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Sleep Studies Needed to Confirm Subjective Improvement in OSA Symptoms After MAD Use


Patients who used a mandibular advancement device (MAD) to address their obstructive sleep apnea (OSA) symptoms reported improvement in their sleep quality and tiredness on waking even if their sleep criteria did not indicate a response to treatment, indicating the importance of a posttreatment sleep study to ensure MAD efficacy.

Mandibular advancement device (MAD) efficacy that was ensured through a sleep study was necessary to confirm subjective improvements in some obstructive sleep apnea (OSA) symptoms, such as sleep quality and tiredness, according to a study published in Sleep and Breathing.

Mild to moderate OSA can be managed through use of MAD, which moves the position of the jaw during sleep and is an alternative option to positive airway pressure therapy. Variability in response MAD treatment is possible, which makes it difficult to predict how each patient will respond. This study aimed to evaluate the change in OSA symptoms from baseline to follow-up at the end of MAD treatment in patients who responded to the treatment compared with those who did not. The study also aimed to find the difference in self-reported OSA symptoms at baseline, first follow-up after MAD delivery, and the end of MAD treatment.

Patients who managed their OSA with MAD after a confirmed diagnosis who were referred to the Orofacial Pain Clinic in Kentucky from 2016 to 2021 were evaluated for this study. Patients were included if they had a posttreatment sleep study with MAD in place which was ordered by a sleep physician and had complete data that were derived from questionnaires evaluating OSA in the follow-up period.

Participants were labeled “responders” if they had a 50% or greater reduction of apnea hypopnea index (AHI) in the posttreatment sleep study with MAD (criterion 1), had 10 or fewer AHI events per hour with 50% or greater reduction compared with the baseline (criterion 2), or had 5 or fewer AHI events per hour with 50% reduction or greater of AHI (criterion 3).

There were 53 participants in this study, with a mean (SD) age of 64.2 (10.7) years and 30 of whom were women. The mean (SD) AHI dereased from 23.3 (17.2) to 10.9 (8.6) after treatment. The number of responders varied from 26% (AHI, 3.1 [1.2]) to 57% (AHI, 7.5 [6.5]) depending on the criteria used. In both responders and nonresponders, MAD improved all self-reported OSA symptoms.

AHI differed in the 2 groups at baseline (27.6 [20.4] in responders vs 17.5 [9.7] in nonresponders), and nonresponders reported higher daytime sleepiness based on the Epworth Sleepiness Scale compared with responders (11.5 [5.9] vs 8.3 [5.7]).

Responders scored higher in tiredness when waking at the first follow-up after delivery of MAD (40.0 [20.0] vs 28.4 [19.4]) and worse in sleep quality (40.5 [22.7] vs 28.2 [19.3]) compared with nonresponders. Responders had a smaller subjective improvement compared with the nonresponders (45.1 [28.4] vs 69.4 [26.0]).

Models at baseline were able to accurately predict from 72% (criterion 1 and 2) to 78% (criterion 3) of treatment outcomes. Models at the first follow-up after delivery of MAD were able to predict from 66% (criterion 1 and 2) to 100% (criterion 3) and models at the end of MAD titration were able to predict 69% (criterion 1), 65% (criterion 2), and 76% (criterion 3). Treatment response at the first follow-up could be predicted by symptoms of OSA at the first follow-up.

Predictive values were found in all symptoms of OSA except for loudness and snoring according to criterion 3, meaning that patients who had episodes of gasping for air or higher daytime fatigue were less likely to respond to treatment; patients were less likely to be a responder with more subjective improvements reported.

There were some limitations to this study. No sample size calculation was performed. Nonvalidated questionnaires were used to collect information on symptoms of OSA. Medical history of the participants was not included in the study, which may have influenced the self-reported outcomes as other systemic disorders known for sleepiness would be left unreported.

The researchers concluded that sleep quality, subjective improvement, and tiredness were different between responders and nonresponders at the follow-up after delivery of MAD. Smaller degrees of subjective improvement were found to be a good predictor of treatment response.


Sangalli L, Yanez-Regonesi F, Fernandez-Vial D, Moreno-Hay I. Self-reported improvement in obstructive sleep apnea symptoms compared to treatment response with mandibular advancement device therapy: a retrospective study. Sleep Breath. Published online November 30, 2022. doi:10.1007/s11325-022-02754-4

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