Does snoring make you MAD or is there a miracle cure?
Does snoring make you MAD or is there a miracle cure?
In response to a questionnaire to discover if Mandibular Advancement Device (MAD) therapy is as good as we expected, 67% of our respondents said it had stopped them snoring and 69% of them said the benefits of the therapy far outweighed any disadvantages.
A total of 367 anonymous MAD users, 292 males and 75 females took part in this robust research conducted by the British Snoring & Sleep Apnoea Association.
FOR SOME, MAD THERAPY REALLY IS A MIRACLE CURE
IN SEARCH OF THAT ELUSIVE CURE
Every night an estimated 15 million snorers disturb the slumber of their bed partner and other family members with noise levels reaching in excess of 90dB. Not suprisingly, a reliable and effective resolution to this troublesome complaint has been the subject of research for over 100 years. Snorers have been bombarded with a plethora of treatments all claiming to stop them snoring some with robust clinical evidence of their effectiveness, others have no clinical or practical use at all.
ARE YOU MAD?
In February 2005, the BBC programme `How To Sleep Better' presented by Professor Lord Robert Winston, featured a woman whose life had been transformed by MAD therapy. Since then this treatment has gained enormous popularity among snores and sleep apnoea sufferers. It has long been recognised that for those individuals whose snoring originates at the base of the tongue, advancing the mandible (lower jaw) can quieten even the loudest of snorers. Consequently, mandibular advancement devices (MADs), or splints as they are sometimes known, are now readily available for all to purchase.
IS IT ALL DRIVVLE OR DRIBBLE?
Whilst the clinical evidence that these devices are effective in the management of snoring is undisputed in the medical literature(1,3,6,8), data relating to compliance and potential adverse events has not always been readily available to the buying public. Both Almeida (2) and Dort (7) suggest that the most frequently cited reasons for discontinuing with these devices are discomfort and ineffectiveness. One respondent to this present study reported `Perhaps I should have persevered a bit more but I found the product made me salivate too much and I did find it uncomfortable'.
Excess salivation is cited by many researchers (2,4,6) and Bates(4) suggests that the presence of these initial side effects may prevent acceptance of the device. Although our results show 20% of MAD users complained of excessive salivation, this adverse effect was not found to be a statistically significant factor for discontinued use.
Our MAD users reported the presence of one or more adverse effects. Jaw and face pain significantly correlated (p=0.025 & p=0.01) with discontinued use. Our data confirms that of Almeida(2) with the most common complaint being discomfort, especially of the teeth, face and jaw.
DO YOU COMPLY WITH DOCTOR'S ORDERS?
However, acceptance of the device certainly seems to be an issue and our data does concur with that of Bates(4) and Dort(7) regarding attrition. In this present study, 33% of men had discontinued using their device. The majority of them (48%), stopped using their device within the 6-12 month period. This was not the case with the women. Of the 4% of women who had discontinued using their device, 50% of them had stopped using it within the first month.
According to Bates(4) `It is important to recognise that generally 40-50% of patients do not comply with any treatment prescribed...'. Dort (7) on the other hand suggests that compliance may be a result of appliance selection and patient suitability. This seems likely as our data confirms that of the 22 most popular devices currently available compliance rates were greatest with appliances that had undergone continued research and development. Additionally, we found that compliance was greatest for appliances bought upon our recommendation and from the provision of continuous help and advice to users during their initial habituation period. Bates(4) also agreed that to achieve the best results, comprehensive instructions for use must be given. Cistulli(6) recommends that to increase the chance of success users should be encouraged to make regular contact with their device provider whenever the appliance does not relieve symptoms or other problems occur.
HORSES FOR COURSES
`Oral appliance compliance might differ depending on the type of the appliance, disease severity and perhaps patient management' says Almeida(2). Many MAD purchasers do not appreciate that MADs have differing features and are often misled by manufacturers' advertising puff. One of our respondents remarked `The differences between models is striking and I think this should be emphasised to customers. I have previously tried one device which was extremely uncomfortable and ineffective, but have now tried another which is completely different. It is much more comfortable and grips very well, although not without its side effects (some jaw discomfort). I can't imagine any device of this type could be more effective'.
Cistulli(6) states, `There is a general consensus that customized appliances are better tolerated and tend to be more effective than the less commonly used prefabricated (boil & bite style) appliances, but this is not based on research evidence'. We would argue this point, as boil & bite devices sold by reputable organisations in the UK have CE marking and/or FDA approval. They have robust clinical evidence of their effectiveness and are no less common than customised appliances. We found no other research that upheld this comment by Cistulli(6); indeed, our research clearly found the opposite. Only 10 (2.7%) of our respondents had found any success with a custom made device as opposed to 316 (86%) who were currently using a `boil & bite' device.
We observed a marked drop-off in compliance after the first 2 years and we can only speculate as to why this has happened. We know that many patients discontinue use due to adverse effects, but as Bates(4) has already stated, some patients simply do not use their device. We can however offer an alternative explanation. Some `boil & bite' appliances are known to deteriorate within 1-2 years depending on the device and how often it is remoulded. We suggest this deterioration in the appliance results in it becoming ineffective in controlling snoring and therefore the user will simply stop using it.
MAD OR THE SPARE ROOM!
Much of the suffering associated with snoring and sleep apnoea is borne by the bed partner and as evidence suggests(5) the bed partner often suffers extreme sleep deprivation. 49% of our respondents reported that the motivation to use a MAD was initiated by their partner. From that group, 68% of them are still using their device. `The device you supplied has been a great investment, particularly for my partner' said one respondent.
Similarly, Cistulli(6) says `The overall benefit of a treatment is related to the product of its effectiveness and the patient's adherence to treatment, the latter being determined to a large extent by the acceptability of the treatment to the patient, and often the bed partner'. 'It really has improved my life and improved my partner's sleep issues' commented one respondent. Many respondents to our study provide evidence to this effect: `It works but the discomfort means that I only use it when I need to share my bed' said one respondent , `I wear my device to help my wife get some sleep' said another. However, our results found no significant difference in compliance between partner-motivated, self-motivated or motivated by advice from a professional, although anecdotal evidence to the contrary was found.
IS THIS REALLY A MIRACLE CURE?
It is our opinion that any one product or device that has demonstrated a 67% effectiveness in controlling snoring should be viewed as a success. 67% of our respondents said their MAD stopped them snoring completely. 69% said the benefits of the device outweigh the disadvantages. Jaw & face pain was a significant adverse effect but within 1 month, 73% of users had habituated successfully to the device.
3 WAYS TO FIND YOUR MIRACLE CURE.
Find the cause of your snoring.
(do 3 easy `snore tests' - visit: www.britishsnoring.co.uk)
Select a control that is suitable for you.
(be sure you know what you're buying)
If in doubt, seek help and advice.
(www.britishsnoring.co.uk or Tel: 01737 245638)
Facts about snoring:
- 15 million snorers in the UK.
- 10.5 million men 4.5 million women.
- 40-50% of patients do not comply with suggested treatment.
- Snorers should be sure to find the cause of their snoring and treat it appropriately.
- Snoring contributes to relationship breakdown.
- Snorers have less sex than their non-snoring counterparts.
MAD therapy - mandibular advancement devices are suitable for individuals whose snoring originates at the tongue base.
- Those that discontinue treatment do so most often in the 6-12 month period because of discomfort and ineffectiveness.
- 69% of snorers consider the benefit their treatment offers outweighs any adverse effects.
- 67% of snorers found MAD therapy stopped them snoring.
(1) Aarab G et al (2005) Short-term effects of mandibular advancement device on OSA.
Journal of Oral Rehabilitation 32 564-570
(2) Almeida FR et al (2005) Long-term compliance and side effects of oral appliances used for the treatment
of snoring and obstructive sleep apnoea syndrome.
Journal of Clinical Sleep Medicine 1 (2) 143-152
(3) Battagel JM & Kotecha B (2005) Dental side effects of mandibular advancement splint wear in patients
Clin. Otolaryngol 2005 30 149 - 156
(4) Bates CJ & McDonald JP (2006) Patients' and sleeping partner's experience of treatment for sleep
related breathing disorders with a mandibular repositioning splint.
British Dental Journal 200 (2) 95-101
(5) British Snoring & Sleep Apnoea Association (2005) Snoring contributes to the breakdown of the
Royal Society of Medicine April 2005.
(6) Cistulli P et al (2004) Treatment of snoring & OSA with mandibular repositioning appliances.
Sleep Medicine Reviews 8 443-457
(7) Dort L & Hussein J (2004) Snoring & OSA: Compliance with oral appliance therapy.
The Journal of Otolaryngology 33 (3) 172-175
(8) Johal A et al (2005) The effects of mandibular advancement splint in subjects with sleep-related
British Dental Journal 199 591-596