Mild obstructive sleep apnoea: MAD as the most appropriate long-term treatment

In an article published by Lancet journal in May 2016, Walter T McNicholas and his colleagues demonstrate the effectiveness of mandibular advancement devices (DAM), such as OrthoApnea, in the treatment of mild, moderate and even severe sleep apnoea.

In the aforesaid article, they indicate that oral appliance therapy might be more suitable as long-term therapy because of better compliance to treatment.

Ejemplo de Dispositivo de Avance Mandibular, de OrthoApnea

OrthoApnea Mandibular Advancement Device

Mandibular Advancement Device (MAD) treatment is more suitable as long-term therapy because of its effectiveness and better compliance to treatment.

Oral appliance therapy is based on a dental device designed to advance the mandible, thereby enlarging and stabilising the oropharyngeal airway. The treatment improves sleepiness in obstructive sleep apnoea, although less so than with CPAP. Some earlier randomised studies in mild-to-moderate obstructive sleep apnoea comparing oral appliance therapy and CPAP have suggested that CPAP is the superior treatment option. However, a recent comparison of the two therapies in 126 patients with moderate obstructive sleep apnoea (mean AHI 25·6 [SD 12·3])76 showed that after 1 month, the two treatments had similar efficacy in sleepiness, driving simulator performance, and disease-specific quality of life. It’s clear that oral appliance therapy was superior to CPAP.

Overall, these data indicate that oral appliance therapy can be recommended as a firstline therapy for patients with mild, symptomatic obstructive sleep apnoea.

Management considerations for patients with mild obstructive sleep apnoea

A continuous positive airway pressure (CPAP) trial might be recommended in symptomatic patients, at least to ascertain whether or not normalisation of sleep and respiration by CPAP leads to the relief of symptoms attributed to sleep-disordered breathing.

Oral appliances are a viable first-line theraphy in mild obstructive sleep apnoea if feasible, especially from a dental point of view, and in patients who decline or do not respond to CPAP theraphy.

Weight reduction and positional theraphy are suitable management options for obese patients and those with positional obstructive sleep apnoea.

Surgical indications are rare in adults with obstructive sleep apnoea and largely confined to patients with a surgically correctable upper airway-obstructing patholofy, such as adenotonsillar hypertrophy.

The following graph shows the effectiveness of CPAP and DAM by hours used per night and % of nights used. A greater number of patients used the device for more days and more hours.

grafico-dam-cpap

Comparative efficacy and compliance of CPAP and oral appliance therapy in mild-to-moderate obstructive sleep apnoea

Mild obstructve sleep apnoea: clinical relevance and approaches to management

Obstructive sleep apnoea is highly prevalent in the general population worldwide, especially in its mild form. Clinical manifestations correlate poorly with disease severity measured by the apnoea-hypopnoea index (AHI), which complicates diagnosis. Full polysomnography might be more appropriate to assess suspected mild cases because limited ambulatory diagnostic systems are least accurate in mild disease.

Treatmet options in mild obstructive sleep apnoea include continuous positive airway pressure (CPAP) and oral appliance therayphy, in addition to positional theraphy and weight reduction when appropriate. The superior efficacy of CPAP in reducting AHI is offset by greater tolerance of oral appliances, especially in mild disease.

Although severe obstructive sleep apnoea is associated with adverse health consequences, including cardiometabolic comorbidities, the association with mild disease is unclear, and reports differ regarding the clinical relevance of mild obstructive sleep apnoea. Improved diagnostic techniques and evidence-based approaches to management in mild obstructive sleep apnoea require further research.

Walter T McNicholas, Maria R Bonsignore, Patrick Lévy, Silke Ryan

Author: Dr. Pedro Mayoral.

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