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Title Oral Appliance Therapy and Continuous Positive Airway Pressure Demonstrate Similar Improvements in the Treatment of Mild/ Moderate Obstructive Sleep Apnea
Clinical Question Are oral appliances more effective in treating obstructive sleep apnea (OSA) in comparison to continuous positive airway pressure?
Clinical Bottom Line In the treatment of mild/moderate obstructive sleep apnea, mandibular advancement devices (MAD) are similar in efficacy when compared to continuous positive airway pressure (CPAP). (See Comments on the CAT below)
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 21406515Randerath/ 201127 RCT’s with sample sizes ranging from 19-114Systematic review
Key resultsIn all studies, MAD treatment reduced OSA compared with placebo. Treatment success with MAD is defined as an AHI <5, and was found in 19-75% of the patients. While CPAP was more successful at reducing OSA in all studies, the positive effects on symptoms, such as daytime sleepiness and overall quality of life, were similar between the two treatments. Subjective daytime sleepiness was decreased and similar between CPAP and MAD treatment. A prefabricated MAD was less effective than a custom made device and the degree of mandibular advancement should be 50% of maximum protrusion. While side effects of MAD therapy were reported in more than half of the patients, compliance with MADs is reported to be higher than with CPAP and is preferred by patients.
#2) 20962502Aarab/ 201164 patients with mild/moderate obstructive sleep apnea (52.0 +/- 9.6 years)Randomized controlled trial
Key resultsTwo polysomnographic recordings were obtained from all patients before treatment and six months after treatment. The change in the apnea-hyponea index (ΔAHI) between baseline and treatment evaluation demonstrated a significant difference between the three therapy groups: mandibular advancement device (MAD), nasal continuous positive airway pressure (nCPAP), and placebo device. While there were no differences found in ΔAHI when comparing MAD and nCPAP therapy (p=0.092), these treatment modalities still demonstrated a significantly greater change in ΔAHI than those in the placebo group (p=0.000 and 0.002, respectively). No significant difference between MAD and nCPAP exists for the treatment of non-severe OSA.
#3) 21454959Aarab/ 201143 mild/moderate OSA patients (52.2 +/- 9.6 years)Randomized controlled trial
Key resultsOne year follow up of patients with mild/ moderate OSA with mean AHI of 20.8 +/- 9.9 events/ hour and excessive daytime sleepiness (EDS). Patients were randomly assigned to two groups: MAD (n=21) and nCPAP (n=22). Both groups demonstrated improvements in AHI, which remained stable over time (p=0.650). AHI score for the nCPAP group improved 4.1 events/ hour more than the MAD group (p=0.000). In both groups, EDS values improved (p=0.000) and were similar (p=0.367). Although the nCPAP group demonstrated a larger improvement in AHI values, it is not clinically relevant since there was an absence of significant long term differences in EDS values.
Evidence Search "Continuous Positive Airway Pressure"[Mesh]) AND "Mandibular Advancement"[Mesh]) AND "Sleep Apnea, Obstructive"[Mesh]
Comments on
The Evidence
Aarab 2011 published two randomized controlled trials; one trial (64 patients) divided groups into control, CPAP and MAD, the other (43 patients) divided groups into CPAP and MAD. Follow up was 6 months and 6 months/1 year, respectively. There was no recall bias and no competing interests. Randerath 2011 published a systematic review comparing several non-CPAP therapies. Exclusion criteria were used to identify RCTs evaluating effects of MADs compared to placebo, CPAP and appliance designs. Sample sizes ranged from 19-114 and patients were overweight or obese.
Applicability MAD therapy is recommended for patients with mild/ moderate OSA and in patients that cannot tolerate CPAP. While CPAP is statistically more effective in reducing OSA, evidence demonstrates there is no clinical significance between the two treatment modalities in the effects on symptoms, such as excessive daytime sleepiness.
Specialty/Discipline (General Dentistry) (Oral Surgery) (Prosthodontics) (Basic Science)
Keywords Obstructive sleep apnea, oral appliance, continuous positive airway pressure, OSA therapy
ID# 2334
Date of submission: 01/02/2013spacer
E-mail kusbel@livemail.uthscsa.edu
Author Marisol Kusbel
Co-author(s) Yves Smith
Co-author(s) e-mail Yvesmith@gmail.com
Faculty mentor/Co-author S. Thomas Deahl, II, DMD, PhD
Faculty mentor/Co-author e-mail Deahl@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
None available
Comments on the CAT
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by Ryushiro Sugita, DDS (San Antonio, Texas) on 11/17/2015
A PubMed search on the effectiveness of occlusal splints for patients with mild obstructive sleep apnea was performed Oct 2015. A more recent publication was found: Ramar in 2014, PubMed: 26094920. The meta-analysis using the limited available evidence revealed that occlusal splints can significantly reduce the apnea hypopnea index/ respiratory disturbance index/respiratory event index (AHI/ RDI/REI) across all levels of OSA severity in adult patients. Additionally, there was no significant difference between Occlusal splints and CPAP in the percentage of mild OSA patients achieving their target AHI/RDI/ REI (< 5, < 10, > 50% reduction) after treatment. For patients with moderate to severe OSA, however, the odds of achieving the target AHI were significantly greater with CPAP than with OAs.
by Hanna Lindskog (San Antonio, TX) on 05/19/2013
There is a new article by Boyd published in 2003 PMID: 22761095 that also discusses a new measurement instrument, the Effectiveness of Treatment Apnea-Hypopnea Index. More research needs to be completed on the ET-AHI to evaluate how accurately it predicts the true AHI in the home setting. However, this article as well as the ones referenced above indicate that CPAP therapy results in a greater reduction in the AHI than the mandibular advancement device. The efficacy of the CPAP is impacted by the patient's compliance. However, if compliance is not an issue, it cannot be said that CPAP and mandibular advancement devices are equally efficacious.

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