I’ve got some encouraging news about sleep apnea, a common sleep disorder in which breathing repeatedly stops and starts…but first, a word on why we need good news. Sleep apnea can contribute to serious cardiovascular problems and other chronic ailments, doubling the risk for sudden cardiac death and tripling the risk of dying from any cause within a given time frame.
The gold-standard treatment is continuous positive airway pressure (CPAP), an electrical appliance attached to a mask worn over the nose and mouth while sleeping. It provides a constant flow of air that keeps the patient’s airway open. Problem: 46% to 83% of patients don’t comply with treatment because they find CPAP too uncomfortable or noisy.
There’s a low-tech treatment that many patients find more tolerable—a custom-made mandibular advancement device (MAD), which fits in the mouth and is worn overnight like an orthodontic dental retainer. It holds the lower jawbone forward to keep the throat’s soft tissues from collapsing into the airway and blocking it. In past studies, MAD hasn’t performed quite as well as CPAP on most measurements, so it’s usually reserved for mild-to-moderate sleep apnea.
Now the good news: According to a recent study, even for patients with severe sleep apnea, MAD is comparable to CPAP on the most important benchmark—reducing cardiovascular mortality.
The new study involved patients with severe sleep apnea who were prescribed CPAP. After three months, 57% of the participants were no longer complying with CPAP treatment. Most of this noncompliant group refused further treatment (and thus were designated the “untreated” group), but some opted to try MAD. The final analysis included four groups—177 patients using CPAP…72 using MAD…212 who were untreated…and 208 people without sleep apnea, who served as controls. Participants were followed for an average of 6.6 years. During this follow-up period, 42 of the 669 participants died from cardiovascular causes—stroke, heart attack, cardiac arrest or cardiac arrhythmia.
Results: Not surprisingly, the highest cardiovascular mortality rate was among the untreated apnea patients, with 2.1 deaths per 100 person-years (the number of years patients were followed multiplied by the number of people in the group)…and the lowest rate was among the healthy control group, with just 0.28 cardiovascular deaths per 100 person-years. What was surprising was how well the MAD group did—their cardiovascular death rate was 0.61 per 100 person-years…very nearly as low as the CPAP group’s rate of 0.56 per 100 person-years.
The fact that MAD reduced cardiovascular mortality on par with CPAP was particularly interesting given that the oral appliance did not actually control sleep apnea as well as CPAP. Prior to treatment, patients experienced an average of about 44 episodes of interrupted breathing per hour. With MAD, the average number of such interruptions fell to 16.3 per hour…while with CPAP, the average number fell all the way to 4.5 per hour. Where the MAD patients had an advantage—one that probably contributed to their impressive reduction in mortality risk—was in the amount of time they were willing to wear their devices. On average, CPAP patients used their devices for 5.8 hours per night, while MAD patients wore their devices for 6.5 hours per night. The researchers suggested that the increased treatment time with MAD helped compensate for the fact that the dental appliance isn’t quite as effective as CPAP in controlling apnea episodes.
Compliance reality check: Given that many people simply cannot or will not put up with CPAP—in which case it hardly matters how superior CPAP is, because no treatment will help you if you don’t use it!—MAD offers a very attractive alternative. Research has shown that patients generally do prefer MAD over CPAP. In fact, in this study, only 6% of the MAD group gave up the treatment. Caveat: Some patients using MAD experience jaw discomfort.
Bottom line: If you (or your bed partner) have sleep apnea and can’t tolerate CPAP, speak with your doctor about being fitted for MAD. These types of dental appliances can be custom-made by dentists who specialize in sleep disorders…cost between $300 to $2,500…and usually are covered by medical insurance (not dental). To be eligible for MAD, patients generally must have a certain level of gum, jaw and tooth health—your dentist can check you out for that.
