June 19, 2013

DynaMed EBM Journal Volume 8, Issue 25

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: June 19, 2013

Expiration Date: June 19, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

James McLellan, PhD - Senior Medical Writer, DynaMed, Ipswich, Massachusetts, USA


Dr. Ehrlich, Dr. Fleming, Dr. McLellan, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 8, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 6, 2013. Term of approval is for one year from this date with the option of yearly renewal. Each weekly updated is approved for 0.25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304158G


Last week 399 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 242 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Mandibular Advancement Device Appears At Least as Effective as CPAP for Improving Quality of Life and Reducing Sleepiness in Moderate-Severe Obstructive Sleep Apnea
Reference: Am J Respir Crit Care Med 2013 Apr 15;187(8):879, (level 2 [mid-level] evidence)

A consensus statement from the American Academy of Sleep Medicine (AASM) identifies continuous positive airway pressure (CPAP) as the treatment of choice for mild, moderate, and severe obstructive sleep apnea (OSA). Oral appliances, including mandibular advancement devices and tongue retaining devices, are recommended for mild-to-moderate OSA in patients who do not wish to use or are not candidates for CPAP J Clin Sleep Med 2009 Jun 15;5(3):263). A recent crossover randomized trial compared the efficacy of a mandibular advancement device to CPAP in 126 patients with newly diagnosed moderate-to-severe OSA.

Patients with moderate-to-severe OSA (mean apnea-hypopnea index 25.6/hour) were randomized to mandibular advancement device vs. CPAP nightly for 1 month, followed by crossover to the other intervention after a 2-week washout period. Prior to the treatment phase of the trial, all patients completed an acclimatization phase with each intervention (in random order) with nightly use for 4-6 weeks to stabilize usage patterns. Assessments included polysomnography for episodes of apnea and hypopnea, SF-36, and the Epworth Sleepiness Scale score (0-24 scale).

Fourteen percent of the patients did not complete the trial and were excluded from the analyses. Both groups showed significant improvement from baseline in sleepiness and SF-36 scores. The mandibular advancement device was associated with less improvement in polysomnographic outcomes: the mean apnea-hypopnea index was 11.1/hour with mandibular advancement vs. 4.5/hour with CPAP. Despite this difference, the mandibular advancement group had greater improvement in bodily pain, vitality, social function, and mental health components of the SF-36 (p < 0.05 for each). The mean improvement in Epworth score was 1.9 points with mandibular advancement and 1.6 points with CPAP (not significant). Mean patient-reported compliance was 6.5 hours/night with mandibular advancement vs. 5.2 hours/night with CPAP. There were no significant differences between groups in driving simulator performance, 24-hour mean arterial pressure, or blood pressure.

Patients should have a complete dental exam to assess their eligibility for a mandibular advancement device, and fitting should be performed by qualified dental personnel. Dental work might be necessary for some patients. Patients with TMJ dysfunction, limited jaw range of motion, poor dental health may not eligible.

For more information, see the Obstructive sleep apnea (OSA) topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

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