Clinical information

Although continuous positive air pressure (CPAP) is considered the gold standard treatment for OSA, it is estimated that CPAP failure occurs in approximately 35% of patients and that 29–83% of users are nonadherent to this therapy. Mandibular advancement devices (MAD) are an effective alternative treatment to CPAP for many of these patients. Although CPAP is more effective in reducing the apnea–hypopnea index (AHI), MAD is preferred by patients and their partners as they are more portable, make no noise, are more comfortable, and are better tolerated. However, there is a high variability of response for each individual. Numerous studies have aimed to identify suitable candidates for treatment with MAD, on occasions with contradictory results. Therefore, this uncertain variability suggests the need for the identification of potential responders.

The DISE-SAM protocol (Optimizing Mandibular Advancement Maneuvers during Sleep Endoscopy with a Titratable Positioner: DISE-SAM Protocol, Fernández-Sanjuán et al. 2022 is used to identify those patients suffering sleep breathing disorders during Drug Induced Sleep Endoscopy (DISE), who will potentially benefit from oral appliance therapy, using a titratable, reproducible, and measurable maneuver with the Selector Avance Mandibular (SAM·MAS) device.

Furthermore, the use of the SAM·MAS provides information on the degree of advancement required to respond during DISE and suggests different levels of recommendation to optimize MAD treatment in a personalized design according to the expected response.

This study was carried out due to the lack of correlation between the patient’s response to Mandibular Advancement Devices (MAD) and their phenotype or severity and aimed to design a personalised treatment for each patient, prescribing MAD as a single, alternative or multiple treatment. The results suggest that MAD therapy could be recommended to 73.9% of the patients (including S, A or M recommendation) and showed no relationship with severity.

S
Recommendation
(single use)

As a single treatment if collapses are eliminated for patients with simple snoring or OSA.*

A
Recommendation
(alternative treatment)

As an alternative treatment if the collapses are improved by at least 50%, from 2 to 1 or from 1 to 0, with some VOTE levels remaining at 1. Combination of therapies may improve results.
Partial response expected. *

M
Recommendation
(multiple treatment approach)

ONLY as a combined treatment.*

No Recommendation
(MAD not recommended)

MAD is not recommended if no change or worsening is visualized.

SAM·MAS recommendations.

Recommendation S (single use/just MAD) applies if all collapses are removed (VOTE 0000).

Recommendation A (alternative treatment) is applied if the collapses are improved by at least 50%, going from 2 to 1 or from 1 to 0, leaving some VOTE levels at 1. If a collapse 2 persists in a level, it must be momentary and not be responsible for apnea, keeping oxygen saturation stable. A partial response is expected, but the results may improve with the combination of therapies.

The M recommendation (multiple treatment only) applies when an improvement in collapsibility is found, but a complete collapse responsible for the apnea remains at any VOTE level despite the advance maneuver. It is suggested only in combination of MAD with upper airway surgery (VAS) or with CPAP.

The No Recommendation is applied when the SAM·MAS does not modify the VAS or a worsening of collapsibility is observed.

Histograms showing the number of patients for whom the SAM·MAS recommendation was made. No: not recommended; S: single use; A: alternative treatment; M: multiple treatment approach.

Clinical information

Recommendation S (single use/just MAD) applies if all collapses are removed (VOTE 0000).

The M recommendation (multiple treatment only) applies when an improvement in collapsibility is found, but a complete collapse responsible for the apnea remains at any VOTE level despite the advance maneuver. It is suggested only in combination of MAD with upper airway surgery (VAS) or with CPAP.

The No Recommendation is applied when the SAM·MAS does not modify the VAS or a worsening of collapsibility is observed.

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