Oral Appliance Therapy and Sleep Apnea | Journal Scan

Jun 02, 2015
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Authors:
Marklund M, Carlberg B, Forsgren L, Olsson T, Stenlund H, Franklin KA.
Citation:
Oral Appliance Therapy in Patients With Daytime Sleepiness and Snoring or Mild to Moderate Sleep Apnea: A Randomized Clinical Trial. JAMA Intern Med 2015;Jun 1:[Epub ahead of print].
Summary By:
Peter M. Farrehi, MD

Study Questions:

Can an oral appliance improve sleepiness or snoring in mild to moderate obstructive sleep apnea (OSA)?

Methods:

A single-center, single-blind, randomized study using an oral appliance was conducted between 2007 and 2011. Patients with daytime sleepiness and mild to moderate OSA (apnea-hypopnea index [AHI] <30) were randomized to an active oral appliance or a placebo jaw device. The active device allowed gradual advancement of the lower jaw by at least 6-7 mm. Patients were excluded for psychiatric illness, tonsil hypertrophy, dental caries, or periodontal disease and few teeth. Outcomes measured include: completed standard surveys for sleepiness, quality of life as well as symptoms of snoring, restless legs, and AHI by overnight polysomnography.

Results:

A total of 96 patients were randomized, and 91 (45 active and 46 placebo) completed the study. Endpoint analysis was performed at 4 months (mean time 175 days). Average age was slightly higher among the placebo group (54 ± 9 vs. 49 ± 10 years; p = 0.05), but there was no statistical difference in gender (12 vs. 17 women), neck size (42 vs. 42 cm), body mass index (BMI; 27.6 vs. 27.9 kg/m2), or active smoking (6 vs. 9) among active and placebo groups, respectively. The BMI did not change in either group during the study period. The final mandibular advancement in the active arm was 6.8 mm. There was no difference in active and placebo appliance use (86% vs. 83%). There was no difference in daytime sleepiness or quality-of-life scores at follow-up between study groups. However, the number lowering to an AHI <5 at endpoint was 49% using active versus 11% using placebo appliance. Snoring (p < 0.001) and reports of restless legs (p = 0.02) were less frequent when using active over placebo.

Conclusions:

The authors concluded that an oral appliance compared to placebo reduces AHI and snoring without effect on daytime sleepiness among mild to moderate OSA patients who complain of daytime sleepiness.

Perspective:

Mandibular advancement devices widen the upper airway by moving the jaw forward to improve airflow, and reduce snoring and breathing disturbances, such as hypopneas and apneas. Since cardiovascular and metabolic consequences are observed among those most severely affected and not all patients with OSA complain of sleepiness, clinicians are challenged with this population of mild to moderate OSA patients who may be noncompliant with positive airway pressure. Positive airway pressure remains the treatment of choice for OSA. Future studies are needed to assess long-term morbidity and mortality outcomes using mandibular advancement devices in severe OSA.

Keywords: Apnea, Body Mass Index, Dental Caries, Follow-Up Studies, Hypertrophy, Mandibular Advancement, Palatine Tonsil, Periodontal Diseases, Polysomnography, Quality of Life, Respiration, Restless Legs Syndrome, Secondary Prevention, Single-Blind Method, Sleep Apnea, Obstructive, Snoring, Smoking


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