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Efficacy of an Adjustable Oral Appliance and Comparison With Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome

      Background

      We sought to establish the efficacy of an adjustable oral appliance (aOA) in the largest patient population studied to date, to our knowledge, and to provide a comparison with continuous positive airway pressure (CPAP).

      Methods

      We conducted a retrospective analysis of patients using an aOA. Results of overnight polysomnography with aOA titration were evaluated and compared with CPAP. Predictors of a successful aOA titration were determined using a multivariate logistic regression model.

      Results

      A total of 497 patients were given an aOA during the specified time period. The aOA reduced the mean apnea-hypopnea index (AHI) to 8.4 ± 11.4, and 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI < 5, respectively. Patients using an aOA decreased their mean Epworth Sleepiness Score by 2.71 (95% CI, 2.3-3.2; P < .001) at follow-up. CPAP improved the AHI by −3.43 (95% CI, 1.88-4.99; P < .001) when compared with an aOA, but when adjusted for severity of disease, this difference only reached significance for patients with severe disease (−5.88 [95% CI, −8.95 to −2.82; P < .001]). However, 70.1% of all patients achieved an AHI < 5 using CPAP compared with 51.6% for the aOA (P < .001). On multivariate analysis, baseline AHI was a significant predictor of achieving an AHI < 5 on aOA titration, and age showed a trend toward significance.

      Conclusions

      In comparison with past reports, more patients in our study achieved an AHI < 5 using an aOA. The aOA is comparable to CPAP for patients with mild disease, whereas CPAP is superior for patients with moderate to severe disease. A lower AHI was the only predictor of a successful aOA titration.
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      References

        • Ferguson KA
        • Cartwright R
        • Rogers R
        • Schmidt-Nowara W
        Oral appliances for snoring and obstructive sleep apnea: a review.
        Sleep. 2006; 29: 244-262
        • Kushida CA
        • Morgenthaler TI
        • Littner MR
        • American Academy of Sleep
        • et al.
        Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005.
        Sleep. 2006; 29: 240-243
        • Yoshida K
        Effects of a mandibular advancement device for the treatment of sleep apnea syndrome and snoring on respiratory function and sleep quality.
        Cranio. 2000; 18: 98-105
        • Marklund M
        • Stenlund H
        • Franklin KA
        Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success.
        Chest. 2004; 125: 1270-1278
        • Eveloff SE
        • Rosenberg CL
        • Carlisle CC
        • Millman RP
        Efficacy of a Herbst mandibular advancement device in obstructive sleep apnea.
        Am J Respir Crit Care Med. 1994; 149: 905-909
        • Bloch KE
        • Iseli A
        • Zhang JN
        • et al.
        A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment.
        Am J Respir Crit Care Med. 2000; 162: 246-251
        • Pancer JA
        • Al-Faifi S
        • Al-Faifi M
        • Hoffstein V
        Evaluation of variable mandibular advancement appliance for treatment of snoring and sleep apnea.
        Chest. 1999; 116: 1511-1518
        • Gotsopoulos H
        • Chen C
        • Qian J
        • Cistulli PA
        Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial.
        Am J Respir Crit Care Med. 2002; 166: 743-748
        • Kushida CA
        • Littner MR
        • Morgenthaler T
        • et al.
        Practice parameters for the indications for polysomnography and related procedures: an update for 2005.
        Sleep. 2005; 28: 499-521
        • Iber C
        • Anconi-Israel S
        • Chesson Jr, AL
        • Quan SF
        The AASM Manual for Scoring of Sleep and Associated Events: Rules, Terminology, and Technical Specifications. American Academy of Sleep Medicine, Westchester, IL2007: 3-59
        • Kushida CA
        • Chediak A
        • Berry RB
        • Positive Airway Pressure Titration Task Force
        • American Academy of Sleep Medicine
        • et al.
        Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea.
        J Clin Sleep Med. 2008; 4: 157-171
        • Barnes M
        • McEvoy RD
        • Banks S
        • et al.
        Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea.
        Am J Respir Crit Care Med. 2004; 170: 656-664
        • Clark GT
        • Blumenfeld I
        • Yoffe N
        • Peled E
        • Lavie P
        A crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea.
        Chest. 1996; 109: 1477-1483
        • Ferguson KA
        • Ono T
        • Lowe AA
        • al-Majed S
        • Love LL
        • Fleetham JA
        A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea.
        Thorax. 1997; 52: 362-368
        • Randerath WJ
        • Heise M
        • Hinz R
        • Ruehle KH
        An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome.
        Chest. 2002; 122: 569-575
        • Tan YK
        • L'Estrange PR
        • Luo YM
        • et al.
        Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial.
        Eur J Orthod. 2002; 24: 239-249
        • Hoffstein V
        Review of oral appliances for treatment of sleep-disordered breathing.
        Sleep Breath. 2007; 11: 1-22
        • Engleman HM
        • McDonald JP
        • Graham D
        • et al.
        Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint.
        Am J Respir Crit Care Med. 2002; 166: 855-859
        • Ferguson KA
        • Ono T
        • Lowe AA
        • Keenan SP
        • Fleetham JA
        A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea.
        Chest. 1996; 109: 1269-1275
        • Otsuka R
        • Almeida FR
        • Lowe AA
        • Ryan F
        A comparison of responders and nonresponders to oral appliance therapy for the treatment of obstructive sleep apnea.
        Am J Orthod Dentofacial Orthop. 2006; 129: 222-229
        • Liu YL
        • Lowe AA
        • Fleetham JA
        • Park YC
        Cephalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea.
        Am J Orthod Dentofacial Orthop. 2001; 120: 639-647
        • Mehta A
        • Qian J
        • Petocz P
        • Darendeliler MA
        • Cistulli PA
        A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea.
        Am J Respir Crit Care Med. 2001; 163: 1457-1461
        • Marklund M
        • Persson M
        • Franklin KA
        Treatment success with a mandibular advancement device is related to supine-dependent sleep apnea.
        Chest. 1998; 114: 1630-1635
        • Levendowski DJ
        • Morgan TD
        • Patrickus JE
        • et al.
        In-home evaluation of efficacy and titration of a mandibular advancement device for obstructive sleep apnea.
        Sleep Breath. 2007; 11: 139-147
        • Pételle B
        • Vincent G
        • Gagnadoux F
        • Rakotonanahary D
        • Meyer B
        • Fleury B
        One-night mandibular advancement titration for obstructive sleep apnea syndrome: a pilot study.
        Am J Respir Crit Care Med. 2002; 165: 1150-1153
        • Gagnadoux F
        • Fleury B
        • Vielle B
        • et al.
        Titrated mandibular advancement versus positive airway pressure for sleep apnoea.
        Eur Respir J. 2009; 34: 914-920
        • Naismith SL
        • Winter VR
        • Hickie IB
        • Cistulli PA
        Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial.
        J Clin Sleep Med. 2005; 1: 374-380
        • Thorpy M
        • Chesson A
        • Derderian S
        • Kader G
        • American Sleep Disorders Association
        • et al.
        Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances.
        Sleep. 1995; 18: 511-513
        • Schmidt-Nowara W
        • Lowe A
        • Wiegand L
        • Cartwright R
        • Perez-Guerra F
        • Menn S.
        Oral appliances for the treatment of snoring and obstructive sleep apnea: a review.
        Sleep. 1995; 18: 501-510