Oral Appliances in the Management of Obstructive Sleep Apnea
2019; Elsevier BV; Volume: 14; Issue: 1 Linguagem: Inglês
10.1016/j.jsmc.2018.10.012
ISSN1556-4088
Autores Tópico(s)Sleep and Wakefulness Research
Resumo•The concept in oral appliances for obstructive sleep apnea (OSA) management is protrusion of the mandible and/or tongue for structural effects on the upper airway.•The upper airway is a muscular tube and its dimensions are enlarged with mandibular and tongue advancement.•Protrusion of the mandible and tongue stretches the muscles, thereby reducing upper airway collapsibility with airway shape change and increase in muscle tone.•Oral appliances are effective and evidence-based options in managing OSA. •The concept in oral appliances for obstructive sleep apnea (OSA) management is protrusion of the mandible and/or tongue for structural effects on the upper airway.•The upper airway is a muscular tube and its dimensions are enlarged with mandibular and tongue advancement.•Protrusion of the mandible and tongue stretches the muscles, thereby reducing upper airway collapsibility with airway shape change and increase in muscle tone.•Oral appliances are effective and evidence-based options in managing OSA. The primary oral appliance (OA) used in obstructive sleep apnea (OSA) treatment is the mandibular advancement device (MAD). MADs may be either an over-the-counter stock device or customized for individual patients. MADs come in various designs and materials, but most comprise upper and lower splints mounted over the dentition as either a 1-piece monoblock (Fig. 1) or a 2-piece biblock (Fig. 2). Connectors or blocks relate the upper and lower splints in a biblock to protrude the mandible in a forward position during sleep.1Yow M. Lye E.K.W. Obstructive sleep apnea: orthodontic startegies to establish and maintain a patent airway.in: Krishnan V. Davidovitch Z. Integrated clinical orthodontics. 1st edition. Wiley-Blackwell Publishing Ltd, New Jersey (USA)2012: 214-239Crossref Scopus (2) Google ScholarFig. 2Biblock or 2-piece MADs with different connectors.(Courtesy of [upper left] SomnoMed, Sydney, Australia; and [upper right, lower left, and lower right] Orthodontic Master, Singapore.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Tongue-retaining devices, or tongue-stabilizing devices (TSDs) (Fig. 3), are a second type of OA, which displace the tongue anteriorly and may be customized or come in different stock sizes. TSDs use negative pressure and salivary adhesion to hold onto the tongue and anterior lip shields to elongate and reposition the tongue in a more forward position independent of the mandible during sleep, thereby opening the oropharyngeal airway.1Yow M. Lye E.K.W. Obstructive sleep apnea: orthodontic startegies to establish and maintain a patent airway.in: Krishnan V. Davidovitch Z. Integrated clinical orthodontics. 1st edition. Wiley-Blackwell Publishing Ltd, New Jersey (USA)2012: 214-239Crossref Scopus (2) Google Scholar, 2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar TSDs have similar efficacy as MADs but poorer compliance. More than 90% of patients preferred MADs over TSDs for OA therapy.3Deane S.A. Cistulli P.A. Ng A.T. et al.Comparison of mandibular advancement splint and tongue stabilizing device in obstructive sleep apnea: a randomized controlled trial.Sleep. 2009; 32: 648-653Crossref PubMed Scopus (89) Google Scholar The evidence base is stronger for MADs and considerably lower for TSDs.2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar, 4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 5Chang E.T. Fernandez-Salvador C. Giambo J. et al.Tongue retaining devices for obstructive sleep apnea: a systematic review and meta-analysis.Am J Otolaryngol. 2017; 38: 272-278Crossref PubMed Scopus (16) Google Scholar Airway imaging with cone-beam computed tomography, magnetic resonance imaging and nasal endoscopy showed anteroposterior (AP) mandibular protrusion predominantly increases the caliber of the airway at the retropalatal area via lateral expansion and displacement of parapharyngeal fat pads2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar, 6Ishida M. Inoue Y. 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McKenzie D.K. et al.Tongue and lateral upper airway movement with mandibular advancement.Sleep. 2013; 36: 397-404Crossref PubMed Scopus (66) Google Scholar while the tongue and tongue-base muscles shift forward.2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar, 9Chan A.S. Sutherland K. Schwab R.J. et al.The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea.Thorax. 2010; 65: 726-732Crossref PubMed Scopus (205) Google Scholar, 13Brown E.C. Cheng S. McKenzie D.K. et al.Tongue and lateral upper airway movement with mandibular advancement.Sleep. 2013; 36: 397-404Crossref PubMed Scopus (66) Google Scholar The lateral widening from AP movement is attributed to stretching of soft tissue connections between the tongue, soft palate, and lateral pharyngeal walls.11Kuna S.T. Woodson L.C. Solanki D.R. et al.Effect of progressive mandibular advancement on pharyngeal airway size in anesthetized adults.Anesthesiology. 2008; 109: 605-612Crossref PubMed Scopus (25) Google Scholar, 14Isono S. Tanaka A. Sho Y. et al.Advancement of the mandible improves velopharyngeal airway patency.J Appl Physiol (1985). 1995; 79: 2132-2138Crossref PubMed Scopus (163) Google Scholar, 15Isono S. Tanaka A. Tagaito Y. et al.Pharyngeal patency in response to advancement of the mandible in obese anesthetized persons.Anesthesiology. 1997; 87: 1055-1062Crossref PubMed Scopus (109) Google Scholar Dynamic MRI suggests a direct connection between lateral pharyngeal walls and the ramus, postulated to be the pterygomandibular raphe.13Brown E.C. Cheng S. McKenzie D.K. et al.Tongue and lateral upper airway movement with mandibular advancement.Sleep. 2013; 36: 397-404Crossref PubMed Scopus (66) Google Scholar TSDs increase airway AP diameter to a greater degree than MADs, and traction on intrapharyngeal connections through the tongue base additionally increases the lateral dimension of the airway. Compared with MADs, TSDs produce greater increases in retropalatal and retroglossal cross-sectional area (CSA). This is attributed to greater anterior tongue movement with TSDs.2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar Lateral expansion with both MADs and TSDs promotes an elliptical cross-sectional shape with a transverse long axis.2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar A small but significant decrease in upper airway length has been found with MAD use,2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar which may counteract the airway length increase from lying supine demonstrated in OSA patients.16Pae E.K. Lowe A.A. Fleetham J.A. A role of pharyngeal length in obstructive sleep apnea patients.Am J Orthod Dentofacial Orthop. 1997; 111: 12-17Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Electromyography shows that MADs increase activation of masseter, lateral pterygoid, genioglossus, and geniohyoid muscles. It is postulated that on top of the purely structural anatomic effects of MADs, increased neuromuscular activation contributes to upper airway patency.17Yoshida K. Effect of a prosthetic appliance for treatment of sleep apnea syndrome on masticatory and tongue muscle activity.J Prosthet Dent. 1998; 79: 537-544Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 18Johal A. Gill G. Ferman A. et al.The effect of mandibular advancement appliances on awake upper airway and masticatory muscle activity in patients with obstructive sleep apnoea.Clin Physiol Funct Imaging. 2007; 27: 47-53Crossref PubMed Scopus (52) Google Scholar, 19Kurtulmus H. Cotert S. Bilgen C. et al.The effect of a mandibular advancement splint on electromyographic activity of the submental and masseter muscles in patients with obstructive sleep apnea.Int J Prosthodont. 2009; 22: 586-593PubMed Google Scholar Morphologic increase in CSA, change in cross-sectional shape, decrease in airway length, and neuromuscular activation with MAD may contribute to reduced collapsibility.2Sutherland K. Deane S.A. Chan A.S. et al.Comparative effects of two oral appliances on upper airway structure in obstructive sleep apnea.Sleep. 2011; 34: 469-477Crossref PubMed Scopus (59) Google Scholar, 12Choi J.K. Hur Y.K. Lee J.M. et al.Effects of mandibular advancement on upper airway dimension and collapsibility in patients with obstructive sleep apnea using dynamic upper airway imaging during sleep.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 109: 712-719Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 20Malhotra A. Huang Y. Fogel R.B. et al.The male predisposition to pharyngeal collapse: importance of airway length.Am J Respir Crit Care Med. 2002; 166: 1388-1395Crossref PubMed Scopus (305) Google Scholar Empirically, a significant reduction in upper airway collapsibility in stage 2 and stage 3 sleep was observed with MAD use. Improvement in collapsibility was significantly greater in complete responders than in partial responders or nonresponders.21Ng A.T. Gotsopoulos H. Qian J. et al.Effect of oral appliance therapy on upper airway collapsibility in obstructive sleep apnea.Am J Respir Crit Care Med. 2003; 168: 238-241Crossref PubMed Scopus (144) Google Scholar Airway collapsibility may have a dose-dependent relationship with mandibular advancement.10Kato J. Isono S. Tanaka A. et al.Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep-disordered breathing.Chest. 2000; 117: 1065-1072Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar Continuous positive airway pressure (CPAP) and MADs are chronic, noninvasive, symptomatic treatments for OSA that do not treat the underlying anatomic basis of the condition. Pneumatic splinting of the airway with CPAP is acknowledged as the gold standard for treatment of OSA, although MAD has been progressively recommended with each iteration of the American Academy of Sleep Medicine (AASM) guidelines.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 22Kushida C.A. Morgenthaler T.I. Littner M.R. et al.Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005.Sleep. 2006; 29: 240-243Crossref PubMed Scopus (488) Google Scholar, 23Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. American Sleep Disorders Association.Sleep. 1995; 18: 511-513Crossref PubMed Scopus (264) Google Scholar The latest AASM guidelines do not specify a particular disease severity for MAD use due to lack of evidence relating MAD efficacy to disease severity.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar MADs are efficacious in reducing apnea-hypopnea index (AHI) although there is individual variability.24Sutherland K. Vanderveken O.M. Tsuda H. et al.Oral appliance treatment for obstructive sleep apnea: an update.J Clin Sleep Med. 2014; 10: 215-227Crossref PubMed Scopus (262) Google Scholar A nonlinear dose-dependent relationship with degree of advancement is reported.25Raphaelson M.A. Alpher E.J. Bakker K.W. et al.Oral appliance therapy for obstructive sleep apnea syndrome: progressive mandibular advancement during polysomnography.Cranio. 1998; 16: 44-50Crossref PubMed Scopus (40) Google Scholar, 26Tsai W.H. Vazquez J.C. Oshima T. et al.Remotely controlled mandibular positioner predicts efficacy of oral appliances in sleep apnea.Am J Respir Crit Care Med. 2004; 170: 366-370Crossref PubMed Scopus (82) Google Scholar, 27Gindre L. Gagnadoux F. Meslier N. et al.Mandibular advancement for obstructive sleep apnea: dose effect on apnea, long-term use and tolerance.Respiration. 2008; 76: 386-392Crossref PubMed Scopus (53) Google Scholar, 28Almeida F.R. Parker J.A. Hodges J.S. et al.Effect of a titration polysomnogram on treatment success with a mandibular repositioning appliance.J Clin Sleep Med. 2009; 5: 198-204Crossref PubMed Scopus (49) Google Scholar, 29Aarab G. Lobbezoo F. Hamburger H.L. et al.Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea.Clin Oral Investig. 2010; 14: 339-345Crossref PubMed Scopus (107) Google Scholar, 30Dort L. Remmers J. A combination appliance for obstructive sleep apnea: the effectiveness of mandibular advancement and tongue retention.J Clin Sleep Med. 2012; 8: 265-269Crossref PubMed Scopus (12) Google Scholar The efficacy of CPAP over MAD in reducing AHI is well established and has been consistently reported by meta-analyses comparing the 2,4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 31Giles T.L. Lasserson T.J. Smith B.H. et al.Continuous positive airways pressure for obstructive sleep apnoea in adults.Cochrane Database Syst Rev. 2006; (CD001106)Crossref Google Scholar, 32Lim J. Lasserson T.J. Fleetham J. et al.Oral appliances for obstructive sleep apnoea.Cochrane Database Syst Rev. 2006; (CD004435)Google Scholar, 33Schwartz M. Acosta L. Hung Y.L. et al.Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis.Sleep Breath. 2018; 22: 555-568Crossref PubMed Scopus (93) Google Scholar, 34Zhang M. Liu Y. Liu Y. et al.Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: an updated meta-analysis.Cranio. 2018; : 1-18Google Scholar even with increasing numbers of primary studies. According to the AASM/American Academy of Dental Sleep Medicine (AADSM) task force, CPAP is significantly better than MAD at reducing AHI scores (difference of 6.24 events per hour).4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar A recent meta-analysis of 14 randomized controlled trials reported that CPAP reduced AHI by an additional 8.43 events per hour over MAD.34Zhang M. Liu Y. Liu Y. et al.Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: an updated meta-analysis.Cranio. 2018; : 1-18Google Scholar MADs are efficacious in improving minimum arterial oxygen saturation (Sao2), and the improvement has been reported to have a nonlinear dose-dependent relationship with degree of advancement.10Kato J. Isono S. Tanaka A. et al.Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep-disordered breathing.Chest. 2000; 117: 1065-1072Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar Similar to AHI, the finding of better improvement in Sao2 with CPAP over MAD has been consistently reported.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 31Giles T.L. Lasserson T.J. Smith B.H. et al.Continuous positive airways pressure for obstructive sleep apnoea in adults.Cochrane Database Syst Rev. 2006; (CD001106)Crossref Google Scholar, 32Lim J. Lasserson T.J. Fleetham J. et al.Oral appliances for obstructive sleep apnoea.Cochrane Database Syst Rev. 2006; (CD004435)Google Scholar, 34Zhang M. Liu Y. Liu Y. et al.Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: an updated meta-analysis.Cranio. 2018; : 1-18Google Scholar The AASM/AADSM task force reported that CPAP is slightly better at improving oxygenation (Sao2 difference of 3.11%) compared with MADs.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar More recently, a significant effect on Sao2 in favor of CPAP was reported.34Zhang M. Liu Y. Liu Y. et al.Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: an updated meta-analysis.Cranio. 2018; : 1-18Google Scholar Comparing subjective self-reported MAD compliance with objective recorded CPAP compliance, MAD compliance is better. The AASM/AADSM task force reported that MADs were used 0.70 more hours per night than CPAP.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar Objective measurements of OA usage after 3 months of OA treatment ranged from a mean of 6.4 hours to 6.6 hours per night.35Dieltjens M. Verbruggen A.E. Braem M.J. et al.Determinants of objective compliance during oral appliance therapy in patients with sleep-disordered breathing: a prospective clinical trial.JAMA Otolaryngol Head Neck Surg. 2015; 141: 894-900Crossref PubMed Scopus (33) Google Scholar, 36Vanderveken O.M. Dieltjens M. Wouters K. et al.Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing.Thorax. 2013; 68: 91-96Crossref PubMed Scopus (150) Google Scholar A meta-analysis of 6 studies encompassing both subjective and objective MAD compliance measures reported an additional 1.1 hours per night use of MAD over CPAP.33Schwartz M. Acosta L. Hung Y.L. et al.Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis.Sleep Breath. 2018; 22: 555-568Crossref PubMed Scopus (93) Google Scholar A majority of crossover trials report that MADs are preferred to CPAP, which may imply better patient compliance with MADs.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 37Sutherland K. Phillips C.L. 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Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and oral appliances.J Dent Sleep Med. 2015; 2: 175-181Crossref Google Scholar MADs improve subjective daytime sleepiness measured by Epworth Sleepiness Scale (ESS) scores significantly.39Ahrens A. McGrath C. Hagg U. Subjective efficacy of oral appliance design features in the management of obstructive sleep apnea: a systematic review.Am J Orthod Dentofacial Orthop. 2010; 138: 559-576Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Despite better efficacy with CPAP than MADs in reducing AHI and improving Sao2, differences in ESS scores are more ambiguous. A network meta-analysis of 67 studies found that CPAP and MADs are both effective in reducing excessive daytime sleepiness as assessed by the ESS, but CPAP is likely to be more effective than MADs, with a greater reduction in ESS by an average of 0.8 points.40Bratton D.J. Gaisl T. Schlatzer C. et al.Comparison of the effects of continuous positive airway pressure and mandibular advancement devices on sleepiness in patients with obstructive sleep apnoea: a network meta-analysis.Lancet Respir Med. 2015; 3: 869-878Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Other reviews have reported either similar outcomes4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 32Lim J. Lasserson T.J. Fleetham J. et al.Oral appliances for obstructive sleep apnoea.Cochrane Database Syst Rev. 2006; (CD004435)Google Scholar or slightly better outcomes with CPAP.33Schwartz M. Acosta L. Hung Y.L. et al.Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis.Sleep Breath. 2018; 22: 555-568Crossref PubMed Scopus (93) Google Scholar, 34Zhang M. Liu Y. Liu Y. et al.Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: an updated meta-analysis.Cranio. 2018; : 1-18Google Scholar Aside from long-term health effects, untreated OSA also affects health-related quality of life, with hypersomnolence impacting ability to function.41Ng A. Gotsopoulos H. Darendeliler A.M. et al.Oral appliance therapy for obstructive sleep apnea.Treat Respir Med. 2005; 4: 409-422Crossref PubMed Scopus (31) Google Scholar Function and quality of life are commonly measured using both the sleep-specific Functional Outcomes of Sleep Questionnaire (FOSQ) and generic Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). MADs are associated with improvements in FOSQ subscale and total scores as well as SF-36 scores.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 42Blanco J. Zamarron C. Abeleira Pazos M.T. et al.Prospective evaluation of an oral appliance in the treatment of obstructive sleep apnea syndrome.Sleep Breath. 2005; 9: 20-25Crossref PubMed Scopus (111) Google Scholar, 43Gauthier L. Laberge L. Beaudry M. et al.Efficacy of two mandibular advancement appliances in the management of snoring and mild-moderate sleep apnea: a cross-over randomized study.Sleep Med. 2009; 10: 329-336Crossref PubMed Scopus (66) Google Scholar Minimal difference was found between CPAP and MAD with respect to improvements in daytime functional outcomes measured by SF-36 and FOSQ scores.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar This finding was corroborated in a meta-analysis,44Kuhn E. Schwarz E.I. Bratton D.J. et al.Effects of CPAP and mandibular advancement devices on health-related quality of life in OSA: a systematic review and meta-analysis.Chest. 2017; 151: 786-794Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar with direct comparisons as well as network meta-analysis showing no significant difference in treatment outcomes between CPAP and MAD in the mental and physical components of SF-36. Other meta-analyses have also reported no difference in FOSQ or SF-36 scores.31Giles T.L. Lasserson T.J. Smith B.H. et al.Continuous positive airways pressure for obstructive sleep apnoea in adults.Cochrane Database Syst Rev. 2006; (CD001106)Crossref Google Scholar, 32Lim J. Lasserson T.J. Fleetham J. et al.Oral appliances for obstructive sleep apnoea.Cochrane Database Syst Rev. 2006; (CD004435)Google Scholar, 33Schwartz M. Acosta L. Hung Y.L. et al.Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis.Sleep Breath. 2018; 22: 555-568Crossref PubMed Scopus (93) Google Scholar, 34Zhang M. Liu Y. Liu Y. et al.Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: an updated meta-analysis.Cranio. 2018; : 1-18Google Scholar Meta-analyses by multiple groups have found MADs to be the equivalent of CPAP at reducing blood pressure in adults with OSA.4Ramar K. Dort L.C. Katz S.G. et al.Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015.J Clin Sleep Med. 2015; 11: 773-827Crossref PubMed Scopus (427) Google Scholar, 34Zhang M. Liu Y. Liu Y. et al.Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: an updated meta-analysis.Cranio. 2018; : 1-18Google Scholar, 45Bratton D.J. Gaisl T. Wons A.M. et al.CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis.Jama. 2015; 314: 2280-2293Crossref PubMed Scopus (211) Google Scholar, 46de Vries G.E. Wijkstra P.J. Houwerzijl E.J. et al.Cardiovascular effects of oral appliance therapy in obstructive sleep apnea: a systematic review and meta-analysis.Sleep Med Rev. 2018; 40: 55-68Crossref PubMed Scopus (39) Google Scholar, 47Van Haesendonck G. Dieltjens M. Kastoer C. et al.Cardiovascular benefits of oral appliance therapy in obstructive sleep apnea: a systematic review.J Dent Sleep Med. 2015; 2: 9-14Google Scholar A network meta-analysis reported that CPAP was associated with a reduction in systolic blood pressure of 2.5 mm Hg and diastolic blood pressure reduction of 2.0 mm Hg. MADs were associated with reduction in systolic blood pressure of 2.1 mm Hg and diastolic blood pressure of 1.9 mm Hg. There was no significant difference between CPAP and MADs.40Bratton D.J. Gaisl T. Schlatzer C. et al.Comparison of the effects of continuous positive airway pressure and mandibular advancement devices on sleepiness in patients with obstructive sleep apnoea: a network meta-analysis.Lancet Respir Med. 2015; 3: 869-878Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Studies on other cardiovascular markers (heart rate variability, circulating cardiovascular biomarkers, endothelial function, and arterial stif
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