title: Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial.
abstract: BACKGROUND
  Continuous positive airway pressure (CPAP) and mandibular advancement device (MAD) therapy are commonly used to treat obstructive sleep apnea (OSA). Differences in efficacy and compliance of these treatments are likely to influence improvements in health outcomes.
  
  
  OBJECTIVE
  To compare health effects after 1 month of optimal CPAP and MAD therapy in OSA.
  
  
  METHODS
  In this randomized crossover trial, we compared the effects of 1 month each of CPAP and MAD treatment on cardiovascular and neurobehavioral outcomes.
  
  
  RESULTS
  Cardiovascular (24-h blood pressure, arterial stiffness), neurobehavioral (subjective sleepiness, driving simulator performance), and quality of life (Functional Outcomes of Sleep Questionnaire, Short Form-36) were compared between treatments. Our primary outcome was 24-hour mean arterial pressure. A total of 126 patients with moderate-severe OSA (apnea hypopnea index [AHI], 25.6 [SD 12.3]) were randomly assigned to a treatment order and 108 completed the trial with both devices. CPAP was more efficacious than MAD in reducing AHI (CPAP AHI, 4.5 ± 6.6/h; MAD AHI, 11.1 ± 12.1/h; P < 0.01) but reported compliance was higher on MAD (MAD, 6.50 ± 1.3 h per night vs. CPAP, 5.20 ± 2 h per night; P < 0.00001). The 24-hour mean arterial pressure was not inferior on treatment with MAD compared with CPAP (CPAP-MAD difference, 0.2 mm Hg [95% confidence interval, -0.7 to 1.1]); however, overall, neither treatment improved blood pressure. In contrast, sleepiness, driving simulator performance, and disease-specific quality of life improved on both treatments by similar amounts, although MAD was superior to CPAP for improving four general quality-of-life domains.
  
  
  CONCLUSIONS
  Important health outcomes were similar after 1 month of optimal MAD and CPAP treatment in patients with moderate-severe OSA. The results may be explained by greater efficacy of CPAP being offset by inferior compliance relative to MAD, resulting in similar effectiveness. Clinical trial registered with https://www.anzctr.org.au (ACTRN 12607000289415).
authors: Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St. Leonards, Australia. craig.phillips@sydney.edu.au
authors: Craig L
authors: CL
authors: Phillips
authors: Ronald R
authors: RR
authors: Grunstein
authors: M Ali
authors: MA
authors: Darendeliler
authors: Anastasia S
authors: AS
authors: Mihailidou
authors: Vasantha K
authors: VK
authors: Srinivasan
authors: Brendon J
authors: BJ
authors: Yee
authors: Guy B
authors: GB
authors: Marks
authors: Peter A
authors: PA
authors: Cistulli
mesh_terms: D000328:Adult; D000368:Aged; D001334:Automobile Driving; D018660:Blood Pressure Monitoring, Ambulatory / Q000295:instrumentation; D003198:Computer Simulation; D045422:Continuous Positive Airway Pressure / Q000295:instrumentation / Q000379:methods / Q000706:statistics & numerical data*; D018592:Cross-Over Studies; D005221:Fatigue / Q000209:etiology / Q000503:physiopathology; D005260:Female; D006801:Humans; D006973:Hypertension / Q000209:etiology / Q000503:physiopathology; D008297:Male; D019186:Mandibular Advancement / Q000295:instrumentation / Q000379:methods / Q000706:statistics & numerical data*; D008875:Middle Aged; D009517:New South Wales; D010349:Patient Compliance / Q000706:statistics & numerical data; D017286:Polysomnography / Q000295:instrumentation; D011788:Quality of Life; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome; D059289:Vascular Stiffness / Q000502:physiology; D055815:Young Adult