| Abstract|| |
Obstructive sleep apnea (OSA) is an independent risk factor for increased cardiovascular and cerebro-vascular morbidity and mortality. OSA leads to loss of human life and huge economical burden to our Society worldwide. The adult's prevalence of OSA ranges between 9.3-13.5% in India. India is the second largest populated country of the world and by the end of 2030 it may become the most populated nation. This developing nation is already known as the world's capital of T2 DM, and other non-communicable diseases like Obesity, Hypertension, Stroke, Ischemic heart diseases (IHD), Hypercholesterolemia congestive heart failure are on a rising trend. These cardiovascular disorders were found to be associated with OSA. OSA treatment may improve these co-morbid conditions. Continuous positive airway pressure (CPAP) is a preferred choice for OSA treatment in western and developed countries. In India, where CPAP is out of the reach of most of the OSA affected population due to high cost and other socio-economic and cultural factors, MAD may become a preferred treatment option. MAD is cheaper than CPAP and generally equally effective. The patients suffering from sleep-related breathing disorder (SBD) may have an alternative to CPAP or surgery for their disease management. Mandibular Advancement Device (MAD) may become an additional standard treatment of OSA in India, and has great potential for reducing associated undesirable cardiovascular co-morbidities and mortalities. This review highlights the prospects of MAD as a preferred treatment of Obstructive Sleep Apnea in India by extensively researching scientific literature, PubMed, Google Scholar, scientific, and academic web portals.
Keywords: Hypertension, mandibular advancement device, obesity, obstructive sleep apnea, stroke
Key messages: In India, T2 DM, Hypertension, Stroke, and Ischemic heart diseases are on a rising trend. As these diseases are associated with OSA, and CPAP is out of the reach of most of the OSA affected Indian population due to socio-economic factors, MAD may become a preferred treatment option for treating OSA and reducing cardiovascular morbidities.
|How to cite this article:|
Dubey A, Kant S, Bajaj DK, Singh BP. Prospects of mandibular advancement device (MAD) as a preferred treatment of obstructive sleep apnea in India: a systematic review. Ann Trop Med Public Health 2017;10:1-6
|How to cite this URL:|
Dubey A, Kant S, Bajaj DK, Singh BP. Prospects of mandibular advancement device (MAD) as a preferred treatment of obstructive sleep apnea in India: a systematic review. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 22];10:1-6. Available from: http://www.atmph.org/text.asp?2017/10/1/1/205552
| Introduction|| |
OSA is an established risk factor for increasing cardiovascular and cerebro-vascular morbidity and mortality. India is known for very high prevalence of T2DM, Hypertension, Stroke, and Ischemic heart diseases. These cardiovascular disorders are linked with OSA. OSA treatment may recover these associated disease conditions.
MAD is cheaper than CPAP and generally equally effective. MAD has great potential for reducing OSA associated adverse cardiovascular morbidities and mortalities in Indian OSA patients. This review highlights the prospects of MAD treatment of OSA in India by researching scientific literature, PubMed, Google Scholar, scientific, and academic web portals.
| Epidemiology|| |
OSA is characterized by loud snoring, witnessed breathing interruptions, awakenings due to gasping or choking , periodic reduction, cessation of breathing due to narrowing of the upper airways during sleep, resulting in nocturnal hypoxemia, arousals, excessive day time sleepiness (EDS), and other relatedsymptoms., OSA is an independent risk factor for adverse cardiometabolic profile, and it has been associated with increased cardiovascular and cerebro-vascular morbidity and mortality. Cognitive dysfunction, impaired work performance, anxiety, difficulties in personal relations, and an increased risk of fatal and non -fatal automobile accidents are some other important health consequences of OSA, which lead to loss of human life and huge economical burden to our Society worldwide. The prevalence rates of OSA in adults ranges between 3-27% in total in different settings and population.,,,,,,,,, [Table 1], [Table 2] The prevalence in men ranges between 3-28% while estimations are nearly half as 2.2-16% in women through large-scale epidemiological studies conducted in different countries including India.,, [Table 1] The prevalence of OSA in India is three times higher in men as compared to women. The major risk factors for OSA include advanced age, male sex, and obesity.,
Disease Burden in India
India is the second largest populated country of the world. At the end of 2030, it is projected to get most populated nation's tag. According to census 2011, population of India is approximately 1, 21, 01, 93, 422. It consists of 69.2% of population of 15+ age group (15-64 years: 64.3%, 65+ years: 4.9%) with median age of 25.1 years. The average life expectancy has increased from 41 years in 1951-1961 to 61.4 years in 1991-1996 and is projected to reach 72 years by 2030. The bracket of middle age group and middle class is expected to expand with an expansion of population and economy growth in next 10 years. At the end of this decade, middle and old age population of India will achieve a huge figure of more than 1220 million people in total. This will lead to multifold burden of SDB and cardiovascular co-morbidities in Indian population. In a resource-poor nation like India, where there is a lack of awareness of sleep disorders among physicians as well as public, even diagnosis of the condition is a farfetched possibility in the dearth of resources, infrastructure, and trained human resource to carry out sleep studies. Infectious diseases such as malaria, tuberculosis, and HIV/AIDS still remain on top priority for Indian health care system.
In the coming years, the emerging epidemic of obesity including childhood obesity and its consequences are bound to impose dual-burden and pose challenges to the functioning of health services. Obesity is a major risk factor for OSA. Obesity is propelled by adoption of sedentary lifestyle, availability of motorized transport, labor-saving mechanical devices, overuse of laptops and computers, televisions, easy availability of highly refined fats and carbohydrates, and consumption of ad lib fast-food items.
Further, OSA also contributes to development of increased cardiovascular morbidity and mortality,,,, [Table 3]. India is already known as the world's capital of T2 DM. Essential hypertension, obesity, and type 2 diabetes mellitus were found to be most frequently associated with OSA. Tobacco use (Past or present), IHD, hypercholesterolemia congestive heart failure, and atrial fibrillation were also found common in the OSA patients.
| Definition|| |
The diagnosis of OSA needs the objective manifestation of abnormal breathing during sleep by calculating the respiratory disturbance index (RDI, events per hour of sleep), that is the frequency of apnea (complete upper airway obstruction), hypopnea (partial upper airway obstruction), and arousals from sleep related to respiratory efforts. OSA is defined by combining symptoms and an RDI (≥5) or by an RDI (≥15) without symptoms. The apnea-hypopnea index (AHI), the frequency of apnea and hypopnea events per hour of sleep, is widely used to define OSA. OSA is classified as mild (5-15), moderate (16-30), and severe (>30) based on an average number of apneas and/or hypopneas per hour of total sleep time.
Mandibular Advancement Devices (MAD)
MAD, reposition the mandible and the tongue downward and forward. This way the airway passage is increased first, by the forward positioning of these structures, second, by increasing the tension of the airway muscles. Advancing mechanism is engaged until the patient begins to feel any discomfort in his temporomandibular joint .Other oral appliances (OA) like tongue repositioning devices (TRD) and tongue stabilizing device (TSD) are also used for treatment of OSA. TRD works by pulling only the tongue forward and not the entire lower jaw. The advantage of it is that the teeth, jaw muscles and joints are less affected. TRD has few disadvantages like less chance of success due to inadequate retention during sleep.,,, TSD works by holding the tongue forward by a gentle suction, thus, preventing it from falling back against the back of the throat, keeping the airway open during sleep.,,,
OSA and Insulin Resistance
Epidemiologic studies have demonstrated that OSA is associated with insulin resistance and glucose intolerance, independent of obesity.,, Clinical investigations have also shown that OSA results in low-grade systemic inflammation., Both insulin resistance and systemic inflammation may contribute to the increased cardiovascular risk in patients with OSA.,, Insulin resistance, systemic inflammation, and OSA are particularly prevalent in patients with severe obesity defined as a body mass index (BMI) exceeding 40 kg/m2.,,, While obesity causes systemic inflammation, insulin resistance, and sleep apnea.,,, It may further exacerbate the inflammatory and metabolic disturbances but previous data showthat weight loss, physical activity and surgical interventions can significantly avert and treat obesity-related coronary heart disease risk factors.,,,,
Mandibular Advancement Device (MAD) in Treatment of OSA
MAD treatment of OSA has gained considerable popularity because of its simplicity and supposed reversibility. Total 41 studies satisfied adequate standards of evidence, and addressed the question of efficacy by providing objective sleep data before and after treatment. Ten of them were Randomized well-designed trials with low-α & low-beta errors. There were 5 Level II (Randomized trials with high-beta errors) studies 1 Level III (Nonrandomized controlled or concurrent cohort studies) study and there were 25 Level V (Case series) studies.
Although initial side-effects, such as jaw discomfort, tooth tenderness, excessive salivation and/or temporary occlusal changes, were reported in approximately half of the patients even then 76% of the patients continued treatment after one year and 65% were using their devices after 4 years as observed in two different studied. MADs ccompliance has been reported to be superior than with CPAP, and MADs are preferred by the patients.,,,, The effect on sleepiness was generally parallel between CPAP and MADs.,,,,, Titratable custom-made MADs have been used in the majority of the efficacy studies. Comparison between device designs indicated that there are only minor differences in treatment effects between custom-made device,,, while a prefabricated device was less effective.
What is lacking?
An assessment of efficacy of treatment of OSA with MAD in terms of metabolic markers, inflammatory markers, and quality of life is lacking while there are numerous studies already in literature about same in CPAP therapy. MAD treatment modality if found effective in these terms may get stronger base to be used for treatment in OSA for prevention of multiple burden of cardiovascular risk associated with OSA. In this way, it may also improve cardiovascular profile as well as disease prognosis and treatment success rate of OSA cases.
Potential role of MAD to existing treatment for OSA and associated co-morbidities
OSA is a multifactor disease with many risk factors related with anthropometrical, biochemical, physiological, and pathological profile of a person. In Indian context SDB; OSA is the most under diagnosed and almost never treated problem due to numerous facts associated with lack of awareness, education, and issues related with socio-economic conditions. Establishment of MAD as core and preferred choice treatment for OSA subjects in Indian population may make a remarkable effect.
Currently we do not have any national or international prospective data of metabolic markers, inflammatory markers of MAD intervention in subjects suffering from OSA. We anticipate a positive outcome in MAD intervention as like in case of related published research work in OSA cases with CPAP. Insulin resistance and cardiovascular parameters were found to be improved by the treatment of OSA., It may improve and sustain overall health of this group and will reduce the burden of health care utilities, which are already inappropriate for our population.
MAD is the cheapest treatment modality available for treatment of Sleep disorder Breathing (Snoring, Upper airway resistance and Obstructive sleep apnea) in India. It costs around INR 500-1,500/- in development of a MAD which is 50-160 times cheaper than CPAP (Cost INR—25,000-80,000/-) and possibly equally effective. We have sufficient number of well skilled Dental surgeons and Specialist in Dental sciences to treat a large number of patients suffering from OSA. Graduate dentist may also be trained if required, with a short term training module to treat this diseased population in assistance with concern Medical specialist.MAD is a preferred choice, of treatment in OSA in regular practice internationally, even then, when MAD development cost is very high in these countries (Approx-1000$; 550 times higher than in India). Various published literature confirms efficacy of MAD in short and long term.
In Indian situations where CPAP is out of the reach of most of the population due to high cost and othersocio-economic factors including electricity supply hindrance in all over India. In these circumstances MAD with life style modification may become an additional standard treatment of OSA in India and may play a vital role in reducing associated undesirable cardio-vascular co-morbidities and mortalities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing amongmiddle-aged adults. N Engl J Med 1993;328:1230-12.
Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP, et al
. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5:263-76.
Mc Nicholas WT, Bonsignore MR. the Management Committee of EU COS ACTION b26. Sleep apnoea as an independent risk factor for cardiovascular disease: current evidence, basic mechanisms and research priorities.Eur Respir J 2007;29:156-78.
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005;365:1046-53.
Thorarinn Gislason, Magnus Almqvist, Gösta Eriksson Adam Taube, Gunnar Boman, Prevalence of sleep apnea syndrome among Swedish men—an epidemiological study. J Clin Epidemiol. 1988;41:571-76.
Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Althaus W, et al
. Snoring and sleep apnea. A population study in Australian men. Am J Respir Crit Care Med 1995;151:1459-65.
Olson LG, King MT, Hensley MJ, Saunders NA. A community study of snoring and sleep-disordered breathing. Prevalence.Am J Respir Crit Care Med 1995;152:711-16.
Bixler EO, Alexandros NV, LinHM, Ten HT, ReinJ, Bueno AV, et al
.Prevalence of sleep-disordered breathing in women. Am J Respir Crit Care Med 2001;163:608-13.
Durán J, Esnaola S, Rubio R, Iztueta A, Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med 2001;163:685-89.
Ip MS, Lam B, Lauder IJ, Tsang KW, Chung KF, Mok YW, Lam WK, A community study of sleep-disordered breathing in middle-aged Chinese men in Hong Kong. Chest 2001;119:62-69.
Huang SG, Li QY. Sleep respiratory disorder study group respiratory disease branch Shanghai medical association.Prevalence of obstructive sleep apnea-hypopnea syndrome in Chinese adults aged over 30 yr in Shanghai. Zhonghua Jie He He Hu Xi Za Zhi 2003;26:268-72.
Kim J, In K, Kim J, You S, Kang K, Shim J, et al
. Prevalence of sleep-disordered breathing in middle-aged Korean men and women.Am J Respir Crit Care Med 2004;170:1108-13.
Ip MS, Lam B, Tang LC, Lauder IJ, Ip TY, Lam WK. A community study of sleep-disordered breathing in middle-aged Chinese women in Hong Kong: prevalence and gender differences. Chest 2004;125:127-34.
Sharma SK, Ahluwalia G. Epidemiology of adult obstructive sleep apnoea syndrome in India. Indian J Med Res 2010;131:171-75.
] [Full text]
Lam Jamie C.M, Sharma S.K, Lam Bing. Obstructive sleep apnoea: Definitions, epidemiology & natural history. Indian J Med Res2010;131:165-70.
Reddy EV, Kadhiravan T, Mishra HK, Sreenivas V, Handa KK, Sinha S, et al
. Prevalence and risk factors of OSA in Middle aged urban Indians: A community based study. Sleep Med 2009;10:913-18.
Udwadia ZF, Doshi AV, Lonkar SG, Singh CI. Prevalence of sleep-disordered breathing and sleep apnea in middle-aged urban Indian men. Am J Respir Crit Care Med 2004;169:168-73.
Sharma SK, Kumpawat S, Banga A, Goel A. Prevalence and Risk Factors of Obstructive Sleep Apnea Syndrome in a Population of Delhi, India. Chest 2006;130:149-56.
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med2005;353:2034-41.
Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al
. Association of Sleep-Disordered Breathing, Sleep Apnea, and Hypertension in a Large Community-Based Study. JAMA2000;283:1829-36.
Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342:1378-84.
ShaharE, CoralynWW, RedlineS, ElisaTL, AnneBN, NietoF, et al
. Sleep-disordered Breathing and Cardiovascular Disease. Am J Respir Crit Care Med 2001;163:19-25.
Erán-Santos JT, Gómez AJ, Uevara JO, Engl N. The Association between Sleep Apnea and The Risk of Traffic Accidents. J Med 1999;340:847-51.
HuangQR, QinZ, ZhangS, Chow CM. Clinical patterns of obstructive sleep apnea and its comorbid conditions: a data mining approach. J Clin Sleep Med 2008;4:543-50.
Kurtulmus H, Cortert HS. Management of obstructive sleep apnea with a mandibular and tongue advancement splint (MTAS) in a completely edentulous patient. A clinical report. J Prosthodont 2009;18:348-52.
Meyer JB, Knudson RC. Fabrication of prosthesis to prevent sleep apnea in edentulous patients. J Prosthet Dent 1990;63:448-51.
Knudson RC, Meyer JB. Sleep apnea prosthesis in dentate patients. J Prosthet Dent 1992;68:109-11.
Sadan A, Navoselesky A, Rores WA. An alternative technique for mandibular advancement prosthesis fabrication. J Prosthodont 1998;7:40-44.
Rose E, Staats R, Virchow C, Jonas IE. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnea. Eur J Orthod2002;24:191-98.
George PT. A modified functional appliance for treatment of obstructive sleep apnea. J Clin Orthod 1987;21:171-75.
Schmidt-Nowara WW, Meade TE, Hays MB. Treatment of snoring and obstructive sleep apnea with a dental orthosis. Chest 1991;99:1378-85.
Wade PS. Oral appliance therapy for snoring and sleep apnea: Preliminary report on 86 patients fitted with an anterior mandibular positioning device, the Silencer. J Otolaryngol 2003;32:110-13.
Harsch IA, Schahin SP, Radespiel-Troger M, Weintz O, Jahreiss H, Fuchs FS, et al
. Continuous positive airway pressure treatment rapidly improves insulin sensitivity in patients with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2004;169:156-62.
Punjabi NM, Sorkin JD, Katzel LI, Goldberg AP, Schwartz AR, Smith PL. Sleep-disordered breathing and insulin resistance in middle-aged and overweight men. Am J Respir Crit Care Med 2002;165:677-82.
Punjabi NM, Shahar E, Redline S, Gottlieb DJ, Givelber R, Resnick HE. Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health Study. Am J Epidemiol 2004;160:521-30.
Punjabi NM, Beamer BA. C-reactive protein is associated with sleep disordered breathing independent of adiposity. Sleep 2007;30:29-34.
Vgontzas AN, Papanicolaou DA, Bixler EO, Hopper K, Lotsikas A, Lin HM, et al
. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab 2000;85:1151-58.
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea–hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005;365:1046-53.
Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med 2005;172:1447-51.
Vgontzas AN, Tan TL, Bixler EO, Martin LF, Shubert D, Kales A. Sleep apnea and sleep disruption in obese patients. Arch Intern Med 1994;154:1705-11.
Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg 2003;13:676-83.
Kopp HP, Kopp CW, Festa A, Krzyzanowska K, Kriwanek S, Minar E, et al
. Impact of weight loss on inflammatory proteins and their association with the insulin resistance syndrome in morbidly obese patients. Arterioscler Thromb Vasc Biol 2003;23:1042-47.
Manco M, Fernandez-Real JM, Equitani F, Vendrell J, Valera Mora ME, Nanni G, et al
. Effect of massive weight loss on inflammatory adipocytokines and the innate immune system in morbidly obese women. J Clin Endocrinol Metab 2007;92:483-90.
Klein S, Burke LE, Bray GA, Blair S, Allison DB, Pi-Sunyer X, et al
. Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Circulation 2004;110:2952-67.
Williams DB, Hagedorn JC, Lawson EH, Galanko JA, Safadi BY, Curet MJ, et al
. Gastric bypass reduces biochemical cardiac risk factors. Surg Obes Relat Dis 2007;3:8-13.
Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleepapnea with mandibular repositioning appliances. Sleep Med Rev 2004;8:443-57.
Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. SLEEP
Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success. Chest 2004;125:1270-78.
Walker-Engstrom ML, Tegelberg A, Wilhelmsson B, Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest 2002;121:739-46.
Barnes M, McEvoy RD, Banks S,Tarquinio N, Murray CG, Vowles N, et al
. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 2004;170:656-64.
Gagnadoux F, Fleury B, Vielle B, Pételle B, Meslier N, N'Guyen XL, et al
. Titrated mandibular advancement versus positive airway pressure for sleep apnoea. Eur Respir J 2009;34:914-20.
Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest 1996;109:1269-75.
Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax 1997;52:362-68.
Randerath WJ, Heise M, Hinz R, Ruehle KH. An individually adjustable oral appliance vs continuous positive airway pressure in mild-tomoderate obstructive sleep apnea syndrome. Chest 2002;122:569-75.
Tan YK, L'Estrange PR, Luo YM, Smith C, Grant HR, Simonds AK, et al
. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Eur J Orthod 2002;24:239-49.
Hoekema A, Stegenga B, Wijkstra PJ, van der Hoeven JH, MeineszAF, de BontLG. Obstructive sleep apnea therapy. J Dent Res 2008;87:882-87.
Bloch KE, Iseli A, Zhang JN, Xie X, Kaplan V, Stoeckli PW, et al
. A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment. Am J Respir Crit Care Med 2000;162:246-51.
Rose E, Staats R, Virchow C, Jonas IE. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnoea. Eur J Orthod 2002;24:191-98.
Lawton HM, Battagel JM, Kotecha B. A comparison of the Twin Block and Herbst mandibular advancement splints in the treatment of patients with obstructive sleep apnoea: a prospective study. Eur J Orthod 2005;27:82-90.
Gauthier L, Laberge L, Beaudry M, Laforte M, Rompré PH, Lavigne GJ. Efficacy of two mandibular advancement appliances in the management of snoring and mild-moderate sleep apnea: a cross-over randomized study. Sleep Med 2009;10:329-36.
Vanderveken OM, Devolder A, Marklund M, Boudewyns AN, Braem MJ, Okkerse W, et al
. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med 2008;178:197-02.
Harsch IA, Hahn EG, Konturek PC. Insulin resistance and other metabolic aspects of the obstructive sleep apnea syndrome. Med Sci Monit 2005;11:70-75.
SharmaSK, AgrawalS, DamodaranD, SreenivasV, KadhiravanT, LakshmyR, et al
. CPAP for the Metabolic Syndrome in Patients with Obstructive Sleep Apnea. N Engl J Med 2011;365:2277-86.
Sivapathasundharam B, Dental education in India.Indian J Dent Res2007;18:93.
Chan AS, Lee RW. Cistulli PA Dental appliance treatment for obstructive sleep apnea.CHEST2007;132:693-99.
KushidaCA, MorgenthalerTI, Littner MR, et al
. Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005An American Academy of Sleep Medicine Report-AASM Practice Parameters. An Update for 2005. SLEEP 2006;29:240-43.
Dr. Surya Kant
Department of Respiratory Medicine, King Georg's Medical University, Lucknow, UP
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]