Respiratory Treatment and Prevention (Advances in Experimental Medicine and Biology)

On the other side, studies assessing the suste-
nance of improvement indicate a significant
decrease in AHI compared with baseline over a
two-year treatment time, using both methods
(Doff et al. 2013 ). These results encourage to
consider the use of oral appliance as a viable
alternative to CPAP therapy in patients with
mild-to-moderate OSA. However, CPAP remains
undubiously the treatment of first choice.
Following the treatment with both CPAP and
MAA, arterial blood oxygen saturation signifi-
cantly increases; the increase is greater after
CPAP, but MAA also significantly increases
arterial blood oxygen saturation compared with
placebo (Doff et al. 2013 ; Barnes et al 2004 ). Tan
et al. ( 2002 ) have reported decreases in the mean
arterial blood desaturation from the basal OSA
level of 7.1
2.7 % to 3.3
1.6 % after CPAP
and 4.8
2.7 % after MAA; the former
decrease being significant while the latter being
insignificant.
The subjective evaluation of CPAP and MAA
is distinctly different from the objective index-
based evaluation. The ESS score decreases
significantly in relation to baseline, with no
significant differences between the CPAP and
MAA effects (Table2). The study of Mehta
et al. ( 2001 ) performed in a group of 24 OSA
patients has shown a good tolerance of MAA in
90 % of patients and the AHI decreased below
5 apneic episodes per hour in 37.5 % of patients.
When the cut-off level for therapeutic efficacy of
AHI is taken as fewer than 10 apneic episodes
per hour, then the percentage of patients with
adequate therapeutic response increased to
54 % compared with untreated OSA control
subjects. Almost 70 % of patients reported a
reduced snoring and in 91 % of patients the
sleep quality improved. Similar findings,
indicating a significant subjective improvement
after MAA application, compared with controls
using inactive oral appliances, have been
presented by Gotsopoulos et al. ( 2002 ), even
though objective improvements were lacking.
Therapeutic efficacy of MAA is distinctly depen-
dent on the degree of mandibular protrusion
achieved with the appliance (Petri et al. 2008 ;
Hans et al. 1997 ; Blanco et al. 2005 ).

Randomized studies aimed at the assessment

of efficacy of different standard splints (self-

molded, semi-bespoke, and fully-bespoke) for

OSA treatment have also been performed and

the findings compared with the observations in

untreated patients (Quinnell et al. 2014 ). All

these appliances decrease the AHI value by

26 % compared with no treatment (95 % CI;

11–38 %; p¼0.001). Further, the splints con-

siderably improve the patients’ self-assessment.

Non-adjustable MAA achieve clinically impor-

tant improvements in mild-to-moderate OSA and

are cost-effective.

7 Synopsis

It is well known that the use of CPAP is the most

effective protection from obstructive apneic

episodes at sleep. Regular CPAP application

causes a regression of apneic events, normalizes

circadian disturbance of hormonal secretion,

decreases blood pressure, and improves sleep

quality. This method can be applied in edentu-

lous patients. A complete nasal patency is the

only requirement for the method. CPAP is a

relatively safe procedure. However, its long-

term application carries risk of certain

complications; notably of nasal injuries such as

necrosis, irritation and swelling of mucous mem-

brane, or nasal septum bending. In 40 % of

patients, upper respiratory complaints also

occur such as rhinitis, sneezing, and mucosal

drying. The accumulation of stomach gases,

caused by swallowed air, is frequently reported.

It also happens that the method itself proves

ineffective, which leads to the development of

atelectasis (Sharples et al. 2016 ; Phillips

et al. 2013 ; Fergusson et al. 1996 ; Sallivan

et al. 1981 ).

Bearing in mind the considerations above

outlined, numerous research centers carry out

reliable randomized studies, which create the

basis for assessing how far other techniques

could go to ensure safe sleep and optimal upper

airway patency for adequate supply of oxygen.

Mandibular advancement appliances are

designed to maintain the mandible in the

68 J. Kostrzewa-Janicka et al.