Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnoea syndrome: a randomised, placebo-controlled trial on self-reported symptoms of common sleep disorders and sleep-related problems

Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review

STUDY OBJECTIVES

We performed a systematic review of long-term health outcomes of continuous positive airway pressure (CPAP) use in adults with obstructive sleep apnea.

METHODS

We updated prior systematic reviews with searches in multiple databases through January 3, 2023. We included randomized controlled trials (RCTs) and adjusted nonrandomized comparative studies that reported prespecified long-term (mostly > 1 year) health outcomes. We assessed risk of bias, conducted meta-analyses, and evaluated strength of evidence.

RESULTS

We found 38 eligible studies (16 trials, 22 observational). All conclusions were of low strength of evidence given study and data limitations. RCTs found no evidence of effect of CPAP on mortality (summary effect size [ES] 0.89; 95% confidence interval [CI] 0.66, 1.21); inclusion of adjusted nonrandomized comparative studies yields an association with reduced risk of death (ES 0.57; 95% CI 0.44, 0.73). RCTs found no evidence of effects of CPAP for cardiovascular death (ES 0.99; 95% CI 0.64, 1.53), stroke (ES 0.99; 95% CI 0.73, 1.35), myocardial infarction (ES 1.05; 95% CI 0.78, 1.41), incident atrial fibrillation (ES 0.89; 95% CI 0.48, 1.63), or composite cardiovascular outcomes (all statistically nonsignificant). RCTs found no evidence of effects for incident diabetes (ES 1.02; 95% CI 0.69, 1.51) or accidents (all nonsignificant) and no clinically significant effects on depressive symptoms, anxiety symptoms, or cognitive function.

CONCLUSIONS

Whether CPAP use for obstructive sleep apnea affects long-term health outcomes remains largely unanswered. RCTs and nonrandomized comparative studies are inconsistent regarding the effect of CPAP on mortality. Current studies are underpowered, with relatively short duration follow-up and methodological limitations.

CITATION

Balk EM, Adam GP, Cao W, Bhuma MR, D'Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. J Clin Sleep Med. 2024;20(6):895-909.

Effect of mandibular advancement appliance use on oral and periodontal health in patients with OSA: a systematic review

STUDY OBJECTIVES

Use of a mandibular advancement appliance (MAA) is an effective treatment option for mild-to-moderate obstructive sleep apnea (OSA). MAA is well-tolerated but undesirable effects may be observed over time. The present systematic review aimed to assess the effect of MAA use on oral and periodontal health in patients with OSA.

METHODS

MEDLINE (PubMed), Cochrane, and Scopus were searched for randomized and non-randomized controlled trials (RCTs, NRCTs), cohorts, and case-control studies reporting on side effects of MAA treatment in OSA patients during a follow-up of at least 6 months.

RESULTS

From a total of 169 articles screened, 28 were selected. The most frequently reported MAA-related effects on oral health were: hypersalivation (weighted mean prevalence, 33.3%), occlusal changes (30.2%), muscle pain (22.9%), tooth discomfort or pain (20.2%), and xerostomia (18.3%). No MAA-related periodontal effect was reported. The periodontal status prior to MAA treatment was rarely assessed and described, but 5 studies (17.8%) stated that periodontitis was an exclusion criterion for MAA. Only one retrospective study specifically evaluated periodontal parameters and reported no significant changes in periodontally healthy patients with OSA using MAA for over 7 years.

CONCLUSION

MAA use is associated with a number of clinical consequences on oral health, but there is no evidence to conclude whether or not MAA affects periodontal health in patients with OSA. This aspect appears to be under-evaluated and should be further investigated in relation to the type of MAA, the duration of treatment, and prior history of periodontitis.

Appliances Therapy in Obstructive Sleep Apnoea: A Systematic Review and Meta-Analysis

Obstructive sleep apnea (OSA) is a recurrent partial or complete obstruction of the upper airway during sleep caused by narrowing or collapse of the pharyngeal wall. It leads to microstimulation and oxyhemoglobin desaturation, resulting in sleepiness and loud snoring. OSA negatively affects the cardiovascular system and may contribute to neurocognitive impairment. The aim of this systematic review is to evaluate the effectiveness and efficacy of appliance therapy in obstructive sleep apnea. The effectiveness was assessed by using the Apnea Hypopnea Index (AHI). An electronic search of the Cochrane Library, PubMed, and Google Scholar was conducted between 1998 and 2021. Articles were independently assessed by three reviewers. The quality of a randomised control trial (RCT) is assessed using the Cochrane risk of bias method. The tool GRADE was used to achieve the desired level of confidence for each outcome reported. Several studies used continuous positive airway pressure (CPAP), mandibular advancement devices (MAD), and tongue retention devices (TRD). The meta-analysis included a total of six papers that met the inclusion criteria. Results showed that CPAP significantly improved AHI compared with an oral appliance (random effects: difference in means = 8.40, 95% CI = 7.21 to 9.60). It was also found that oral appliance (OA) therapy significantly improved AHI compared with baseline before appliance therapy (random effects: mean difference = 13.40, 95% CI = 10.87 to 15.93; p.00001). For mild to moderate OSA, CPAP is considered the gold standard. Our meta-analysis of six RCTs found favorable evidence for OSA patients receiving oral devices; however, they were less effective than CPAP. A subgroup analysis found that MAD may be a beneficial treatment for mild to moderate OSA patients who do not respond to CPAP. The findings suggest that oral appliances may be an effective treatment for OSA, especially in patients with mild to moderate OSA.

Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions

PURPOSE OF REVIEW

Insomnia and obstructive sleep apnea have previously been viewed as completely independent conditions. However, there is now increasing recognition that insomnia and sleep apnea frequently co-occur. Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent condition that is associated with impairment of sleep, daytime function, mental health and physical health outcomes, and mortality risk. This review aims to provide an update on COMISA prevalence, consequences, treatment approaches, and future research directions.

RECENT FINDINGS

People with COMISA experience worse sleep, mental health, physical health, quality of life and longevity compared to people with neither condition, and often compared to those with insomnia alone and sleep apnea alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia is an effective treatment in the presence of treated and untreated sleep apnea, that may also improve manifestations and subsequent management of sleep apnea. Future research is required to understand the etiology of COMISA, and to develop and implement tailored treatment approaches.

SUMMARY

It is important for sleep and respiratory technicians, researchers and clinicians to be aware of the high co-morbidity rates, consequences, and treatment requirements of patients with co-morbid insomnia and sleep apnea.

To compare different non-surgical treatment modalities on treatment of obstructive sleep apnea: A systematic review and meta-analysis

The study aimed to assess the effect of mandibular advancement device (MAD) in patients with obstructive sleep apnea for reduction in 24-h mean blood pressure, sleep quality, Apnea Hypopnea Index (AHI), and patient compliance, compared to continuous positive airway pressure (CPAP), other interventions, or no treatment. Three different databases such as PubMed, EMBASE, and CENTRAL were searched using different search terms till July 2021 as per the inclusion and exclusion criteria. After inclusion of studies, data extraction including risk of bias assessment was done. For each study, we used odds ratio, mean difference, and 95% confidence interval to assess and synthesize the outcomes. The quality of evidence was evaluated as per the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Twenty-one randomized controlled trials were included: 497 patients in the MAD group, 239 patients in the CPAP group, and 274 patients in the sham group. In MAD-CPAP comparison, the results favored CPAP in the reduction of AHI of 3.48 (1.76-5.19). However, unclear results were found for sleep quality measured as Epworth Sleepiness Scale (ESS), patient compliance, and 24-h mean blood pressure. In MAD-sham comparison, the results favored MAD in the reduction of AHI of - 8.39 (-10.90--5.88] and ESS of - 0.91 (-1.70--0.12) and favored sham in terms of patient compliance while, unclear results for 24-h mean blood pressure. The GRADE score indicated that the quality of evidence is very low, low, and moderate for different outcomes. CPAP in comparison to MAD and MAD in comparison to sham showed a significant AHI reduction. However, patient compliance and 24-h mean blood pressure were not significantly different in MAD-CPAP or MAD-sham. Quality of evidence is very low and low when MAD was compared with CPAP and sham, respectively, for AHI.

European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

OSA-patients who refuse/don't adhere to CPAP can profit from established/emerging treatment options. High scientific evidence is lacking. Patients’ values/preference may weigh heavy in the decision for non-CPAP options, while health inequity is a concern.https://bit.ly/3o0tJeP

Clinical Evidence in the Treatment of Obstructive Sleep Apnoea with Oral Appliances: A Systematic Review

Background

Recent clinical guidelines have extended indications for oral appliances to subjects affected by moderate-to-severe obstructive sleep apnoea (OSA). The aim of this systematic review covering this important issue for public health is twofold: updating and summarizing the best available scientific evidence by selecting RCTs of quality only, and identifying the therapeutic pathways that can be transferred to the current clinical practice.

Methods

All the abstracts which were published before February 18, 2019, have been identified in three electronic databases (PubMed, Web of Science, and Cochrane). The Cochrane Collaboration's tool for assessing risk of bias was used as an assessment tool in order to evaluate the quality of the selected studies.

Results

The search strategy yielded 2,260 studies. After removing duplicates and studies that did not comply with the inclusion criteria, 32 full-text articles were assessed for eligibility, and 17 RCTs were finally included in the qualitative synthesis. The 17 selected studies were very heterogeneous in the type of included RCTs in terms of patient inclusion criteria, sample size, distribution of the two genders in the various groups, duration of treatment, and definition of primary and secondary outcomes, without any restriction on the definition of the control group. A common finding was the positive responsiveness of oral appliance treatment in subjects affected by mild-to-moderate OSA with some evidence for cases of severe OSA.

Conclusion

Higher-quality studies are needed in order to provide additional useful guidelines for dental clinicians for OSA management.

[Oral appliances for obstructive sleep apnoea: What can we expect?]

INTRODUCTION

Mandibular appliances are a treatment option for obstructive sleep apnea. There are many designs, but in the literature they tend to be grouped into a single entity without considering that efficiency, tolerance, compliance, or side effects are inherent in the design of each of them. A more detailed literature review is therefore warranted for the reader who wants to understand the relative effectiveness of each appliance.

STATE OF KNOWLEDGE

We conducted a literature search using the "oral appliance" and "obstructive sleep apnea" criteria on Pubmed, Embase and Cochrane. This allowed us to compare outcome parameters by appliance class and to highlight the rare studies comparing different appliances.

CONCLUSIONS

Mandibular appliances are not a homogeneous entity. Common use includes only appliances designed for propulsion (with rods and jacks) and retention. However, the few comparative studies available do not identify which are the most effective types or the types with an optimal efficacy/tolerance ratio.

PERSPECTIVES

Further appliance comparison studies are needed to determine the most effective type or with an optimal efficacy/tolerance ratio.

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions.

METHODS

In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

Prospective Randomized Controlled Trial on the Efficacy of Continuous Positive Airway Pressure and Adaptive Servo-Ventilation in the Treatment of Chronic Complex Insomnia

BACKGROUND

Complex insomnia, the comorbidity of chronic insomnia and obstructive sleep apnea (OSA), is a common sleep disorder, but the OSA component, whether presenting overtly or covertly, often goes unsuspected and undiagnosed due to a low index of suspicion. Among complex insomniacs, preliminary evidence demonstrates standard CPAP decreases insomnia severity. However, CPAP causes expiratory pressure intolerance or iatrogenic central apneas that may diminish its use. An advanced PAP mode-adaptive servo-ventilation (ASV)-may alleviate CPAP side-effects and yield superior outcomes.

METHODS

In a single-site protocol investigating covert complex insomnia (ClinicalTrials.gov identifier: NCT02365064), a low index of suspicion for this comorbidity was confirmed by exclusion of 455 of 660 eligible patients who presented during the study period with overt OSA signs and symptoms. Ultimately, stringent inclusion/exclusion criteria to test efficacy yielded 40 adult, covert complex insomnia patients [average Insomnia Severity Index (ISI) moderate-severe 19.30 (95% CI 18.42-20.17)] who reported no definitive OSA symptoms or risks and who failed behavioral or drug therapy for an average of one decade. All 40 were diagnosed with OSA and randomized (using block randomization) to a single-blind, prospective protocol, comparing CPAP (n = 21) and ASV (n = 19). Three successive PAP titrations fine-tuned pressure settings, facilitated greater PAP use, and collected objective sleep and breathing data. Patients received 14 weeks of treatment including intensive biweekly coaching and follow-up to foster regular PAP use in order to accurately measure efficaciousness. Primary outcomes measured insomnia severity and sleep quality. Secondary outcomes measured daytime impact: OSA-induced impairment, fatigue severity, insomnia impairment, and quality of life. Performance on these seven variables was assessed using repeated measures ANCOVA to account for the multiple biweekly time points.

FINDINGS

At intake, OSA diagnosis and OSA as a cause for insomnia were denied by all 40 patients, yet PAP significantly decreased insomnia severity scores (p = 0.021 in the primary ANCOVA analysis). To quantify effect sizes, mean intake vs endpoint analysis was conducted with ASV yielding nearly twice the effects of CPAP [- 13.2 (10.7-15.7), Hedges' g = 2.50 vs - 9.3 (6.3-12.3), g = 1.39], and between mode effect size was in the medium-large range 0.65. Clinically, ASV led to remission (ISI < 8) in 68% of cases compared to 24% on CPAP [Fisher's exact p = 0.010]. Two sleep quality measures in the ANCOVA analysis again demonstrated superior significant effects for ASV compared to CPAP (both p < 0.03), and pre- and post-analysis demonstrated substantial effects for both scales [ASV (g = 1.42; g = 1.81) over CPAP (g = 1.04; g = 0.75)] with medium size effects between modes (0.54, 0.51). Measures of impairment, residual objective sleep breathing events, and normalized breathing periods consistently demonstrated larger beneficial effects for ASV over CPAP.

INTERPRETATION

PAP therapy was highly efficacious in decreasing insomnia severity in chronic insomnia patients with previously undiagnosed co-morbid OSA. ASV proved superior to CPAP in this first efficacy trial to compare advanced to traditional PAP modes in complex insomnia. Future research must determine the following: pathophysiological mechanisms to explain how OSA causes chronic insomnia; general population prevalence of this comorbidity; and, cost-effectiveness of ASV therapy in complex insomnia. Last, efforts to raise awareness of complex insomnia are urgently needed as patients and providers appear to disregard both overt and covert signs and symptoms of OSA in the assessment of chronic insomnia.

Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: An updated meta-analysis

Objective: To update the meta-analysis comparing the effectiveness of oral appliance (OA) with continuous positive airway pressure (CPAP) in treating patients with obstructive sleep apnea (OSA). Methods: PubMed, ISI Web of Knowledge, Ovid, EBSCO Dentistry & Oral Science Source, The Cochrane Library, and Embase database were searched for RCTs until 23 May 2017. Meta-analyses were performed using RevMan 5.3. Results: Sixteen RCTs were included. Compared with OA, CPAP significantly decreased AHI, min SaO2, ARI, ESS (p < 0.05), with no significant difference in REM%, FOSQ, BP (p ≥ 0.05). OA significantly improved REM% in the severe groups and ESS in the adjustable OA group (p < 0.05). OA shared greater preference. Conclusion: Even though CPAP can better decrease the severity of OSA, more patients opted for OA, which showed better results in severe patients, especially adjustable OA.

The Effects of Noncontinuous Positive Airway Pressure Therapies on the Aerodynamic Characteristics of the Upper Airway of Obstructive Sleep Apnea Patients: A Systematic Review

PURPOSE

The effects of noncontinuous positive airway pressure (non-CPAP) therapies on the airflow in the upper airway in obstructive sleep apnea (OSA) patients are not completely clear yet. Therefore, the primary aim of this systematic review was to determine the effects of various non-CPAP therapies on the aerodynamic characteristics of the upper airway in OSA patients.

MATERIALS AND METHODS

A PICO (population or patient, intervention, comparison, outcome) search strategy, focusing on the effects of various non-CPAP therapies on the aerodynamic characteristics of the upper airway (ie, velocity, wall shear stress, wall static pressure, airway resistance, pressure drop, and pressure effort) of OSA patients, was conducted in the following databases: MEDLINE (PubMed), Embase (Excerpta Medica), and Web of Science. In this systematic review, the inclusion criteria were 1) adults diagnosed with OSA by polysomnography, 2) treatment outcome assessed by a second polysomnography, and 3) computational fluid dynamics (CFD) applied.

RESULTS

Of 51 unique studies retrieved, 9 fulfilled the criteria for this systematic review. Seven studies were on maxillomandibular advancement (MMA) surgery, and 2 were on mandibular advancement device (MAD) therapy. The aerodynamic characteristics of the upper airway improved in OSA patients who underwent MMA surgery. However, the studies on MMA surgery included only responders to MMA surgery. In the responders to MAD therapy, the velocity, wall static pressure, and airway resistance of the upper airway decreased. In nonresponders to MAD therapy, the wall static pressure and airway resistance of the upper airway increased.

CONCLUSIONS

This systematic review suggests that MMA surgery and MAD therapy may improve several aerodynamic characteristics of the upper airway in OSA patients by CFD analysis. However, because of limitations of the selected studies, there is not enough evidence yet to support CFD analysis as a routine tool to predict the treatment outcome in OSA patients.

Non-surgical treatment of obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS), a pervasive disease, is closely associated with complications such as cardiovascular diseases, neurocognitive diseases, and metabolic syndromes. Continuous positive airway pressure (CPAP) is the standard treatment for OSAS, with low compliance due to multifarious factors. The two other modes of ventilation, bi-level positive airway pressure (BPAP) and autotitrating positive airway pressure (APAP), which were developed from CPAP, are slightly different from CPAP in specific groups, as well as the corresponding treatment effect and compliance. The compliance of traditional positional therapy is not high, but with the emergence of the neck-based position treatment device, its compliance and indications have changed. Although CPAP is superior to mandibular advancement device (MAD) in improving AHI, MAD seems to be comparable to CPAP in improving other indicators. Corticosteroids and leukotriene receptor antagonists are effective treatments for mild OSAS children. Whether corticosteroids can be used in other OSAS groups and their adjunctive functions to CPAP remains unclear. The combination of these two kinds of drugs appears to be more effective than single drug. Researches on transcutaneous electrical stimulation are still not enough. Its effectiveness and stimulation settings still need further study. This review summarized the various OSAS non-surgical treatments from indications, treatment outcomes, compliance, adverse reactions, and recent progress.