Prediction of Mandibular Advancement Device Response Using CPAP Pressure in Different Polysomnographic Phenotypes

OBJECTIVE: Both continuous positive airway pressure (CPAP) pressure and polysomnographic phenotypes have been associated with mandibular advancement device (MAD) treatment response, but the precise relationship has not been fully elucidated. We hypothesized that utilizing CPAP pressure would predict the MAD response in treatment-naïve patients with moderate-severe obstructive sleep apnea (OSA), and the MAD response would be associated with two polysomnographic phenotypes, including sleep stage dependency and positional dependency. METHODS: OSA treatment-naïve patients with an apnea-hypopnea index (AHI) ≥15/h who declined CPAP treatment and received MAD treatment for 3–6 months were enrolled. The MAD treatment response was defined as 1) residual AHI under MAD (AHI(MAD)) <5/h and 2) AHI(MAD) <10/h. Logistic regression was applied to identify the association between CPAP pressure and MAD treatment responders. The predictability of the MAD responder status utilizing CPAP pressure was assessed with the area under the receiver operating characteristic (AUROC). RESULTS: A total of 128 enrolled patients (AHI ≥30/h in 74.2%) were recruited, of whom 119 patients and 80 patients were included for analysis of sleep stage and positional dependency, respectively. REM-predominant OSA had lower AHI than stage-independent OSA, while the supine-predominant phenotype had lower anthropometrics than the nonpositional-dependent phenotype. The response rates for AHI(MAD) <5/h and AHI(MAD) <10/h were 25.8% and 48.4%, respectively. Lower anthropometrics, baseline AHI, and supine predominance were associated with the responder status, while CPAP pressure was an independent predictor. The AUROCs for the prediction of AHI(MAD) <5/h and AHI(MAD) <10/h responders were 0.635 and 0.664, respectively. Utilizing a CPAP level >14 cmH(2)O as the cutoff to predict criterion 1 and 2 nonresponders, the sensitivity was 93.9% and 95.2%, respectively. CONCLUSION: In treatment-naïve patients with moderate-severe OSA, the supine-predominant phenotype and lower CPAP pressure were associated with the MAD response, while the sleep stage dependency phenotype was not. Utilization of a CPAP level >14 cmH(2)O could be a sensitive measure to identify nonresponders.