ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title All Active Mandibular Advancement Devices Improved Polysomnographic Indices
Clinical Question Which oral Mandibular Advancement Device is best for A patient with OSA (Obstructive Sleep Apnea) that wants to decrease his AHI (Apnea Hypopnea Index)?
Clinical Bottom Line There is no one MAD that most effectively improves AHI. Three studies showed there was a 63% efficacy rate for mild to severe OSA patients and 79% for mild to moderate OSA patients. This corresponds with other studies investigated that there is lower treatment success with MAD’s and severe OSA.
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) 21239397Ahrens/2011Patient Group 14 RCT’s, with majority of studies specifying a sample size of between 20 & 30 subjects.Systematic Review
Key resultsMAD’s comparing various designs to inactive devices or other MAD’s with different design features mostly in mild to moderate OSA patients, were reviewed and compared in 14 high quality trials. In comparison to inactive appliances, all MAD’s improved AHI/RDI (Respiratory Distress Index) suggesting that mandibular advancement is crucial in establishing efficacy. There is no “one fits all” MAD.
#2) 22075487Marklund/2012Patient Group 34 RCT’s, with sample sizes of 15-103.Study Type Narrative Review
Key resultsComparison of MAD’s with a CPAP (Continuous Positive Airway Pressure) device and or placebo were made by using mostly adjustable custom made MAD’s. Prefabricated or custom made monoblock MAD’s were used in the remainder of the RCT’s. It is recommended that a Mandibular Advancement custom device should be made from an initial 50% maximum Mandibular advancement.
Evidence Search MAD, OSA AND ("last 5 years"[PDat] AND Humans[Mesh])
Comments on
The Evidence
Validity: Systematic Review of 14 studies with RCT’s, from an initial search of 1,475 studies from multiple database searches. Studies chosen were exclusively focusing on OA (Oral Appliance) therapy as OSA treatment modality. Studies were identified as “effective” papers and eligibility for methodological appraisal according to the American Association of Sleep Medicine. In the second study, RCT’s compared MAD’s to treatment with placebo, CPAP, and different appliance designs. AHI was used for diagnosis in 86% of the studies, RDI was used in the remainder of the studies.
Applicability Efficacy of the MAD is dependent on the following factors; 1.) Custom made MAD resulted in significantly higher treatment success (60 versus 31%; P< 0.05) than thermoplastic monoblock MADs. 2.) Mandibular advancement is crucial to MAD efficacy. Increase airway obstruction has been reported in patients wearing devices with a high degree of maximum advancement, patients should start with no more than 50% Mandibular advancement. 3.) Vertical opening of 4 mm resulted in 74% Treatment success, whereas 14 mm opening resulted in 61% success. 4.) The most effective MAD is one that the patient will wear, choose on an individual basis.
Specialty/Discipline (General Dentistry) (Oral Surgery) (Orthodontics) (Pediatric Dentistry) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords Mandibular Advancement Device, Oral Appliance, Occlusal Splints, Orthodontic Appliance Design, Polysomnography, Sleep Apnea, Obstructive, therapy, treatment, AHI
ID# 2349
Date of submission: 04/13/2013spacer
E-mail drrogera@aol.com
Author Roger Arredondo, DDS
Co-author(s) Wilmer P. Orjuela
Co-author(s) e-mail orjuela@livemail.uthscsa.edu
Faculty mentor/Co-author
Faculty mentor/Co-author e-mail
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