Evaluation of Therapeutic Efficacy of Adjustable Mandibular Advancement Device in the Management of Obstructive Sleep Apnea
Sunil Kumar, Mohit Sharma, Amit Bansal, B Jayan, Prasanna Kumar MP
AHI, ESS, MDSA, OSA
Citation Information :
Kumar S, Sharma M, Bansal A, Jayan B, Kumar MP P. Evaluation of Therapeutic Efficacy of Adjustable Mandibular Advancement Device in the Management of Obstructive Sleep Apnea. Indian Sleep Med 2018; 13 (1):5-12.
Introduction: Medical dental sleep appliance (MDSA) is an adjustable mandibular advancement device (MAD) recommended for treatment of snoring and obstructive sleep apnea (OSA). There are very few studies on Indian population which evaluate the therapeutic efficacy of mandibular advancement devices in the management of OSA.
Materials and Methods: A prospective clinical study was carried out. Twenty polysomnography diagnosed OSA patients fulfilling the inclusion and exclusion criteria were treated with MDSA and changes in pre and post-treatment sleep para-meters (apneahypopnea index (AHI) and epworth sleepliness scale (ESS)) were recorded.
Results: Mean differences in pre- (T1 = 30.7 ± 5.0) and posttreatment (T2 = 17.2 ± 3.9) AHI values and ESS pre-treatment (T1 = 17.2 ± 0.6) and post-treatment (T2 = 10.9 ± 0.9) were highly statistically significant (p < 0.001). Clinically the maximum improvement was observed in mild and moderate OSA cases. Although significant clinical improvement was also observed in severe OSA cases, the post-treatment AHI and ESS were still high.
Conclusion: MDSA is a non-invasive, low risk and cost-effective treatment option for patients suffering from mild and moderate obstructive sleep apnea and also in cases of severe OSA who are not comfortable with CPAP or not willing for surgery.
American Sleep Disorders Association Standard of Practice committee: Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Sleep. 1995; 18(6): 511-513.
Lowe AA. Dental appliances for snoring and Obstructive sleep apnea. In: Kryger M, Roth T, Dement W, editors. Principles and practice of sleep medicine. 3rd edition. Philadelphia: WB Saunders 2000; 929-939.
Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest. 1996; 109:1269-1275.
Clark GT, Blumenfeld I, Yoffe N, Peled E, Lavie P. A crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest. 1996; 109:1477–1488.
Ferguson KA, Ono T, Lowe AA, Majed SA, Keenan SP, Love LL, et al. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax. 1997; 52:362-368.
Jayan B, Prasad BNBM, Kamat UR, Kharbanda OP, Bhattacharrya D. Therapeutic efficacy of Thornton adjustable positioned in the management of patients with severe Obstructive sleep apnea: A Pilot study. Indian J Sleep Med. 2008; 3.3:97-101.
Jayan B, Prasad BNBM, Rajput AK, Bhattacharya R, Dhiman RK. Management of Obstructive Sleep Apnea with Oral Appliances: Our Experience. Indian J Sleep Med. 2006; 1.4:204-207.
Jayan B, Prasad BNBM, Dhiman RK. Role of Oral Appliances in the Management of Sleep Disorders. Med J Armed Forces India. 2009; 65:123-127.
Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep. 1999; 22(5):667-689.
Li W, Xiao L, Hu J. The Comparison of CPAP and Oral Appliances in Treatment of Patients with OSA: A Systematic Review and Meta-analysis. Respir Care. 2013; 58(7):1184–1195.
American Academy of Sleep Medicine Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update, 2005.
Johal A. A review on the use of mandibular advancement appliances in sleep disordered breathing. Dent Update. 2008; 35:230-235.
Ichioka M, Tojo N, Yoshizawa M, Chida M, Miyazato I, Taniai S, et al. A dental device for the treatment of obstructive sleep apnea: a preliminary study. Otolaryngol Head Neck Surg. 1991; 104:555–558.
Pepin JL, Leger P, Veale D. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest. 1995; 107:375- 381.
Wilhelmsson B, Tegelberg Å, Walker- Engström ML, Ringqvist M, Andersson L, Krekmanov L, et al. A prospective randomized study of a dental appliance compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnoea. Acta Otolaryngol. 1999; 119:503-509.
Pancer J, Al-Faifi S, Al-Faifi M, Hoffstein V. Evaluation of variable mandibular advancement appliance for treatment of snoring and sleep apnea. Chest. 1999; 116:1511-1518.
Barthlen GM, Brown LK, Wiland MR, Sadeh JS, Patwari J, Zimmerman M. Comparison of three oral appliances for treatment of severe obstructive sleep apnea syndrome. Sleep Med. 2000; 1(4):299-305.
Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2002; 166:743-748.
Tan YK, L'Estrange PR, Luo YM, Smith C, Grant HR, Simonds AK. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Eur J Orthod. 2002; 24:239-249.
Engleman HM, McDonald JP, Graham D, Lello GE, Kingshott RN, Coleman EL. Randomized crossover trial of two treatments for sleep apnea/ hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med. 2002; 166:855-859.
Randerath WJ, Heise M, Hinz R, Ruehle KH. An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Chest. 2002; 122:569-575.
Rose EC, Germann M, Sorchter S, Jonas IE. Case Control study in the treatment of Obstructive sleep disordered breathing with a mandibular protrusive appliance. J Orofac Orthop. 2004; 65:489-500.
Barnes M, McEvoy RD, Banks S, Tarquinio N, Murray CG, Vowles N, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med. 2004; 170:656-664.
Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial. Sleep. 2004; 27(5):934-941.
Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success. Chest. 2004; 125:1270-1278.
Izci B, McDonald JP, Coleman EL, Mackay TW, Douglas NJ, Engleman HM. Clinical audit of subjects with snoring & sleep apnoea/hypopnoea syndrome fitted with mandibular repositioning splint. Respir Med. 2005; 99:337-346.
Vecchierini MF, Léger D, Laaban JP, Putterman G, Figueredo M, Levy J, et al. Efficacy and compliance of mandibular repositioning device in obstructive sleep apnea syndrome under a patient-driven protocol of care. Sleep Med. 2008; 9(7):762-769
Aarab G, Lobbezoo F, Hamburger HL, Naeije M.Oral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial. Respiration. 2011; 81:411– 419.
Holley AB, Lettieri CJ, Shah AA. Efficacy of an Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome. Chest. 2011; 140:1511-1516.
Vuorjoki-Ranta TR, Lobbezoo F, Tuomilehto H, Könönen M, Pihakari A, Ahlberg J. Mandibular Advancement Device Therapy in Obstructive Sleep Apnea and Snoring in Community Dental Care: Two-year Follow-up Study on Self-reported Sleep Quality, Side Effects, and Compliance. Sleep Disord Ther. 2014; 3:5.
Ballanti F, Ranieri S, Baldini A, Cozza P. Long Term Therapeutic Efficacy of a Soft Monobloc Mandibular Advancement Device in Adults with Obstructive Sleep. Scientific World Journal. 2015, Article ID 408469.
Tsuchiya M, Lowe AA, Pae EK, Fleetham JA. Obstructive sleep apnoea subtypes by cluster analysis. Am J Orthod Dentofac Orthop. 1992; 101:533-542.
Mayer P, Pépin JL, Bettega G, Veale D, Ferretti G, Deschaux C, et al. Relationship between body mass index, age and upper airway measurements in snorers and sleep apnoea patients. Eur Respir J. 1996; 9:1801–1809.
Kumar PVG, M Bhatia, M Tripathi, AK Srivastava, S Jain. Obstructive sleep apnoea: a case controlled study. Neurology India. 2003; 51(4):497-499.
Lee RW, Chan AS, Grunstein RR, Cistulli PA. Craniofacial phenotyping in obstructive sleep apnoea – A novel quantitative photographic approach. Sleep. 2009; 32(1):37- 45.
Johnston CD, Gleadhill IC, Cinnamond MJ, Peden MW. Oral appliances for management of snoring: a randomized controlled trial. Eur J Orthod. 2001; 23:127-134.
Sharples LD, Clutterbuck-James AL, Glover MJ, Bennett MS, Chadwick R, Pittman MA, et al. Meta-analysis of randomised controlled trials of oral mandibular advancement devices and continuous positive airway pressure for obstructive sleep apnoea-hypopnoea. Sleep Medicine Reviews. 2015.
Pantin CC, Hillman DR, Tennant M. Dental side effects of an oral device to treat snoring and obstructive sleep apnea. Sleep. 1999; 22(2):237-240.
Fritsch KM, Iseli A, Russi EW, Bloch KE. Side effects of mandibular advancement devices for sleep apnea treatment. Am J Respir Crit Care Med. 2001; 164:813-818.
Bondemark L, Lindman R. Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal treatment with a mandibular advancement splint: a 2-year follow-up. Eur J Orthod. 2000; 22:53-60.
Almeida FR, Lowe AA, Sung JO, Tsuiki S, Otsuka R. Longterm sequelae of oral appliance therapy in obstructive sleep apnea patients: Part 1. Cephalometric analysis. Am J Orthod Dentofacial Orthop. 2006; 129:195-204.
Marklund M, Franklin KA, Persson M. Orthodontic sideeffects of mandibular advancement devices during treatment of snoring and sleep apnoea. Eur J Orthod. 2001; 23:135-144.
Bhalsing K, Suresh K, Muthane UB, Pal PK. Prevalence and profile of Restless Legs Syndrome in Parkinson's disease and other neurodegenerative disorders: a case-control study. Parkinsonism Relat Disord 2013 Apr;19(4):426-430.
Fereshtehnejad SM, Shafieesabet M, Shahidi GA, Delbari A, Lökk J. Restless legs syndrome in patients with Parkinson's disease: a comparative study on prevalence, clinical characteristics, quality of life and nutritional status. Acta Neurol Scand 2015 Apr;131(4):211-218.
Moccia M, Erro R, Picillo M, Santangelo G, Spina E, Allocca R, Longo K, Amboni M, Palladino R, Assante R, et al. A four-year longitudinal study on restless legs syndrome in Parkinson disease. Sleep 2016 Feb;39(2):405-412.
Högl B, Stefani A. Restless legs syndrome and periodic leg movements in patients with movement disorders: specific considerations. Mov Disord 2017 May;32(5):669-681.
Allen RP, Picchietti D, Hening WA, Trenkwalder C, Walters AS, Montplaisi J; Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health; International Restless Legs Syndrome Study Group. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology: a report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med 2003 Mar;4(2):101-119.
Szatmari S Jr, Bereczki D, Fornadi K, Kalantar-Zadeh K, Kovesdy CP, Molnar MZ. Association of restless legs syndrome with incident Parkinson disease. Sleep 2017 Feb;40(2): zsw065.
Winkelman JW, Armstrong MJ, Allen RP, Chaudhuri KR, Ondo W, Trenkwalder C, Zee PC, Gronseth GS, Gloss D, Zesiewicz T. Practice guideline summary: treatment of restless legs syndrome in adults: report of the Guideline Development Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016 Dec;87(24):2585-2593.
Splinter MY. Rotigotine: transdermal dopamine agonist treatment of Parkinson's disease and restless legs syndrome. Ann Pharmacother 2007 Feb;41(2):285-295.
Iranzo A, Molinuevo JL, Santamaría J, Serradell M, Martí MJ, Valldeoriola F, Tolosa E. Rapid-eye-movement sleep behaviour disorder as an early marker for a neurodegenerative disorder: a descriptive study. Lancet Neurol 2006 Jul;5(7):572-577.
Howell MJ, Schenck CH. Rapid eye movement sleep behavior disorder and neurodegenerative disease. JAMA Neurol 2015 Jun;72(6):707-712.
Sixel-Döring F, Trautmann E, Mollenhauer B, Trenkwalder C. Rapid eye movement sleep behavioral events: a new marker for neurodegeneration in early Parkinson disease? Sleep 2014 Mar;37(3):431-438.
Vibha D, Shukla G, Goyal V, Singh S, Srivastava AK, Behari M. RBD in Parkinson's disease: a clinical case control study from North India. Clin Neurol Neurosurg 2011 Jul;113(6):472-476.
Vibha D, Shukla G, Singh S, Goyal V, Srivastava AK, Behari M. Lower prevalence of sleep disturbances in familial versus sporadic Parkinson's disease: a questionnaire based study. J Neurol Sci 2010 Aug;295(1-2):27-30.
Abu Alhaija ES, Al-Nimri KS, Al-Khateeb SN. Self perception of malocclusion among Jordanian school children. Eur J Orthod 2005 Jun;27(3):292-295.
Kolawole KA, Otuyemi DE, Jebode SO, Unweni AA. Awareness for malocclusion and desire for orthodontic treatment need in 11-14year old Nigerian school and their parents. Aust Orthod J 2008 May;24(1):21-25.
Cucalon A 3rd, Smith RJ. Relationship between by adolescent orthodontics patients and performance on psychological tests. Angle Orthod 1990 Summer;60(2):107-114.
Southard KA, Tolley EA, Arheart KL, Hackett-Renner CA, Southard TE. Application of the Millon Adolescent Personality Inventory in evaluating orthodontic compliance. Am J Orthod Dentofacial Orthop 1991 Dec;100(6):553-561.
Kharbanda OP. What is the prevalence of malocclusion in India? Do we know orthodontic treatment needs of our country. J Indian Orthod Soc 1999 Apr-Jun;32(2):33-41.
Siddiqui TA, Shaikh A, Fida M. Agreement between orthodontist and patient perception using Index of Orthodontic Treatment Need. Saudi Dent J 2014 Oct;26(4):156-165.
Borzabadi-Farahani A, Borzabadi-Farahani A, Eslamipour F. Orthodontic treatment needs in an urban Iranian population in epidemiological study of 11-14 years old children. Eur J Paediatr Dent 2009 Jun;10(2):69-74.
Grando G, Young AA, Vedovello Filho M, Vedovello SA, Ramirez-Yañez GO. Prevalence of malocclusions in a young Brazilian population. Int J Orthod Milwaukee 2008 Summer;19(2):13-16.
Nadim R, Aslam K, Rizwan S. Frequency of malocclusion among 12 -15 years old school children in three sectors of Karachi. Pak Oral Dent J 2014 Sep;34(3):510-514.
Reddy ER, Manjula M, Sreelakshmi N, Rani ST, Aduri R, Patil BD. Prevalence of malocclusion among 6 to 10 year old Nalgonda school children. J Int Oral Health 2013 Dec;5(6): 49-54.
Onyeaso CO. Prevalence of malocclusion among adolescents in Ibadan, Nigeria. Am J Orthod Dentofacial Orthop 2004 Nov;126(5):604-607.
Kaur H, Pavithra US, Abraham R. Prevalence of malocclusion among adolescents in South Indian population. J Int Soc Prev Community Dent 2013 Jul-Dec;3(2):97-102.
Lauc T. Orofacial analysis on the Adriatic islands: an epidemiological study of malocclusions on Hvar Island. Eur J Orthod 2003 Jun;25(3):273-278.
Zimmermann E, Gamborg M, Holst C, Baker JL, Sørensen TI, Berentzen TL. Body mass index in school-aged children and the risk of routinely diagnosed non-alcoholic fatty liver disease in adulthood: a prospective study based on the Copenhagen School Health Records Register. BMJ Open 2015 May;5(4):e006998.
Reece EA, Hagay Z, Roberts AB, DeGennaro N, Homko CJ, Connolly-Diamond M, Sherwin R, Tamborlane WV, Diamond MP. Fetal Doppler and behavioral responses during hypoglycemia induced with the insulin clamp technique in pregnant diabetic women. Am J Obstet Gynecol 1995 Jan;172(1 Pt 1):151-155.
Patrick J, Campbell K, Carmichael L, Natale R, Richardson B. Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. Am J Obstet Gynecol 1982 Feb;142(4):363-371.
Ornoy A, Ratzon N, Greenbaum C, Peretz E, Soriano D, Dulitzky M. Neurobehavior of school age children born to diabetic mothers. Arch Dis Child Fetal Neonatal Ed 1998 Sep;79(2):F94-F99.
Wolf, A. Developmental evaluation on early school age children born to gestational diabetic mothers. Israel: Hebrew University; 1997.
Mulder EJ, Leiblum DM, Visser GH. Fetal breathing movements in late diabetic pregnancy: relationship to fetal heart rate patterns and Braxton Hicks’ contractions. Early Hum Dev 1995 Nov;43(3):225-232.
Schulte FJ, Michaelis R, Nolte R, Albert G, Parl U, Lasson U. Brain and behavioral maturation in newborn infants of diabetic mothers. I. Nerve conduction and EEG patterns. Neuropadiatrie 1969 Jan-Jul;1(1):24-35.
Devoe LD, Youssef AA, Castillo RA, Croom CS. Fetal biophysical activities in third-trimester pregnancies complicated by diabetes mellitus. Am J Obstet Gynecol 1994 Aug;171(2):298-303.
Dierker LJ Jr, Pillay S, Sorokin Y, Rosen MG. The change in fetal activity periods in diabetic and nondiabetic pregnancies. Am J Obstet Gynecol 1982 May;143(2):181-185.
Doherty NN, Hepper PG. Habituation in fetuses of diabetic mothers. Early Hum Dev 2000 Aug;59(2):85-93.
Kainer F, Prechtl HF, Engele H, Einspieler C. Assessment of the quality of general movements in fetuses and infants of women with type-1 diabetes mellitus. Early Hum Dev 1997 Nov;50(1):13-25.
Mulder EJ, O'Brien MJ, Lems YL, Visser GH, Prechtl HF. Body and breathing movements in near-term fetuses and newborn infants of type-1 diabetic women. Early Hum Dev 1990 Nov;24(2):131-152.
Mulder EJ, Visser GH. Growth and motor development in fetuses of women with type-1 diabetes. I. Early growth patterns. Early Hum Dev 1991 May;25(2):91-106.
Mulder EJ, Visser GH. Growth and motor development in fetuses of women with type-1 diabetes. II. Emergence of specific movement patterns. Early Hum Dev 1991 May;25(2):107-115.
Mulder EJ, Visser GH. Impact of early growth delay on subsequent fetal growth and functional development: a study on diabetic pregnancy. Early Hum Dev 1992 Dec;31(2):91-95.
Mulder EJ, Visser GH, Bekedam DJ, Prechtl HF. Emergence of behavioral states in fetuses of type-1 diabetic women. Early Hum Dev 1987 Jul;15(4):231-251.
Mulder EJ, Visser GH, Morssink LP, de Vries JI. Growth and motor development in fetuses of women with type-1 diabetes. III. First trimester quantity of fetal movement patterns. Early Hum Dev 1991 May;25(2):117-133.
Aberg A, Westbom L, Kallen B. Congenital malformations among infants whose mothers had gestational diabetes or preexisting diabetes. Early Hum Dev 2001 Mar;61(2):85-95.
Deregnier RA, Nelson CA, Thomas KM, Wewerka S, Georgieff MK. Neurophysiologic evaluation of auditory recognition memory in healthy newborn infants and infants of diabetic mothers. J Pediatr 2000 Dec;137(6):777-784.
Nelson CA, Wewerka S, Thomas KM, Tribby-Walbridge S, deRegnier R, Georgieff M. Neurocognitive sequelae of infants of diabetic mothers. Behav Neurosci 2000 Oct;114(5):950-956.
Reece EA, Homko CJ. Infant of the diabetic mother. Semin Perinatol 1994 Oct;18(5):459-469.
Reece EA, Homko CJ. Why do diabetic women deliver malformed infants? Clin Obstet Gynecol 2000 Mar;43(1):32-45.
Rizzo T, Metzger BE, Burns WJ, Burns K. Correlations between antepartum maternal metabolism and intelligence of offspring. N Engl J Med 1991 Sep;325(13):911-916.
Rizzo TA, Metzger BE, Dooley SL, Cho NH. Early malnutrition and child neurobehavioral development: insights from the study of children of diabetic mothers. Child Dev 1997 Feb;68(1):26-38.
Schwartz R, Teramo KA. Effects of diabetic pregnancy on the fetus and newborn. Semin Perinatol 2000 Apr;24(2):120-135.
Vaarasmaki MS, Hartikainen A, Anttila M, Pramila S, Koivisto M. Factors predicting peri- and neonatal outcome in diabetic pregnancy. Early Hum Dev 2000 Jul;59(1):61-70.
Robertson SS, Dierker LJ. Fetal cyclic motor activity in diabetic pregnancies: sensitivity to maternal blood glucose. Dev Psychobiol 2003 Jan;42(1):9-16.
Accardo PJ, Blondis TA, Whitman BY. Disorders of attention and activity level in a referral population. Pediatrics 1990 Mar;85(3 Pt 2):426-431.
Ornoy A, Uriel L, Tennenbaum A. Inattention, hyperactivity and speech delay at 2-4 years of age as a predictor for ADDADHD syndrome. Isr J Psychiatry Relat Sci 1993;30(3):155-163.
Smyth TR. Impaired motor skill (clumsiness) in otherwise normal children: a review. Child Care Health Dev 1992 Sep-Oct;18(5):283-300.
Petersen MB, Pedersen SA, Greisen G, Pedersen JF, Mølsted- Pedersen L. Early growth delay in diabetic pregnancy: relation to psychomotor development at age 4. Br Med J (Clin Res Ed) 1988 Feb;296(6622):598-600.
Sells CJ, Robinson NM, Brown Z, Knopp RH. Long-term developmental follow-up of infants of diabetic mothers. J Pediatr 1994 Jul;125(1):S9-S17.
Vladareanu R, Lebit D, Constantinescu S. Ultrasound assessment of fetal neurobehaviour in high risk pregnancies. DSJUOG 2012 Apr-Jun;6(2):132-147.
Talic A, Kurjak A, Ahmed B, Stanojevic M, Predojevic M, Kadic AS, Di Renzo GC. The potential of 4D sonography in the assessment of fetal behavior in high-risk pregnancies. J Matern Fetal Neonatal Med 2011 Jul;24(7):948-954.
Bekedam DJ, Visser GH, de Vries JJ, Prechtl HF. Motor behaviour in the growth retarded fetus. Early Hum Dev 1985 Nov;12(2):155-165.
Cioni G, Prechtl HF. Preterm and early postterm motor behaviour in low-risk premature infants. Early Hum Dev 1990 Sep;23(3):159-191.
Seme-Ciglenecki P. Predictive value of assessment of general movements for neurological development of highrisk preterm infants: comparative study. Croat Med J 2003 Dec;44(6):721-727.
Abo-Yaqoub S, Kurjak A, Mohammed AB, Shadad A, Abdel-Maaboud M. The role of 4-D ultrasonography in prenatal assessment of fetal neurobehaviour and prediction of neurological outcome. J Matern Fetal Neonatal Med 2012 Mar;25(3):231-236.
Athanasiadis AP, Mikos T, Tambakoudis GP, Theodoridis TD, Papastergiou M, Assimakopoulos E, Tarlatzis BC. Neurodevelopmental fetal assessment using KANET scoring system in low and high-risk pregnancies. J Matern Fetal Neonatal Med 2013 Mar;26(4):363-368.
Fauser BC, Tarlatzis BC, Rebar RW, Legro RS, Balen AH, Lobo R, Carmina E, Chang J, Yildiz BO, Laven JS, et al. Consensus on women's health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril 2012 Jan;97(1):28-38.e25
Sirmans SM, Pate KA. Epidemiology, diagnosis and management of polycystic ovary syndrome. Clin Epidemiol 2014; 6:1-13.
Fauser BC, Diedrich K, Bouchard P, Domínguez F, Matzuk M, Franks S, Hamamah S, Simón C, Devroey P, Ezcurra D, et al. Contemporary genetic technologies and female reproduction. Human Reproduction Update 2011 Nov;17(6):829-847.
Balen A, Conway G, Kaltsas G. Polycystic ovary syndrome: the spectrum of the disorder in 1741 patients. Hum Reprod 1995 Aug;10(8):2107-2111.
Azziz R, Sanchez L, Knochenhauer ES, Moran C, Lazenby J, Stephens KC, Taylor K, Boots LR. Androgen excess in women: experience with over 1000 consecutive patients. J Clin Endocrinol Metab 2004 Feb;89(2):453-462.
Wild S, Pierpoint T, McKeigue P, Jacobs H. Cardiovascular disease in women with polycystic ovary syndrome at longterm follow-up: a retrospective cohort study. Clin Endocrinol (Oxf) 2000 May;52(5):595-600.
Hollinrake E, Abreu A, Maifeld M, Van Voorhis BJ, Dokras A. Increased risk of depressive disorders in women with polycystic ovary syndrome. Fertil Steril 2007 Jun;87(6): 1369-1376.
Zawadski JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome. In: Givens JHF, Merriman G, editors. The polycystic ovary syndrome. Cambridge, MA: Blackwell Scientific; 1992. p. 377-384.
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004 Jan;81(1):19-25.
Azziz R, Carmina E, DeWailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, et al. Position statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline. J Clin Endocrinol Metab 2006 Nov;91(11):4237-4245.
Lujan ME, Jarrett BY, Brooks ED, Reines JK, Peppin AK, Muhn N, Haider E, Pierson RA, Chizen DR. Updated ultrasound criteria for polycystic ovary syndrome: reliable thresholds for elevated follicle population and ovarian volume. Hum Reprod 2013 May;28(5):1361-1368.
Badawy A, Elnashar A. Treatment options for polycystic ovary syndrome. Int J Womens Health 2011 Feb;3:25-35.
ACOG Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No 108: Polycystic ovary syndrome. Obstet Gynecol 2009 Oct;114(4):936-949.
Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril 2008 Mar;89(3): 505-522.
Balen AH. Ovulation induction in the management of anovulatory polycystic ovary syndrome. Mol Cell Endocrinol 2013 Jul;373(1-2):77-82.
Berridge DL, Winter TC. Saline infusion sonohysterography: technique, indications, and imaging findings. J Ultrasound Med 2004 Jan;23(1):97-112.
Allison SJ, Horrow MM, Kim HY, Lev-Toaff AS. Salineinfused sonohysterography: tips for achieving greater success. Radiographics 2011 Nov-Dec;31(7):1991-2004.
O'Neill MJ. Sonohysterography. Radiol Clin North Am 2003 Jul;41(4):781-797.
Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002 Apr;102(1):42-47.
Lindheim SR, Adsuar N, Kushner DM, Pritts EA, Olive DL. Sonohysterography: a valuable tool in evaluating the female pelvis. Obstet Gynecol Surv 2003 Nov;58(11):770-784.
Lindheim SR, Sprague C, Winter TC. Hysterosalpingography and sonohysterography: lessons in technique. AJR Am J Roentgenol 2006 Jan;186(1):24-29.
Jeanty P, Besnard S, Arnold A, Turner C, Crum P. Air-contrast sonohysterography as a first step assessment of tubal patency. J Ultrasound Med 2000 Aug;19(8):519-527.