• On snoring, 5

    You don’t care about this, but it’ll haunt me for the rest of my life: When I started this series “on snoring” I had a pile of papers that I thought were about snoring and a separate pile that I thought were about obstructive sleep apnea (OSA). In truth, they’re both on the same continuum of sleep disordered breathing (SDB), and therapies that address one also address the other. The only difference in the piles of papers is that the word “snoring” appears in one and not the other. That’s not a good reason to separate the piles, but I did.

    So, “On snoring” was poor choice of title for the series — a huge, consequential mistake from which I may never recover. Such are the perils of blogging. But I can’t turn back now. I’ve got three more papers in my “snoring” pile, notes on which follow. The part about the rabbits is my favorite.

    Gagnadoux, F., Nguyen, X.L., Le Vaillant, M., Priou, P., Meslier, N., Eberlein, A., Kun-Darbois, J.D., Chaufton, C., Villiers, B., Levy, M. and Trzépizur, W., 2017. Comparison of titrable thermoplastic versus custom-made mandibular advancement device for the treatment of obstructive sleep apnoeaRespiratory medicine131, pp.35-42.

    • “Observational prospective cohort studies indicate that regular CPAP therapy is also associated with a lower risk of driving-related accidents and cardiovascular events [4,5].” Comment: (1) I haven’t chased down any statistics on it yet, but I’ve heard that many (a high proportion of) auto accidents are caused by people falling asleep at the wheel. Those with untreated sleep apnea are at much higher risk of doing so. (2) The second of these citations includes in its abstract that OSA can activate pathways that cause inflammation, suggesting my inference that my OSA and my tendinitis are connected.
    • “[A]pproximately 40% are at risk of nonadherence [to CPAP] especially if they have mild to moderate OSA [6]. Mandibular advancement devices (MAD) have emerged as the main therapeutic alternative for OSA. Despite the superior efficacy of CPAP in reducing sleep-disordered breathing (SDB), most randomized
      trials comparing MAD and CPAP in OSA have reported similar heath outcomes in terms of sleepiness, neurobehavioral functioning, quality of life and blood pressure [3,7-10].When MAD therapy is prescribed, practice guidelines also suggest with a low quality of evidence to use a custom, titratable MAD over noncustom
      devices [11]. However, potential disadvantages of these custom-made MAD are the cost and delay required to manufacture the device. In addition, not all patients benefit from MAD, and presently no method exists to predict the outcome prior to fabrication of the device [12]. Thus, a trial with an inexpensive thermoplastic
      titrable MAD would be of great interest.” Comment: Yes. Yes it would. More precisely, I would like to see more studies of OTC (non-custom) MADs (see below).
    • Unfortunately, this is not that study (see below). It compares a less expensive, thermoplastic MAD (BluePro®) with the more expensive, custom ones (AMO® and Somnodent®, all from SomnoMed). The difference is in how the devices are molded to teeth. Thermoplastic is, as the name suggests, self-molding by heating the material, biting, and then cooling. The other devices require dental impressions, which is a more expensive process. This was a non-randomized study and included patients in the thermoplastic arm that were younger and had lower BMI than the other arm.
    • “This study demonstrates the efficacy of a titrable thermoplastic MAD in reducing SDB and related symptoms in patients with mild to severe OSA. Reported compliance at 6 months was high despite more dental discomfort than with custom-made MAD.”
    • There are other studies. “Among thermoplastic devices evaluated in the literature, those without chairside impressions and/or customized design were found to be poorly effective and uncomfortable, leading to poor compliance and treatment discontinuation [23,24] […] Discrepant findings were obtained in previous studies evaluating the impact of ready-made or partially customized MADs on SDB and related symptoms. The TOMADO randomized trial compared non-adjustable “boil and bite” thermoplastic appliances with a custom-made MAD for the treatment of mild OSA [23]. All devices reduced AHI compared with no treatment but compliance was lower with the self-moulded device, which was the least preferred treatment at trial exit. Friedman et al. [27] found that a custom-made device achieved higher rates of objective improvement
      and cure of OSA than a thermoplastic MAD. Self-reported adherence was present in 54% of patients on thermoplastic MAD versus 65% on custom-made MAD. At 6 months, only one third of patients on thermoplastic MAD were still considered adherent, compared to 51% in the other group. Using the same thermoplastic device Vanderveken et al. [13] found that thermoplastic MAD was completely or partially effective in 31% of patients versus 60% for the custom-made MAD. In a recent randomized study, Johal et al. [24] reported a response rate of only 24% with a thermoplastic MAD versus 64% in the custom-made arm.”
    • “Although open trials with thermoplastic devices showed mild side effects [25,31,32], most comparative trials found that tolerance and overnight retention were lower with thermoplastic than custom-made devices [13,23,24,27]. Most patients expressed preference for the custom-made device in cross-over trials [13,24].”
    • Upshot: It seems like it is possible for one to relieve snoring and OSA symptoms with some OTC (non-custom) oral appliances. Which ones? Beats me. Maybe digging into the references would be informative. On the other hand, it’s reasonable to be concerned that symptom relief will not be as great (or not occur at all) with the OTC devices, relative to custom-made ones. Moreover, it’s pretty clear that the OTC ones are harder to tolerate. In the end, it seems it would be hard for a typical patient who wants to address a snoring problem to avoid spending considerable money on a custom device.

    Guzman, M.A., Sgambati, F.P., Pho, H., Arias, R.S., Hawks, E.M., Wolfe, E.M., Ötvös, T., Rosenberg, R., Dakheel, R., Schneider, H. and Kirkness, J.P., 2017. The Efficacy of Low-Level Continuous Positive Airway Pressure for the Treatment of SnoringJournal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine13(5), pp.703-711.

    • About 40% of the adult population snores.
    • There are studies that suggest snoring may contribute to hypertension and cardiovascular disease, at least in certain populations (diabetics [9], men under 50 years old [10], rabbits [11], 18-50 year olds [12]).
    • “Snoring constitutes a recognized source of noise pollution that may disrupt the sleep of bed partners and degrade a couple’s overall quality of life [13,14].” See also [39,40].
    • “Agents that reduce nasal airflow obstruction including nasal splints, nasal saline sprays, nasal decongestants, and anti-inflammatory medications have limited clinical efficacy in snorers [2].”
    • “Despite the wide range of available treatment options, many snorers remain untreated due to limited tolerability and/or therapeutic efficacy of therapies.”
    • “This study demonstrates that low-level CPAP during sleep is highly efficacious in mitigating snoring in habitual snorers without significant sleep apnea. On CPAP titration nights, we found that CPAP decreased snoring frequency markedly at all levels of snoring intensity. Progressive decreases in snoring severity were observed when CPAP was increased stepwise from 0 to 4 cm H2O.”

    Scherr, S.C., Dort, L.C., Almeida, F.R., Bennett, K.M., Blumenstock, N.T., Demko, B.G., Essick, G.K., Katz, S.G., McLornan, P.M., Phillips, K.S. and Prehn, R.S., 2014. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep MedicineJ Dent Sleep Med1(1), pp.39-50.

    • “Sleep disordered breathing constitutes a spectrum of repetitive upper airway narrowing episodes during sleep characterized by snoring, elevated upper airway resistance, and/or obstructive sleep apnea (OSA).”
    • “Common symptomatic manifestations include hypersomnolence [4], insomnia, neurocognitive deficits, [5,6]
      bed partner disturbance, mood disorders, [7,8] nocturia, [9] and fatigue. Diminished reaction time and increased susceptibility to motor vehicle crashes have also been reported. [10,11] OSA is an independent risk factor for the development of hypertension, coronary artery disease, epithelial dysfunction leading to ischemia, [12] cardiac arrhythmias, [13] stroke, insulin resistance, [14,15] and all-cause mortality. [16-22]”
    • “Pierre Robin was the first to document the use of a mandibular advancement oral appliance for the treatment of nocturnal airway obstruction in 1923. However, oral appliances were apparently forgotten until 1982, when Cartwright and Samelson reported the use of a novel tongue retainer. [38] Within a few years, several authors rediscovered mandibular advancement oral appliances. [39]”
    • This paper includes a fine lit review. But I think what I’ve read before is enough.


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