Obstructive Sleep Apnea: What’s best? Oral appliance or CPAP?

Surprise, surprise! An adjustable oral appliance was about as effective as continuous positive airway pressure. I was rather shocked by this study. But, it’s good news for many patients.

Oral appliances that advance the mandible are effective treatments for patients with mild obstructive sleep apnea (OSA).

However, in most studies, investigators have not compared the relative effectiveness of oral appliances and continuous positive airway pressure (CPAP) in the same patients.

In a rescent a study, researchers examined the efficacy of both approaches in 378 patients with OSA.

They used an adjustable appliance that was titrated for optimal effect by turning a dial that changed the degree of jaw protrusion.

At baseline, the cohort had roughly equal proportions of patients with mild, moderate, or severe OSA (corresponding to apnea-hypopnea indexes [AHI] of 5–15, 15–30, and >30 events per hour).

During appliance use, the AHI fell to <5 in 62%, 51%, and 40% of patients with mild, moderate, or severe OSA, respectively.

In contrast, CPAP lowered the AHI to <5 in 76%, 71%, and 63% of patients in the three categories.

The response rate was significantly greater with CPAP than with the oral appliance in patients with moderate or severe, but not mild, OSA.

Comment by Allan S. Brett, MD, of Journal Watch:

The finding that patients with mild OSA did almost as well with oral appliances as with CPAP is not surprising.

The new information here is that about half of patients with moderate or severe OSA responded to an oral appliance.

The authors attribute this response rate — higher than that seen in most previous studies –– to use of an adjustable appliance that was titrated for effect and to absence of selection bias (because both treatments were studied in all patients and not just patients in whom CPAP failed).

Holley AB et al. Efficacy of an adjustable oral appliance and comparison with continuous positive airway pressure for the treatment of obstructive sleep apnea syndrome. Chest 2011 Dec; 140:1511. [Medline® Abstract]

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