Mandibular Advancement Device Appears At Least as Effective as CPAP for Improving Quality of Life and Reducing Sleepiness in Moderate-Severe Obstructive Sleep Apnea

EBM Focus - Volume 8, Issue 25

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Reference: Am J Respir Crit Care Med 2013 Apr 15;187(8):879, (level 2 [mid-level] evidence)

A consensus statement from the American Academy of Sleep Medicine (AASM) identifies continuous positive airway pressure (CPAP) as the treatment of choice for mild, moderate, and severe obstructive sleep apnea (OSA). Oral appliances, including mandibular advancement devices and tongue retaining devices, are recommended for mild-to-moderate OSA in patients who do not wish to use or are not candidates for CPAP (J Clin Sleep Med 2009 Jun 15;5(3):263). A recent crossover randomized trial compared the efficacy of a mandibular advancement device to CPAP in 126 patients with newly diagnosed moderate-to-severe OSA.

Patients with moderate-to-severe OSA (mean apnea-hypopnea index 25.6/hour) were randomized to mandibular advancement device vs. CPAP nightly for 1 month, followed by crossover to the other intervention after a 2-week washout period. Prior to the treatment phase of the trial, all patients completed an acclimatization phase with each intervention (in random order) with nightly use for 4-6 weeks to stabilize usage patterns. Assessments included polysomnography for episodes of apnea and hypopnea, SF-36, and the Epworth Sleepiness Scale score (0-24 scale).

Fourteen percent of the patients did not complete the trial and were excluded from the analyses. Both groups showed significant improvement from baseline in sleepiness and SF-36 scores. The mandibular advancement device was associated with less improvement in polysomnographic outcomes: the mean apnea-hypopnea index was 11.1/hour with mandibular advancement vs. 4.5/hour with CPAP. Despite this difference, the mandibular advancement group had greater improvement in bodily pain, vitality, social function, and mental health components of the SF-36 (p < 0.05 for each). The mean improvement in Epworth score was 1.9 points with mandibular advancement and 1.6 points with CPAP (not significant). Mean patient-reported compliance was 6.5 hours/night with mandibular advancement vs. 5.2 hours/night with CPAP. There were no significant differences between groups in driving simulator performance, 24-hour mean arterial pressure, or blood pressure.

Patients should have a complete dental exam to assess their eligibility for a mandibular advancement device, and fitting should be performed by qualified dental personnel. Dental work might be necessary for some patients. Patients with TMJ dysfunction, limited jaw range of motion, poor dental health may not eligible.

For more information, see the Obstructive sleep apnea (OSA) topic in DynaMed.