Ghosh Parvathy, Janakiram Chandrashekar, Nk Sapna Varma, K Sarika, Vv Ajith
Department of Orthodontics and Dentofacial Orthopedics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India.
Amrita Centre for Evidence Based Oral Health: A JBI Centre of Excellence, Ernakulam, Kerala, India.
JBI Evid Synth. 2025 May 1;23(5):876-919. doi: 10.11124/JBIES-23-00539. Epub 2025 Mar 31.
The aim of this umbrella review was to assess the effectiveness of oral appliance therapy compared to continuous positive airway pressure (CPAP), surgery, inactive appliances/controls, exercise, or other conservative techniques in mitigating symptoms among adults diagnosed with obstructive sleep apnea.
Sleep-disordered breathing encompasses a spectrum of recurrent episodes of upper airway narrowing during sleep, marked by symptoms such as snoring, heightened upper airway resistance, or obstructive sleep apnea. The management of obstructive sleep apnea involves a range of conservative and surgical approaches. Among conservative methods, oral appliances are the preferred treatment for primary snoring, mild to moderate cases, and severe cases in patients who are intolerant to CPAP. While several systematic reviews have explored the effectiveness of oral appliance therapy for obstructive sleep apnea, there has been no comprehensive evaluation or synthesis of these reviews.
Systematic reviews, with or without meta-analysis, were examined to assess the effectiveness of various forms of oral appliances in treating obstructive sleep apnea. Polysomnography was employed as the method for evaluating the effectiveness of the appliance. The primary outcome of interest was the effectiveness of oral appliance therapy in reducing the apnea-hypopnea index. Secondary outcomes included the mean change in the respiratory arousal index, Epworth Sleepiness Scale scores, minimum oxygen saturation, sleep efficiency, rapid eye movement sleep, blood pressure, quality of life, patient preference, and adverse effects.
A comprehensive search was conducted up to October 2023 in MEDLINE (Ovid), CINAHL (EBSCOhost), Scopus, Web of Science Core Collection, Epistemonikos, ProQuest Dissertations and Theses, Shodhganga, and the Cochrane Database of Systematic Reviews. Supplementary searches were manually performed using Google Scholar. The critical appraisal and data extraction processes were carried out independently by 2 reviewers. The extracted data were summarized using a tabular format accompanied by supporting text. The quality of evidence was evaluated utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
This umbrella review incorporated 27 systematic reviews published between 2004 and 2022. The primary studies in these systematic reviews were published between 1996 and 2021. Of the 68 primary studies, 50 were published between 1996 and 2014 and 18 were published between 2015 and 2021. The corrected covered area index was 15.04%, indicating very high overlap between the primary studies included in the systematic reviews. All systematic reviews that compared oral appliances with CPAP consistently reported that CPAP was more efficacious, evidenced by a decrease in the apnea-hypopnea index, respiratory arousal index, and improved minimum oxygen saturation levels. However, patient preference favored oral appliances over CPAP. Additionally, oral appliances demonstrated improvements in subjective sleepiness scores and indices including the apnea-hypopnea index and respiratory arousal index when compared with inactive appliances/controls. The overall quality of evidence using GRADE ranged from very low to moderate.
CPAP demonstrated greater efficacy than oral appliances in reducing the apnea-hypopnea index and respiratory arousal index while increasing minimum oxygen saturation levels, indicating significant improvements in obstructive sleep apnea and contributing to enhanced sleep quality and overall health. Despite these advantages, patient preference often leans toward oral appliances over CPAP. Compared with inactive appliances/controls, surgery, and other conservative management approaches, oral appliances have also shown efficacy in improving obstructive sleep apnea. This umbrella review reinforces CPAP as the gold standard for obstructive sleep apnea treatment, although oral appliances represent a viable alternative, particularly for patients who experience difficulties in accessing or tolerating CPAP. The majority of included systematic reviews were published over a decade ago, highlighting a research gap in this area; therefore, future studies should focus on comparing newer treatment options for obstructive sleep apnea.
本系统综述的目的是评估口腔矫治器疗法与持续气道正压通气（CPAP）、手术、无活性矫治器/对照、运动或其他保守技术相比，在减轻阻塞性睡眠呼吸暂停成年患者症状方面的有效性。
睡眠呼吸障碍包括睡眠期间上气道反复狭窄的一系列发作，其特征为打鼾、上气道阻力增加或阻塞性睡眠呼吸暂停等症状。阻塞性睡眠呼吸暂停的管理涉及一系列保守和手术方法。在保守方法中，口腔矫治器是原发性打鼾、轻度至中度病例以及不耐受CPAP的重度病例的首选治疗方法。虽然有几项系统综述探讨了口腔矫治器疗法对阻塞性睡眠呼吸暂停的有效性，但尚未对这些综述进行全面评估或综合。
对有或无荟萃分析的系统综述进行审查，以评估各种形式的口腔矫治器在治疗阻塞性睡眠呼吸暂停方面的有效性。多导睡眠图被用作评估矫治器有效性的方法。感兴趣的主要结局是口腔矫治器疗法在降低呼吸暂停低通气指数方面的有效性。次要结局包括呼吸唤醒指数、爱泼华嗜睡量表评分、最低血氧饱和度、睡眠效率、快速眼动睡眠、血压、生活质量、患者偏好和不良反应的平均变化。
截至2023年10月，在MEDLINE（Ovid）、CINAHL（EBSCOhost）、Scopus、科学引文索引核心合集、Epistemonikos、ProQuest学位论文和论文库、Shodhganga以及Cochrane系统综述数据库中进行了全面检索。使用谷歌学术进行了补充手动检索。由2名评审员独立进行批判性评价和数据提取过程。提取的数据以表格形式汇总，并附有支持性文本。使用推荐分级评估、制定和评价（GRADE）方法评估证据质量。
本系统综述纳入了2004年至2022年发表的27项系统综述。这些系统综述中的原始研究发表于1996年至2021年之间。在68项原始研究中，50项发表于1996年至2014年之间，18项发表于2015年至2021年之间。校正覆盖面积指数为15.04%，表明系统综述中纳入的原始研究之间重叠度非常高。所有比较口腔矫治器与CPAP的系统综述一致报告，CPAP更有效，呼吸暂停低通气指数、呼吸唤醒指数降低以及最低血氧饱和度水平改善证明了这一点。然而，患者更倾向于选择口腔矫治器而非CPAP。此外，与无活性矫治器/对照相比，口腔矫治器在主观嗜睡评分以及呼吸暂停低通气指数和呼吸唤醒指数等指标方面有所改善。使用GRADE评估的证据总体质量从极低到中等不等。
在降低呼吸暂停低通气指数和呼吸唤醒指数以及提高最低血氧饱和度水平方面，CPAP比口腔矫治器显示出更大的疗效，表明阻塞性睡眠呼吸暂停有显著改善，并有助于提高睡眠质量和整体健康。尽管有这些优点，但患者通常更倾向于选择口腔矫治器而非CPAP。与无活性矫治器/对照、手术和其他保守管理方法相比，口腔矫治器在改善阻塞性睡眠呼吸暂停方面也显示出疗效。本系统综述强化了CPAP作为阻塞性睡眠呼吸暂停治疗的金标准地位，尽管口腔矫治器是一种可行的替代方法，特别是对于难以获得或耐受CPAP的患者。大多数纳入的系统综述发表于十多年前，突出了该领域存在研究空白；因此，未来的研究应侧重于比较阻塞性睡眠呼吸暂停的新治疗选择。
