## 4 Discussion
Subsequently, [PERSON] in 1998 reported that in 72% of patients with mild to moderate obstructive sleep apnea (OSA), the post-treatment AHI had decreased to values below 10. In the severe OSAS group, the AHI was significantly reduced from an average of 53 to an average of 14 [33]. Then, [PERSON] et al. in 2011 described the results of their retrospective study conducted on a sample of 497 OSA patients treated with MAD, regardless of the initial severity level of their condition. It was highlighted that the therapy reduced the average AHI from 30.0 to 8.4, with significant improvements also observed in the daytime sleepiness parameter, assessed through the completion of the ESS questionnaire [34]  
Regarding the Oxygen Desaturation Index (ODI), the initial mean value has significantly reduced compared to the final mean value (\(p<0.05\)). In the examined sample, the initial ODI was 13.4 \(\pm\) 8.8, and in the final sample it was 6.2 \(\pm\) 5.2. These results suggest that the MAD therapy has effectively improved the ODI, resulting in a significant reduction in the number of oxygen desaturation events during sleep. Regarding the snoring percentage, it is evident that in the examined sample, the mean value of snoring percentage has significantly decreased from 30.7 \(\pm\) 7 to 7.5 \(\pm\) 10.8, with a \(p\)-value of 0.0001, indicating strong statistical significance (\(p<0.01\)). This indicates that the MAD therapy has been highly effective in reducing snoring in the patients, resulting in a significant improvement in this aspect of their sleep disorder. A study has shown that 75% of patients treated with MAD for simple snoring reported an improvement in their relationships with their bed partners, who are often the ones urging the individual to seek medical evaluation for the resolution of this condition [35]. In this regard, other studies have considered the evaluation of bed partners as the most relevant outcome to assess the reduction of snoring with MAD, and 86% of them reported an improved quality of sleep for their partner thanks to the application of the intraoral device [36]. Regarding the scores obtained from the self-completion of the Epworth questionnaire, a significant decrease was observed with a \(p\)-value of 0.0006, indicating strong statistical significance (\(p<0.01\)). However, for clinical relevance, a reduction of at least two points in the questionnaire score is required to confirm a real improvement in clinical symptoms with a reduction in daytime sleepiness [37], with a score of \(>\)10/24 indicating pathological daytime sleepiness. Specifically, in the examined sample, the majority of patients (12 out of 19) obtained a score \(<\)10 on the initial questionnaire, indicating they were not sleepy, while another 3 out of 19 did not report any difference in the score before and after the questionnaire, and the same number of patients reduced the score by only 1 point before and after treatment. However, 7 out of 19 patients who initially had a score \(>\)10 achieved a reduction of at least 2 points in the score after therapy, indicating an effective improvement in daytime sleepiness. Although a statistically significant improvement is observed in the evaluation of this parameter, given the limited sample size clinical relevance is less evident. We also note that daytime sleepiness may not always be present as a symptom in patients with OSAS [38]. In the data analysis, it was chosen to examine the percentage of time spent in the supine position during sleep. The examined sample consists of patients with OSAS or simple snorers, all of whom are positional, with positional OSAS defined as a patient whose Apnea-Hypopnea Index (AHI) in the supine position is at least double that recorded in the non-supine position. Therefore, the percentage of time spent in the supine position was compared before (without MAD) and after (with MAD in place) to avoid overestimating the therapeutic effects of the F22 MAD.