The Effect of Bite Raise on AHI Values in Adult Patients Affected by OSA: A Systematic Review with Meta-Regression.

Obstructive sleep apnea (OSA) is a highly prevalent sleep breathing disorder characterized by the collapse of the pharyngeal walls that entails recurrent episodes of cessation of breathing or decrease in airflow while sleeping. This results in sleep fragmentation, decreased oxygen saturation and an increase in the partial pressure of carbon dioxide, causing excessive daytime sleepiness, hypertension and increased prevalence of cardiovascular morbidity and mortality. Mandibular advancement devices (MAD) represent a valid alternative therapy to Continuous Positive Airway Pressure, thrusting the mandible forward, increasing the lateral diameter of the pharynx and reducing the collapsibility of the airway. Several investigations have focused on the detection of the best mandibular advancement amount in terms of effectiveness and tolerance, but few and contrasting data are available on the role of occlusal bite raise in reducing the apnea/hypopnea index (AHI). The aim of this systematic review with meta-regression analysis was to investigate the effect of the bite raise of MAD on AHI values in adult patients affected by OSA. An electronic search was performed in MEDLINE, the Cochrane Database, Scopus, Web of Science and LILACS. Randomized controlled trials (RCT) investigating the effectiveness of MAD in OSA patients were included. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias with the Cochrane risk-of-bias tool for randomized trials (RoB2). Six RCT were included. The success rate of each study was computed: (mean baseline AHI - mean post treatment AHI)/mean baseline AHI. The GRADE scores indicated that the quality of evidence was very low. The meta-regression analysis showed that there was no correlation between the occlusal bite raise and the AHI improvement.

Dropout and adherence of obstructive sleep apnoea patients to mandibular advancement device therapy: A systematic review of randomised controlled trials with meta-analysis and meta-regression.

BACKGROUND: Mandibular advancement devices (MADs) are used as an alternative to continuous positive airways pressure to treat obstructive sleep apnoea (OSA) patients, but to date, specific data on the adherence to MAD therapy are lacking. OBJECTIVES: The aim of the present systematic review was to investigate the dropout rate and adherence of OSA patients to different custom-made (CM) and non-custom-made (NCM) MAD therapies. SEARCH METHODS: An electronic search was performed in MEDLINE, Cochrane Database of Systematic Reviews, Scopus, LILACS and Web of Science. SELECTION CRITERIA: Randomised controlled trials (RCTs) assessing the compliance to customised and not customised MADs in the treatment of adult OSA patients were included. DATA COLLECTION AND ANALYSIS: The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in RCT. The dropout rate of each study was computed and the adherence to MAD therapy in terms of hours per night and nights per week was extracted from each study. RESULTS: Thirty-two RCTs were included. The risk of bias resulted low in most of the studies. The GRADE scores indicated that the quality of evidence was from very low to moderate. The meta-analyses showed that the mean dropout rate did not significantly differ between CM and NCM MADs: The overall mean dropout rate was 0.171 [0.128-0.213] with a mean follow-up of 4.1 months. The hours per night adherence was significantly higher for CM MADs (6.418 [6.033-6.803]) compared to NCM MADs (5.107 [4.324-5.890]. The meta-regression showed that the dropout rate increases significantly during time (p < .05). CONCLUSIONS: There is a very low to moderate quality of evidence that the dropout rate of MAD therapy is similar among CM and NCM MADs, that the dropout rate increases significantly during time and that CM MADs have higher hours per night adherence compared with NCM MAD. REGISTRATION: The study protocol was registered on PROSPERO (n. CRD42020199866).

Effectiveness of different mandibular advancement device designs in obstructive sleep apnoea therapy: A systematic review of randomised controlled trials with meta-analysis.

Mandibular advancement devices (MADs) are used to treat patients with obstructive sleep apnoea (OSA). To date, there are no data that identify the most effective MAD design for apnoea-hypopnea index (AHI) reduction. The purpose of this systematic review is to investigate the effectiveness of different MAD designs in AHI reduction and oxygen saturation improvement in OSA patients. An electronic search was performed in MEDLINE, Cochrane Database, Scopus, Web of Knowledge and LILACS. Randomised controlled trials (RCTs) investigating the reduction of AHI on adult patients wearing MAD for OSA were included. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in randomised controlled trial. The success rate of each study was computed: [(mean baseline AHI - mean AHI after treatment)/mean baseline AHI]. Fifty RCTs were included. The risk of bias resulted with some concerns in most of the studies. The GRADE scores indicated that the quality of evidence was very low. The meta-analysis showed a success rate with mono-bloc and duo-bloc MADs respectively of 0.821 [0.722-0.887] and 0.547 [0.443-0.637]. The mono-bloc compared with duo-bloc better improved the minimum oxygen saturation (10.048 [7.733-12.363] and 3.357 [2.290-4.423], respectively). There is a very low quality body of evidence that mono-bloc MADs are more effective in reducing AHI and improving minimum oxygen saturation compared with duo-bloc MADs. The study protocol was registered on PROSPERO (n. CRD42019118084).

Dental and skeletal long-term side effects of mandibular advancement devices in obstructive sleep apnea patients: a systematic review with meta-regression analysis.

Background: Mandibular advancement devices (MAD) are effective in reducing apnea episodes and they are frequently used as first-line therapy in obstructive sleep apnea (OSA) patients. Objectives: The MAD must be used every night for a lifetime and since it performs its function discharging the forces on dental elements the aim of this systematic review was to identify the dental and skeletal long-term side effects of MAD therapy and to evaluate the influence of time on them in OSA or snoring patients. Search Methods: An electronic search was performed in MEDLINE, Cochrane Database, Google Scholar Beta, Scopus, and LILACS. Studies until 4 April 2018 were analysed, without language restrictions. Selection Criteria: Randomized controlled trials and cohort studies investigating dental and/or skeletal side effects on adult patients wearing MAD for OSA or snoring treatment with at least 2 years follow-up were included and independently evaluated by two investigators. Data Collection and Analysis: The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by means of Cochrane's tools. For each study included and for each dental and/or skeletal parameter, the difference in means and 95% CI was calculated between baseline and follow-up. Results: Twenty-one studies with follow-up between 2 and 11 years were included. The side effects reported were a reduction in overjet, overbite, and in the upper incisor inclination, and an increase in lower incisor inclination, A point-Nasion-B point, and anterior facial height. The meta-regression analysis showed that the side effects were influenced by the therapy duration for all parameters (P < 0.05). The quality of evidence was low/moderate. Conclusions: MAD therapy produces time-related dental and skeletal side effects. After a long period of treatment, the dental side effects are clinically relevant and therefore the clinician should inform the patients about this issue. Since the side effects are progressive, patients need to be continuously monitored over time. Registration: The study protocol was not registered.