A eficácia dos aparelhos ortopédicos fucionais como alternativa de tratamento em crianças e adolescentes com apnéia obstrutiva do sono : revisão sistemática e meta-análise

Abstract

Introduction: Obstructive Sleep Apnea (OSA) is a sleep disorder that affects children and teenagers with consequences in systemic health and craniofacial development, having an impact on the quality of life of the individual, as well as in the economy. Identify and treat apnea is most importantly in children, whose facial skull is in continued growth and development, being this the opportune time for corrections of dentoskeletal alterations. Its origins come from various factors, thus it must be treated multi disciplinarily. growth abnormalities, cardiovascular complications, neurobehavioral, inflammatory/metabolic and neurocognitive comorbidities are consequences of OSA. Treatments during childhood include adenotonsillectomy, pharmacotherapy, myofunctional therapy and Continuous Positive Airway Pressure (CPAP), all with important limitations, which have led to a search for therapeutic alternatives. Oral appliances have been tested on the treatment of OSA in children, specifically Rapid Maxillary Expansion and Mandibular Advancement, among these the Functional Orthopaedics, in their turn, aim at bone remodeling and the change in shape through redirect of natural forces such as eruption/growth, jaw and tongue posture change. They are effective in the treatment of malocclusions and re orient maxillomandibular growth. The use of Functional Orthopaedic Oral appliances may represent an effectice treatment, less invasive and better tolerated than others available for patients with OSA and craniofacial alterations. Objective: Systematically review in the literature the efficiency of the Functional Orthopaedic Oral Appliances on the treatment of children and/or teenagers with Obstructive Sleep Apnea (OSA), in relation to Apnea and Hypopnea Index (AHI) and minimum percentage of Oxygen Saturation, in the polysomnography (PSG), as well as an assessment of symptoms in the Obstructive Sleep Apnea-18 (OSA-18) validated questionnaire, for Apnea assessment in children, when compared to patients without treatment or only the treated patients, intra-group, before and after the treatment with Maxillary Functional Orthopaedic. Methods: This systematic review and meta-analysis outlined herein followed the standards of PRISMA 2020 and have the protocol number CRD42021253341 as registration in PROSPERO. Search in the literature took place in October 2021 and it was updated until May 2022, on the databases: MEDLINE (via PubMed), BVS (LILACS and BBO), ISI of knowledge (via Web of Science), SciELO (via Web of Science), COCHRANE, EMBASE (Elsevier), SCOPUS, WHO and grey literature. They were included studies with children and teenagers of up to 16 years of age bearer of the obstructive sleep apnea and hypopnea syndrome (OSAHS), diagnosed by polysomnography (PSG), treated with Functional Orthopaedic Oral Appliances and, compared the treated group with control group (without treatment) or same patients before and after treatment (intra-group). Primary outcome was the assessment of Apnea and Hypopnea Index (AHI) per sleep hour and, secondary, it was Minimum Oxygen Saturation (SaO2), seen in percentage, also in PSG, as well as scores assessment of the OSA-18 validated questionnaire (for diagnosis and follow up of children with apnea). The selection of the studies has been made by two independent assessors and, applied as analysis agreement between the assessors, Cohen Kappa Test. Selected studies have been submitted to an analysis through a data extraction table. After the extraction of data, the quaility of clinical tests (ECs) was assessed by means of List Method Delphi and the cohort studies by means of the Newcastle-Ottawa Scale. Subsequently, it was analysed bias risk and, for Random Clinical Tests, it was used the Cochrane tool for Bias Risk; for the non-random clinical tests, it was used RoBANS and, for the cohort studies it was used the Cochrane´s bias risk for observational studies tool. The meta-analysis was carried out in the “R” software, using as frequency measurement the average with standard deviation, in which measurement of association was the difference of average Standardized Mean Difference (SMD), with graphic representation by means of forest plot graphs. For heterogeneity calculations of the studies, it was used I2 statistics. The outcomes were AHI, SaO2 and the OSA-18 questionnaire. It was used Confidence Interval of 95% and fixed and random effect models. Results: Of the 4860 selected articles in the Search, 34 were left for systematic review ando f those, 9 were used in meta-analyses, in addition to 90, whose purpose were the references of the articles selected in the searches. In the fixed model, for AHI, the four meta-analysis carried out were statistically significant (the treatment reduced AHI), and in the random model, two of them. For SaO2, in the fixed model, one of the two carried out was significant (the treatment increased minimum oxygen saturation in percentage) and for the random there has been no significance. For the OSA-18 score the two meta-analysis carried out were statistically significant (the treatment reduced the scores of symptoms for both fixed and random models). However, even the analysis which were not statistically significant, they showed the results of statistics (diamond) significantly more displaced to the side that the treatment favours the aforementioned outcome. In percentage of response, the AHI in all combinations / comparisons carried out responded to the treatment with an improvement (reduction in AHI) that varied from 51,30% to 58,89% in the treated group and, in the control group (without treatmet) there was a worsening (increase in AHI) that varied from 28,43% to 39,43%. For the outcome of the Saturation, there has been improvement (increase) that varied from 4% to 9,49% in the treated and for the control group there has also been increase of 1,18% so in a smaller proportion than the treated group. For the questionnaire, there has been improvement (reduction) on the scores in 20,11% in the treated group, whereas in the control group there has been worsening (increase) in the same period of time. Heterogeneities varied bewteen 0 to 98% and for this reason, it has been used the fixed and random effects. The quality of the articles was good, although with varied scoring. There has been no risk of bias, although the scores have been different between the studies assessed. Conclusion: Treatment with Functional Orthopaedic Oral Appliances is appropriate and effective for children and teenagers bearer of the Obstructive Sleep Apnea and Hypopnea Syndrome (OSAHS), as long as these patients are diagnosed, as a possible etiology of the OSAHS, the deficiency on the development and growth of the maxillomandibular complex, such particularities that tend to leave the airways smaller, this way contributing to OSAHS. The Functional Orthopaedics aids treating the shape and function of stomatognathic system and, as a result, expanding the quality of life of these patients.