Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content ›...
Transcript of Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content ›...
![Page 1: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/1.jpg)
Precision Sleep Medicine Picking Winners Improves Outcomes and Avoids Side-Effects
North American Dental Sleep Medicine Conference February 17-18, 2017Clearwater Beach, FL
John E. Remmers, MD
![Page 2: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/2.jpg)
• Part owner of a company that manufactures a sleep recorder (Sagatech)
• Part owner and Chief Medical Officer of a company that manufactures a dental titration device (Zephyr Sleep Technologies, Calgary, Alberta CANADA)
Conflict of Interest
2
![Page 3: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/3.jpg)
Objectives
• To understand the current balance of patient adherence to therapy versus therapeutic efficacy in outcomes with continuous positive airway pressure (CPAP) and oral appliance therapy (OAT)
• To be familiar with the role of wakefulness in permitting reflex compensation for the pharyngeal anatomic abnormality
• To understand the importance of patient selection in the management of OSA with OAT: what methods work and why
• To learn why mandibular protruding appliances produce a successful outcome in some patients but not others
• To be familiar with the possible role for emerging technologies in enhancing the accuracy of patient selection for OAT
3
![Page 4: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/4.jpg)
Apnea– absence of breathing for 10 seconds
or more
Hypopnea– 50% reduction in breathing for 10
seconds followed by a 3% dip in O2 sat or an arousal
Definition of Respiratory Disturbances
4
![Page 5: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/5.jpg)
Contraction of Inspiratory Muscles in OSA
Negative luminal pressure
5
![Page 6: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/6.jpg)
Pathophysiology of OSA:Two possibilities
Neural Hypothesis(lazy tongue)
Anatomic Hypothesis(small airway)
Apneics have asub-normal genioglossal
activity during sleep
Apneics have a structurally narrowed
pharyngeal airway
6
![Page 7: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/7.jpg)
The Passive Pharyngeal Airway
General Anesthesia
Complete Paralysis
7
![Page 8: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/8.jpg)
Closing pressure is elevated in OSA
8
![Page 9: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/9.jpg)
Maximal Area of the Passive Pharynx
9
![Page 10: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/10.jpg)
Lazy Tongue Hypothesis
• Tantalizing but fragmentary evidence supports this hypothesis
• Currently, no hard evidence supports the lazy tongue
• In fact, the tongue seems to be working overtime while awake
10
![Page 11: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/11.jpg)
Genioglossal EMG is elevated in OSA while awake
11
![Page 12: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/12.jpg)
Here’s the deal -
• OSA is caused by a structural narrowing of the pharynx
• This structural narrowing causes airway obstruction ONLY during sleep
12
![Page 13: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/13.jpg)
While Awake - Neuromuscular Compensation
NO Pharyngeal Obstruction
13
Structural
Narrowing
![Page 14: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/14.jpg)
Non-REM Sleep Pharyngeal Obstruction
Structural
Narrowing 14
![Page 15: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/15.jpg)
REM Sleep - Muscle Atonia
Severe Pharyngeal Obstruction
Pharyngeal
Occlusion 15
![Page 16: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/16.jpg)
Oral Appliance TherapyHow Does it Work?
Studies of the passive pharynx reveal that protruding the mandible acts mechanically to open the pharynx
16
![Page 17: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/17.jpg)
Mandibular Protrusion Dilates the Passive Pharynx
Note dependence of nasopharynx and oropharynx 17
![Page 18: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/18.jpg)
OAT eliminates pharyngeal obstruction in OSA by dilating the velo-pharynx and oro-pharynx
No evidence for muscle activation
18
Oral Appliance TherapyHow Does it Work?
![Page 19: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/19.jpg)
Sleep Apnea & Comorbid Disease
Depression
Stroke
Heart Failure
Severe Obesity
Drug-ResistantHypertension
Coronary Artery Disease
A-fib
Type 2 Diabetes
45%
63%
76%
77% 72%
50%
57%
83%
19
![Page 20: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/20.jpg)
CV EffectsClearly sleep apnea is associated with CV disease
Marin JM, Carrizo SJ, Vicente E, Agusti AGN. 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. 20
![Page 21: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/21.jpg)
All CauseMortalityWisconsin Sleep Cohort
Young T; Finn L; Peppard PE; Szklo-Coxe M; Austin D; Nieto FJ; Stubbs R; Hla KM. Sleep disordered breathing and mortality: eighteen-year follow-up of the wisconsin sleep cohort. SLEEP 2008;31(8):1071-1078. 21
![Page 22: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/22.jpg)
22
![Page 23: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/23.jpg)
• Barbe et al. JAMA 2012
• Peker et al. Am J Resp Crit Care Med 2016
• McEvoy et al. New Eng J Med 2016
3 recent clinical trials comparing CPAP with usual care
Does CPAP prevent CV disease?
23
![Page 24: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/24.jpg)
McEvoy et al. (n=2687)SAVE Trial
New Eng J Med 2016; 375: 919-931 – SAVE Trial (Sleep Apnea Cardiovascular Endpoints) 24
![Page 25: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/25.jpg)
McEvoy et al. (n=2687)No significant difference in prevention of CV events
comparing CPAP vs. controls
New Eng J Med 2016; 375: 919-931 – SAVE Trial (Sleep Apnea Cardiovascular Endpoints) 25
![Page 26: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/26.jpg)
• CPAP did not significantly reduce the occurrence of serious CV events in non-sleepy patients with moderate to severe OSA
Why not?
Conclusions
26
![Page 27: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/27.jpg)
Poor CPAP compliance
3.3 hours per night
27
![Page 28: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/28.jpg)
• Prescribing CPAP with the sole purpose of reducing future CV events in asymptomatic patients with OSA and established CV disease cannot be recommended
• Need for novel treatment options
This is why I’m so concerned
Editorial. Mokhlesi B, Ayas N. New Eng J Med 2016; 375(10): 994-996 28
![Page 29: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/29.jpg)
YOU have a treatment that will reduce heart attacks
and strokes
BUT only if you treat the patients who will
respond!29
![Page 30: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/30.jpg)
Which ONES?
30
![Page 31: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/31.jpg)
Selection
Selection
Selection31
![Page 32: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/32.jpg)
We need a validated method to prospectively select
patients for OAT
• More efficient delivery of therapy
• Better outcomes
32
![Page 33: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/33.jpg)
33
Available Methods for Selecting Patients for OAT
• Clinical features
• Imaging the pharynx
• Mandibular titration
![Page 34: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/34.jpg)
• OSA is caused by a structural narrowing of the pharynx
• This structural narrowing is not apparent while awake because of neuromuscular compensations
34
Here’s the deal -
![Page 35: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/35.jpg)
35
Available Methods for Selecting Patients for OAT
• Clinical features
• Imaging the pharynx
• Mandibular titration – during sleep
![Page 36: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/36.jpg)
Mandibular TitrationDuring Sleep in the Lab
36
![Page 37: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/37.jpg)
1. Accurately selects patients who will respond to OAT and
2. Identifies an efficacious protrusive position for each responder
Single-night, Attended
Polysomnographic Test
MATRx
Remmers J, Charkhandeh S, Grosse J, Topor Z, Brant R, Santosham P, Bruehlmann S. Remotely controlled mandibular protrusion during sleep predicts therapeutic success with oral appliances in patients with obstructive sleep apnea. SLEEP 2013; 36(10): 1517-25. 37
![Page 38: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/38.jpg)
Mandibular TitrationDuring Sleep at Home
Replacing the Tech with a Computer
38
![Page 39: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/39.jpg)
1. Accurately selects patients who will respond to OAT and
2. Identifies an efficacious protrusive position for each responder
Home Sleep Test
MATRx plus
Note: This device is approved by Health Canada for sale in Canada. This device is pending 510(k) and 513(f)(2) clearance and is not available for sale in the United States. 39
![Page 40: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/40.jpg)
The MATRx plus Difference
40
Every other HST device only supports the diagnosis of OSA
MATRx plus does it all
![Page 41: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/41.jpg)
• Auto-titrating mandibular positioner
• MATRx style dental trays
• Feedback signals:‒Oxyhemoglobin saturation‒Respiratory airflow
• Real-time detection of respiratory events
• Automated analysis of data
MATRx plus: A-MP Technology
41
![Page 42: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/42.jpg)
MATRx plus
42
![Page 43: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/43.jpg)
43
![Page 44: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/44.jpg)
44
![Page 45: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/45.jpg)
MATRx plus Patient Information Portal
45
![Page 46: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/46.jpg)
Night 1
• Dynamic interaction between respiratory events and mandibular movement
Night 2
• Refinement of mandibular position in response to respiratory events
MATRx plus Titration: A two night study in the home
46
![Page 47: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/47.jpg)
Time (h)
0 1 2 3 4 5 6 7 8
8
10
1
2
14
1
6
Pro
tru
sive
po
siti
on
(m
m)
47
MATRx plus Results: Responder
![Page 48: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/48.jpg)
Time (h)
0 1 2 3 4 5 6 7 8
6
8
10
12
14
16
18
Pro
tru
sive
po
siti
on
(m
m)
48
MATRx plus Results: Non-Responder
![Page 49: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/49.jpg)
Obese Patient with Severe OSA
Patient Profile62 year old malePre-study AHI = 40.2BMI = 34.3
Tray FittingLower Limit (Resting Position) - 3.5mmUpper Limit (Maximum Protrusion) + 5.5mm
49
Case Study
![Page 50: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/50.jpg)
50
Night 1 - Dynamic Theragnostic Study
![Page 51: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/51.jpg)
51
Night 2 - Static Theragnostic Study
![Page 52: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/52.jpg)
52
Night 3 - Static Theragnostic Study
3.1mm
![Page 53: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/53.jpg)
53
Theragnostic Study Summary
![Page 54: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/54.jpg)
Objective
To assess the ability of an auto-titrating mandibular positioner test in:
• Prospectively identifying therapeutic responders
• Determining an efficacious protrusive position
MATRx plus Clinical Investigation
54
![Page 55: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/55.jpg)
All participants received:
2-night auto-titrating mandibular positioner test
Custom oral appliance (SomnoMed G2, MicrO2)
MATRx plus Trial Study Design
55
![Page 56: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/56.jpg)
Broad inclusion criteria:
• ODI > 10 hr-1
• BMI < 45 kg/m2
Inclusion Criteria
56
![Page 57: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/57.jpg)
Distribution of BaselineODI and BMI
57
![Page 58: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/58.jpg)
MATRx plus
Machine Learning
(Random Forest)
Prediction of
Outcome with OAT
Auto-titration + Machine Learning
58
![Page 59: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/59.jpg)
Training and Validation of Predictive Model
Phase 1:
n = 131
Phase 2:
n = 48
Extract
266
feature
s
Extract
266
feature
s
Training of
Random Forest
Machine
Trained
Random Forest
Machine
Responder
or Non-
Responder
Therapeutic
Outcome
59
![Page 60: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/60.jpg)
Baseline and Outcome ODI
n=48
60
![Page 61: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/61.jpg)
Therapeutic success defined as ODI < 10hr-1
Predictive Accuracy:Patient Selection
61
![Page 62: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/62.jpg)
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
Effi
caci
ou
s P
rotr
usi
on
(%
)
Target Protrusion (%)
PPV=86%
Predictive Accuracy:Efficacious Protrusive Position
62
![Page 63: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/63.jpg)
Test circumstances mimic the outcome situation
Why does MATRx work so well?
Test
Prediction
Outcome
63
![Page 64: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/64.jpg)
Efficiency: Fewer Clinic Visits
64
![Page 65: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/65.jpg)
Efficiency: Reduced Time-to-Treatment
Days from OA Insertion to
Therapeutic Success
Prediction Mean±SD Range
Predicted Success 29.3±27.1 6.0-111.0
Predicted Failure 76.9±56.7 8.0-243.0
65
![Page 66: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/66.jpg)
Conclusions
•CPAP is still standard treatment for OSA but it has “clay feet”
•OAT is great treatment for OSA BUTit must incorporate patient selection
•The at-home sleep test, MATRx plus, provides accurate patient selection for OAT
66
![Page 67: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/67.jpg)
Know, in advance, OSA patients who will be effectively treated with an oral appliance
Improve your efficiency of appliance fitting at target
Decrease the time-to-therapy
Minimize the risk of over-titration
MATRx plus Empowering the Sleep Dentist
67
![Page 68: Picking Winners Improves Outcomes and Avoids Side-Effectsdentalsleepsymposium.com › wp-content › uploads › 2012 › 07 › Preci… · purpose of reducing future CV events in](https://reader033.fdocuments.us/reader033/viewer/2022042402/5f115e47e4b66540f131511b/html5/thumbnails/68.jpg)
Acknowledgements
• National Research Council Canada –Industrial Research Assistance Program
• Alberta Innovates Technology Futures
• SomnoMed
• MicroDental Laboratories
• Zephyr Sleep Technologies
68