Skip to main content

Advertisement

SpringerLink
Log in

Oral appliance titration in patients with obstructive sleep apnea induces the appearance of periodic limb movements

  • Original Article
  • Published:
Sleep and Breathing Aims and scope Submit manuscript

An Erratum to this article was published on 10 August 2010

Abstract

Study objectives

Oral appliance (OA) therapy is considered a first line choice of therapy for some patients with mild or moderate obstructive sleep apnea (OSA) and an alternative form of treatment in those intolerant of continuous positive airway pressure (CPAP) use. According to several studies, periodic limb movements (PLM) appear during effective treatment of OSA with CPAP, but a similar phenomenon has not been described with the use of oral appliance. Herein, we describe the incidence of PLM in patients with OSA who underwent oral appliance therapy titration.

Design

This is a prospective, observational study set in a six-bed sleep center in an academic, military referral hospital.

Patients and methods

Patients with OSA (n = 21; 15 men and six women; mean age, 43 years; and age range, 25 to 53 years) treated with OA during a 1-year period were enrolled. Patients were categorized according to the severity of sleep apnea and incidence of PLM on diagnostic polysomnography. Effective treatment of OSA and appearance or disappearance of PLM with arousal on subsequent oral appliance titration polysomnography were recorded and compared.

Results

Twenty-one patients were enrolled. During baseline polysomnography, three of 21 (14%) patients had five or more PLM with arousal per hour while 11 of 21 (52%) patients had PLM with arousal during the oral appliance titration trial.

Conclusion

Oral appliance therapy for obstructive sleep apnea is an effective treatment and ideal for use in military recruits. The appearance of periodic limb movements with arousal during oral appliance use should be considered as a cause of persistent daytime sleepiness despite effective treatment of obstructive sleep apnea in this subset of patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

EDS:

Excessive daytime sleepiness

OSA:

Obstructive sleep apnea

AHI:

Apnea hypopnea index

PLM:

Periodic limb movement

PLMD:

Periodic limb movement disorder

OA:

Oral appliance

EEG:

Electroencephalogram

CPAP:

Continuous positive airway pressure

MSLT:

Multiple sleep latency testing

ESS:

Epworth Sleepiness Scale

References

  1. Hornyak M, Feige B, Riemann D, Voderholzer U (2006) Periodic leg movements in sleep and periodic limb movement disorder: prevalence, clinical significance and treatment. Sleep Med Rev 10(3):169–177

    Article  PubMed  Google Scholar 

  2. Scofield H, Roth T, Drake C (2008) Periodic limb movements during sleep: population prevalence, clinical correlates, and racial differences. Sleep 31(9):1221–1227

    PubMed  Google Scholar 

  3. McCall WV, Haponik E (1993) Relationship of nasal continuous positive airway pressure to periodic limb movement disorder in a patient without sleep apnea. Chest 103(5):1609–1611

    Article  CAS  PubMed  Google Scholar 

  4. Briellmann RS, Mathis J, Bassetti C, Gugger M, Hess CW (1997) Patterns of muscle activity in legs in sleep apnea patients before and during nCPAP therapy. Eur Neurol 38(2):113–118

    Article  CAS  PubMed  Google Scholar 

  5. Carelli G, Krieger J, Calvi-Gries F, Macher JP (1999) Periodic limb movements and obstructive sleep apneas before and after continuous positive airway pressure treatment. J Sleep Res 8(3):211–216

    Article  CAS  PubMed  Google Scholar 

  6. Baran AS, Richert AC, Douglass AB, May W, Ansarin K (2003) Change in periodic limb movement index during treatment of obstructive sleep apnea with continuous positive airway pressure. Sleep 26(6):717–720

    PubMed  Google Scholar 

  7. Fry JM, DiPhillipo MA, Pressman MR (1989) Periodic leg movements in sleep following treatment of obstructive sleep apnea with nasal continuous positive airway pressure. CHEST 96:89–91

    Article  CAS  PubMed  Google Scholar 

  8. Yamashiro Y, Kryger MH (1994) Acute effect of nasal CPAP on periodic limb movements associated with breathing disorders during sleep. Sleep 17(2):172–175

    CAS  PubMed  Google Scholar 

  9. Schmidt-Nowara W, Lowe A, Wiegand L (1995) Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Sleep 18:511–513

    Google Scholar 

  10. Kushida CA, Morgenthaler TI, Littner MR (2006) Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 29:240–243

    PubMed  Google Scholar 

  11. Ferguson KA, Cartwright R, Rogers R (2006) Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 29:244–262

    PubMed  Google Scholar 

  12. Center for Devices and Radiologic Health (2002) Class II special controls guidance document: intraoral devices for snoring and/or obstructive sleep apnea: guidance for industry and FDA. Rockville, MD: US Food and Drug Administration

  13. Haba-Rubio J, Staner L, Krieger J, Macher JP (2005) Periodic limb movements and sleepiness in obstructive sleep apnea patients. Sleep Med 6(3):225–229

    Article  PubMed  Google Scholar 

  14. Al-Alawi, Mulgrew A, Tench E, Ryan CF (2006) Prevalence, risk factors and impact on daytime sleepiness and hypertension of periodic leg movements with arousals in patients with obstructive sleep apnea. J Clin Sleep Med 2(3):281–287

    PubMed  Google Scholar 

  15. Guilleminault C, Lopes C, Hagen CC (2007) The cyclic alternating pattern demonstrates increased sleep instability and correlates with fatigue and sleepiness in adults with upper airway resistance syndrome. Sleep 30:641–647

    PubMed  Google Scholar 

  16. Guilleminault C, Stoohs R, Clerk A (1992) From obstructive sleep apnea syndrome to upper airway resistance syndrome: consistency of daytime sleepiness. Sleep 15:S13–S16

    CAS  PubMed  Google Scholar 

  17. Kristo DA, Lettieri CJ, Andrada T (2005) Silent upper airway resistance syndrome: prevalence in a mixed military population. CHEST 127(5):1654–1657

    Article  PubMed  Google Scholar 

  18. Chervin RD (2001) Periodic leg movements and sleepiness in patients evaluated for sleep-disordered breathing. Am J Respir Crit Care Med 164(8):1454–1458

    CAS  PubMed  Google Scholar 

  19. Krishnan V, Collop NA, Scherr SC (2008) An evaluation of a titration strategy for prescription of oral appliances for obstructive sleep apnea. CHEST 133:1135–1141

    Article  PubMed  Google Scholar 

  20. Saletu A, Anderer P, Parapatics S (2007) Effects of mandibular repositioning appliance on sleep structure, morning behavior and clinical symptomatology in patients with snoring and sleep-disordered breathing. Neuropsychobiology 55:184–193

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Behavioral Biology, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA

    Melanie L. Guerrero, Tracy L. Rupp & Thomas J. Balkin

  2. Department of Medicine, Pulmonary, Critical Care, and Sleep Service, Walter Reed Army Medical Center, Washington, DC, 20307, USA

    Melanie L. Guerrero & Daniel Kim

Authors
  1. Melanie L. Guerrero
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tracy L. Rupp
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thomas J. Balkin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Melanie L. Guerrero.

Additional information

This was not an industry supported study. The authors have no financial conflicts of interest.

An erratum to this article can be found at http://dx.doi.org/10.1007/s11325-010-0401-0

Rights and permissions

Reprints and permissions

About this article

Cite this article

Guerrero, M.L., Kim, D., Rupp, T.L. et al. Oral appliance titration in patients with obstructive sleep apnea induces the appearance of periodic limb movements. Sleep Breath 14, 359–363 (2010). https://doi.org/10.1007/s11325-009-0321-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11325-009-0321-z

Keywords

Search

Navigation