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Self-reported compliance with MAD was greater than the objectively measured one
with CPAP therapy, raising the possibility that OSA was better treated with MADs.
Another case series study showed that MAD treatment led to blood pressure declines
in OSA patients over a 3-year period [ 87 ]. A more recent trial from the same author
among hypertensive OSA patients showed that MAD treatment could reduce the
24-h mean systolic blood pressure compared to the controls and with a greater mag-
nitude of decrease in the subgroup of patients with a baseline daytime mean blood
pressure higher than 135/85 and among OSA patients with a baseline AHI > 15 [ 88 ].
A meta-analysis confirmed that MADs can decrease systolic, diastolic, and noctur-
nal blood pressure, albeit, modestly, in mild-to-moderate OSA [ 89 ]. A large ran-
domized crossover controlled trial [ 90 ] comparing the efficacy of MAD to CPAP
found that, after 1 month of therapy, blood pressure reductions among patients with
moderate-to-severe OSA were equivalent between patients on CPAP and MAD,
despite CPAP more effectively treating patients’ sleep-disordered breathing. Most
patients preferred MAD over CPAP therapy and showed higher compliance with the
MAD compared to CPAP therapy.
As far as long-term data, a randomized controlled study following patients over
2 years found no clinically significant difference in efficacy in mild-to-moderate
OSA patients treated with MADs compared to CPAP [ 91 ]. A cohort study found
that the efficacy of the MADs on the respiratory indices of severe OSA patients was
slightly inferior to the one of CPAP therapy over a 5-year period but was non-
inferior to CPAP in reducing the cardiovascular risks associated with OSA [ 92 ]. A
single study has provided evidence for reduced cardiovascular mortality in severe
OSA patients using MADs compared to controls, in a manner non-inferior to the
efficacy of CPAP [ 93 ].
In summary, the beneficial effects of MAD treatment on blood pressure param-
eters in patients with OSA appear to be modest but likely sustained over the long
term [ 87 ], perhaps in part due to higher adherence with the therapy than is typically
seen with CPAP.
Other Therapies
Nocturnal supplemental oxygen therapy has been proposed as another possible
alternative for patients unable to tolerate CPAP. Based on the results of a study of
patients with cardiovascular disease or risk factors in whom treatment of obstructive
sleep apnea with CPAP—but not oxygen—resulted in significant blood pressure
reductions, we cannot recommend this as an acceptable first-line therapy [ 94 ].
Other alternative therapies include upper airway surgeries (e.g., uvulopalatopha-
ryngoplasty), nasal expiratory resistance devices, or implantation of a hypoglossal
nerve stimulator, but none of these therapies is as effective as CPAP in treating OSA
[ 95 , 96 ]. A small group of carefully selected patients may be appropriate candidates
for more invasive options including maxillomandibular advancement surgery or
tracheostomy.
L.A. Tobias and F. Roux