Non-CPAP therapies in obstructive sleep apnoea: Mandibular advancement device therapy

Article (PDF Available)inEuropean Respiratory Journal 39(5):1241-7 · November 2011with76 Reads
DOI: 10.1183/09031936.00144711 · Source: PubMed
Abstract
Mandibular advancement devices (MADs) represent the main non-continuous positive airway pressure (non-CPAP) therapy for patients with obstructive sleep apnoea (OSA). The aim of the European Respiratory Society Task Force was to review the evidence in favour of MAD therapy. Effects of tongue-retaining devices are not included in this report. Custom-made MADs reduce apnoea/hypopnoea index (AHI) and daytime sleepiness compared with placebo devices. CPAP more effectively diminishes AHI, while increasing data suggest fairly similar outcomes in relation to symptoms and cardiovascular health from these treatments. Patients often prefer MADs to CPAP. Milder cases and patients with a proven increase in upper airway size as a result of mandibular advancement are most likely to experience treatment success with MADs. A custom-made device titrated from an initial 50% of maximum mandibular advancement has been recommended. More research is needed to define the patients who will benefit from MAD treatment compared with CPAP, in terms of the effects on sleep-disordered breathing and on other diseases related to OSA. In conclusion, MADs are recommended for patients with mild to moderate OSA (Recommendation Level A) and for those who do not tolerate CPAP. The treatment must be followed up and the device adjusted or exchanged in relation to the outcome.
REVIEW
Non-CPAP therapies in obstructive sleep
apnoea: mandibular advancement device
therapy
Marie Marklund*, Johan Verbraecken
#
and Winfried Randerath
"
ABSTRACT: Mandibular advancement devices (MADs) represent the main non-continuous
positive airway pressure (non-CPAP) therapy for patients with obstructive sleep apnoea (OSA).
The aim of the European Respiratory Society Task Force was to review the evidence in favour of
MAD therapy. Effects of tongue-retaining devices are not included in this report.
Custom-made MADs reduce apnoea/hypopnoea index (AHI) and daytime sleepiness compared
with placebo devices. CPAP more effectively diminishes AHI, while increasing data suggest fairly
similar outcomes in relation to symptoms and cardiovascular health from these treatments.
Patients often prefer MADs to CPAP. Milder cases and patients with a proven increase in upper
airway size as a result of mandibular advancement are most likely to experience treatment
success with MADs. A custom-made device titrated from an initial 50% of maximum mandibular
advancement has been recommended. More research is needed to define the patients who will
benefit from MAD treatment compared with CPAP, in terms of the effects on sleep-disordered
breathing and on other diseases related to OSA.
In conclusion, MADs are recommended for patients with mild to moderate OSA
(Recommendation Level A) and for those who do not tolerate CPAP. The treatment must be
followed up and the device adjusted or exchanged in relation to the outcome.
KEYWORDS: Mandibular advancement device, mandibular advancement splint, mandibular
repositioning appliance, oral appliance, sleep apnoea
Mandibular advancement devices (MADs)
represent the main non-continuous posi-
tive airway pressure (non-CPAP) alter-
native for patients with obstructive sleep apnoea
(OSA). These devices aim to increase the upper
airway size and reduce the risk of sleep apnoeas
and snoring in patients with OSA. The upper
airway is widened particularly in its lateral dimen-
sion [1, 2]. The pharyngeal fat pads relocate
laterally from the airway and the tongue base
muscles move anteriorly [1]. This leads to a
reduction in pharyngeal collapsibility [3]. There
are indications that MADs cause a change in
muscle activity during sleep, with the relaxation
of the genioglossus muscle during incremental
mandibular advancement [4] and the activation of
the masseter and submental muscles [5].
Tongue-retaining devices (TRDs) are another type
of intra-oral device that has been suggested for the
treatment of patients with OSA. This device is
designed to produce suction of the tongue into an
anterior bulb, move the tongue forwards and
widen the upper airway dimensions during sleep.
There is insufficient evidence for TRDs and the
effects from these devices will, therefore, not be
discussed any further in this report [6].
MADs have been recommended for patients with
mild to moderate OSA who prefer a MAD to
CPAP, provided that the MAD has a sufficient
objective effect [7, 8]. MADs may also be used in
patients with more severe disease who do not
respond to or who fail treatment attempts with
CPAP. Some studies have suggested that the
AFFILIATIONS
*Dept of Orthodontics, Faculty of
Medicine, Umea
˚University, Umea
˚,
Sweden.
#
Dept of Pulmonary Medicine and
Multidisciplinary Sleep Disorders
Centre, Antwerp University Hospital
and University of Antwerp, Antwerp,
Belgium.
"
Bethanien Hospital, Institute of
Pneumology, University Witten/
Herdecke, Solingen, Germany.
CORRESPONDENCE
M. Marklund
Dept of Orthodontics
Umea
˚University
SE-901 87 Umea
˚
Sweden
E-mail: Marie.Marklund@
odont.umu.se
Received:
Aug 22 2011
Accepted after revision:
Nov 01 2011
First published online:
Nov 10 2011
European Respiratory Journal
Print ISSN 0903-1936
Online ISSN 1399-3003
This article has supplementary material available from www.erj.ersjournals.com
EUROPEAN RESPIRATORY JOURNAL VOLUME 39 NUMBER 5 1241
Eur Respir J 2012; 39: 1241–1247
DOI: 10.1183/09031936.00144711
CopyrightßERS 2012
c
efficacy of MADs in modifying the health risks associated with
OSA is somewhat similar to that of CPAP [9]. The treatment effect
of MADs has to be verified in a renewed sleep apnoea recording
with the device in all patients with OSA [7], since patients may
have a suboptimal treatment response. One major limitation of
MAD treatment is its dependence on oral health and the fact that
ittakessometimetobecomeaccustomedtothedevice.Side-
effects from the treatment, such as pain from the teeth and jaws,
are generally mild and transient [8, 9]. In the longer term, bite
changes become more common, but these are usually minor and
do not disturb patients who are satisfied with the treatment
outcome in terms of snoring and daytime symptoms [9]. The
patients may continue with their devices for many years,
although the treatment needs to be followed up in terms of
side-effects and effectiveness.
The European Respiratory Society funded a Task Force with the
aim of screening the scientific literature on non-positive-pressure
therapies, to evaluate the studies according to the criteria for
evidence-based medicine and to make recommendations for use
in OSA patients. The results produced by the Task Force are
presented in a summary report [6] and in more detail in the
current review.
SEARCH CRITERIA
A literature search ending on January 1, 2009 was performed,
with additional searches in May 2010 and July 2011 for more
recently published papers containing information that was of
importance for the results of this report. The search for clinical
trials and randomised controlled trials used PubMed with the
following Mesh terms: sleep apnoea syndromes AND orthodon-
tic appliances; functional or removable activator appliances or
mandibular advancement. In addition, a search in PubMed
was performed using the following terms: sleep apnoea AND
oral appliances; mandibular advancement devices; mandibular
advancement splints; mandibular repositioning appliances; or
mandibular repositioning splints. The Cochrane Library and the
reference lists from the included studies were searched for
articles about MADs in the treatment of patients with OSA.
No reviews, guidelines or studies that aimed specifically to
determine the type and degree of side-effects, such as bite
changes and influence on craniofacial morphology from MAD
treatment, were included. Of a total of 84 articles, 29 were
excluded because the topic was covered in the randomised
controlled trials (RCTs) or the aims were not directly related to
the efficacy of the device.
29 randomised studies of the treatment effects of MADs [10–38]
and five RCTs investigating other outcomes of MAD treatment
[39–43] were found. In addition, 21 further clinical trials that
highlighted particular aspects of MAD treatment, such as the
mechanisms of action and prediction of treatment outcome, were
identified [1–3, 44–61]. A table is available in the online
supplementary material.
DESCRIPTION OF THE INCLUDED STUDIES
The RCTs evaluated the effects of MADs compared with placebo
treatment [11, 13, 14, 22, 23, 25, 28–30], CPAP [11, 13, 16–19, 24, 26,
32, 34] or between appliance designs [15, 20, 27, 31, 33, 35, 36, 38].
Three studies reported longer-term results from MAD treatment
after 1–4 yrs, compared with CPAP [12], surgery [37] or between
two types of MAD [21]. The sample sizes ranged between 19 and
114 patients, with 15–103 patients completing the trials. Eight out
of the 17 RCTs comparing MADs with placebo or CPAP
evaluated f25 patients, while six studies included .70
completing participants. The patients were overweight or obese;
their range of mean body mass index was 27–33 kg?m
-2
.The
range of mean age of the included patients was 44–57 yrs. The
mean Epworth Sleepiness Scale (ESS) values ranged 8–14. The
completing samples comprised 69–100% males.
The majority (74%) of the RCTs used polysomnography (PSG),
while the other researchers utilised limited sleep recordings or
combinations of these methods to analyse sleep-disordered
breathing. The apnoea/hypopnoea index (AHI) was used for
diagnosis in 86% of the studies, while the remaining studies used
the respiratory disturbance index (RDI).
Adjustable custom-made MADs were used in most of the RCTs
comparing MADs with placebo and/or CPAP [11, 13, 18, 19, 22,
24, 28, 29, 32]. The remaining studies utilised monoblockdevices,
either custom-made [14, 16, 25, 26, 30, 34] or prefabricated ones
[17, 23]. Some studies used more than one type of device [16, 34].
In all the studies that compared the effect of MADs with positive
airway pressure, CPAP with fixed pressure was used [11, 13, 16–
19, 24, 26, 32, 34].
EFFECTS ON OSA
MADs reduced AHI or RDI compared with placebo devices in all
studies [11, 22, 23, 25, 28–30]. CPAP was more effective in
reducing OSA, as MADs may be partially effective or ineffective
in some patients [11, 13, 16–19, 24, 26, 32, 34].
Patients included in the RCTs had mild to severe OSA [13, 14, 17,
18, 20, 24–27, 29–38], with mean AHI or RDI of 10–50. With MADs,
AHI or RDI decreased to mean values of 4.5–34, which cor-
responded to reductions in the frequency of respiratory dis-
turbances of means of 28–80% (mean reduction from all studies of
55%). CPAP reduced the indices from means of 18–40 to treated
values of 2.4–8.0 [13, 16–18, 24, 26, 32, 34]. This corresponded to
reductions of 74–94% (mean reduction from all studies of 83%).
There was no change in AHI or RDI with placebo treatment or
conservative treatment [13, 22, 23, 25, 26, 28–30], although
borderline significant reductions have been observed [11, 14].
EFFECTS ON SYMPTOMS AND QUALITY OF LIFE
Subjective daytime sleepiness evaluated by the ESS score was
reduced by MADs compared with placebo devices in three
studies [22, 29, 30] and there were positive effects on sleepiness
with active treatment in four other smaller studies [14, 23, 25, 28].
Control interventions reduced daytime sleepiness in some
studies, despite having no influence on sleep apnoea [22, 26].
CPAP and MADs usually had a similar effect on daytime
sleepiness [11, 13, 18, 19, 24, 32, 34]. CPAP may produce a better
outcome than MADs when it comes to sleepiness [16, 17, 26],
even in milder cases [16].
Objective evaluations of daytime sleepiness revealed an improve-
ment in the multiple sleep latency test by a MAD compared with
a placebo device in one study [22]. A similar outcome in terms of
daytime sleepiness from both MADs and CPAP was reported in
two studies using the maintenance of wakefulness test (MWT)
[16] or the Osler test [19]. Another study revealed no effect of
either MADs or CPAP, according to the results of the MWT [13].
About half the patients who were objectively sleepy during MAD
REVIEW: MANDIBULAR ADVANCEMENT DEVICE THERAPY M. MARKLUND ET AL.
1242 VOLUME 39 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL
treatment had poor apnoea control [22]. Simulated driving
performance has been shown to improve to a similar degree
with a MAD as with CPAP, according to one study [40].
Snoring was more effectively controlled with CPAP than with
MADs [11, 18], but MADs had a better effect than placebo [11, 22,
28]. Persistent snoring during MAD treatment may be a sign of
poor apnoea control [17].
More self-reported sexual dysfunction was identified in OSA
patients compared with control subjects, but there was no
significant improvement after 2–3 months’ treatment with either
the MAD or CPAP in that study [41].
Quality of life was improved by MADs compared with control
treatments [13, 26, 29, 30]. The effect of MADs and CPAP was
similar [13, 19, 24] or better with CPAP treatment [16]. Factors
that have been discussed as being as important as daytime
sleepiness, such as vigour, fatigue and reaction times, were
improved by an active device compared with a control device
[29]. Some effects on neurobehavioural function were no better
than the placebo effect [13].
EFFECTS ON CARDIOVASCULAR HEALTH
A significant reduction in blood pressure has been reported from
MAD treatment [13, 20, 26, 39]. A 2-mmHg decrease in 24-h
diastolic blood pressure was found, together with a halving of the
mean AHI, as a result of a MAD compared with a control splint
after 4 weeks’ treatment [39]. Blood pressure during wakefulness
decreased significantly by 3 mmHg, but there was no difference
in blood pressure measured while asleep in that study. Another
study reported a significant improvement in night-time diastolic
blood pressure, together with a reduction in mean AHI of one-
third, as a result of MAD treatment comparedwith the effects of a
placebo tablet or CPAP after 3 months of intervention [13]. The
24-h blood pressure was unchanged by both MADs and CPAP.
MADs normalised the nocturnal dips in blood pressure in a
significant proportion of non-dipper subjects compared with
CPAP or a placebo tablet that produced no effects [13]. Another
two studies evaluated blood pressure on single occasions during
wakefulness and found significant reductions compared with
baseline [20, 26].
Improved endothelial reactivity has been found in conjunction
with MAD therapy. One small RCT revealed a similar improve-
ment in microvascular reactivity as a result of a MAD or CPAP
[43]. There was a smaller reduction in AHI but a higher
compliance with the MAD than with CPAP during 2 months of
treatment in that study. Furthermore, the increase in vasodilation
during treatment correlated with the decrease in nocturnal
oxygen desaturation. Another small study reported an improve-
ment in endothelial function to levels similar to those seen in a
healthy control group after 1 yr of treatment with MADs [51]. In
addition, markers of oxidative stress improved. There was a
partial treatment response, with a halving of the AHI after
3 months and a decrease of about one-third after 1 yr of MAD
treatment in that study.
Improved cardiac autonomic modulation was found after
3 months’ treatment with MADs in a small sample of otherwise
healthy patients with mild OSA [47]. Further support for im-
proved cardiac function was reported from an RCT including
patients with moderate to severe OSA. Significant changes in
N-terminal pro-brain natriuretic peptide values were found with
effective MAD therapy but not with CPAP [42].
DEFINITION OF TREATMENT SUCCESS
Treatment success with MADs, defined as an AHI of ,5, was
found in 19–75% of the patients and an index of ,10 was
reported in 30–94% of the patients in all the included studies [10,
13, 15–20, 22, 25, 28–32, 34–36, 38, 50, 55]. A partial treatment
success is often defined as a reduction in AHI of .50%,
sometimes with the requirement of a treated AHI below a
specific level of 20, for example. Definitions of success for MAD
therapy were based on the frequency of sleep-disordered
breathing, sometimes with an additional requirement of a
symptomatic improvement. A more detailed definition of MAD
treatment response based on sleep-disordered breathing and
symptomsandextendedtoincludeotherhealthoutcomesmay
be of interest when defining treatment success in the future.
PREDICTION OF TREATMENT SUCCESS
Patient selection is important in order to improve the more
variable outcome in terms of sleep-disordered breathing as a
result of MADs compared with CPAP. An improved effect in
milder cases has been found in some studies [24, 28, 30].
Complete treatment success, defined as an AHI of ,5with
MADs, was reported in eight out of 26 patients with severe OSA
and in 21 out of 25 patients with mild to moderate OSA [24]. The
success rate was similar for MADs and CPAP in patients with
mild to moderate OSA, as 20 out of a further 25 patients who had
been randomised to CPAP treatment had a successful outcome
[24]. Younger or leaner patients, females or patients with supine-
dependent sleep apnoea have been reported to experience
particular success with the device [28, 32, 36, 53, 55], although
the result for obesity was favourable in one study [32].
Promising prediction methods based on the mechanism of MADs
and their influence on upper airway structures have been
proposed. Various imaging techniques have been used to
visualise the individual increase in upper airway size during
mandibular advancement. The velopharyngeal area is central to
this modification process [2, 45], which leads to reduced
pharyngeal collapsibility and sleep apnoea [3]. Good responders
had a larger increase in velopharyngeal airway size compared
with poor responders [1, 45]. The airway was still open during a
Muller manoeuvre and mandibular advancement in good
responders compared with a clear collapse in poor responders
visualised by nasendoscopy [45]. A previous small study
produced similar results by magnetic resonance imaging [57].
A model of the upper airway using combined upper airway
imaging and computational fluid dynamics has been used to
evaluate the influence of MADs on upper airway volume and
resistance and this method has future potential for the prediction
of treatment success [48].
A remotely controlled device represents another promising
prediction method for MAD therapy, since the use of this device
during an initial night at the sleep laboratory showed high
sensitivity and specificity for the assessment of treatment success
or failure in a small sample of OSA patients [49].
The localisation of the upper airway obstruction contains
predictive information. A collapse in the oropharyngeal area
has been related to a successful outcome with MADs, compared
M. MARKLUND ET AL. REVIEW: MANDIBULAR ADVANCEMENT DEVICE THERAPY
c
EUROPEAN RESPIRATORY JOURNAL VOLUME 39 NUMBER 5 1243
with the occurrence of a velopharyngeal collapse, in two studies
[44, 56]. In one of these studies, the upper airway collapse
was mimicked by phrenic nerve stimulation [44]. The use of
morphological predictors, measured on cephalograms, has
produced inconsistent results [28, 53, 58]. A high position of the
hyoid bone and smaller upper airways have been related to
treatment success [53, 58].
The measurement of flow–volume curves [46, 60] or nasal
resistance [61] have been suggested as other ways of predicting
success with MADs. Validations of prediction methods are few in
number and they have only been performed on small samples
[44, 46]. Combined functional and morphological assessments
have been suggested for future prediction models [46].
For patients who have already tried CPAP, an optimal pressure
of f10 mmHg was related to a higher chance of success with
MADs than higher CPAP pressures [59].
MANDIBULAR POSITIONING
The degree of mandibular advancement is an important
modulator of the treatment outcome, since there is a dose-
dependent effect on nocturnal oxygenation and pharyngeal
collapsibility [52]. Mandibular titration is, therefore, a key
procedure when it comes to obtaining optimal effects on OSA
with the device. A small advancement produces a suboptimal
treatment effect, while too large an advancement produces more
side-effects [10]. A non-advanced device is ineffective in reducing
sleep apnoea [23, 25, 30] and may even increase the apnoea
frequency. One study revealed an impaired effect by MADs
during the first 6 weeks without titration [32]. A titration
procedure millimetre by millimetre has, therefore, been recom-
mended in order to achieve optimal results [50]. To optimise the
mandibular positioning, a remotely controlled MAD can be used
during the concomitant measurement of respiratory events
during sleep [49]. The combined evaluation of the symptomatic
improvement and oximetry, which has been recommended to
find the most effective mandibular positioning, is probably easier
in the clinic [50]. It is possible that the exact degree of mandibular
advancement is of less importance for patients with mild to
moderate disease compared with patients with more severe sleep
apnoea [35, 36]. A mouth opening of 4–14 mm has not been
found to influence the treatment outcome in terms of sleep
apnoea, although patients preferred the device with a smaller
opening [31]. There is currently no agreement regarding the
method for measuring and defining the degree of mandibular
repositioning in the individual patient, which causes uncertainty
regarding comparisons between studies.
DEVICE DESIGN
MADs exist in many designs and with various types of
adjustment mechanism. With adjustable devices, it is easy for
the patient or the dentist to change the mandibular positioning in
order to achieve the desired effects. The monoblock devices have
to be adjusted at a dental laboratory. The variety of device
designs may explain some of the variability in outcome between
patients and studies. Comparison studies between the many
custom-made device designs are few in number. These studies
have indicated that there may be some differences in treatment
effects, albeit minor [15, 20, 27, 33]. The stability of the device is
probably a limiting factor for its effectiveness [38]. Poor retention
and a high compliance failure rate have been reported for a
thermoplastic non-custom-made device compared with a
custom-made device [38]. This thermoplastic device was not
recommended as a screening tool for a custom-made device [38].
A comparison after 2 yrs of treatment showed that two different
types of adjustable custom-made MAD were equally effective in
patients who chose to continue treatment [21].
In the studies comparing adjustable MADs with placebo and/or
with CPAP, the mandibular positioning was titrated to the
maximum comfortable position [13, 22, 29] and/or until the relief
of symptoms [18, 24, 28]. In another study, four different
positions were tested and the most effective one was thereafter
used to evaluate the effect of MADs [10, 11]. A larger
advancement of 50% or 75% of maximum mandibular advance-
ment was most effective in all but one out of 17 patients in that
study. The authors recommended starting the titration at 50% of
maximum advancement in order to reduce the initial side-effects.
In another study, both CPAP and MADs were titrated during the
nights before the trial in order to find the most effective
mandibular position [19]. The majority of the studies using
monoblock devices reported no change in mandibular position-
ing [14, 16, 17, 23, 25, 26], while some studies described
reconstruction of the device in order to optimise the lower jaw
position in relation to the outcome on sleep-disordered breathing
[30, 34]. More standardisation of these methodologies of
advancing the mandible is required for reliable comparison of
results between studies.
A MAD is usually adjusted using a screw located in the midline,
anteriorly or in the palate, or laterally with arms of different
lengths or screws on both sides of the appliance. Some designs
permit the opening of the mandible and/or some lateral
movement, while others fixate the jaws more rigidly. The use of
rigid intermaxillary elastics makes these two types approach each
other. The stability of these designs in the longer term is
unknown. More research is needed about the influence of various
MAD designs on the efficacy of the treatment in order to further
improve the quality of this treatment modality.
SIDE-EFFECTS, PREFERENCE AND COMPLIANCE
Side-effects, such as jaw discomfort, tooth tenderness and
excessive salivation, occur more frequently as a result of MADs
than a control plate [11, 22]. Therefore, the patients need an
adaptation period that may sometimes last for months before
they become accustomed to the device [22, 28, 29]. Side-effects of
similar severity have been reported from MADs and CPAP [16].
Patients generally prefer MADs to CPAP or a control plate [17, 18,
22, 32, 34]. Similar preferences for MADs and CPAP have been
reported [13, 16]. There is probably a difference between patient
groups, since overweight patients and those with more severe
symptoms favoured CPAP in one study of sleepy OSA patients
[16]. Self-reported short-term compliance with MAD treatment
ranged from 76% to 95% of the patients [17, 18, 34, 38]. Some
studies observed a higher nightly compliance with MADs than
with CPAP [19, 32], while other studies described a similar
nightly compliance [11, 16–18, 24]. Compliance monitors have
been introduced into the market and are being evaluated [54].
Objective compliance monitoring of MAD use is currently not
widely available and generally only subjective compliance
reporting has been relied upon in the studies. This is a
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1244 VOLUME 39 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL
shortcoming in truly being able to compare compliance between
MAD and CPAP treatments.
LONG-TERM EFFICACY
In the longer term, patients usually continue to use their MADs,
although compliance appears to decrease slightly with time.
After 1 yr, 76% of the patients were still on treatment [55] and,
after 2–4 yrs, about half the patients were still using their devices
[21, 37]. The treatment effect by MADs on AHI was usually stable
or decreased slightly in patients who had a good initial treatment
outcome. After 2 yrs, MADs effectively reduced the AHI in those
who continued with the device, which constituted about half the
study sample [21]. Daytime sleepiness was reported to increase,
despite the good effect on sleep apnoea [21]. After 4 yrs, the AHI
was still significantly reduced by MADs, although the treated
index was higher than after 1 yr [37]. The only longer-term
comparison between MADs and CPAP revealed a larger
reduction in AHI as a result of using CPAP compared with
MADs after 1 yr of treatment [12]. About a quarter of the patients
discontinued treatment in each group, because of either side-
effects or ineffective treatment.
CONCLUSIONS FROM THE STUDIES
In patients with mild to moderate sleep apnoea, MADs reduce
sleep apnoea and subjective daytime sleepiness and improve
quality of life compared with placebo devices. The apnoea
reduction produced by MADs is smaller and more variable than
that achieved by CPAP. An increasing number of studies report
similar results from MADs and CPAP in terms of other health
outcomes, such as blood pressure, microvascular reactivity,
cardiac function, symptoms, quality of life and driving perfor-
mance. These results suggest that MADs have complex effects on
OSA and its consequences. Patients often prefer and comply
better with MADs than with CPAP, which may influence the final
outcome in comparisons between these treatments.
The variable response to MAD treatment, with some patients
experiencing no improvement in OSA, highlights the necessity of
objective assessment of treatment outcome and also the need for
better understanding predictors of treatment success. Some
studies show that MADs more effectively reduce sleep apnoea
in milder cases than in more severe ones, although patients with
severe OSA may have a successful outcome. These predictions are
usually based on the results of PSG, and the use of other methods
of sleep monitoring might influence the results. Promising results
for prediction of treatment outcome are reported from various
techniques that visualise an improvement in pharyngeal size
during mandibular advancement. The identification of the airway
collapse in the oropharyngeal region might be another useful
predictor of success. For patients who have already tried CPAP,
low therapeutic pressure has been related to success with MADs.
There is insufficient evidence to indicate the type of custom-made
device that is most effective and how these devices should be
adjusted to produce the optimal effects on OSA. A titration
procedure, starting at 50% of maximum mandibular advance-
ment,isrecommended,togetherwiththeuseofthecombined
improvement in symptoms and oxygenation or sleep-disordered
breathing.
The longer-term treatment effect of MADs on sleep apnoea is
stable or may slightly diminish in patients who have an initially
successful outcome and choose to continue with the device in the
long term. There is a need for more knowledge about the long-
term outcome of MAD treatment. Mild oral side-effects, such as
tender teeth and bite changes, are consistently found.
More knowledge about symptomatic effects, cardiovascular
effects and other health-related effects of MADs is desirable.
Studies that identify patients who will benefit from a MAD as an
alternative treatment to CPAP, also in a long-term perspective,
are needed. This will form the basis of more precise indications
and longer-term follow-up guidelines for MAD treatment in
teamwork between various specialists.
SUMMARY
MADs are indicated in the treatment of patients with mild to
moderate OSA (Recommendation Level A) and in patients who
do not tolerate CPAP. MADs reduce sleep apnoea and daytime
sleepiness and improve quality of life compared with placebo
devices. CPAP more effectively reduces sleep apnoea, while an
increasing number of studies suggest fairly similar outcomes in
terms of symptoms and cardiovascular health as a result of these
treatments. Patients generally prefer MADs to CPAP. A custom-
made MAD titrated from an initial 50% of maximum mandibular
advancement has been recommended. The follow-up of treat-
ment effects is necessary, even in the longer term, because of the
larger variability in treatment effects from MADs compared with
CPAP. More research is needed to define the patients who will
benefit from MAD treatment for OSA and its consequences
compared with positive airway pressure, in order to provide
patients with the most optimal treatment for OSA.
STATEMENT OF INTEREST
None declared.
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    • "Meta-analyses of multiple randomized controlled trials shows significant benefit from blood pressure reduction with PAP therapy of approximately 2–3 mm Hg, albeit modest, but to a sufficient degree to result in beneficial cardiovascular outcomes. Alternative therapies for treatment for OSA include mandibular advancement devices or oral appliance therapy for those with mild to moderate OSA [56] and various surgical procedures depending on the level of collapse of upper airway such as uvulopharyngoplasty [57] and maxillomandibular advancement [58]. Novel treatment therapies such as hypoglossal nerve stimulation are also becoming increasingly considered [59]. "
    [Show abstract] [Hide abstract] ABSTRACT: Sleep disorders are very common, often under-recognized and therefore undertreated, are associated with a myriad of medical conditions and could lead to significant impairment of quality of life. This review provides an up-to-date synopsis of common sleep disorders encompassing insufficient sleep syndrome, insomnia, circadian rhythm disorders and obstructive sleep apnea with a brief overview of epidemiology, screening, diagnostic testing and treatment. We also emphasize the emerging area of the intersection of sleep disorders and dermatologic conditions and present compelling data regarding underlying mechanisms including sleep dysfunction in relation to disorders of skin inflammation, aging and skin cancer.
    Full-text · Article · Apr 2016
    • "In addition to nCPAP, oral appliances may be considered as a long-term alternative in patients with severe OSAS who do not respond to CPAP or in whom treatment attempts with CPAP fail. Surgery may also be recommended with curative intent for patients with an obvious anatomic obstruction such as large palatine or lingual tonsils or used as a salvage procedure to improve OSA in patients who fail CPAP and/or other treatment measures [15, 16]. The standard treatment, nCPAP, has been proven to reduce upper airway obstructions and improves quality of life. "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose. This study aims to determine the clinical efficacy of acupuncture therapy in the treatment of obstructive sleep apnea. Methods. A systematic literature search was conducted in five databases including PubMed, EMBASE, CENTRAL, Wanfang, and CNKI to identify randomized controlled trials (RCTs) on the effect of acupuncture therapy for obstructive sleep apnea. Meta-analysis was conducted using the RevMan version 5.3 software. Results. Six RCTs involving 362 subjects were included in our study. Compared with control groups, manual acupuncture (MA) was more effective in the improvement of apnea/hypopnea index (AHI), apnea index, hypopnea index, and mean SaO 2 . Electroacupuncture (EA) was better in improving the AHI and apnea index when compared with control treatment, but no statistically significant differences in hypopnea index and mean SaO 2 were found. In the comparison of MA and nasal continuous positive airway pressure, the results favored MA in the improvement of AHI; there was no statistical difference in the improvement in mean SaO 2 . No adverse events associated with acupuncture therapy were documented. Conclusion. Compared to control groups, both MA and EA were more effective in improving AHI and mean SaO 2 . In addition, MA could further improve apnea index and hypopnea index compared to control.
    Full-text · Article · Apr 2016
    • "Mandible advancement devices (MADs) are known to improve the airway space, particularly in adult patients with sleep apnoea and snoring problems [1][2][3] . MADs are nonsurgical approaches and are currently recognised as the primary noncontinuous positive airway pressure (CPAP) therapy [1] used to treat mild to moderate obstructive sleep apnoea (OSA) and daytime sleepiness, and for those who do not tolerate CPAP [2, 4]. MADs are effective in patients over 65 years old with good dental health [5]. "
    [Show abstract] [Hide abstract] ABSTRACT: Aims . To assess the effects of two-phase treatment with the Herbst and the preadjusted edgewise appliances on upper airway dimensions and to investigate the correlation between changes in the upper airway dimensions and skeletal morphologies. Methods . A total of 27 Chinese male adolescents aged 12.8 ± 1.3 years were selected. Lateral cephalograms were collected to assess the skeletal morphology and upper airway dimensions. Results . Following Herbst appliance treatment, the upper airway space was significantly enlarged, with the retropalatal (U-MPW) increasing by 1.1 ± 1.6 mm ( P < 0.001 ), the retroglossal (PASmin) increasing by 1.3 ± 2.9 mm ( P < 0.05 ), and the hypopharynx (V-LPW) enlarging by 1.6 ± 3.0 mm ( P < 0.01 ). PASmin was found to show a negative correlation to the mandibular plane angle (MnPl-SN) by r = - 0.413 ( P < 0.05 ). There was no significant change ( P > 0.05 ) in upper airway dimensions during the second-phase treatment. Conclusions . Herbst appliance treatment increased the oropharyngeal and hypopharyngeal airway dimensions among adolescents with Class II malocclusion, and the effects were maintained throughout the second treatment phase with a preadjusted edgewise appliance. There was a negative correlation between the change in the depth of the retroglossal pharynx and the mandibular plane angle.
    Full-text · Article · Mar 2016
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