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Sleep and Breathing

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01-12-2014 | Original Article

Mandibular advancement device and CPAP upon cardiovascular parameters in OSA

Authors: Cibele Dal-Fabbro, Silvério Garbuio, Vânia D’Almeida, Fátima D. Cintra, Sergio Tufik, Lia Bittencourt

Published in: Sleep and Breathing | Issue 4/2014

Abstract

Purpose

This study aims to compare the effects of a mandibular advancement device (MAD) with continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA) on blood pressure (BP), oxidative stress, and heart rate variability (HRV) in a randomized, crossed-over, single-blind, and controlled trial.

Methods

Twenty-nine moderate-to-severe adult OSA patients underwent MAD, CPAP, and placebo oral appliance treatment. Polysomnography, Epworth sleepiness scale, 24-h ambulatory BP monitoring, oxidative stress parameters (malondialdehyde, catalase, superoxide dismutase, vitamins C, E, B₆, B₁₂, folate, homocysteine, uric acid), and HRV were assessed at baseline and after 1 month of each treatment. Diaries were used to evaluate compliance for devices and a pressure–time meter for CPAP.

Results

Both active treatments resulted in decreases in apnea and hypopnea index and Epworth sleepiness scale; CPAP showed a greater effect. Frequency of diastolic BP dipping was higher in the MAD group compared with the CPAP group. A significant drop from baseline levels for catalase activity was observed after MAD. For HRV, there was a significant decrease in total power at night with CPAP and MAD compared with POA, and a decrease in index of sleep autonomic variation with MAD compared with baseline levels. Compliance rates were higher with MAD rather than CPAP.

Conclusions

Even though CPAP proved to be more effective at attenuating OSA, better compliance with MAD favored the reduction of one of the enzymes which participates in oxidative stress and better autonomic modulation during sleep.

Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342:1378–1384PubMedCrossRef

Young T, Peppard PE, Gottlieb DJ (2002) Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 165:1217–1239PubMedCrossRef

Shamsuzzaman AS, Gersh BJ, Somers VK (2003) Obstructive sleep apnea. Implications for cardiac and vascular disease. JAMA 290:1906–1914PubMedCrossRef

Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, Stubbs R, Hla KM (2008) Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin Sleep Cohort. Sleep 31:1071–1078PubMedCentralPubMed

Marshall NS, Wong KK, Liu PY, Cullen SR, Knuiman MW, Grunstein RR (2008) Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep 31:1079–1085PubMedCentralPubMed

Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O’Connor GT, Rapoport DM, Redline S, Resnick HE, Robbins JA, Shahar E, Unruh ML, Samet JM (2009) Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 6(8):e1000132PubMedCentralPubMedCrossRef

Prabhakar NR (2001) Oxygen sensing during intermittent hypoxia: cellular and molecular mechanisms. J Appl Physiol 90:1986–1994PubMedCrossRef

Prabhakar NR (2002) Sleep apneas: an oxidative stress? Am J Respir Crit Care Med 165:859–860PubMedCrossRef

Lavie L, Vishnevsky A, Lavie P (2004) Evidence for lipid peroxidation in obstructive sleep apnea. Sleep 27:123–128PubMed

10.

Lavie L (2003) Obstructive sleep apnoea syndrome—an oxidative stress disorder. Sleep Med Rev 7:35–51PubMedCrossRef

11.

Dyugovskaya L, Lavie P, Lavie L (2002) Increased adhesion molecules expression and production of reactive oxygen species in leukocytes of sleep apnea patients. Am J Respir Crit Care Med 165:934–939PubMedCrossRef

12.

Carpagnano GE, Foschino-Barbaro MP, Resta O, Barnes PJ (2005) Oxidative stress and cardiovascular complications in sleep apnea. Chest 127:2294PubMedCrossRef

13.

Somers VK, Dyken ME, Clary MP, Abboud FM (1995) Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest 96:1897–1904PubMedCentralPubMedCrossRef

14.

Narkiewicz K, Montano N, Cogliati C, van de Borne PJ, Dyken ME, Somers VK (1998) Altered cardiovascular variability in obstructive sleep apnea. Circulation 98:1071–1077PubMedCrossRef

15.

Schulz R, Mahmoudi S, Hattar K, Sibelius U, Olschewski H, Mayer K, Seeger W, Grimminger F (2000) Enhanced release of superoxide from polymorphonuclear neutrophils in obstructive sleep apnea: impact of continuous positive airway pressure therapy. Am J Respir Crit Care Med 162:566–570PubMedCrossRef

16.

Jelic S, Jemtel THL (2008) Inflammation, oxidative stress, and the vascular endothelium in obstructive sleep apnea. Trends Cardiovasc Med 18:253–260PubMedCrossRef

17.

Becker HF, Jerrentrup A, Ploch T, Grote L, Penzel T, Sullivan CE, Peter JH (2003) Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea. Circulation 107:68–73PubMedCrossRef

18.

Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, Boehlecke B, Brown TM, Coleman J Jr, Friedman L, Kapen S, Kapur VK, Kramer M, Lee-Chiong T, Owens J, Pancer JP, Swick TJ, Wise MS; American Academy of Sleep Medicine (2006) Practice parameters for the use of continuous and bi-level positive airway pressure devices to treat adult patients with sleep-related breathing disorders. An American Academy of Sleep Medicine Report. Sleep 29:375–380

19.

Narkiewicz K, Kato M, Phillips BG, Pesek CA, Davison DE, Somers VK (1999) Nocturnal continuous positive airway pressure decreases daytime sympathetic traffic in obstructive sleep apnea. Circulation 100:2332–2335PubMedCrossRef

20.

Bonsignore MR, Parati G, Insalaco G, Marrone O, Castiglioni P, Romano S, Di Rienzo M, Mancia G, Bonsignore G (2002) Continuous positive airway pressure treatment improves baroreflex control of heart rate during sleep in severe obstructive sleep apnea syndrome. Am J Respir Crit Care Med 166:279–286PubMedCrossRef

21.

Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP, American Academy of Sleep (2006) Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 29:240–243PubMed

22.

Bittencourt LRA (2008) Academia Brasileira de Neurologia, Associação Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial. Diagnóstico e tratamento da Síndrome da Apnéia Obstrutiva do Sono (SAOS) - Guia Prático. São Paulo: Livraria Médica Paulista Editora

23.

Naismith SL, Winter VR, Hickie IB, Cistulli PA (2005) Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med 1:374–380PubMed

24.

Johal A (2006) Health-related quality of life in patients with sleep-disordered breathing: effect of mandibular advancement appliances. J Prosthet Dent 96:298–302PubMedCrossRef

25.

Barnes M, McEvoy RD, Banks S (2004) Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 170:656–664PubMedCrossRef

26.

Gotsopoulos H, Kelly JJ, Cistulli PA (2004) Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial. Sleep 27:934–941PubMed

27.

Otsuka R, Almeida FR, Lowe AA, Linden W, Ryan F (2006) The effect of oral appliance therapy on blood pressure in patients with obstructive sleep apnea. Sleep Breath 10:29–36PubMedCrossRef

28.

Yoshida K (2006) Effect on blood pressure of oral appliance therapy for sleep apnea syndrome. Int J Prosthodont 19:61–66PubMed

29.

Lam B, Sam K, Mok WYW, Cheung MT, Fong DY, Lam JC, Lam DC, Yam LY, Ip MS (2007) Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea. Thorax 62:354–359PubMedCentralPubMedCrossRef

30.

Andrén A, Sjöquist M, Tegelberg A (2009) Effects on blood pressure after treatment of obstructive sleep apnoea with a mandibular advancement appliance—a three-year follow-up. J Oral Rehabil 36:719–725PubMedCrossRef

31.

Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ, Marks GB, Cistulli PA (2013) Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med 187:879–887PubMedCrossRef

32.

Itzhaki S, Dorchin H, Clark G, Lavie L, Lavie P, Pillar G (2007) The effects of 1-year treatment with a herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest 131:740–749PubMedCrossRef

33.

Coruzzi P, Gualerzi M, Bernkopf E, Brambilla L, Brambilla V, Broia V, Lombardi C, Parati G (2006) Autonomic cardiac modulation in obstructive sleep apnea—effect of an oral jaw-positioning appliance. Chest 130:1362–1368PubMedCrossRef

34.

Bittencourt LR, Suchecki D, Tufik S, Peres C, Togeiro SM, Bagnato MC, Nery LE (2001) The variability of the apnoea–hypopnoea index. J Sleep Res 10:245–251PubMedCrossRef

35.

Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14:540–545PubMed

36.

Bertolazi AN, Fagondes SC, Hoff LS, Pedro VD, Menna Barreto SS, Johns MW (2009) Portuguese-language version of the Epworth sleepiness scale: validation for use in Brazil. J Bras Pneumol 35:877–883PubMedCrossRef

37.

Dal-Fabbro C, Chaves Junior CM, Bittencourt LRA, Tufik S (2010) Clinical and polysomnographic assessment of obstructive sleep apnea syndrome treatment with BRD appliance. Dent Press J Orthod 15:107–117CrossRef

38.

Mehta A, Qian J, Petocz P, Darendeliler MA, Cistulli PA (2001) A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med 163:1457–1461PubMedCrossRef

39.

Barnes M, Houston D, Worsnop CJ, Neill AM, Mykytyn IJ, Kay A, Trinder J, Saunders NA, Douglas McEvoy R, Pierce RJ (2002) A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea. Am J Respir Crit Care Med 165:773–780PubMedCrossRef

40.

Bittencourt LR, Silva RS, Santos RF, Pires ML, Mello MT (2005) [Excessive daytime sleepiness]. Rev Bras Psiquiatr Suppl 1:16–21. Review in Portuguese

41.

Rechtschaffen A, Kales A (1968) A manual of standardized terminology, techniques and scoring system for sleep stages of human subjects. US Department of Health, Education and Welfare Public Health Service—National Institute of Health, Bethesda, MD

42.

Atlas Task Force (1992) Electro-encephalogram (EEG) arousals: scoring rules and examples: a preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association. Sleep 15:173–184

43.

American Sleep Disorders Association (1993) Recording and scoring leg movements. The Atlas Task Force. Sleep 16:748–759

44.

American Academy of Sleep Medicine (1999) Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep 22:667–689

45.

Cerutti S, Bianchi AM, Mainardi LT (1995) Spectral analysis of heart rate variability signal. In: Malik M, Camm AJ (eds) Heart rate variability. Futura, New York, pp 63–74

46.

Ohkubo T, Hozawa A, Nagai K, Kikuya M, Tsuji I, Ito S, Satoh H, Hisamichi S, Imai Y (2000) Prediction of stroke by ambulatory blood pressure monitoring versus screening blood pressure measurements in a general population: the Ohasama study. J Hypertens 18:847–854PubMedCrossRef

47.

Ohkawa H, Ohishi N, Yagi K (1979) Assay for lipid peroxides in animal-tissues by thiobarbituric acid reaction. Anal Biochem 95:351–358PubMedCrossRef

48.

Adamo AM, Llesuy SF, Pasquini JM, Boveris A (1989) Brain chemiluminescence and oxidative stress in hyperthyroid rats. Biochem J 263:273–277PubMedCentralPubMed

49.

Mccord JM, Fridovic I (1969) Superoxide dismutase an enzymic function for erythrocuprein (hemocuprein). J Biol Chem 244:6049–6055PubMed

50.

Guerra-Shinohara EM, Paiva AA, Rondo PH, Yamasaki K, Terzi CA, D’Almeida V (2002) Relationship between total homocysteine and folate levels in pregnant women and their newborn babies according to maternal serum levels of vitamin B₁₂. BJOG 109:784–791PubMedCrossRef

51.

Fossati P, Prencipe L, Berti G (1980) Use of 3,5-dichloro-2-hydroxybenzenesulfonic acid/4-aminophenazone chromogenic system in direct enzymic assay of uric acid in serum and urine. Clin Chem 26:227–231PubMed

52.

Sharma SK, Dakshinamurti K (1992) Determination of vitamin B₆ vitamers and pyridoxic acid in biological samples. J Chromatogr 578:45–51PubMedCrossRef

53.

Gagnadoux F, Fleury B, Vielle B, Pételle B, Meslier N, N’Guyen XL, Trzepizur W, Racineux JL (2009) Titrated mandibular advancement versus positive airway pressure for sleep apnoea. Eur Respir J 34:914–920PubMedCrossRef

54.

Dimsdale JE, Loredo JS, Profant J (2000) Effect of continuous positive airway pressure on blood pressure: a placebo trial. Hypertension 35:144–147PubMedCrossRef

55.

Pepperell JC, Ramdassingh-Dow S, Crosthwaite N, Mullins R, Jenkinson C, Stradling JR, Davies RJ (2002) Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised parallel trial. Lancet 359:204–210PubMedCrossRef

56.

Faccenda JF, Mackay TW, Boon NA, Douglas NJ (2001) Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea–hypopnea syndrome. Am J Respir Crit Care Med 163:344–348PubMedCrossRef

57.

Rauchová H, Vokurková M, Koudelová J (2005) Developmental changes of erythrocyte catalase activity in rats exposed to acute hypoxia. Physiol Res 54:527–532PubMed

58.

Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, Van de Heyning PH, Braem MJ (2013) Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax 68:91–96PubMedCentralPubMedCrossRef

59.

Randerath WJ, Heise M, Hinz R, Ruehle KH (2002) An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Chest 122:569–575PubMedCrossRef

60.

Hernandez C, Abreu J, Abreu P, Colino R, Jiménez A (2006) Effects of nasal positive airway pressure treatment on oxidative stress in patients with sleep apnea–hypopnea syndrome. Arch Bronconeumol 42:125–129PubMed

61.

Ozturk L, Mansour B, Yuksel M, Yalçin AS, Celikoğlu F, Gökhan N (2003) Lipid peroxidation and osmotic fragility of red blood cells in sleep-apnea patients. Clin Chim Acta 332:83–88PubMedCrossRef

62.

Svatikova A, Wolk R, Lerman LO, Juncos LA, Greene EL, McConnell JP, Somers VK (2005) Oxidative stress in obstructive sleep apnoea. Eur Heart J 26:2435–2439PubMedCrossRef

63.

Wali SO, Bahammam AS, Massaeli H, Pierce GN, Iliskovic N, Singal PK, Kryger MH (1998) Susceptibility of LDL to oxidative stress in obstructive sleep apnea. Sleep 21:290–296PubMed

64.

Junqueira VB, Barros SB, Chan SS, Rodrigues L, Giavarotti L, Abud RL, Deucher GP (2004) Aging and oxidative stress. Mol Aspects Med 25:5–16PubMedCrossRef

65.

Refsum H, Smith AD, Ueland PM, Nexo E, Clarke R, McPartlin J, Johnston C, Engbaek F, Schneede J, McPartlin C, Scott JM (2004) Facts and recommendations about total homocysteine determinations: an expert opinion. Clin Chem 50:3–32PubMedCrossRef

66.

Droge W (2005) Oxidative stress and ageing: is ageing a cysteine deficiency syndrome? Philos Trans R Soc Lond B Biol Sci 360:2355–2372PubMedCentralPubMedCrossRef

67.

Keaney JF Jr, Larson MG, Vasan RS, Wilson PW, Lipinska I, Corey D, Massaro JM, Sutherland P, Vita JA, Benjamin EJ, Framingham Study (2003) Obesity and systemic oxidative stress: clinical correlates of oxidative stress in the Framingham Study. Arterioscler Thromb Vasc Biol 23:434–439PubMedCrossRef

68.

Lavie L (2009) Oxidative stress—a unifying paradigm in obstructive sleep apnea and comorbidities. Prog Cardiovasc Dis 51:303–312PubMedCrossRef

69.

Olusi SO (2002) Obesity is an independent risk factor for plasma lipid peroxidation and depletion of erythrocyte cytoprotectic enzymes in humans. Int J Obes 26:1159–1164CrossRef

70.

Ozkan Y, Ozkan E, Simsek B (2002) Plasma total homocysteine and cysteine levels as cardiovascular risk factors in coronary heart disease. Int J Cardiol 82:269–277PubMedCrossRef

71.

Dyken ME, Somers VK, Yamada T, Ren ZY, Zimmerman MB (1996) Investigating the relationship between stroke and obstructive sleep apnea. Stroke 27:401–407PubMedCrossRef

72.

Hedner J, Darpö B, Ejnell H, Carlson J, Caidahl K (1995) Reduction in sympathetic activity after long-term CPAP treatment in sleep apnoea: cardiovascular implications. Eur Respir J 8:222–229PubMedCrossRef

Title: Mandibular advancement device and CPAP upon cardiovascular parameters in OSA
Authors: Cibele Dal-Fabbro
Silvério Garbuio
Vânia D’Almeida
Fátima D. Cintra
Sergio Tufik
Lia Bittencourt
Publication date: 01-12-2014
Publisher: Springer Berlin Heidelberg
Published in: Sleep and Breathing / Issue 4/2014
Print ISSN: 1520-9512
Electronic ISSN: 1522-1709
DOI: https://doi.org/10.1007/s11325-014-0937-5

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