Oral appliances for obstructive sleep apnoea
Abstract
Background
Obstructive sleep apnoea‐hypopnoea is a syndrome characterised by recurrent episodes of partial or complete upper airway obstruction during sleep that are usually terminated by an arousal. Nasal continuous positive airway pressure is the primary treatment for obstructive sleep apnoea‐hypopnoea, but many patients are unable or unwilling to comply with this treatment. Oral appliances are an alternative treatment for sleep apnoea.
Objectives
The objective was to review the effects of oral appliance in the treatment of sleep apnoea in adults.
Search methods
We searched the Cochrane Airways Group Sleep Apnoea RCT Register. Searches were current as of June 2004. Reference lists of articles were also searched.
Selection criteria
Randomised trials comparing oral appliance with control or other treatments in adults with sleep apnoea.
Data collection and analysis
Trial quality was assessed and two reviewers extracted data independently. Study authors were contacted for missing information.
Main results
Thirteen trials involving 553 participants were included. All the studies had some shortcomings, such as small sample size, under‐reporting of methods and data, and lack of blinding. Oral appliances versus control appliances (five studies): Oral appliances reduced daytime sleepiness in two crossover trials (WMD ‐1.81 [95%CI: ‐2.72, ‐0.90]), and improved apnoea‐hypopnoea index (AHI) (‐13.17 [‐18.53 to ‐7.80] parallel group data ‐ four studies). Oral appliances versus CPAP (seven studies): Oral appliances were less effective than continuous positive pressure in reducing apnoea‐hypopnoea index (WMD 13 [95% CI: 7.63, 18.36], parallel studies ‐ two trials; WMD 6.96 [4.82, 9.10] cross‐over studies ‐ six trials). However, no significant difference was observed on symptom scores. Nasal continuous positive pressure was more effective at improving minimum arterial oxygen saturation during sleep compared with oral appliance. In two small crossover studies, participants preferred oral appliance therapy to continuous positive airways pressure. Oral appliances versus surgery (one study): Symptoms of daytime sleepiness were initially lower with surgery, but this difference disappeared at 12 months. AHI did not differ significantly initially, but did so after 12 months in favour of OA.
Authors' conclusions
There is some evidence suggesting that oral appliance improves subjective sleepiness and sleep disordered breathing compared with a control. Nasal continuous positive airways pressure appears to be more effective in improving sleep disordered breathing than oral appliance. Until there is more definitive evidence on the effectiveness of oral appliances, it would appear to be appropriate to restrict oral appliance therapy to patients with sleep apnoea who are unwilling or unable to comply with continuous positive airways pressure therapy.
PICOs
Plain language summary
Current evidence has not demonstrated that oral appliances are as effective as continuous positive airways pressure in the treatment of obstructive sleep apnoea‐hypopnoea.
Sleep apnoea is characterized by recurrent episodes of partial or complete upper airway obstruction during sleep, leading to a variety of symptoms including excessive daytime sleepiness. The current first choice therapy is continuous positive airways pressure that keeps the upper airway patent during sleep. However, this treatment can be difficult for patients to tolerate and comply with on a long‐term basis. Oral appliances have been proposed as an alternative to continuous positive pressure therapy. They are designed to keep the upper airway open by either advancing the lower jaw forward or by keeping the mouth open during sleep. This review found that there was insufficient evidence to recommend the use of oral appliances as first choice therapy for sleep apnoea. When an active oral appliance was compared with an inactive oral appliance, there were improvements in daytime sleepiness and apnoea/hypopnoea severity. However, oral appliances proved less successful than continuous positive pressure in decreasing sleep disordered breathing. When oral appliances were effective in treating sleep apnoea it was preferred to continuous positive pressure by some patients. Oral appliances may be more effective than corrective upper airway surgery.
