Oral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea Obstructive Sleep apnea Therapy Effect of oral appliance therapy on upper airway collapsibility in obstructive sleep apnea. Simulated driving in obstructive sleep apnoea–hypopnoea; effects of oral appliances and continuous positive airway pressure Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Long-Term Follow-Up of a Randomized Controlled Trial of Oral Appliance Therapy in Obstructive Sleep Apnea Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Effects of oral appliances and CPAP on the left ventricle and natriuretic peptides. Microvascular endothelial function in obstructive sleep apnea: Impact of continuous positive airway pressure and mandibular advancement. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Sexual function and obstructive sleep apnea-hypopnea: a randomized clinical trial evaluating the effects of oral-appliance and continuous positive airway pressure therapy. An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Long-term oral-appliance therapy in obstructive sleep apnea: a cephalometric study of craniofacial changes.
Background : Previous r and omized controlled trials have addressed the efficacy of m and ibular advancement devices ( MADs ) in the treatment of obstructive sleep apnea ( OSA ) . Their common control condition , nasal continuous positive airway pressure ( nCPAP ) , was frequently found to be superior to MAD therapy . However , in most of these studies , only nCPAP was titrated objective ly but not MAD . To enable an unbiased comparison between both treatment modalities , the MAD should be titrated objective ly as well . Objective : The aim of the present study was to compare the treatment effects of a titrated MAD with those of nCPAP and an intra-oral placebo device . Methods : Sixty-four mild/moderate patients with obstructive sleep apnea ( OSA ; 52.0 ± 9.6 years ) were r and omly assigned to three parallel groups : MAD , nCPAP and placebo device . From all patients , two polysomnographic recordings were obtained at the hospital : one before treatment and one after approximately 6 months of treatment . Results : The change in the apnea-hypopnea index ( ΔAHI ) between baseline and therapy evaluation differed significantly between the three therapy groups ( ANCOVA ; p = 0.000 ) . No differences in the ΔAHI were found between the MAD and nCPAP therapy ( p = 0.092 ) , whereas the changes in AHI in these groups were significantly larger than those in the placebo group ( p = 0.000 and 0.002 , respectively ) . Conclusion : There is no clinical ly relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objective ly M and ibular repositioning splints ( MRSs ) and continuous positive airway pressure ( CPAP ) are used to treat the sleep apnea/hypopnea syndrome ( SAHS ) . There are some data suggesting that patients with milder symptoms prefer MRS , but there are few comparative data on outcomes . Therefore , we performed a r and omized crossover trial of 8 weeks of CPAP and 8 weeks of MRS treatment in consecutive new out patients diagnosed with SAHS ( apnea/hypopnea index [ AHI ] > or= 5/hour , and > or= 2 symptoms including sleepiness ) . Assessment s at the end of both limbs comprised home sleep study , subjective ratings of treatment value , sleepiness , symptoms , and well-being , and objective tests of sleepiness and cognition .  Forty-eight of 51 recruited patients completed the trial ( 12 women ; age [ mean + /- SD ] , 46 + /- 9 years ; Epworth 14 + /- 4 ; median AHI , 22/hour ; interquartile ratio [ IQR ] , 11 - 43/hour ) . Significant ( p < or= 0.01 ) differences between MRS and CPAP were observed for 7 of 21 variables ( effect sizes , 0.3 - 0.6 SDs ) , all favoring CPAP , including AHI ( 15 + /- 16 and 8 + /- 6/hour , respectively ) , effectiveness rating , symptoms , Epworth ( 12 + /- 5 and 8 + /- 5 , respectively ) , functional outcomes of sleepiness question naire , short-form 36 health survey mental component , and health transition scores . Objective sleepiness , cognitive performance , and preference for treatments were not different . In patients experiencing a mild form of the syndrome ( AHI < 15 , n = 18 ) , symptoms , treatment efficacy and satisfaction , and subjective sleepiness were also better with CPAP than with MRS ( effect sizes , 0.7 - 1.1 SDs ) . These results do not support these MRS devices as first-line treatment for sleepy patients with SAHS Background : Patients with mild to moderate obstructive sleep apnoea ( OSA ) may be managed with different treatment options . This study compared the effectiveness of three commonly used non-surgical treatment modalities . Methods : Subjects with mild to moderate OSA were r and omised to one of three treatment groups for 10 weeks : conservative measures ( sleep hygiene ) only , continuous positive airways pressure ( CPAP ) in addition to conservative measures or an oral appliance in addition to conservative measures .  All overweight subjects were referred to a weight-reduction class . OSA  was assessed by polysomnography .  Blood pressure was recorded in the morning and evening in the sleep laboratory . Daytime sleepiness was assessed with the Epworth Sleepiness Scale . Health-related quality of life ( HRQOL ) was assessed with the 36-Item Short-Form Health Survey ( SF-36 ) and Sleep Apnoea Quality of Life Index ( SAQLI ) . Results : 101 subjects with a mean ( SEM ) apnoea – hypopnoea index ( AHI ) of 21.4 ( 1.1 ) were r and omised to one of the three groups . The severity of sleep-disordered breathing was decreased in the CPAP and oral appliance groups compared with the conservative measures group , and the CPAP group was significantly better than the oral appliance group . Relief from sleepiness was significantly better in the CPAP group . CPAP was also better than the oral appliance or conservative measures in improving the “ bodily pain ” domain , and better than conservative measures in improving the “ physical function ” domain of SF-36 . Both CPAP and the oral appliance were more effective than conservative measures in improving the SAQLI , although no difference was detected between the CPAP and oral appliance groups . CPAP and the oral appliance significantly lowered the morning diastolic blood pressure compared with baseline values , but there was no difference in the changes in blood pressure between the groups . There was also a linear relationship between the changes in AHI and body weight . Conclusion : CPAP produced the best improvement in terms of physiological , symptomatic and HRQOL measures , while the oral appliance was slightly less effective . Weight loss , if achieved , result ed in an improvement in sleep parameters , but weight control alone was not uniformly effective In clinical practice , oral appliances are used primarily for obstructive sleep apnea patients who do not respond to continuous positive airway pressure ( CPAP ) therapy . We hypothesized that an oral appliance is not inferior to CPAP in treating obstructive sleep apnea effectively . We r and omly assigned 103 individuals to oral-appliance or CPAP therapy .  Polysomnography after 8–12 weeks indicated that treatment was effective for 39 of 51 persons using the oral appliance ( 76.5 % ) and for 43 of 52 persons using CPAP ( 82.7 % ) . For the difference in effectiveness , a 95 % two-sided confidence interval was calculated . Non-inferiority of oral-appliance therapy  was considered to be established when the lower boundary of this interval exceeded −25 % . The lower boundary of the confidence interval was −21.7 % , indicating that oral-appliance therapy was not inferior to CPAP for effective treatment of obstructive sleep apnea . However , subgroup analysis revealed that oral-appliance therapy was less effective in individuals with severe disease ( apnea-hypopnea index > 30 ) . Since these people could be at particular cardiovascular risk , primary oral-appliance therapy appears to be supported only for those with non-severe apnea Oral appliance therapy is emerging as an alternative to continuous positive airway pressure for the treatment of obstructive sleep apnea ( OSA ) . However , its precise mechanisms of action are yet to be defined . We examined the effect of a m and ibular advancement splint ( MAS ) on upper airway collapsibility during sleep in OSA . Ten patients with proven OSA had a custom-made MAS incrementally adjusted during an acclimatization period until the maximum comfortable limit of m and ibular advancement was reached .  Polysomnography  with the splint was then performed . After a 1-week washout period , upper airway closing pressures during sleep ( with and without MAS ) were determined . Significant improvements with MAS therapy were seen in the apnea/hypopnea index ( 25.0 + /- 3.1 vs. 13.2 + /- 4.5/hour , p < 0.03 ) and upper airway closing pressure in Stage 2 sleep ( -1.6 + /- 0.4 vs. -3.9 + /- 0.6 cm H2O , p < 0.01 ) and in slow wave sleep ( -2.5 + /- 0.7 vs. -4.7 + /- 0.6 cm H2O , p < 0.02 ) compared with no therapy . These preliminary data indicate that MAS therapy is associated with improved upper airway collapsibility during sleep . The mediators of this effect remain to be determined Impaired simulated driving performance has been demonstrated in obstructive sleep apnoea – hypopnoea syndrome ( OSAHS ) patients . Although continuous positive airway pressure ( CPAP ) generally improves simulated driving performance , the effects of oral-appliance ( OA ) therapy are unknown . The aims of this study were to determine to what extent OSAHS patients have more difficulty with a monotonous simulated driving test when compared with control subjects and to compare the effects of OA with CPAP therapy .  Simulated driving performance was evaluated in 20 OSAHS patients and 16 control subjects during a 25-min driving test . After r and omization , ten patients started OA and CPAP therapy , respectively . After 2 to 3 months of treatment , patients repeated the driving test . At baseline , the total number of lapses of attention during driving was significantly higher in OSAHS patients as compared with control subjects . As a result of treatment , the total number of lapses of attention was significantly decreased in both the OA and CPAP group . When comparing driving performance between the OA and CPAP group , no significant differences were noted . OSAHS patients  perform worse on a simulated driving test when compared with control subjects . When evaluating the effects of treatment , adequate OSAHS management with either OA or CPAP therapy usually result ed in substantial improvements of simulated driving . Conclusions beyond both treatments improving simulated driving performance are , however , not justified by the data in the present study Patients with the sleep apnea/hypopnea syndrome ( SAHS ) treated by nasal continuous positive airway pressure ( CPAP )  need to use CPAP long-term to prevent recurrence of symptoms . It is thus important to clarify the level of long-term CPAP use and the factors influencing long-term use . We examined determinants of objective CPAP use in 1 , 211 consecutive patients with SAHS who were prescribed a CPAP trial between 1986 and 1997 . Prospect i ve CPAP use data were available in 1 , 155 ( 95.4 % ) , with a median follow-up of 22 mo ( interquartile range [ IQR ] , 12 to 36 mo ) . Fifty-two ( 4.5 % ) patients refused CPAP treatment ( these were more often female and current smokers ) ; 1,103 patients took CPAP home , and during follow-up 20 % stopped treatment , primarily because of a lack of benefit . Methods of survival analysis showed that 68 % of patients continued treatment at 5 yr . Independent predictors of long-term CPAP use were snoring history , apnea/hypopnea index ( AHI ) , and Epworth score ; 86 % of patients with Epworth > 10 and an AHI > /= 30 were still using CPAP at 3 yr . Average nightly CPAP use within the first 3 mo was strongly predictive of long-term use . We conclude that long-term CPAP use is related to disease severity and subjective sleepiness and can be predicted within 3 mo BACKGROUND Although oral appliances are effective in some patients with obstructive sleep apnoea ( OSA ) , they are not universally effective . A novel anterior m and ibular positioner ( AMP ) has been developed with an adjustable hinge that allows progressive advancement of the m and ible . The objective of this prospect i ve crossover study was to compare efficacy , side effects , patient compliance , and preference between AMP and nasal continuous positive airway pressure ( nCPAP ) in patients with symptomatic mild to moderate OSA . METHODS Twenty four patients of mean ( SD ) age 44.0 ( 10.6 ) years were recruited with a mean ( SD ) body mass index of 32.0 ( 8.2 ) kg/m2 , Epworth sleepiness score 10.7 ( 3.4 ) , and apnoea/hypopnoea index 26.8 (11.9)/hour . There was a two week wash-in and a two week wash-out period and two treatment periods ( AMP and nCPAP ) each of four months . Efficacy , side effects , compliance , and preference were evaluated by a question naire and home sleep monitoring . RESULTS One patient dropped out early in the study and three refused to cross over so treatment results are presented on the remaining 20 patients . The apnoea/hypopnoea index ( AHI ) was lower with nasal CPAP 4.2 (2.2)/hour than with the AMP 13.6 (14.5)/hour ( p < 0.01 ) . Eleven of the 20 patients ( 55 % ) who used the AMP were treatment successes ( reduction of AHI to < 10/hour and relief of symptoms ) , one ( 5 % ) was a compliance failure ( unable or unwilling to use the treatment ) , and eight ( 40 % ) were treatment failures ( failure to reduce AHI to < 10/hour and /or failure to relieve symptoms ) . Fourteen of the 20 patients ( 70 % ) who used nCPAP were treatment successes , six ( 30 % ) were compliance failures , and there were no treatment failures . There was greater patient satisfaction with the AMP ( p < 0.01 ) than with nCPAP but no difference in reported side effects or compliance . CONCLUSIONS AMP is an effective treatment in some patients with mild to moderate OSA and is associated with greater patient satisfaction than nCPAP Background : Long-term trials are needed to capture information regarding the persistence of efficacy and loss to follow-up of both m and ibular advancement device ( MAD ) therapy and continuous positive airway pressure ( CPAP ) therapy . Objectives : The aim of the study was to compare these treatment aspects between MAD and nasal CPAP ( nCPAP ) in a 1-year follow-up . Methods : Forty-three mild/moderate obstructive sleep apnea patients ( 52.2 ± 9.6 years ) with a mean apnea-hypopnea index ( AHI ) of 20.8 ± 9.9 events/h were r and omly assigned to two parallel groups : MAD ( n = 21 ) and nCPAP ( n = 22 ) . Four polysomnographic recordings were obtained : one before treatment , one for the short-term evaluation , and two recordings 6 and 12 months after the short-term evaluation . Excessive daytime sleepiness ( EDS ) was also evaluated at the polysomnographic recordings . Results : The initially achieved improvements in the AHI remained stable over time within both groups ( p = 0.650 ) . In the nCPAP group , the AHI improved 4.1 events/h more than in the MAD group ( p = 0.000 ) . The EDS values showed a gradual improvement over time ( p = 0.000 ) , and these improvements were similar for both groups ( p = 0.367 ) . In the nCPAP group , more patients withdrew from treatment due to side effects than in the MAD group . Conclusions : The absence of significant long-term differences in EDS improvements between the MAD and the nCPAP groups with mild/moderate obstructive sleep apnea may indicate that the larger improvements in AHI values in the nCPAP group are not clinical ly relevant . Moreover , nCPAP patients may show more problems in accepting their treatment modality than MAD patients This prospect i ve , r and omized , cross-over trial was design ed to compare the efficacy of a m and ibular advancement splint ( MAS ) with that of nasal continuous positive airway pressure ( nCPAP ) in patients with obstructive sleep apnoea ( OSA ) . Twenty-four patients ( 20 males and four females ) with mild to moderate OSA ( AHI between 10 and 49 events per hour ) were enrolled in the study . Each patient used both MAS and nCPAP , with the initial therapy being allocated at r and om . Treatment periods lasted for two months with a two-week wash-out interval between .  Polysomnography  was performed prior to the study and after each clinical intervention . Patient and partner question naires were used to assess changes in general health and daytime somnolence . The AHI decreased from 22.2 to 3.1 using nCPAP , and to 8.0 using the MAS ( P < 0.001 for both devices ) and there was no statistically significant difference between the two treatments . The Epworth Sleepiness Score ( ESS ) fell from 13.4 to 8.1 with nCPAP , and to 9.2 with MAS ( P < 0.001 ) , again with no differences between the use of MAS or nCPAP . The question naire data showed an improvement in general health scores ( P < 0.001 ) after both treatments , but daytime sleepiness only improved significantly using nCPAP ( P < 0.001 ) . Despite this , 17 out of the 21 subjects who completed both arms of the study preferred the MAS . The splints were well tolerated and their efficacy suggests that the MAS may be a suitable alternative to nCPAP in the management of patients with mild or moderate OSA BACKGROUND In patients without cardiac disease , obstructive sleep apnea-hypopnea syndrome ( OSAHS ) is associated with systolic and diastolic dysfunction and left ventricular hypertrophy . Although continuous positive airway pressure ( CPAP ) therapy has been demonstrated to improve left ventricular structure and function in these patients , the effects of oral-appliance therapy on cardiac function are largely unknown . The aims of this study were to determine the left ventricular structure and function and natriuretic peptides in untreated OSAHS patients without cardiovascular disease , and to compare the effects of oral-appliance with CPAP therapy . METHODS In 28 moderate to severe OSAHS patients echocardiography and measurements of concentrations of the amino-terminal fragment of pro-brain natriuretic peptide ( NT-pro-BNP ) were performed . Fifteen patients were r and omized to oral-appliance  and 13 to CPAP therapy .  After 2 to 3 months of treatment echocardiography and NT-pro-BNP measurements were repeated . RESULTS Of the 28 patients , 7 had left ventricular hypertrophy , 6 had left ventricular dilatation , and 3 had elevated NT-pro-BNP values . No significant improvements in echocardiographic outcomes were observed following treatment . The median NT-pro-BNP values improved significantly following oral-appliance therapy ( 52 pg/ml to 22 pg/ml ) whereas not following CPAP therapy ( 31 pg/ml to 37 pg/ml ) . CONCLUSIONS This study demonstrates that 50 % of patients with moderate to severe OSASH , without cardiovascular disease , have left ventricular hypertrophy , left ventricular dilatation or elevated natriuretic peptides . Significant changes in NT-pro-BNP values indicate an improvement of cardiac function following effective oral-appliance therapy OBJECTIVES Endothelial dysfunction has been proposed as a potential mechanism implicated in the pathogenesis of cardiovascular complications of obstructive sleep apnea syndrome ( OSAS ) . This study aim ed to evaluate the microvascular endothelial function ( MVEV ) in OSAS and the impact on MVEF of 2 months of treatment with continuous positive airway pressure ( CPAP ) and m and ibular advancement device ( MAD ) . METHODS Microvascular reactivity was assessed using laser Doppler flowmetry combined with acetylcholine ( Ach ) and sodium nitroprusside ( SNP ) iontophoresis in 24 OSAS patients and 9 control patients . In 12 of the 24 OSAS patients , microvascular reactivity was reassessed after 2 months of CPAP and MAD using a r and omized cross-over design . RESULTS Ach-induced vasodilation was significantly lower in OSAS patients than in matched controls and correlated negatively with apnea hypopnea index ( r=-0.49 , p<0.025 ) and nocturnal oxygen desaturations ( r=-0.63 , p<0.002 ) . Ach-induced vasodilation increased significantly with both CPAP and MAD . The increase in Ach-induced vasodilation under OSAS treatment correlated with the decrease in nocturnal oxygen desaturations ( r=0.48 , p=0.016 ) . CONCLUSION Our study shows an impairment of MVEF in OSAS related to OSAS severity . Both CPAP and MAD treatments were associated with an improvement in MVEF that could contribute to improve cardiovascular outcome in OSAS patients STUDY OBJECTIVE To compare efficacy , side effects , patient compliance , and preference between oral appliance ( OA ) therapy and nasal-continuous positive airway pressure ( N-CPAP ) therapy . DESIGN R and omized , prospect i ve , crossover study . SETTING University hospital and tertiary sleep referral center . PATIENTS Twenty-seven unselected patients with mild-moderate obstructive sleep apnea ( OSA ) . INTERVENTIONS There was a 2-week wash-in and a 2-week wash-out period , and 2 x 4-month treatment periods ( OA and N-CPAP ) . Efficacy , side effects , compliance , and preference were evaluated by a question naire and home sleep monitoring . MEASUREMENTS AND RESULTS Two patients dropped out early in the study and treatment results are presented on the remaining 25 patients . The apnea/hypopnea index was lower with N-CPAP ( 3.5 + /- 1.6 ) ( mean + /- SD ) than with the OA ( 9.7 + /- 7.3 ) ( p < 0.05 ) . Twelve of the 25 patients who used the OA ( 48 % ) were treatment successes ( reduction of apnea/hypopnea to < 10/h and relief of symptoms ) , 6 ( 24 % ) were compliance failures ( unable or unwilling to use the treatment ) , and 7 ( 28 % ) were treatment failures ( failure to reduce apnea/hypopnea index to < 10/h and /or failure to relieve symptoms ) . Four people refused to use N-CPAP after using the OA . Thirteen of the 21 patients who used N-CPAP were overall treatment successes ( 62 % ) , 8 were compliance failures ( 38 % ) , and there were no treatment failures . Side effects were more common and the patients were less satisfied with N-CPAP ( p < 0.005 ) . Seven patients were treatment successes with both treatments , six of these patients preferred OA , and one preferred N-CPAP as a long-term treatment . CONCLUSIONS We conclude that OA is an effective treatment in some patients with mild-moderate OSA and is associated with fewer side effects and greater patient satisfaction than N-CPAP INTRODUCTION The obstructive sleep apnea-hypopnea syndrome ( OSAHS ) is associated with sexual dysfunction . Although successful treatment with continuous positive airway pressure ( CPAP ) has been demonstrated to improve sexual function , the effects of oral-appliance therapy are unknown . AIM The aims of this study were to determine to what extent untreated male OSAHS patients experience sexual dysfunctions compared with control subjects , and second , to evaluate the effects of oral-appliance and CPAP therapy on sexual functioning . METHODS Sexual functioning was determined in 48 OSAHS patients with the Golombok Rust inventory of sexual satisfaction ( GRISS ) and a testosterone measurement . GRISS outcomes were compared with 48 age-matched male controls without any sexual problems . Patients were r and omized for either oral-appliance or CPAP therapy . After 2 - 3 months of treatment , the GRISS and testosterone measurements were repeated . MAIN OUTCOME MEASURE The outcomes on the GRISS were used as the main outcome measure . RESULTS Compared with controls , OSAHS patients had significantly more erectile dysfunction ( mean + /- st and ard deviation ; OSAHS 8.7 + /- 3.8 vs. controls 6.8 + /- 2.6 ) and sexual dissatisfaction ( mean + /- st and ard deviation ; OSAHS 9.7 + /- 4.2 vs. controls 8.1 + /- 2.6 ) as indicated by the GRISS . No significant changes in the GRISS or testosterone levels were observed in the 20 and 27 patients completing the follow-up review for oral-appliance and CPAP therapy . A correlation was demonstrated between the extent of erectile dysfunction at baseline and improvements in erectile function following treatment ( r = -0.547 , P = 0.000 ) . CONCLUSIONS This study confirms that male OSAHS patients show more  sexual dysfunctions  compared with age-matched control subjects . Although significant improvements in sexual functioning in neither the oral-appliance nor CPAP-treated group could be established , our findings suggest that untreated OSAHS patients with pronounced erectile dysfunction experience some improvement following treatment BACKGROUND For the treatment of nonsevere obstructive sleep apnea syndrome ( OSAS ) , m and ibular advancement devices ( MADs ) are employed as an alternative to nasal continuous positive airway pressure ( CPAP ) therapy . However , very few specific data on the effectiveness of MADs in this group of patients are available . We therefore compared an individually adjustable intraoral sleep apnea device ( ISAD ) that permits movements of the lower jaw in three dimensions , with CPAP in the treatment of patients with an apnea/hypopnea index ( AHI ) < or = 30/h . METHODS In a r and omized crossover study , 16 men and 4 women ( mean + /- SD age , 56.5 + /- 10.2 years ; body mass index , 31.2 + /- 6.4 ; AHI , 17.5 + /- 7.7/h ) were treated for 6 weeks with each modality . RESULTS In the initial phase , a significant improvement in AHI ( baseline , 17.5 + /- 7.7/h ; ISAD , 10.5 + /- 7.5/h [ p < 0.05 ] ; CPAP , 3.5 + /- 2.9/h [ p < 0.01 ] ) and in breathing-related arousals ( baseline , 8.9 + /- 6.1/h ; ISAD , 3.7 + /- 3.3/h [ p < 0.01 ] ; CPAP , 1.4 + /- 1.6/h [ p < 0.01 ] ) was achieved with both modalities . Considering all 20 subjects , after 6 weeks of treatment , normalization of the respiratory parameters was seen only with CPAP . However , 30 % of the patients had a lasting reduction in AHI to < 10/h with the ISAD also . The patients considered the ISAD to be easier to use ( scale of 1 to 6 : ISAD , 1.8 + /- 1.1 ; CPAP , 3.1 + /- 1.5 [ p < 0.05 ] ) , and indicated greater utilization of the device in comparison with CPAP . CONCLUSION Even in patients with mild-to-moderate OSAS , CPAP is the more effective long-term treatment modality . In the individual case , the better compliance seen with the ISAD may be advantageous The efficacy of currently recommended treatments is uncertain in patients with mild to moderate obstructive sleep apnea ( apnea-hypopnea index [ AHI ] , 5 - 30 ) . A group of 114 sleep clinic patients with an AHI of 5 - 30 have participated in a r and omized controlled crossover trial of 3 months of treatment with each of nasal continuous positive airway pressure ( CPAP ) , a m and ibular advancement splint , and a placebo tablet . Outcomes were sleep fragmentation and hypoxemia , daytime sleepiness , quality of life , neurobehavioral function , and blood pressure . Both active treatments improved sleep outcomes , but positive airway pressure had a greater effect . The quality of life , symptoms , and subjective but not objective sleepiness improved to a similar degree with both treatments ; however , many of the improvements seen in neuropsychologic function and mood were not better than the placebo effect . Some aspects of nocturnal blood pressure were improved with the splint but not with CPAP . This study has shown that although both CPAP and m and ibular advancement splint effectively treated sleep-disordered breathing and sleepiness , the expected response in neurobehavioral function was incomplete . This may be due to the splint having a lesser therapeutic effect and CPAP being poorly tolerated and therefore used less in this patient group OBJECTIVES The aim of this r and omized controlled study was to cephalometrically assess possible changes in craniofacial morphology associated with long-term use of an adjustable oral-appliance compared with continuous positive airway pressure ( CPAP ) in patients with the obstructive sleep apnea/hypopnea syndrome ( OSAHS ) . In addition , we wanted to study the relationship between these possible changes and the degree of m and ibular protrusion associated with oral-appliance therapy . METHODS Fifty-one patients were r and omized to oral-appliance therapy and 52 patients to CPAP therapy .  At baseline and after follow-up ( 2.3±0.2 years ) , a lateral cephalogram of all patients was made in maximum intercuspation to determine relevant cephalometric variables . Both baseline and follow-up cephalograms were traced digitally whereupon cephalometric variables were compared . Changes in craniofacial morphology between the oral-appliance- and CPAP group were evaluated with a linear regression analysis . RESULTS Compared with CPAP , long-term use of an oral-appliance result ed in small but significant ( dental ) changes . Overbite and overjet decreased , 1.0 (±1.5)mm and 1.7 (±1.6)mm , respectively . Furthermore we found a retroclination ( -2.0 ( ±2.8 ) ° ) of the upper incisors and a proclination ( 3.7 ( ±5.4 ) ° ) of the lower incisors . Moreover , the lower- and total anterior facial height increased significantly , 0.8 (±1.5)mm and 0.9 (±1.4)mm , respectively . No changes in skeletal variables were found . Linear regression analysis revealed that the decrease in overbite was associated with the mean m and ibular protrusion during follow-up ( B=-0.029 , SE=0.014 , p<0.05 ) . CONCLUSIONS Oral-appliance therapy should be considered as a life long treatment , and there is a risk of craniofacial changes to occur . Therefore , patients treated with an oral-appliance , need a thorough follow-up by a dentist or dental-specialist experienced in the field of dental sleep medicine
BACKGROUND : A systematic review and meta- analysis was performed to compare the outcomes of oral appliances ( OAs ) with those of CPAP in treatment of patients with obstructive sleep apnea ( OSA ) .