appropriate treatment modality for some patient.3. It is essential, however, that dentists work as part of the treatment team and not assume responsibility for diagnosis and treatment without the involvement of a physician or sleep specialist.
  • 7. Barsh LI. Sleep Disorders Dental Society Wexford, Pennsylvania, USA.Compend Contin Educ Dent. 1996 May;17(5):490-4, 496 passim; quiz 502. Responsibilities of the dental profession in recognizing and treating sleep breathing disorders. dentist can identify patients with sleep-breathing disorders and participate in their treatment it is essential that dentists realize that snoring and obstructive sleep apnea are medical and not dental problems
  • 8. Findely LJ Automobile accident involving patients with osasAmerican Review of Respiratory Disease 138: 337-340, 1988 INCIDENTI AUTOMOBILISTICI Rischio 7 volte superiore
  • 9. Riley RW et al Trends in OSA therapyWest J of Medicine 162: 143-148, 1995 PERDITA DI PRODUTTIVITA’ 20 miliardi di dollari annui
  • 10. ODONTOIATRIA ed OSAS1. Cenni storici sulla letteratura2. Linee guide MAS3. Panoramica e caratteristiche dispositivi MAS
  • 11. ODONTOIATRIA e OSASFondata nel 1991 Fondata nel 2004
  • 12. Hoffstein V. Sleep Breath. 2007 Mar;11(1):1-22. Review of oral appliances for treatment of sleep- disordered breathing. 89 publications dealing with oral appliance therapy involving a total of 3,027 patients Parameters:1. reduction in the apnea/hypopnea index2. ability of oral appliances to reduce snoring3. comparison of oral appliances with other treatments4. side effects5. long-term compliance
  • 13. Hoffstein V. Sleep Breath. 2007 Mar;11(1):1-22. Review of oral appliances for treatment of sleep- disordered breathing. Epworth sleepiness score (ESS) dropped from 11.2 to 7.8 in 854 patients 54 % riduzione AHI (<10) 50% negli studi random e placebo-ctr 45 % riduzione snoring MAD reduced initial AHI by 42%, CPAP reduced it by 75%, and UPPP by 30% compliance data shows that at 30 months, 56-68% of patients continue to use oral appliance
  • 14. Hoffstein V. Sleep Breath. 2007 Mar;11(1):1-22. Review of oral appliances for treatment of sleep-disordered breathing. We conclude that oral appliances, although not as effective as CPAP in reducing sleep apnea, snoring, have a definite role in the treatment of snoring and sleep apnea.
  • 15. A. Hoekema et al J Dent Res. 2008 Sep;87(9):882-7 Obstructive sleep apnea therapy 103 individuals N= 51 oral-appliance N= 52 CPAP therapy
  • 16. Obstructive sleep apnea therapy. A. Hoekema et al
  • 17. Aarab G, Lobbezoo F, Hamburger HL, Naeije M . Respiration. 2011;81(5):411-9. Epub 2010 Oct 20. Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial 64 pz mild-moderate OSAS 3 gruppi: MAD – nCPAP – placebo 2 polysomnographic recordings: before and after 6 month CONCLUSIONS There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA
  • 18. Aarab G. et al Clin Oral Investig. 2011 May 3Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on temporomandibular side effects 43 pz (52.2 ± 9.6 years) AHI of 20.8 ± 9.9 2 groups: n=21 MAD n=22 nCPAP 4 polysomnographic recordings no difference between the MAD and the nCPAP groups with mild/moderate obstructive sleep apnea.
  • 19. Holley AB Chest. 2011 Jun 2.Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure For the Treatment of Obstructive Sleep Apnea Syndrome Retrospective analysis 497 pz AHI < 5 70,3% mild 47,6% moderate 41,4% severe with MAS CPAP 70,1% MAS 51,6%The AOA is comparable to CPAP for patients with mild disease, while CPAP is superior for patients with moderate to severe disease.
  • 20. ODONTOIATRIA ed OSAS L’odontoiatra può individuare i fattori predittivi : Circonferenza collo (> 43 cm maschi, > 41 cm femmine) Retrognazia Grading tonsillare Classificazione di Mallampati Epworth Sleepiness Scale
  • 21. ODONTOIATRIA ed OSAS PAS Posterior Airway Space < 9 mm
  • 22. ODONTOIATRIA ed OSAS
  • 23. ODONTOIATRIA ed OSASMeccanismo d’azione
  • 24. ODONTOIATRIA ed OSAS L’APERTURA DELLE VIE AEREE POSTERIORI ALLA LINGUAAVVIENE IN PARTICOLARE NELLA ZONA LATERALE Stiramento dei tessuti molli
  • 25. ODONTOIATRIA ed OSAS
  • 26. ODONTOIATRIA ed OSAS1. Cenni storici letteratura2. Linee guide MAS3. Panoramica e caratteristiche dispositivi MAS
  • 27. Dispositivi intraorali – Oral appliance Dispositivi di ritenzione linguali (TRD) =Tongue retaining devices Propulsori mandibolari (MAS) = Mandibular advamcement device
  • 28. Dispositivi di ritenzione linguali (TRD)
  • 29. Dispositivi di ritenzione linguali (TRD)
  • 30. Propulsori mandibolari (MAS)
  • 31. Propulsori mandibolari (MAS)
  • 32. Propulsori mandibolari (MAS)
  • 33. Propulsori mandibolari (MAS) somnodent
  • 34. Propulsori mandibolari (MAS)
  • 35. Propulsori mandibolari (MAS)
  • 36. Propulsori mandibolari (MAS)Quanto avanzare la mandibola?
  • 37. Propulsori mandibolari (MAS) SCHMIDT-NOWARA W et al SCHMIDT-NOWARA W et al Oral appliance for the treatment of snoring and OSA: a review Oral appliance for the treatment of snoring and OSA: a review Sleep 1995; 18: 501-510 Sleep 1995; 18: 501-510 La mandibola deve essere al 75% della protrusione massima per ottenere risultati. MARKLUND M et alThe effect of a mandibular advancement device on apneas and sleep in patients with OSA Chest 1998; 113: 707-713 La mandibola deve essere dal 41% al 88% della protrusione massima per ottenere risultati.
  • 38. Propulsori mandibolari (MAS)MASSIMA POSIZIONE DI CONFORTO DINAMICA DEL PAZIENTE Ginnastica miofascialePosizione testa a testaDalla massima intercuspidazione scivolarecon gli incisivi in posizione testa atesta inspirando; tenere la posizione per 10 sec, tornare indietro espirando.CarotaRosicchiare e masticare una carota solo con gli incisivi.Contro-resistenzaCon la bocca socchiusa, opporsi alla forza retrusiva esercitata sul mento dalpaziente o dall’operatore.
  • 39. Propulsori mandibolari (MAS) EFFETTI COLLATERALI COMUNI:1)Salivazioneaumentata2)Temporaneo disagio ATM3)Gola secca4)Temporaneo disagio all’occlusione
  • 40. Propulsori mandibolari (MAS) Collaborazione de Almeida et al Journal of Clinical Sleep Medicine 2005;1(2):143-49. Long-term compliance and side effects of oral appliances used from the treatment of snoring and obcstructive sleep apnea syndrome544 pazienti (di cui 251 dopo una media di 5,7 anni)64% stava ancora usando l’apparecchio94% lo portava per più di 4 ore a notte95% era pienamente soddisfatto del trattamento
  • 41. Propulsori mandibolari (MAS) Collaborazione al 75 % ai sette mesi Smidt-Novara WW et al Chest 1991; 99: 1378-1385 Treatment of snoring and OSA with a dental orthosis al 52 % dopo 3 anni Clark Gt et al Am Rev Respir Ds 1993; 147: 624-629 Effect of anterior mandibular positioning on OSA al 70 % dopo 5 anni MarKlund M et al Eur J Orthod 2001; 23: 135-144 Orthodontic side effects of mandibular advancementdevices during the treatment of snoring and sleep apnea