Treatment adherence and preference were largely in favor of the mandibular advancement device compared to continuous positive airway pressure.
Data from a meta-analysis of randomized controlled trials (RCTs) that included patients with severe obstructive sleep apnea (OSA) suggests that titratable mandibular advancement device (MAD) has a similar impact to continuous positive airway pressure (CPAP) on major patient-centered outcomes and may represent an alternative treatment strategy.
Lead author Wojciech Trzepizur, MD, PhD, professor, department of respiratory and sleep medicine, Angers University Hospital, and colleagues used 3 crossover RCTs and 1 parallel-group RCT that corresponded to 151 patients and 249 observations (125 in the CPAP treatment arm and 124 in the MAD treatment arm). To the authors knowledge, this was the first study that directly compared the 2 treatment options in patients with severe OSA.
Two of the 4 studies reported the impact of treatment on quality of life (QoL) using both 36-Item Short Form Survey (SF-36) and the Functional Outcomes of Sleep Questionnaire (FOSQ). When compared to baseline, both CPAP and MAD improved most of the domains, except for “intimacy” on the FOSQ and “bodily pain” for the SF-36, with no other differences between treatment arms.
"This meta-analysis suggests that MAD represents an effective alternative treatment option in all OSA patients intolerant to CPAP or who prefer alternate therapy, including those with severe OSA,” Trzepizur et al noted.
Treatment with MAD had a significantly less reduction of apnea/hypopnea index (AHI; mean difference, 11.1 [95% CI, 6.6-15.7]; P <.0001) and oxygen desaturation index (ODI; mean difference, 4.8 [95% CI, 0.4-9.3]; P = .03) compared to treatment with CPAP. Additionally, 3 studies reported data from overnight polysomnography with both MAD and CPAP treatments. Treatment with either MAD or CPAP both significantly improved sleep efficiency (SE) by about 4%, with no significant difference between them (mean difference, –0.44 [95% CI, –4.8 to 3.9]; P = .84).
Both treatment options also had a similar impact on sleep architecture with an increase of N3 and rapid eye movement (REM) stage duration and a decrease of N1 stage and wake after sleep onset (WASO; CPAP treatment as trend: mean, –19 min [95% CI, –39.0 to 1.0]; P = .06). No significant differences were reported between both treatment arms.
Among 3 studies that reported adherence data, results were higher with MAD than with CPAP (mean difference, 1.1 hours [95% CI, 0.7-1.6]; P <.0001). In total, 48 patients (60.8%) preferred MAD, 14 (17.7%) preferred CPAP, and 17 (21.5%) had no preference.
The study samples included a large proportion of men, ranging from 71.4% to 84.9% (mean, 83%), while the reported mean age ranged from 46.0 to 52.2 years. Most patients included in the trials were overweight or obese, with a mean body mass index (BMI) ranging from 28.5 kg/m2 to 35.3 kg/m2.
Trzepizur and colleagues also concluded that the results provide impetus for future studies to focus on severe OSA, and to explore a range of additional outcomes, including cardiometabolic comorbidities and cognitive function.