Comparison with Other Treatments

There are seven published randomized controlled trials comparing oral appliances to CPAP, and these have been the subject of published systematic reviews (33,34). It is important to note that there is significant variability amongst these studies in terms of the type of oral appliance used, the measurement techniques used for assessing treatment response (e.g., home monitoring versus in-laboratory monitoring), inclusion criteria (including severity of OSA), definitions of severity and treatment response, treatment interval, and drop-out rates, making it difficult to draw firm clinical recommendations. What is clear, is that CPAP is superior at reducing the AHI and improving oxygen saturation, but not arousal index, sleep architecture, or objective sleepiness (33,34). However, patient preference in most of the studies was in favor of oral appliance treatment. In terms of symptomatic outcomes, particularly daytime sleepiness (subjective and objective) but also neuropsychological measures, no substantial differences have been identified between CPAP and oral appliance treatments (33,34). When one considers the recent studies showing a similar reduction in blood pressure with oral appliance as that seen with CPAP, it raises the important possibility that the health effects of both treatments are of similar magnitude, as a result of the superior efficacy of CPAP being offset by its inferior adherence relative to oral appliances. This is an area that merits considerable attention, as it has major implications for clinical practice.

To date, there has only been one randomized study comparing oral appliance therapy to a surgical procedure (UPPP) in patients with mild-to-moderate OSA, over a four-year period (31). They found that both short- (one-year) and long-term (four-year) outcomes were better with oral appliance treatment (31).

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