Mandibular Advancement Devices for the Treatment of Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a prevalent sleep disorder characterized by upper airway collapse during sleep. Continuous Positive Airway Pressure (CPAP) is the gold standard treatment, but its efficacy is hindered by low compliance. Oral appliances, specifically Mandibular advancement appliances (MAD), have gained prominence as an alternative to CPAP. This article explores the effectiveness of MAD therapy, its design features, and the challenges associated with its provision in clinical sleep services.

Mechanism of Action of MADs

MADs prevent upper airway collapse by protruding the mandible forward, leading to an increase in airway volume at the velopharynx level. Various studies have confirmed the efficacy of MADs in reducing apneic events, demonstrating that mandibular protrusion is the primary mechanism of action.Efficacy of MAD: MAD therapy aims to address both physiological and symptomatic aspects of OSA. Studies have reported significant reductions in the Apnea-hypopnea index (AHI), with some achieving complete resolution of OSA. MADs have also shown positive effects on oxygen saturation, arousal index, REM sleep duration, and snoring reduction. Furthermore, MAD treatment has been associated with improvements in excessive daytime sleepiness (EDS), quality of life (QoL), and blood pressure.

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Health Outcomes of MAD

MAD therapy has been found to reduce EDS, as measured by the Epworth Sleepiness score and Stop-Bang Questioners , and to improve both generic and disease-specific QoL measures. Additionally, MAD treatment has shown positive effects on systolic and diastolic blood pressure, particularly in hypertensive patients.

MAD Compared to CPAP

While CPAP is more effective than MADs in reducing sleep-disordered breathing, studies have shown that MADs can achieve similar health outcomes when considering factors such as EDS and QoL. Compliance rates tend to be higher for MAD therapy, which can influence overall effectiveness and cost-effectiveness.

Design Features Influencing the Efficacy of MAD

MADs vary in design and sophistication, with options ranging from non-adjustable over-the-counter appliances to custom-made devices. The ability to adjust mandibular protrusion is a significant advantage of adjustable MADs, although evidence supporting their superiority over fixed MADs is limited. More research is needed to compare the effectiveness of different MAD designs.

Side Effects of MAD

Most side effects of MAD therapy are mild and temporary, occurring during the initial acclimatization period. These side effects include hypersalivation, dry mouth, dental pain, gingival irritation, myofascial pain, and temporomandibular joint discomfort. In a study, it was found that 51% of the sample developed a posterior open bite, characterized by the loss of occlusal contact on at least two posterior teeth. Additionally, 62% of the sample developed an anterior crossbite, with an average of four teeth involved in those cases. These findings highlight potential side effects of the treatment, but it’s important to consult with a Dental Sleep Professional for accurate diagnosis and personalized recommendations.

Mandibular advancement devices offer a viable alternative to CPAP for the treatment of OSA, with evidence supporting their efficacy and positive health outcomes. However, barriers to MAD provisions, such as uncertainty regarding effectiveness prediction and design sophistication, hinder their widespread inclusion in clinical sleep services. Further research is needed to address these uncertainties and optimize the design and selection of MAD therapy.

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