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Treatment Options In Obstructive Sleep Apnea

April 26th, 2022   |   Posted in: Dr. Halstrom News, Education Centre, silencer-news, Uncategorized

Treatment Options In Obstructive Sleep Apnea

Gambino, F., Zammuto, M.M., Virzì, A. et al. Treatment options in obstructive sleep apnea. Intern Emerg Med (2022). https://doi.org/10.1007/s11739-022-02983-1

Preamble by Don Halstrom:

CPAP Alternative - The Silencer

The Silencer – Since the early 1990’s helping patients who struggle with CPAP.

This recent published research article does a nice job of presenting the options and issues surrounding different treatment methods for Obstructive Sleep Apnea.  Since the early 1990’s when Dr. Halstrom and I embarked upon this long journey with The Silencer the primary focus by the medical community on CPAP therapy has not really changed much – however we do now have a much better understanding of the alternative treatments and why they represent such a valuable option for patients and clinicians.  While CPAP works well and is tolerated by many patients – we see many others who have greatly struggled or who simply are looking for an alternative. I encourage you to read the full article – here are a few excerpts specific to the Mandibular Advancement Device.

Mandibular advancement device (MAD)

The principle of MAD is that advancement of the mandible enlarges and stabilizes the upper airway, decreasing snoring and the occurrence of obstructive respiratory events. Custom-made, dual-block MAD represents an established, effective and attractive option in primary snoring, and in patients with OSA not accepting CPAP treatment. Custom, titratable devices should be preferred to non-custom ones, and patients should undergo regular follow-up by both the sleep physician and the dentist.

According to several meta-analyses, CPAP is more effective compared to MAD in decreasing AHI and ODI or daytime sleepiness [38]. However, because compliance to treatment is higher for MAD than for CPAP, MAD is considered a good alternative to CPAP treatment.

Some studies have tested the efficacy of MAD in severe OSA, which is not traditionally considered as a good indication of MAD. An observational study on patients with severe OSA refusing CPAP treatment reported positive results with MAD [44], similarly a multicenter Korean study reported a decrease in AHI by 64 ± 26% after one month of treatment, but the positive effects were especially seen in patients with low BMI [45]. Finally, an individual patient meta-analysis compared the outcomes of CPAP and MAD in patients with severe OSA from 4 randomized controlled trials and found that titratable MAD was less effective than CPAP on AHI, but results were similar for improvement in quality of life, sleepiness, and sleep macrostructure.

Side effects of MAD are usually minor and self-limiting at the start of treatment but can involve bite changes in long-term treatment. Additionally, OSA may worsen over time despite MAD use, suggesting that it may be beneficial to perform periodic control visits, especially after long-term use.


In patients with mild OSA and in patients with predominant functional as opposed to anatomical impairment, alternative OSA treatment should be considered, especially because acceptance of CPAP in these patients is usually low. In patients with moderate-severe OSA refusing CPAP treatment, alternative treatments ought to be taken into consideration according to the clinical and physiological phenotypes and patient preferences. Ongoing work will further clarify how to personalize OSA treatment, but currently, the evidence for non-PAP therapies is insufficient to draw conclusions. On the other hand, the number of patients requesting non-CPAP treatment is high, and patient preferences can affect the choice. Results of treatment should be objectively documented, and follow-up should be regular for all types of treatment, CPAP or non-CPAP, to adjust treatment if needed.