Mandibular Advancement vs Home Treatment for Primary Snoring

Study Overview
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Brief Summary
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This is a randomized controlled trial for non-apneic snorers. The primary goal of the study is to evaluate the efficacy of a mandibular advancement device (MAD) vs conservative treatment for adults with non-apneic snoring as measured by the partners report of response to treatment (CGI-I). The secondary goal is to evaluate the effectiveness of treatment of snoring on the Epworth Sleepiness Scale (ESS), a modified Symptoms of Nocturnal Obstruction and Related Events (SNORE-25) questionnaire, the Pittsburgh Sleep Quality Index (PSQI), and the Clinical Global Impression of Severity Scale (CGI-S)

Detailed Description
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Snoring is a problem which affects roughly half of adults, but rigorous studies on how to treat isolated snoring have not been completed. Mandibular advancement devices (MAD) show consistent improvements in sleep quality for patients with sleep apnea; however, their effect on patients with primary snoring remains less well known. The primary hypothesis proposes that adults with non-apneic snoring treated with a MAD will experience a greater reduction of snoring as measured by the Clinical Global Impression - Improvement (GCI-I) Scale response of the sleeping partner. The plan is to enroll 30 participants and 30 sleeping partner participants for each arm of the trial: 120 participants, or 60 pairs, in total. Participants will use the intervention nightly for a period of 4 weeks after which an end of study visit will occur. All post intervention outcomes will be recorded at the end of the study visit. Knowledge gained from this study will help guide treatment practice and evidence-based approaches regarding non-apneic snoring.

Official Title
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Mandibular Advancement vs Home Treatment for Primary Snoring: A Randomized Trial (SNORE-LESS)

Conditions
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Snoring

Intervention / Treatment
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* Device: Interventional Arm
* Combination Product: Conservative treatment Arm


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥ 18 Report of snoring Prior polysomnogram (PSG) within the past 60 months showing AHI (Apnea Hypopnea Index) < 5 and no more than 10% gain in body weight since the prior polysomnogram OR reasonable clinical suspicion that the participant does not have sleep apnea [Reasonable Clinical Suspicion is defined as: BMI <35, Neck circumference <16.5 inches, lack of uncontrolled hypertension, no witnessed episodes of apnea, or multiple sleep studies in the past all showing lack of sleep apnea but with >5 years since the most recent one.] Possess a sleeping partner who sleeps in the same room as the participant for >= 4 nights a week and who can report outcomes Access to the internet Ability to follow up within 1 month after adequate fitting of MAD or 4 weeks of Mometasone Inclusion criteria for the sleeping partner: Age ≥ 18 Possess a sleeping partner who sleeps in the same room as the participant for >= 4 nights a week and who can report outcomes Access to the internet Exclusion Criteria: Individuals will not be allowed to participate in this study if they meet one or more of the exclusion criteria: Significant hypoxemia as defined as SaO2 (oxygen saturation) below 89% for ≥ 12% of the total nocturnal monitoring time Inability to wear a MAD defined as missing more than 50% of their dentition or their dentition is not in good condition. Prior intolerance of MAD Current treatment for OSA Concurrent use of sedatives or > 2 alcoholic drinks per night Chronic nasal obstruction due to structural anatomic defects, nasal polyps, or history of unresponsiveness to nasal rinses. Sleeping partners do not have any exclusion criteria defined for this study.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This study is a randomized control trial with an active control group.
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Interventional Arm<br>The Mandibular Advancement Device for this study will be the ProSomnus Sleep Device. It is a sleep device intended to reduce nighttime snoring and mild to moderate Obstructive Sleep Apnea in adults by holding the lower jaw forward during sleep | Device: Interventional Arm<br>* The MAD arm will consist of participants given a fitted mandibular advancement device that they will wear for the length of the study.<br>* Other names: MAD (anti-snoring mouthpiece);|
| Active Comparator: Conservative treatment Arm<br>The conservative treatment will consist of four different interventions: Mometasone nasal rinse, External nasal dilatory therapy, Mouth taping and Lateral positional therapy. | Combination Product: Conservative treatment Arm<br>* Participant will undergo a nightly medicated nasal rinse that will occur for a 4 week period, prior to beginning of the other three conservative therapy interventions. The 4-part combination therapy will take place for 4 weeks total.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percent responders of Clinical Global Impression of Improvement Scale - Partner | This will occur asynchronously through email surveys distributed through the Washington University REDCap server or through a scheduled telephone call depending on the participant's preference. The Partner will grade the improvement of the snoring on the following continuous scale, which will be the Clinical Global Impression of Improvement (CGI-I) scale: Very Much Improved Much Improved Minimally Improved No Change Minimally Worse Much Worse Very Much Worse The percentage of responders to treatment will then be compared between the two arms of the trial. A responder will be defined as someone who rates the response to snoring as either Very Much Improved or Much Improved | 4 weeks post intervention beginning | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Clinical Global Impression of Severity Scale | The CGI-Severity Scale poses the question On average, how much of a problem does your [partner's] snoring pose? The 5 response options will include: no problem, mild problem, moderate problem, severe problem, problem as severe as it can be. It will be measured both at baseline and after treatment. Change in CGI-S score will be calculated and reported as a secondary outcome measure as the change in CGI-S score between the two arms. In addition, the CGI-S will be measured by the sleeping partner on a daily basis both before and after treatment. | 4 weeks post intervention beginning | 
| Change in Epworth Sleepiness Scale (ESS) Score | The ESS is a commonly used measure to evaluate the propensity to of a participant to fall asleep in 8 everyday scenarios in recent times. The participant rates each situation on a scale of 0-3, with 0 being least likely to fall asleep and 3 being the most likely. Final score can range from 0-24. Epworth Sleepiness Scale (ESS) score will be recorded by both the partner and the snorer at baseline and follow up. Change in ESS score will be calculated and reported as a secondary outcome measure as the change in ESS score or the difference in percentage of participates recording an ESS improvement above the Minimal Clinically Important Difference between the two arms. | Baseline and 4 weeks post intervention beginning | 
| Change in Symptoms of Nocturnal Obstruction and Related Events (SNORE-25) | The SNORE-25 is a modification of the Obstructive Sleep Apnea Patient-Oriented Severity Index (OSAPOSI) which includes 25 total items. Symptoms of Nocturnal Obstruction and Related Events (SNORE-25) score will be recorded by both the partner and the snorer at baseline and follow up. The SNORE-25 score is calculated as the mean item score for all 25 items. The possible range for the SNORE-25 score is 0-5, with higher scores indicating greater sleep disordered-related health burden. Impact of treatment is assessed with the SNORE-25 Change Score. The SNORE-25 Change Score is the difference between SNORE-25 Pre-treatment and SNORE-25 Post-Treatment scores. Minimal Clinically Important Difference. A SNORE-25 Change Score of 0.5 should be considered the minimal clinically important difference and change scores greater than this should be considered clinically meaningful. | Baseline and 4 weeks post intervention beginning | 
| Change in Pittsburgh Sleep Quality Index (PSQI) | The PSQI is a self-rate questionnaire which assess sleep quality and disturbances over a 1-month time interval. It is composed of 19 items. PSQI score will be recorded by both the partner and the snorer at baseline and follow up. Change in PSQI score will be calculated and reported as a secondary outcome measure as the change in PSQI score or the difference in percentage of participates recording a PSQI improvement above the Minimal Clinically Important Difference (4.4) compared between the two arms. | Baseline and 4 weeks post intervention beginning | 
| Percent Responder of Clinical Global Impression of Improvement Scale - Snorer | The Snorer will grade the improvement of their own snoring on the following scale, which will be the Clinical Global Impression of Improvement (CGI-I) scale: Very Much Improved Much Improved Minimally Improved No Change Minimally Worse Much Worse Very Much Worse The percentage of responders to treatment will then be compared between the two arms of the trial. A responder will be defined as someone who rates the response to snoring as either Very Much Improved or Much Improved | 4 weeks post intervention beginning | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Mandibular Advancement Devices (MAD), external nasal dilator, mouth tapping, lateral positional therapy, Breath-rite strip, Mometasone Nasal Rinse