I thought I would review two scientific articles of interest in the treatment of Obstructive Sleep Apnea.
The first is by Holley et al. It compares Continuous Positive Air Pressure (CPAP) with adjustable Oral Appliances (aOA).
The findings suggest that CPAP is superior to oral appliances for Moderate to Severe OSA –
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.
The problem with this study is that it seeks an Apnea Hypopnea Index (AHI) result of <5 as a satisfactory result. It also measures the end result with a PSG (polysomnogram or sleep study) while the patient is actually using the appliance (aOA or CPAP). It does not take into account the reality that many do not actually use the CPAP for most nights.
A more realistic study was done by Cistulli et al. It also compares the use of Oral appliances (MAD – Mandibular Advancement Devices) with CPAP.
This randomised cross-over trial took into account both effectiveness and efficacy of the different appliances. CPAP has superior efficacy, but its effectiveness is reduced due to lack of satisfactory compliance. OAs have superior effectiveness due to greater compliance.
What This Study Adds to the Field: In the short term, health outcomes in patients with moderate to severe OSA were similar after treatment with CPAP and MAD. This was likely explained by the greater efficacy of CPAP being offset by inferior compliance relative to MAD. These findings strongly challenge current practice parameters recommending MAD treatment be considered only in patients with mild to moderate OSA.
Long-term comparative effectiveness studies between CPAP and MAD that include objectively measured treatment compliance are needed to better define treatment strategies for patients with OSA.
Although Holly et al is accurate, it is misleading from a clinical viewpoint. For clinical practicality, I believe that the Cistulli et al paper is of much greater value.
At Sydney Sleep Dentistry, we offer a renege of Oral Appliances, selecting the best one for the individual, as part of our treatment regime for Snoring or Obstructive Sleep Apnea.