Title Both The Expiratory Positive Airway Pressure And The Mandibular Advancement Device Been Shown To Reduce The Apnea-Hypopnea Index, But The Two Trials Could Not Be Compared On Effectiveness
Clinical Question For a patient with obstructive sleep apnea, will the use of a nasal expiratory positive airway pressure
(EPAP) device, as compared to the mandibular advancement device be more effective.
Clinical Bottom Line Both the expiratory positive airway pressure and the mandibular advancement devices reduced the apnea-hyponea index, but the two trials could not be compared on effectiveness. EPAP device reduced the AHI to 4.7 after twelve months while the MAD decreased the AHI to 25 ± 27.5 after one month. There were no comparison studies on the two devices and the trials were not under the same conditions. (See Comments on the CAT below)
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
22003339Kryger/201134 patients (50.1±13.6 years old)Randomized Controlled Trial
Key resultsTo qualify patients, there was a sham process to select the patients with an AHI reduction to <10 documented by polysomnography with one week off the device and three months on the device. After one year, the median apnea-hyponea index (AHI) for the patients with the device off versus 12 months with the appliance on reduced from 15.7 to 4.7. This was a 71.3% decrease (p< 0.001). The Epworth Sleepiness Scale decreased from 11.1 ± 4.2 to 6.0 ± 3.2, (p<0.001). The unwanted effects were mild and were found to be as effective to other treatments for OSA. There were 41 patients with 7 patients dropping out before the end of the 12 months. According to Kryger, "the limitations to this study included patients with prior CPAP treatment, other serious uncontrolled medical conditions, other sleep disorders, and medications affecting neurocognitive function."
18482111Petri/200893 patients (50 ± 11 years old) with OSA Randomized controlled trial
Key resultsPatients were randomized into 3 groups: mandibular advancement appliance (n=27), mandibular non-advancement appliance (n=25), no intervention (n=29). Twelve patients did not comply. The study lasted 4 weeks. The enrolled patients had a mean AHI of 34.7 and a mean Epworth score of 11. The baseline to outcome AHI for the mandibular advancement appliance was 39.1 ±23.8 to 25 ± 27.5, (p<0.001). There was not a significant difference in the other categories. The Epworth sleepiness score (ESS) reduced from 11.7 ±4.3 to 8.4±4.3, (p<0.001). The mean reduction in AHI was 14.1. The mean reduction in the ESS was 3.2.
Evidence Search ((("Mandibular Advancement"[Mesh]) AND ( "Sleep Apnea, Obstructive/diagnosis"[Mesh] OR "Sleep Apnea, Obstructive/therapy"[Mesh] )) AND "Treatment Outcome"[Mesh]) AND "Occlusal Splints"[Mesh] expiratory positive airway pressure AND "Sleep Apnea, Obstructive"[Mesh]
Comments on
The Evidence
Validity: There were no comparison trials for the expiratory positive airway pressure device and the mandibular advancement device. Both studies were randomized controlled studies. The Kyrger study had a completion rate of 81% due to "negative effects to the study device, unwilling to continue with the study, and called to military duty." The study followed up every 3 months and the adherence for the patient to wear it the entire night was 89.3%. Petri’s study had 87% completion due to adverse effects, no tolerance, and loosening of the teeth with the mandibular advancement appliance and the non-advancement appliance. There was no follow up. Perspective: Although there was not any research comparing the two, the effects were greater in the expiratory positive airway pressure device by decreasing the AHI to less than 5. After one month with the mandibular advancement appliance, the AHI lowered only to a reduction of 25 ± 27.5. Even though the results seemed more effective in the EPAP, the time of trial length varied from 12 months to one month. Also, the starting AHI for patients greatly varied, which could effect the final AHI reduction.
Applicability This is applicable to patients who are not able to use the CPAP and want an alternative treatment device.
Specialty (General Dentistry) (Prosthodontics) (Dental Hygiene)
Keywords Obstructive sleep apnea, oral appliance, expiratory positive airway pressure device, mandibular advancement appliance
ID# 2352
Date of submission 03/08/2013
E-mail laughinghous@livemail.uthscsa.edu
Author Megan Laughinghouse
Co-author(s) Blake Johnston
Co-author(s) e-mail johnstonb@livemail.uthscsa.edu
Faculty mentor
Faculty mentor e-mail
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?)
None available
Comments and Evidence-Based Updates on the CAT
by Kevin Lin (San Antonio, TX) on 05/15/2013
A systemic review published by Ahrens in 2011 (PMID: 21239397 ) supports the efficacy of mandibular advancement devices in lowering the apnea-hypopnea index. The article listed in this CAT discussing expiratory positive airway pressure is of the highest level and most recent evidence on EPAP. While evidence supports the efficacy of both these therapies in treating obstructive sleep apnea, there are no comparison studies to determine which therapy is more effective.