Chest -- eLetters for Randerath et al., 122 (2) 569-575

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SLEEP AND BREATHING:
Winfried J. Randerath, Markus Heise, Rolf Hinz, and Karl-Heinz Ruehle
An Individually Adjustable Oral Appliance vs Continuous Positive Airway Pressure in Mild-to-Moderate Obstructive Sleep Apnea Syndrome^*
Chest 2002; 122: 569-575 [Abstract] [Full text] [PDF]

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Electronic letters published:

Advantages of Oral Appliances over the CPAP therapy: Murat Enoz (31 March 2005)

Advantages of Oral Appliances over the CPAP therapy 31 March 2005

Murat Enoz,
Department of Otolaryngology, Head&Neck Surgery
Istanbul University, School of Medicine Turkey
Send letter to journal:
Re: Advantages of Oral Appliances over the CPAP therapy

muratenoz{at}yahoo.com Murat Enoz

Dear Editor,
Snoring and obstructive sleep apnea form part of a spectrum of sleep disordered breathing affecting a significant proportion of the general population and particularly the middle aged. The combination of anatomical and neuromuscular risk factors in the pathogenesis of OSA has resulted in a varied approach to its management.
Oral appliance treatment includes, in order of decreasing usage, adjustable and nonadjustable mandibular posturing devices, anterior tongue repositioners, and soft palate or uvulalifting devices.
Gotsopoulos et al. forty-one percent of 73 patients treated with an inactive oral appliance and they expressed satisfactory control of OSA symptoms and 49% indicated a desire to continue with such treatment (1).
Johnston et al. showed a significant reduction in AHI with their mandibular repositioning appliances (MRA) compared to the control appliance, but there was no significant difference in symptomatic scores (2).
With the exception of one study where considerations of appliance design may be of relevance (3), MRA therapy has been shown to be preferred by patients in comparison to CPAP (4-7).
The main mechanism of the appliance is to mechanically increase the upper airway and reduce pharyngeal collapsibility. Consequently, causes for an attenuation of the treatment effect of MRA over time will be related to factors that alter the mechanical properties of the pharyngeal airway. Based on limited long-term data, the main reasons appear to be deterioration in the condition of the MRA so that it no longer maintains advancement to the prescribed position (8), or an increase in body weight with reduced upper airway dimensions(8, 9).
An appliance that advances the tongue, or tongue and mandible together with adjacent soft tissue, increases the posterior airway space, increases the activity of the genioglossal and lateral pterygoid muscles (10), and effects a stretch induction of the pharyngeal motor system (11).
Mandibular advancement devices also alter position of the hyoid and modify the hypopharyngeal airway space. Soft palate or uvula lifters reduce soft tissue vibrations that result in snoring. With respect to the many variations of appliance designs, it is not possible to predict what device will be most effective for a particular patient.
Sincerely
Dr. Murat Enoz
References
1- Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial. Am J Respir Crit Care Med 2002; 166: 743—748.
2- Johnston CD, Gleadhill IC, Cinnamond MJ, Gabbey J, Burden DJ. Mandibular advancement appliances and obstructive sleep apnoea: a randomized clinical trial. Eur J Orthod 2002; 24: 251—262.
3- Engleman HM, McDonald JP, Graham D, Lello GE, Kingshott RN, Coleman EL, Mackay TW, Douglas NJ. Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med 2002; 166: 855—859.
4- Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal continuous positive airway pressure in the treatment of mild—moderate obstructive sleep apnea. Chest 1996; 109: 1269—1275.
5- Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA. A short term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax 1997; 52: 362—368.
6- Randerath WJ, Heise M, Hinz R, Ruehle KH. An individually adjustable oral appliance vs continuous positive airway pressure in mild to moderate obstructive sleep apnea syndrome. Chest 2002; 122: 569—575.
7- Tan YK, L’Estrange PR, Luo YM, Smith C, Grant HR, Simonds AK, Spiro SG, Battagel JM. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Eur J Orthod 2002; 24: 239—249.
8- Marklund M, Sahlin C, Stenlund H, Persson M, Franklin KA. Mandibular advancement device in patients with obstructive sleep apnea: long-term effects on apnea and sleep. Chest 2001; 120: 162—169.
9- Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring- tolerability and predictors of treatment success. Chest 2004; 125: 1270—1278.
10- Yoshida K. Effect of a prosthetic appliance for treatment of sleep apnea syndrome on masticatory and tongue muscle activity. J Prosthet Dent 1998;79:537-544.
11- Clark GT, Sohn J-W, Hong CN. Treating obstructive sleep apnea and snoring: Assessment of an anterior mandibular positioning device. J Am Dent Assoc 2000;131: 765-771.