title: Mandibular advancement devices: rate of contraindications in 100 consecutive obstructive sleep apnea patients.
abstract: Mandibular advancement devices (MAD) should be contraindicated (Clark GT, Sleep Med Rev 1998;2:163-174) if there are: (1) insufficient teeth to support the device, (2) periodontal problems inducing tooth mobility, (3) active temporomandibular joint (TMJ) disorder, and (4) limited maximum protrusive distance (< 6 mm). The aim of the present study was to evaluate the proportion of the obstructive sleep apnea population that exhibits any contraindication (CI) to MAD. For this study there were 100 unselected adult patients consecutively diagnosed by polysomnography in a tertiary sleep laboratory. Clinical and radiologic evaluation of the dental, periodontal, and TMJ status of these 100 patients were performed by two expert maxillofacial surgeons, blind to each other, permitting the identification of MAD CIs. The two maxillofacial surgeons agreed on MAD absolute CIs in 96 of the 100 patients. CIs were identified in 34% of the patients. The nature of the CIs systematically referred to an insufficient number of remaining teeth (mean number of teeth lost: 7.8 +/- 6.1 with 31 patients having had more than 10 teeth removed). The tooth avulsions were significantly higher in contraindicated compared with noncontraindicated patients (16 +/- 8 versus 4 +/- 3, p < 0.00001). Periodontal abnormalities coexisted with dental CI in approximately half of the patients. A TMJ disorder was considered as significant enough to lead to CI in two patients. Dental and periodontal care was needed in 16 patients before the use of MAD could be considered. Conclusions were that primary CIs were present in 34% of 100 consecutive patients, mainly owing to dental problems. Moreover, another subgroup of patients (16%) required close supervision and follow-up to avoid impairment of preexisting TMJ and dental problems. Such a high rate of CI should be considered when the overall efficacy of oral appliances is compared with other treatments, such as surgery or nasal continuous positive airway pressure.
authors.affiliation: Department of Acute Specialized Medicine and Sleep Laboratory, PRETA Laboratory TIMC UMR CNRS 5525, University Hospital Grenoble, BP 217 X, 38043 Grenoble, France.
authors.forename: Francois-Xavier
authors.initials: FX
authors.lastname: Petit
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Pépin
authors.forename: Georges
authors.initials: G
authors.lastname: Bettega
authors.forename: Hazem
authors.initials: H
authors.lastname: Sadek
authors.forename: Bernard
authors.initials: B
authors.lastname: Raphaël
authors.forename: Patrick
authors.initials: P
authors.lastname: Lévy
mesh_terms: D000328:Adult; D000075202:Contraindications; D004864:Equipment and Supplies; D005260:Female; D006801:Humans; D008297:Male; D019186:Mandibular Advancement; D008875:Middle Aged; D009909:Oral Health; D009910:Oral Hygiene; D011446:Prospective Studies; D020181:Sleep Apnea, Obstructive / Q000453:epidemiology* / Q000628:therapy*; D013705:Temporomandibular Joint Disorders / Q000453:epidemiology*; D014086:Tooth Mobility / Q000453:epidemiology*