Nice Guidelines on Mandibular Advancement Splints (MAS)

Nice Guidelines (NG202) recommended customised, or semi-customised, mandibular advancement splints (MAS) for the treatment of people with mild, moderate and severe symptomatic OSAHS as an alternative to CPAP, if CPAP is not tolerated or declined.

Many people cannot adjust to CPAP therapy despite their best efforts. NG202 reviewed the strong evidence base for MAS:

• Treatment efficacy particularly in mild OSA and snoring
• Treatment efficacy as a second choice in moderate and severe OSA. Here, the evidence is stronger for CPAP in people with OSA, but there are benefits from MAS. This would be suitable therefore in people with OSA who cannot use CPAP.

MAS therefore represents robust evidence based alternative therapy to CPAP: to reduce OSA severity, associated symptoms and longer-term OSA morbidity. Experts agree that regular nightly use of a MAS will offer better control of OSA, and its associated co-morbidities, than non-use of prescribed CPAP.

MAS is a cost effective therapy, as assessed by NG202, hence its recommendation. In the NHS, MAS cannot be reliably, universally and equally accessed at present because of the absence of NHSE pathways and tariffs. There are current inequities of access, with many areas unable to offer these to any patients, for example Newcastle upon Tyne and University Hospitals Birmingham. The current NHS model therefore can only offer CPAP to patients with symptomatic OSA and if they cannot tolerate this or decline this option, they have to self-fund MAS, having been given the information about these from the Sleep Centre.

We are seeking NHS access to a MAS pathway with suitable tariffs, so that NHS sleep professionals can access this therapy for selected suitable patients.

All patients referred for sleep assessment would have a diagnostic sleep study and initial consultation with a sleep professional. For some patients, MAS will be determined to be the appropriate therapy instead of CPAP. This would be following review of the patient data and discussion with the patient to advise on best therapy and to ascertain patient choice.

The initial pathway model should be appropriate to whichever therapy option (CPAP or MAS) is considered appropriate by the sleep professional, with the patient’s response to treatment measured, further titration as needed to optimise response and ongoing input from dental team (MAS) or Sleep team (CPAP) as required for long term therapy use. Sleep and dental teams may be a combined team with a single point of contact in some centres.

Adjustments to either therapy (CPAP or MAS) would be made in response to patient symptom improvement, or lack thereof (ESS, subjective report), side effects (CPAP mask/machine issues or MAS discomfort) and patient adherence (Hours used per night from CPAP download or remote monitoring, or self-reported use with MAS diary/App). A repeat sleep study with therapy may be needed to demonstrate treatment efficacy with either therapy (although CPAP devices now provide nightly data on treatment efficacy when worn).

Note: MAS adherence chips are not standard in clinical practice only research, so direct adherence data not possible. MAS remote monitoring is said to be in development but with associated higher MAS costs.