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1 원저 성균관대학교의과대학, 삼성서울병원신경과학교실, 수면장애클리닉, 치과진료부교정과 a 김수경김대영김영남이지현조재욱주은연김영호 a 홍승봉 Therapeutic Effect of Mandibular Advancement Device in Sleep-Related Breathing Disorders Soo-Kyoung Kim, M.D., Daeyoung Kim, M.D., Youngnam Kim, Ji-Hyun Lee, M.D., Jae-Wook Cho, M.D., Eun Yeon Joo, M.D., Young Ho Kim, D.D.S., M.S., Ph.D. a, Seung Bong Hong, M.D., Ph.D. Department of Neurology, Sleep Disorders Clinic, Department of Orthodontics, The Institute of Oral Health & Science a, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background: The Mandibular advancement device (MAD) was known to be one of the effective treatments for the broad spectrum of sleep related breathing disorders. The aim of the present study was to evaluate the therapeutic effects and the determinants of success or failure of MAD in patients with sleep-related breathing disorders (SRBD). Methods: We enrolled 20 patients with SRBD confirmed by overnight polysomnography. All patients were fitted with temporary MAD. Apnea-hypopnea index (AHI) and risk index (RI) were measured by a portable respiratorymonitoring device (MESAM Ⅳ) before and after temporary MAD use. Results: Overall, MAD significantly reduced AHI (18.9±11.6/hr to 13.8±11.9/hr, p=0.029), but Epworth sleepiness scale was not improved (10.9±3.9 to 9.8±3.9, p=0.086). More than 50% of reduction in AHI was observed in 6 patients (30%, 6/20). When subjects were divided into patients who were satisfied with the temporary MAD and decided to keep wearing permanent MAD during the night (good response, GR, N=12) and patients who refuse to wear permanent MAD because they could not get accustomed to the temporary MAD (poor response, PR, N=8), There were no differences in age, body mass index, and pre-treatment AHI during the overnight polysomnography between both groups. There were significant reductions in AHI, and ESS were observed in GR, not in PR. Seven patients in GR group decided to apply the permanent MAD (two-piece Herbst type). Conclusions: These findings suggested that having good response to MAD determined the improvement of SRBD and daytime sleepiness. However, it is uncertain whether other factors affected the patients compliance to MAD. J Korean Neurol Assoc 25(4): , 2007 Key Words: Sleep-related breathing disorder, Oral appliance, Mandibular advancement device, Apnea-hypopnea index, Risk index 서론 Received June 20, 2007 Accepted August 6, 2007 *Seung Bong Hong, M.D., Ph.D. Department of Neurology, Samsung Medical Center, Sungkyunkwan University, 50 Irwon-dong, Gangnam-gu, Seoul, , Korea Tel: Fax: sbhong@skku.edu, sbhongsmc@gmail.com * This work was supported bya grant (No. A050462) from the Good Health R&D Project, Ministry of Health & Welfare, Republic of Korea, and by a grant (M103KV K ) from the Brain Research Center of the 21 st Century Frontier Research Program funded by the Ministry of Science and Technology of the Republic of Korea. 수면호흡장애 (Sleep-Related Breathing Disorder, 이하 SRBD 로약칭 ) 는성인인구의 4-25% 정도에서관찰되는흔한수면장애이다. 1 이는만성또는습관성코골이부터상기도저항증후군 (upper airway resistance syndrome, 이하 UARS 로약칭 ) 및폐쇄성수면무호흡-저호흡증후군 (Obstructive Sleep Apnea-Hypopnea Syndrome, 이하 OSAHS 로약칭 ) 까지포함하는호흡장애의큰스펙트럼을칭한다. 그중 OSAHS 는 30세에서 60세사이의중년여성의 2%, 남성의 4% 에서관 500 대한신경과학회지제 25 권제 4 호, 2007

2 찰되는흔한질환이며, 연령대가높을수록높은이환율을보인다. 1,2 심한 OSAHS 는반복적인상부기도의폐쇄, 흉강내압력변동의증가와빈번한수면중각성을유발하여수면의질을떨어뜨리고만성저산소증을유발하여주, 야간으로다양한증상을야기하는데업무나운전중의졸음등으로인하여가정이나사회생활에서여러가지문제를야기할수도있고, 고혈압, 허혈성심장질환, 뇌졸중등과같은심혈관계질환을악화시켜전신건강에영향을줄수있으며사망의위험을증가시키는독립적인위험인자가될수있다. 3 SRBD 의치료로수술요법, 4,5 약물요법 6 및지속적상기도양압술 (continuous positive airway pressure, 이하 CPAP 으로약함 ) 7,8 등이사용되어그유용성이입증된바있으나, 수술요법은출혈과통증, 수술후반흔에의한불편감, 합병증, 증상재발및비가역성등의이유로, CPAP 은장비가비싸고이동성이제한되며소음과마스크착용시의불편함때문에환자의순응도가비교적낮아 9,10 더경제적이고간편한치료방법의필요성이대두되었다. 수면과관련된호흡장애의또다른치료방법으로 1900 년대초기부터대두된여러종류의구강내장치들은이후활발하게개발되어현재 30여종이미국식품의약안전청 (FDA) 의승인을받았다. 11,12 구강내장치의종류로는하악을전방으로위치시켜주는하악전진기구 (mandibular advancement device; MAD), 혀만을전방으로당겨주는혀유지장치 (tongue retaining device), 그리고연구개거상장치 (soft palatal lifter) 의세가지가있으며, 착용목적은혀뒤의공간을확보하여충분한공기통로를만들어주려는것이다. 이중코골이와 OSAHS 에효과가있다고인정되어가장널리쓰이는구강내장치는 MAD 이다. MAD 는하악을전방으로당겨서간접적으로혀와그기저부를전진시켜혀뒤의공간을넓히고인두벽을안정화시킨다. 이장치는경성또는반경성레진 (resin) 으로제작하며, 상하악치열궁 (maxillary and mandibular dental arch) 을덮는역할을한다. 상악과하악은레진을이용하여개구와하악의측방운동을할수있도록다양한형태의스크류혹은연장암 (extension arm) 으로연결하여고정한다. OSAHS 환자를대상으로구강내장치를사용한이전연구결과를보면 72명의대상자중 53% (38/72) 에서장치착용후수면무호흡-저호흡지수 (apnea-hypopnea index, 이하 AHI 로칭함 ) 와이로인한각성지수 (arousal index, 이하 AI로칭함 ) 가유의하게감소하였다 (AHI 44±28 to 12±15/hr, AI 37±27 to 16±13/hr). 9 구강내장치의수면무호흡증치료성공률은 31-66% 로보고되었다. 9 구강내장치는수술요법이나 CPAP 에비해간편하고소음이없으며, 착용이가역적이고비침습적이어서, 환자가적응도가높을뿐만아니라, 치료효과는 CPAP 보 다낮지만, 수술요법과는큰차이가없다고보고되었다 따라서구강내장치는 CPAP 에잘적응하지못하거나, 수술을기피하는환자및단순코골이환자와경도나중등도의 OSAHS 환자에게도움이될수있을것으로기대되었다 국내에서는 54명의 OSAHS 환자와보호자를대상으로설문지를통해구강내장치착용후 AHI, 코골이의빈도와크기, 주간졸림증의정도와수면후개운함이유의하게개선되었다고보고된예가있었다. 19 그러나코골이와 OSAHS 의심도를판단하고, 치료결과를예측하는것은수면동안의호흡장애, 혈액내산소포화도의감소정도, 수면구조의분절및다른임상적증상등에의해서결정된다. 따라서설문지를통한역학연구는많은환자를대상으로비교적간편하게시행할수있는연구이지만, 관찰자에따라증상변화를보고하는정도의차이가있어서, 신뢰성과타당성이낮은한계가있다. 현재까지국내에서 SRBD 환자에대한구강내장치의치료효과와만족도에대한객관적인연구가이루어지지않았다. 본연구는야간수면다원검사 (overnight polysomnography) 로확인된 SRBD 환자들을대상으로구강내장치의치료효과와만족도에따른임상적차이점을알아보고자하였다. 대상과방법 1. 대상 2005 년 1월부터코골이와수면중무호흡을주소로삼성서울병원에내원한환자중에서 1995 년 The American Sleep Disorders Association (ASDA) 에서제시한구강내장치적응기준을 13 바탕으로포함기준 (inclusion criteria) 을설정한후이를만족하는 24명을대상군으로하였다. 야간수면다원검사에서 AHI 가시간당 5 이상으로증가하여 OSAHS 로진단되거나, AHI 는시간당 5 미만이지만, 무호흡단계검사 (apnea level test) 를이용하여상기도저항증후군 (UARS) 으로진단된 SRBD 환자중 1) 이비인후과검진을통해코골이와수면중무호흡에수술적치료가도움이안될것으로판단된경우나수술적치료에반응하지않은경우, 2) CPAP 치료를거부하거나, 3) 1) 과 2) 에해당되면서치과검진에서악안면및턱관절 (temporo-mandibular joint) 에기형이없는환자를선별하였다. J Korean Neurol Assoc Volume 25 No. 4,

김수경김대영김영남이지현조재욱주은연김영호홍승봉 Figure 1. A temporary mandibular advancement device. This monobloc appliance consists of a hypoallergenic thermoplastic body.

While soft, the appliance is fitted to a patient s upper and lower jaws and then is cooled to be ready for use at night. Figure 2.

3 김수경김대영김영남이지현조재욱주은연김영호홍승봉 Figure 1. A temporary mandibular advancement device. This monobloc appliance consists of a hypoallergenic thermoplastic body. After heating the appliance in water that has been boiled, the thermoplastic co-polymer becomes soft and moldable. While soft, the appliance is fitted to a patient s upper and lower jaws and then is cooled to be ready for use at night. Figure 2. (A) A permanent mandibular advancement device (monobloc type) (B) A lateral view of monobloc type MAD (C), (D) The fitted oral appliance allows two-thirds of maximum forceful protrusion of a mandible. 502 대한신경과학회지제 25 권제 4 호, 2007

4 2. 야간수면다원검사 (Overnight polysomnography) Alice-3 system (Healthdyne, USA) 과 Somnologica TM (Embla, USA) 를이용하여시행하였다. 기본검사항목으로는 4채널의뇌파 (C3-A2, C4-A1, O1-A2, O2-A1), 2-4채널의안전도 (electro-oculogram) 와 1채널의턱근전도 (chin EMG) 를기록하여수면의단계와각성빈도를측정하였다. 호흡에관련된채널로는온도감지센서 (thermistor) 를이용하여공기흐름을측정하고 (airflow monitoring) 동시에비강공기압 (nasal pressure monitoring) 을측정하였다. 호흡또는무호흡시흉부와복부의움직임을기록하였고, 호흡노력 (respiratory effort) 을평가하기위하여늑간근근전도 (intercostal muscle electromyogram) 를실시하였고, 산소포화도 (oxygen saturation) 를측정하였으며, 코골이의양과크기를측정하였다. 다리움직임을보기위하여움직임센서를사용하였다. 온도감지센서에의해무호흡 (apnea) 은공기흐름이 90% 이상감소하여 10초이상지속될때로정의하였고, 저호흡 (hypopnea) 은공기흐름이 50-90% 감소하여 10초이상지속할때와공기흐름의감소가없어도혈중산소포화도가 4% 이상감소하고각성이동반되는경우로정의하였다. 한시간수면중에발생하는무호흡과저호흡의합의평균을계산하여무호흡-저호흡지수 (Apnea-Hypopnea Index, AHI) 를구하였다. 3. 휴대용수면감시기구 (Portable sleep monitoring device, MESAM IV) MESAM IV는 1986 년제작된 2채널의 MESAM (Madaus Electronics Sleep Apnea Monitor, Munich, Germany) 을개량한 portable sleep monitoring device 이다. 20,21 산소포화도는손가락맥박산소측정법 (finger pulse oximetry) 으로, 코골이는후두위에위치하는소형마이크로폰으로측정하며, 흉골바로위에원형센서를이용하여심장박동수 (beat-tobeat heart rate analysis) 와수면중체위를분석하였다. MESAM 은 AHI 값과 AHI에공기흐름제한 (flow limitation) 과코골이의수를포함하여계산한위험지수 (risk index, RI) 를측정한다. RI는다음의수식을이용하여계산하였다. RI = point score as a sum of AHI + score of FL/FS Points calculated from AHI: AHI 1 h* = number of points (e.g. AHI = 5/h 1 h = 5 points), *Evaluation period FL/FS point score: 10 (0.8 FL FS) / Az) number of points FL = number of flow-limited breaths without snoring FS = number of flow-breaths with snoring Az = total number of breaths MESAM IV가기계적으로측정한값들은수면전문의 (HSB) 가다시확인하여정확성을기하였다. 4. 구강내장치 (Oral Appliance) 일시구강내장치 (temporary oral appliance) 는먼저뜨거운물 ( 약 80 ) 에넣어연화시킨후환자의양쪽어금니에부착시켜교합을맞추고입술주위를눌러서제작하였다 (Fig. 1). 자택에서일시 MAD 를착용한후휴대용수면감시기구를이용하여 AHI 와 RI값을구하여 MAD 를착용하기전의값과비교한다. 영구적구강내장치 (permanent oral appliance) 는 twopiece devices Herbst type MAD로하였으며 (Fig. 2), 환자마다 SRBD 에효과적인하악의전방유도량이다르기때문에, 최적의하악전방위치를확인하고착용시불편함을줄이기위하여두차례이상치과를방문하여구강내장치를조정하게하였다. 결과 총대상자 20명중 OSAHS 는 18명 ( 남자 17명, 여자 4명 ), UARS 는 2명 ( 남자 1명, 여자 1명 ) 이었으며, 평균연령은 57.7 ±10.3 세 (41-75 세 ) 이었다. 야간수면다원검사의평균 AHI 는 26.2±21.6/ 시간 ( ) 이었으며, 평균각성지수 (arousal index, AI) 는 35.3±17.9/ 시간 ( ) 이었다. 전체환자들의평균수면잠복기는 21.0±33.4 분 ( ), 수면구조중얕은잠인 1단계수면은평균 27.9±14.0% ( ), 2단계수면은 51.5±9.3% ( ), 깊은잠인서파수면 (3, 4단계수면 ) 은 4.8±5.9% (0-20.6), 렘수면은 15.8± 6.2% ( ) 이었다. 평균총주기성하지운동지수 (total periodic limb movement during sleep index) 는 8.2±17.5/ 시간, 주기성하지운동에의한각성지수 (movement arousal index) 는 2.0±5.0/ 시간이었다. 일시 MAD 착용전 MESAM IV로다시측정한환자들의평균 AHI 는 18.9±11.6/ 시간, 평균 RI는 22.6±11.4/ 시간으로수면다원검사의평균 AHI 인 26.2±21.6/ 시간과통계학적차이는없었다 (Wilcoxon Signed Rank test, p > 0.05). 일시 MAD 착용후 MESAM IV로다시측정한평균 AHI 는 13.8±11.9/ 시간으로통계학적으로유의하게감소했으나 (p=0.029), 평균 RI는 18.2±12.4/ 시간으로의미있는차이는없었다 (p=0.086). 주간 J Korean Neurol Assoc Volume 25 No. 4,

5 김수경김대영김영남이지현조재욱주은연김영호홍승봉 졸림증의척도인 Epworth Sleepiness Scale 은구강내장치착용전에 10.9±3.9 점 (4-22) 이었는데, 착용후에 9.8±3.9 점으로차이가없었다 (p=0.065). 일시 MAD 착용후 AHI 가 50% 이상감소한환자는 6명 (-55.6~89.2%), 50% 미만으로감소한환자는 9명 (-7.1~ -45.5%) 이었으며, 나머지 5명에서는오히려 AHI 가증가했다 (+5.7~+300%). 일회용 MAD 착용후 RI가 50% 이상감소한환자는 4명 (-50.0~77.5%), 50% 미만으로감소한환자는 10명 (-7.7~-46.2%) 이었으며, 나머지 6명에서는오히려 RI가증가했다 (+2.5~+64.0%). 일시 MAD 착용후만족도가높았던환자들 (good response, GR, N=12) 과만족도가낮았던환자들 (poor response, PR, N=8) 로나누었다 (Table 1). 두군의분류는일시 MAD 에대한환자들의주관적인만족도를바탕으로하였다. 일시 MAD 를착용하고수면을취한다음날전화인터뷰를통해환자가 MAD 에대해만족하는지 ( 일시 MAD 착용전에비해착용한날더잠을잘잤기때문에 MAD 를제작하여계속착용하겠다 ) 또는불만 족하는지 (MAD 로인해더잠을못자거나, 별다른차이를느끼지못해지속적으로 MAD 를착용하고싶지않다 ) 에대해질문했다. 환자의주관적인답변에따라 good response 와 poor response 로나누었다. GR군과 PR군간의연령, 체질량지수 (body mass index, BMI), ESS 및구강내장치착용전수면다원검사의 AHI 와 MESAM IV로측정한 AHI 및 RI 간의차이는없었다 (Mann-Whitney test, p >0.05). GR 군에서는일시 MAD 착용후평균 AHI 가 19.9±9.9/ 시간에서 8.8±6.0/ 시간 (-50.3%) 로유의하게감소했으며 (Wilcoxon signed rank test, p=0.002), 평균 RI는 40.8% (23.3 ±9.9/ 시간 to 12.7±5.8/ 시간 ) 감소했다 (p=0.002). ESS도 10.5±3.5점에서착용후 8.5±3.0점으로의미있게감소했다 (p =0.042)(Fig. 3-A). 반면 PR군에서는일회용 MAD 착용후평균 AHI 는오히려 33.1% 증가했으며 (16.3±12.4/ 시간 to 17.5±14.1, p=0.160) RI 는착용전에비해 13% 증가하였다 (20.1±12.4/ 시간 to 22.0 ±15.0/ 시간, p=0.091). ESS 도 10.4±4.8점에서착용후 10.4 Table 1. The results of the night polysomnography and portable sleep monitoring device (MESAM IV) in patients before and after appliance of temporary mandibular advance device PSG Portable sleep monitoring device BMI AHI Arousal index AHI RI ESS Age kg/m 2 Pre Post % Pre Post % Pre Post % Good Response 1 M M M M M M M M F F M M Poor Response 1 M F M M F M M F PSG; polysomnography, BMI; body mass index, AHI; apnea-hypopnea index, RI; risk index, ESS; Epworth sleepiness scale, pre; pretemporary MAD (mandibular advance device), post; post-temporary MAD, %, [(post temporary MAD - pre temporary MAD)/ pre- temporary MAD] 대한신경과학회지제 25 권제 4 호, 2007

고찰 Figure 3. The changes of Apnea-hypopnea index and Risk index after a temporary mandibular advancement device (MAD) in patients with sleep-related breathing disorders.

6 고찰 Figure 3. The changes of Apnea-hypopnea index and Risk index after a temporary mandibular advancement device (MAD) in patients with sleep-related breathing disorders. (A) After a temporary MAD application, AHI was significantly reduced in patients with good response (GR), not in those with poor response (PR). (B) Risk index was also remarkably decreased in patients with GR to temporary MAD not in those with PR after the MAD application. *Wilcoxon Signed rank test, p<0.05. ±4.8 점으로차이가없었다 (p=0.564) (Fig. 3-B). 일회용 MAD 의합병증은착용직후턱과치아의통증, 입마름, 타액분비의증가, 또는부정교합에의한불편감을호소했었다. 그러나대개저절로호전되었으며, GR 군에서각각 1명씩치료가필요한치주염과턱관절 (temporo-mandibular joint) 통증이발생했으나, 적절한치료후증상이완쾌되었다. GR 군중 7명은치과에서영구적 MAD (two-piece devices, Herbst type) 를제작하였으며, 그중 3명은영구적 MAD 착용전후의 AHI 와 RI를측정하였다. 영구적 MAD 착용후평균 AHI 는시간당 25.0±13.7 에서 5.3±1.5 로, RI는시간당 28.3 ±8.6 에서 13.8±1.2 으로감소했으며 ESS 도 10.4±4.8 점에서착용후 3.5±2.8 점으로호전되었다. OSAHS 의가장효과적인치료법인 CPAP 은고가의장비와소음, 마스크와호흡시의불편감때문에환자가적응하기힘들고휴대가어렵다는단점으로인해모든환자들에게적용하기는어렵다. 구강내장치의이상적인대상자는정상체중으로코골이만있거나, 중등도이하의 OSAHS 환자로서하악관절의전진운동범위와적절한치열조건을만족시켜야한다. 그러나 CPAP 에대한순응도가떨어지거나, 수술적치료에실패한 OSAHS 환자들도구강내장치의대상자가될수있다. 22 두부계측법 (cephalometry) 이구강내장치의적절한대상자를찾는데도움을줄수있다고한다. 23 환자가젊을수록 (60 세이하 ), BMI 가낮을수록, 상악이길수록, 입인두가작을수록, 상하앞니간의전후방공간 (overjet) 이적을수록, 상악어금니의발진이덜할수록, 인두가길거나연구개가작을수록, 구강내장치에대한순응도가우수하다. 24 그러나 OSA 의정도와기도폐쇄의위치가구강내장치의효능을예측하지못한다고한다. 25 One-piece와 two-piece devices 모두 OSAHS 에대해효과적이며큰차이가없으며, 하악의전진이클수록구강내장치의치료효과가높은것은아니라고한다 본환자들은각개인의악안면과치아구조에맞는 two-piece devices, Herbst type 을제작하여, 하악을전방으로약 75% 를전진시켰다. 중등도이상의 OSAHS 환자 (N=24) 에서 Herbst-type MAD 를 3년이상장착하여 RDI (respiratory disturbance index) 가의미있게감소하였고 (48 2/ 시간 ), 그중 52% 은지속적으로구강내장치를사용하고있다고한다. 32 같은구강내장치로 19명 OSAHS 환자에서시행한다른연구에서는 RDI 가 35회 / 시간에서 13회로줄었으며, 68% 의환자가 2년이상사용하였다. 33 구강내장치는입천장인두면적 (velopharyngeal area) 을약 35% 넓힌다. 34 CPAP 과구강내장치의효과를비교했을때 one-piece MAD 와 CPAP 은모두의미있게 RDI 를감소시켰지만, CPAP (78%) 이구강내장치 (50%) 보다더효과적이었다. 35 그러나순응도는구강내장치가더우수했다 구강내장치와 CPAP 모두에만족스러운효과를보였던 OSAHS 환자들의대부분 (91%, 11/12 명 ) 이구강내장치를선택한것은치료효과가비슷할경우혹은다소떨어지더라도더간편하고경제적인치료법을선택하려는환자들의욕구를보여준다. 35 국내에서도수술을받거나 CPAP 경험이있던환자들이구강내장치를더선호한다고보고되었다. 19 본연구에포함된 20 명의 OSAHS 또는 UARS 환자들은구강내장치를착용한후, 전체적인 AHI 는 11%, RI는 16% 씩감소하여다른연구에비해치료효과가높지는않았다 또한주간졸림증의척도인 ESS 도 J Korean Neurol Assoc Volume 25 No. 4,

7 김수경김대영김영남이지현조재욱주은연김영호홍승봉 구강내장치착용후평균 9% 감소하여임상적호전은없었다. 그러나대상자들은구강내장치에대한만족도가높은 GR군 (N=12) 과만족도가낮은 PR군 (N=8) 으로나누어분석했을때, 장치장착후 GR군의 AHI 와 RI 및 ESS 는유의하게감소한데비해, PR군에서는오히려증가하였다. PR군에속한환자들은구강내장치를착용해도코골이, 수면의질, 및피로감이호전되지않아불만족스럽다고했다. 이는구강내장치사용후 AHI 및 RI의호전과주간졸림증의소실이장치의순응도를좌우함을시사한다. 한편, GR 군과 PR군간의휴대용수면감시기구착용전의기본적인신체정보와야간수면다원검사의값및휴대용수면감시기구의 AHI 과 RI간의차이는없었다. 이전보고에서도구강내장치의치료효과와만족도는치료전 AHI 나 RDI 와유의한상관관계를보이지않는다고하였으며, 32 이는본연구결과와일치하는소견이다. 그러나본환자중 UARS 두명은모두 PR에속하여, AHI 값이낮다고구강내장치에대한효과가높은것은아닌것으로추측되지만, 환자수가적어추가적인연구가필요하다. GR 군중 7명은치과에서영구적 MAD 를제작하였으며, 그중 3명에서착용전후의 AHI 와 RI를측정한결과모두유의하게감소하였으나, 대상자수가적어통계학적분석을시행하지는못하였다. 구강내장치는특히수면무호흡증여자환자, 바로누움자세 -의존성수면무호흡증남자환자 (men with supine-dependent sleep apneas) 에서특히유용하다고하였는데, 36 본연구의대상환자들중여성의비율이낮고, 바로누움자세- 의존성수면무호흡증남자는대상자에포함되지않아분석할수없었다. 구강내장치착용직후이갈이, 턱관절의동통, 개구장애, 활동성저작근동통, 치아상실, 치주상태불량등이보고되었다. 20,32 하지만, 2-3 개월사용한후대부분이장치에잘적응하였으며, 치아와지지조직및턱관절의비가역적인손상은아직보고된바가없다. 32 본연구의환자들이구강내장치를장착한직후에는경미한부작용을호소했지만, 모두일시적이었으며, 적절한치료후지속적으로구강내장치를착용한것으로보아, 장치에의한부작용이환자의순응도를좌우하지는않는것으로보인다. 본연구에서는구강내장치의치료효과를보기위하여휴대용수면감시기구인 MESAM IV를시행하였다. 임상적으로 OASHS 가의심되는환자들에서휴대용수면감시기구와야간수면다원검사간에 75% 의진단적일치를보였고, 숙련된전문가가직접수기작업을할때정확도가훨씬높아진다고보고했다. 37 본연구에서 MESAM IV로다시측정한환자들의평균 AHI (18.9±11.6/ 시간 ) 는수면다원검사의 AHI 값 (26.2±21.6/ 시간 ) 보다작았지만, 통계학적차이는없었고, 공기흐름제한과코골이를추가한 RI (22.6±11.4/ 시간 ) 와도차이는없었다. 비록휴대용수면감시기구가수면다원검사의수기로측정한데이터보다정확하지는않지만, 검사비용과시간을고려하고또한구강내장치와같이여러차례맞춤과교정이필요한치료도구를사용할때는오히려휴대용수면감시기구가더실질적인도움이된다고생각한다. 결론 일시구강내장치를착용하여만족도가높았던 SRBD 환자들에서일시구강내장치착용후 AHI 와 RI및주간졸음증이유의하게호전되었다. GR군과 PR군간의구강내장치작용전의기본적인신체정보와야간수면다원검사의값및휴대용수면감시기구의 AHI 과 RI간의차이는없었기때문에현재로서는 GR 군과 PR군간의만족도를결정하여치료효과의차이를유발하는요인은정확하지않다. 구강내장치는단순코골이나중등도이하의 OSAHS 환자뿐만아니라심한 OSAHS 환자중 CPAP 에적응을하지못할때사용할수있다. 또한수술의위험성이큰환자나침습적치료를꺼리는환자, 좀더안전하고간편한치료방법을원하는환자들에게유용하게적용할수있을것으로기대한다. REFERENCES 1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993:328: Ferini-Strambi L. Ferini-Strambi L, Fantini ML, Catronovo C. Epidemiology of obstructive sleep apnea syndrome. Minerva Med 2004; 85: 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 Med 2005;353: 민양기, 이재서. 폐쇄성수면무호흡증의수술적치료. 수면 - 정신생리 1994;1: Fairbanks DN. Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg 1990;102: 문화식, 최영미. 수면무호흡증군의내과적치료. 수면 - 정신생리 1996;3: Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnea by continous positive airway pressure applied through the nares. Lancet 1981;1: Sanders MH, Moore SE, Eveslaae J. CPAP via nasal mask; a treatment for occlusive sleep apnea. Chest 1983;83: Pancer J, Al-Fsifi S, Al-Faifi M, Hoffstein V. Evaluation of variable mandibular advancement appliance for treatment of snoring and sleep apnea. Chest 1999;116: 대한신경과학회지제 25 권제 4 호, 2007

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<30322DC0B1BDC2C7F65FC6F3BCE2BCBA2E687770> 종 설 J Kor Sleep Soc / Volume 3 / December, 2006 연세대학교치과대학병원구강내과, 턱관절및안면통증클리닉 Efficacy of Mandibular Advancement Device in Management of Obstructive Sleep Apnea Seung Hyun Yoon, D.D.S., Seong Taek Kim,