This is a reprint of a recent PRlog press release. CPAP can no longer be considered the “Gold Standard” of treatment for mild to moderate sleep apnea. There is a rapidly changing dynamic in the field of sleep medicine. It should be noted that CPAP and Oral Appliances are equal with “careful titration”. It remains to be seen if home sleep studies can meet the “careful titration” standard.

Oral Appliances Are Equally Effective to CPAP according to a New Study in Respiration

Nasal CPAP has always been considered the “Gold Standard” of trreatment for sleep apnea. A new study in Respiration changes that forever. The study shows that oral appliances are equally effective to CPAP for mild to moderate sleep apnea.

Sleep Apnea treatment will dramatically change in the future. Nasal CPAP has always been the “Gold Standard” of treatment even though the majority of patients could not tolerate treatment and as many as 60% discontinue treatment. The field of Dental Sleep Medicine has been brought front and center by the website http://www.ihatecpap.com. Thousands of patients have learned about oral appliance therapy and are currently receiving treatment as a direct result of I HATE CPAP.com.

This may have immediate adverse effects on the stock prices of CPAP companies that are already feeling pressure from new medicare rules that demand significant patient compliance to qualify nasal CPAP for reimbursement. It will lead to better treatment of patients who almost always prefer oral appliances to CPAP when offered a choice. Unfortunately most patients have not historically been offered oral appliance treatment. An excellent case to that point is that sleep apnea has been listed as the cause of death for a prominent Pennsylvania State Representative. Robert C. Donatucci died in his sleep on Tuesday, just one week after he won the election for his 16th House term. He refused CPAP treatment according to his brother.

Another recent article showed that CPAP cuases orthopedic and orthodontic changes in patients after two years of use. The following is reprinted from Wikipedia “The CPAP mask can act as an orthodontic headgear and move the teeth and the upper and/or lower jaw backward. This effect can increase over time and may or may not cause TMD disorders in some patients. These facial changes have been dubbed “Smashed Face Syndrome”. Chest. 2010 Oct;138(4):870-4. Epub 2010 Jul 8. Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea. Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA.”

The power of CPAP companies in the field of sleep medicine is evidenced by the fact that I HATE CPAP LLC was banned from presenting or having a booth at the American Academy of Dental Sleep Medicine meetings. The website www.ihatecpap.com is recognized as a leading source of information on Dental Sleep Medicine and Oral Appliance Therapy.

A recent article ” Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial” in Respiration compared oral appliance therapy and nasal CPAP therapy in treating mild to moderate sleep apnea. The article looked at carefully controlled studies in which both the CPAP and the oral appliances were carefully titrated. The article concluded that “There is no clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.”

It is important to note that the article clearly states that treatment is equal when there is objective titration of the oral appliances. I have strongly been recommending titration on all oral appliance therapy for over ten years. This is trtuly a landmark study because while CPAP has always been considered “the gold standard for treatment of sleep apnea” that statement is no longer true for mild to moderate sleep apnea.

This study did not cover severe sleep apnea therefore CPAP is still considered the gold standard of treatment for severe sleep apnea and oral appliances are an alternative for patients who do not tolerate CPAP.

The major problem with CPAP has always been low compliance. A recent study showed 60% of patients do not tolerate CPAP treatment. If compliance is factored in then it is clear that oral appliances are now the “Gold Standard” of treatment for mild to moderate sleep apnea.

PubMed abstract:
Respiration. 2010 Oct 20. [Epub ahead of print]ral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial.
Aarab G, Lobbezoo F, Hamburger HL, Naeije M.

Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, Research Institute MOVE, University of Amsterdam and VU University Amsterdam, The Netherlands.
Abstract
Background: Previous randomized controlled trials have addressed the efficacy of mandibular 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 objectively but not MAD. To enable an unbiased comparison between both treatment modalities, the MAD should be titrated objectively 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 randomly 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 clinically relevant difference between MAD and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively.

Copyright © 2010 S. Karger AG, Basel.
PMID: 20962502 [PubMed – as supplied by publisher]