REVIEW ARTICLE | https://doi.org/10.5005/jp-journals-10069-0088 |
Effect of Mandibular Advancement through Oral Appliance Therapy on Quality of Life in Obstructive Sleep Apnea: A Scoping Review
1–4Department of Orthodontics and Dentofacial Orthopaedics, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India
Corresponding Author: Nisha Kalonia, Department of Orthodontics and Dentofacial Orthopaedics, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India, Phone: +91 8527024024, e-mail: nishakalonia032@gmail.com
How to cite this article: Kalonia N, Raghav P, Amit K, et al. Effect of Mandibular Advancement through Oral Appliance Therapy on Quality of Life in Obstructive Sleep Apnea: A Scoping Review. Indian J Sleep Med 2021;16(4):125–130.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Purpose: The scoping review was conducted for the evaluation of effect of mandibular advancement through oral appliance therapy on quality of life in obstructive sleep apnea (OSA).
Methods: Strategic and thorough literature search using free text and MESH terms in three major database systems PubMed, SCOPUS, and Web of Science was undertaken till October 30, 2020, followed by PRISMA for the identification of studies for data extraction.
Results and conclusions: Summarization of evidence was done for study characteristics, and diagnostic methods for the evaluation of effect of mandibular advancement through oral appliance therapy on quality of life in OSA.
The literature supports that patients using mandibular advancement appliances (MADs) showed better adherence and compliance in comparison with those using continuous positive airway pressure (CPAP); along with the patients’ compliance, the daytime sleepiness, state on waking, morning headache, oxygen saturation, frequency and intensity of snoring, and quality of sleep for both patients and their bed partners showed a marked improvement with MAD.
Keywords: Health status, MAD, Obstructive sleep apnea, Oral appliance, Quality of life, Scoping review.
INTRODUCTION
Recurrence of partial or complete upper airway obstruction during sleep leads to variable symptoms such as excessive daytime sleepiness,1 snoring, gasping, snorting, insomnia, nocturia, bedwetting, memory loss or concentration issues, mood swings, irritation, and decreased libido.2
According to the Sleep Heart Health Study, the increased risk of moderate to severe obstructive sleep apnea (OSA) was 20% in blacks and 23% in American Indians compared with that of whites, that is, 17%.2
Higher risk for OSA was found in men than in women, even once women reach menopause risk for OSA increases similar in percentage to men.2 The risk of OSA increases with age, and this may be due to a reduction in slow-wave sleep with age (i.e., deep sleep), which is a protective mechanism against sleep-disordered breathing and collapse of airway.
Comorbid conditions associated with OSA include stroke, hypertension, hyperlipidemia, myocardial infarction, glucose intolerance, diabetes, pulmonary hypertension, congestive heart failure, arrhythmias including atrial fibrillation, and depression. Patients suffering from moderate or severe OSA are at higher risk for these conditions.2
To assess the risk of OSA among the population, different questionnaires have been formulated, and the proposed notable ones among them are Berlin questionnaire (BQ), used in the setting for primary care, and the STOP-Bang Questionnaire, for the screening of preoperative procedures. The Epworth sleepiness scale (ESS) is used to assess sleepiness in both clinical practices and research work.
If clinically it is evaluated as OSA, it requires overnight testing for confirmatory diagnosis. The polysomnography (PSG) is the standard diagnostic test, in which monitoring of both sleep parameters and respiratory parameters is done. Behavioral modification measures, medical devices, and surgery are the treatments for OSA.3
Behavioral modifications include regular aerobic exercise, weight loss abstinence from alcohol, and not to sleep in supine position. In patients suffering from positional OSA [i.e., elevated apnea hypopnea index (AHI) predominantly in the supine position], avoid sleeping to the side or sleeping in prone position is the treatment. Other factors associated with improvement in severity of OSA are lifestyle interventions, bariatric surgery, and weight loss medication.3
Primary therapy for individuals with symptomatic OSA of any severity is continuous positive airway pressure (CPAP) as it keeps the upper airway patent during sleep. However, on a long-term basis, there is difficulty in patient tolerance and compliance to this treatment. Oral appliances have been proposed as an alternative method to CPAP therapy. They are designed in such a way so that the upper airway is kept open by either forward advancement of the lower jaw or by keeping the mouth open during sleep.3 Thus, OAs can be offered as alternate therapies due to side effects or inability to use CPAP.4
Therefore, this scoping review was conducted to evaluate the “Effect of mandibular advancement through oral appliance therapy on quality of life in obstructive sleep apnea (OSA)”.
SEARCH STRATEGY AND SELECTION CRITERIA
The scoping review was conducted to evaluate the “Effect of mandibular advancement through oral appliance therapy on quality of life in obstructive sleep apnea (OSA)”. Considering the effect of oral appliances on the quality of life in OSA patients, this review included the publications that hold the search terms that were searched up till October 30, 2020. The PRISMA search strategy was prepared using the MESH terms and Boolean terminology: ((obstructive AND sleep AND (apnoea OR apnea)) OR (sleep AND breathing AND disorder* OR respiratory AND disorder*)) OR “sleep-disordered breathing”) AND (“Orthodontic Appliances” OR ((oral OR dental OR (mandib* AND (advancement OR repositioning*))) AND (device* OR appliance* OR splint) AND (“quality of life” OR qol OR “health status” OR “functional status” OR “self rated health” OR “self perceived health” OR nhp OR “SF-36 mental component” OR “SF-36 physical component” OR “FOSQ” OR “EuroQol” OR “SAQLI”). This search strategy was applied to the PUBMED, SCOPUS, and WEB OF SCIENCE databases. All types of studies are included. Using PICO (participants, intervention, comparator, and outcome) criteria, data extraction was done by two researchers individually, and discordance was addressed by the third researcher. Thorough screening of included articles was done, and the level of evidence was determined based on Oxford Centre for Evidence-based Medicine (OCEBM) (Table 1).
| Question | Step 1 (Level 1*) | Step 2 (Level 2*) | Step 3 (Level 3*) | Step 4 (Level 4*) | Step 5 (Level 5) |
|---|---|---|---|---|---|
| How common is the problem? | Local and current random sample surveys (or censuses) | Systematic review of surveys that allow matching to local circumstances** | Local non-random sample** | Case-series** | n/a |
| Is this diagnostic or monitoring test accurate? (Diagnosis) | Systematic review of cross-sectional studies with consistently applied reference standard and blinding | Individual cross-sectional studies with consistently applied reference standard and blinding | Non-consecutive studies, or studies without consistently applied reference standards** | Case-control studies, or “poor or non-independent reference standard** | Mechanism-based reasoning |
| What will happen if we do not add a therapy? (Prognosis) | Systematic review of inception cohort studies | Inception cohort studies | Cohort study or control arm of randomized trial* | Case-series or case-control studies, or poor quality prognostic cohort study** | n/a |
| Does this intervention help? (Treatment Benefits) | Systematic review of randomized trials or n-of-1 trials | Randomized trial or observational study with dramatic effect | Non-randomized controlled cohort/follow-up study** | Case-series, case-control studies, or historically controlled studies** | Mechanism-based reasoning |
| What are the COMMON harms? (Treatment Harms) | Systematic review of randomized trials, systematic review of nested case-control studies, n-of-1 trial with the patient you are raising the question about, or observational study with dramatic effect | Individual randomized trial or (exceptionally) observational study with dramatic effect | Non-randomized controlled cohort/follow-up study (post-marketing surveillance) provided there are sufficient numbers to rule out a common harm. (For long-term harms the duration of follow-up must be sufficient.)** | Case-series, case-control, or historically controlled studies** | Mechanism-based reasoning |
| What are the RARE harms? (Treatment Harms) | Systematic review of randomized trials or n-of-1 trial | Randomized trial or (exceptionally) observational study with dramatic effect | |||
| Is this (early detection) test worthwhile? (Screening) | Systematic review of randomized trials | Randomized trial | Non-randomized controlled cohort/follow-up study** | Case-series, case-control, or historically controlled studies** | Mechanism-based reasoning |
RESULTS
Study Selection
A total of 3,202 articles were determined through search strategy and sources listed previously. After the removal of duplicates, 1,013 articles remained. After the titles had been screened, a total of 937 articles were rejected as they were not matching the search question. After the screening of abstracts, 10 articles were excluded as they had no relation to orthodontic appliance therapy, not explaining the quality of life, and were not in the English language. The remaining 66 articles were completely evaluated for the text, out of which 28 articles were excluded as they had no relation to oral appliance therapy, not explaining the quality of life, included surgical intervention, and were not in the English language. Finally, 38 articles were included in the review (Flowchart 1).
Flowchart 1: The search algorithm followed according to PRISMA statement
Study Characteristics
Summarized methodological data and study results are mentioned in Table 2. The included articles were in English and published between 2011 and 2020. The articles included were on mandibular advancement appliances (MAD); comparison between the different designs of MAD; the effect of orthodontic appliances on temporomandibular joint (TMJ) and stomatognathic system; and comparison between positional therapy, CPAP, and oral appliances with their effects on quality of life. There were three pilot studies, one longitudinal follow-up study, one case–control study, two nonrandomized prospective studies, two prospective observational studies, one prospective study, three cohort studies, four clinical trials, 13 randomized controlled trials, one review article, four systematic reviews, and meta-analysis, and three network meta-analysis.
| SI. No. | Outcomes | Results significant to the research topic |
|---|---|---|
| 1 | AHI Index, AI, HI | Decreased AHI5,9,11,14–35 |
| Decreased AI13,22–24 | ||
| Decreased HI22,23 | ||
| 2 | Respiratory Disturbance Index (RDI) | No effect36 |
| 3 | Epworth Sleepiness Scale (ESS) | Overall decreased5–7,11–13,15,16,20,22,24,25,27,28,30, 34,35,37 |
| Improved daytime sleepiness8,9,14,18,21,38 | ||
| Improved neurobehavioral outcome17,26 | ||
| Improved snoring, daytime sleepiness23 | ||
| 4 | Oxygen saturation (SpO2) | Increased7,15,17,24,30–32,39 |
| No significant effect8 | ||
| 5 | SaO2 nadir (lowest oxygen saturation) | Increased5,8,16,18,31,34,39 |
| Decreased7 | ||
| 6 | Oxygen Desaturation Index (ODI) | Decreased7,9,22,31,35,39,40 |
| 7 | Sleep Apnea Quality of Life Index (SAQLI) | Alleviated symptoms (Domain D)16 |
| Decreased26,27,36 | ||
| 8 | Subjective symptoms: Snoring, daytime sleepiness, and night sleep quality | Improved snoring, daytime sleepiness and night sleep quality39 |
| Improved snoring, daytime sleepiness19,22 improved snoring15 | ||
| 9 | BQ variables | Reduced snoring loudness, frequency, tiredness after sleeping, breathing pauses11,38 |
| 10 | Pichot QD2A depression score | Improved symptoms of depression9,32 |
| 11 | Hospital anxiety and depression (HAD) scale | Improved depression rate20 |
| 12 | Functional outcomes of sleep quality (FOSQ score) | Improved neurobehavioral outcome17 |
| Improved daytime sleepiness18 | ||
| Increased except general productivity $ social outcome5 | ||
| Overall improved (increased)12,14,15,22,26–29,31,37 | ||
| 13 | FOSQ-SE | No improvement in sexual activity17 |
| 14 | Short-form 36 (SF36) score | Increased12,15,26,30,33,37,41 |
| 15 | SF12 score | Increased15,32 |
| 16 | Quebec sleep Questionnaire (QSQ) | Increased7,8 |
| 17 | Visual Analog Scale | Decreased snoring loudness and frequency5,8,32 |
| 18 | Pichot fatigue score | Decreased7,8,15,32 |
| 19 | Pittsburg Sleep Quality Index (PSQI) | Decreased22,30–32 |
| 20 | DASS21score | State of depression improved31 |
| 21 | MSLT | Improved sleep latency33 |
| 22 | SPAS (superior posterior airway space); MAS (middle airway space); IAS (inferior airway space) | Increased23 |
| 23 | TMJ disorder | No change in shape and magnitude of incision edge, percussion, masticatory, and condylar movement42 |
| MAD therapy is not a risk factor for TMD signs10 | ||
| 24 | BP | No change8,24,37 |
| 25 | Non-REM sleep | Stage N3 $ N4 percent increased17 |
| Improved stage N1 $ N3 (mild and moderate)18 | ||
| Improved stage R, stage N329 | ||
| 26 | REM sleep | Increased REM sleep duration14,33 |
| 27 | Arousal index | Reduced14,25,30 |
| 28 | HBA1c Level (Objective outcome) | Decreased in the mild and moderate group11 |
| 29 | Vitamin C, B6 Level | Increased25 |
| 30 | Oxidative stress parameters | Reduced25 |
| 31 | Inflammatory markers | Mild-to-moderate OSA: Improved CRP, IL-1β, TNF-α18 |
| Severe OSA: Improved TNF-α18 | ||
| 32 | Cost-effectiveness | Costs per quality-adjusted life-years (QALY)15,24,25 |
DISCUSSION
This scoping review aimed to analyze the effectiveness, efficacy, different design features, side effects of the appliance, and patient selection for MAD therapy. Targeted symptoms are sleepiness, snoring, quality of life, and possible comorbidities. In this study, the outcomes were evaluated by AHI, ESS, lowest oxygen saturation level, ODI, QD2A depression score, BQ variable, FOSQ, SF-36 physical component summary and mental component summary, QSQ, Pichot score, Pittsburg sleep quality index (PSQI), home sleep apnea test (HSAT), KIIEF-5, and SAQLI scores to check the effectiveness of MADs.
Different levels of evidence studies were selected to answer the clinical question proposed in this scoping review, and different studies used different designs of MADs. These were AT-MAD, elastomer appliance with an adjustable Herbst mechanism, titratable PAT-MAD, custom-made Narval MRDs, monoblock, and SILENT NITE appliances, TAP3, KLEARWAY, thermoplastic heat-molded titratable MAD, self-molded bespoke, semi-bespoke, and fully bespoke MAD.
According to the studies conducted by Banhiran et al.5 and Agarwal et al.,6 it was concluded that MAA resulted in a statistically significant reduction of baseline AHI index and the subjective outcomes with ESS scores (snoring intensity and frequency, and daytime sleepiness). The first study conducted among Asians by Banhiran et al.5 demonstrated that an AT-MAD, if done properly, had good outcomes including improved quality of life (QOL) with a short-term treatment. Its advantages were cost-effectiveness and readily available. The continuous wearing of OAs reduces the AHI from severe to mild or moderate OSA along with the reduction of incidence of systemic complication and improvement in the life quality of the patients.
Follow-up studies by Attali et al.7 and Vecchierini et al.8 stated that libido disorders and polyuria resolved in 81 and 64% of the participants, respectively, and there was a significant improvement in visual analog scale scores for sleep, morning headache, and state on waking (p <0.0001) during MRD therapy.
Further, the effectiveness and efficacy of thermoplastic and custom-made MAD appliances were compared; various studies concluded that the titratable thermoplastic MAD is more efficacious in reducing SDB and associated symptoms in patients with mild to severe OSA and the effectiveness was the same for severity of symptoms, quality of life, and in reducing blood pressure but the side effects were comparatively more to custom-made MAD. For the patients with OSA who refused or did not tolerate the CPAP therapy, the thermoplastic heat-molded titratable MAD was demonstrated to be equivalent in the short term to the custom-made acrylic MAD.9
Alessandri-Bonetti et al.10 analyzed the effects of MADs on TMD in patients with and without the presence of signs and symptoms, which indicated that the evidence available was of moderate to low quality, showing that MAD therapy was not a risk factor for TMD signs and symptoms. Therefore, the TMD should not be considered an absolute contraindication for the use of MADs in the treatment of OSA.
The study by Baslas et al.,11 after intervention with MAD found a statistically significant difference between HbA1c level and apnea hypopnea index AHI score in all groups except HbA1c level in severe OSA patients. It was therefore concluded that MAD may be recommended for patients with OSA and T2DM. This study provided evidence to inform health workers about the possible use of MAD in OSA and T2DM. Considering the higher level of evidence, systematic review can provide excellent evidence in comparing the quality of life outcomes with other outcomes between CPAP and MAD. So the systematic reviews and meta-analysis showed that the treatment effect of CPAP was greater in the vitality dimension. The score estimates of the improvement in the vitality scale (not the other seven scales) were similar for CPAP and MADs when compared with control. There were no statistically significant differences in quality of life, cognitive function outcomes, or functional outcomes in patients using CPAP vs MAD. However, CPAP was more effective in reducing AHI compared to oral appliances. With quality of life (SF-36 score), the results showed that both CPAP and MAD had similar improvements in mental health and physical functioning. In terms of performance results, the results showed that both CPAP and MAD improved FOSQ scores without significant statistical differences, consistent with previous review studies where MAD users showed significantly higher compliance (p = 0.004) than CPAP users.12–14
Further, it was reviewed that maintenance costs for MAD were low and relatively high for CPAP therapy, which could influence cost-effectiveness when considering long-term therapy. De Vries et al.15 compared clinical efficacy with the cost of MAD treatment with CPAP treatment in the moderate OSA, where CPAP was more effective clinically (in terms of AHI reduction) and less expensive than MAD.
Finally to conclude, although both CPAP and MAD improved the quality of life, sleep, and performance and cognitive outcomes in patients with OSA, this review presented limited quality of evidence to suggest a significant difference in favor of CPAP in reducing AHI. Although the two therapies worked differently with the efficacy and treatment usage profiles, these results were similar in the overall performance. As effectiveness is a combination of efficacy and treatment compliance, sleep medicine specialists should monitor the use of treatment and provide patients who do not comply with CPAP orally for treatment. Choosing CPAP as the first line of treatment for patients with OSA symptoms but MAD should be considered as an appropriate alternative to reducing symptoms and improving QOL, where apnea and hypopnea are successfully reduced based on the findings of this scoping review.
The limitation of this review was that all the studies available were comparative. The designs of orthodontic appliances and the degree of titration were different in different studies. In addition, different levels of evidence studies were taken for this review, which had different limitations such as small sample size; the subjects had dropped out in between the treatment in follow-up studies; nonrandomized trials were included; along with this, there was a lack of blinding of participants and outcome in the trials.
CONCLUSION
This scoping review finally concluded that:
There were no differences in quality of life, functional outcomes, or cognitive function outcomes in patients using CPAP and MAD.
Patients using MAD showed better adherence and compliance as compared to CPAP; along with this, the daytime sleepiness, state on waking, morning headache, oxygen saturation, frequency and intensity of snoring, and sleep quality for both patients who snore and their bed partners showed a marked improvement with MAD.
The effectiveness of titratable MAD thermoplastic was to reduce SDB and associated symptoms in patients with mild to severe OSA, and the efficacy was similar in both the thermoplastic and custom-made MAD machine in terms of severity, symptoms, quality of life, and reducing blood pressure.
Side effects of oral appliances include aggravation of temporomandibular disorder (TMD) but the presence of TMD should not be considered a general objection to the use of MAD in OSA administration.
Maintenance costs for MAD were low and relatively high for CPAP therapy, which could influence cost-effectiveness when considering long-term therapy. However, the cost per QALY was better with MAD compared to that with CPAP.
Choosing CPAP as a first-line treatment for patients with OSA symptoms but MAD should be considered an appropriate alternative to reducing symptoms and improving QOL when apnea and hypopnea are successfully reduced.
RECOMMENDATIONS
We recommend that future research projects should include appropriate randomized studies, blinding treatment groups, concealing outcome tests, robust fitness method, critical and reproductive diagnostic approach, and quality-tested studies included to reduce bias.
ORCID
Kumar Amit https://orcid.org/0000-0002-4265-1034
REFERENCES
1. Lim J, Lasserson TJ, Fleetham J, et al. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev 2006;1(2):30–45. DOI: 10.1002/14651858.CD004435.pub3.
2. Rundo JV. Obstructive sleep apnoea basics. Cleve Clin J Med 2019;86(1):2–9. DOI: 10.3949/ccjm.86.s1.02.
3. Gottlieb DJ, Punjabi NM. Diagnosis and management of obstructive sleep apnoea: a review. JAMA 2020;323(14):1389–1400. DOI: 10.1001/jama.2020.3514.
4. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnoea and snoring with oral appliance therapy: an update for 2015: an American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine clinical practice guideline. J Clin Sleep Med 2015;11(7):773–827. DOI: 10.5664/jcsm.4858.
5. Banhiran W, Kittiphumwong P, Assanasen P, et al. Adjustable thermoplastic mandibular advancement device for obstructive sleep apnoea: outcomes and practicability. Laryngoscope 2014;124(10):2427–2432. DOI: 10.1002/lary.24607.
6. Agarwal P, Ariga P, Jain AR. Efficacy of custom-made mandibular advancement appliance on patients with obstructive sleep apnoea: a prospective clinical trial. Drug Invent Today 2018;10(6):1–7. DOI: 10.4103/0976-237X.161881.
7. Attali V, Vecchierini MF, Collet JM, et al. Efficacy and tolerability of a custom-made Narval mandibular repositioning device for the treatment of obstructive sleep apnoea: ORCADES study 2-year follow-up data. J Dent Sleep Med 2019;63(8):64–74. DOI: 10.1016/j.sleep.2015.05.020.
8. Vecchierini MF, Attali V, Collet JM, et al. A custom-made mandibular repositioning device for obstructive sleep apnoea–hypopnoea syndrome: the ORCADES study. J Dent Sleep Med 2016;19(4):131–140. DOI: 10.1016/j.sleep.2015.05.020.
9. Gagnadoux F, Nguyen XL, Le Vaillant M, et al. Comparison of titrable thermoplastic versus custom-made mandibular advancement device for the treatment of obstructive sleep apnoea. Respir Med 2017;131(11):35–42. DOI: 10.1016/j.rmed.2017.08.004.
10. Alessandri-Bonetti A, Bortolotti F, Moreno-Hay I, et al. Effects of mandibular advancement device for obstructive sleep apnea on temporomandibular disorders: A systematic review and meta-analysis. Sleep Med Rev 2019;48:101211. DOI: 10.1016/j.smrv.2019.101211.
11. Baslas V, Chand P, Jurel SK, et al. A pilot study to determine the effect of three months of oral appliance therapy using a mandibular advancement device on HbA1c in subjects with Type II diabetes mellitus and obstructive sleep apnoea. J Prosthodont 2019;28(3):271–275. DOI: 10.1111/jopr.12973.
12. Schwartz M, Acosta L, Hung YL, et al. Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnoea patients: a systematic review and meta-analysis. Sleep Breath 2018;22(3):555–568. DOI: 10.1007/s11325-017-1590-6.
13. Bratton DJ, 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(11):869–878. DOI: 10.1016/S2213-2600(15)00416-6.
14. Zhang TJ, Liu XY, Qiao X, et al. Effect of oral appliance on reproductive system of the male New-Zealand rabbit with obstructive sleep apnoea-hypopnoea syndrome. Cranio 2018;98(38):3090–3095. DOI: 10.3760/cma.j.issn.0376-491.2018.38.010.
15. De Vries GE, Hoekema A, Vermeulen KM, et al. Clinical-and cost-effectiveness of a mandibular advancement device versus continuous positive airway pressure in moderate obstructive sleep apnoea. J Clin Sleep Med 2019;15(10):1477–1485. DOI: 10.5664/jcsm.7980.
16. Shin HW, Park JH, Park JW, et al. Effects of surgical vs nonsurgical therapy on erectile dysfunction and quality of life in obstructive sleep apnoea syndrome: a pilot study. J Sex Med 2013;10(8):2053–2059. DOI: 10.1111/jsm.12128.
17. Uniken Venema JA, Doff MH, Joffe-Sokolova D, et al. Long-term obstructive sleep apnea therapy: a 10-year follow-up of mandibular advancement device and continuous positive airway pressure. J Clin Sleep Med 2020;16(3):353–359. DOI: 10.5664/jcsm.8204.
18. Fernández‐Julián E, Pérez‐Carbonell T, Marco R, et al. Impact of an oral appliance on obstructive sleep apnoea severity, quality of life, and biomarkers. Laryngoscope 2018;128(7):1720–1726. DOI: 10.1002/lary.26913.
19. Haviv Y, Bachar G, Aframian DJ, et al. A 2‐year mean follow‐up of oral appliance therapy for severe obstructive sleep apnoea: a cohort study. Oral Dis 2015;21(3):386–392. DOI: 10.1111/odi.12291.
20. Nerfeldt P, Friberg D. Effectiveness of oral appliances in obstructive sleep apnoea with respiratory arousals. J Clin Sleep Med 2016;12(8):1159–1165. DOI: 10.5664/jcsm.6058.
21. Schutz TC, Cunha TC, Moura-Guimaraes T, et al. Comparison of the effects of continuous positive airway pressure, oral appliance and exercise training in obstructive sleep apnoea syndrome. Clinics 2013;68(8):1168–1174. DOI:10.6061/clinics/2013(08)17.
22. Soh L, Han HJ, Yue Y, et al. Evaluation of prefabricated adjustable thermoplastic mandibular advancement devices (Pat-Mads) for obstructive sleep apnoea: an Asian experience. J Dent Sleep Med 2020;75(3):96–102. DOI: 10.1016/j.sleep.2020.02.025.
23. Zhou J, Liu YH. A randomised titrated crossover study comparing two oral appliances in the treatment for mild to moderate obstructive sleep apnoea/hypopnoea syndrome. J Oral Rehabil 2012;39(12):914–922. DOI: 10.1111/joor.12006.
24. Sharples L, Glover M, Clutterbuck-James A, et al. Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure. Health Technol Assess 2014;18(67):1–25. DOI: 10.3310/hta18670.
25. Dal-Fabbro C, Garbuio S, D’Almeida V, et al. Mandibular advancement device and CPAP upon cardiovascular parameters in OSA. Sleep Breath 2014;18(4):749–759. DOI: 10.1007/s11325-014-0937-5.
26. Quinnell TG, Bennett M, Jordan J, et al. A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO). Thorax 2014;69(10):938–945. DOI: 10.1136/thoraxjnl-2014-205464.
27. Doff MH. A mandibular advancement device did not affect daytime sleepiness and quality of life in obstructive sleep apnoea. BMJ Evid Based Med 2015;20(6):215–216. DOI: 10.1136/ebmed-2015-110248.
28. Benoist L, de Ruiter M, de Lange J, et al. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnoea. Sleep Med 2017;34(10):109–117. DOI: 10.1016/j.sleep.2017.01.024.
29. Banhiran W, Assanasen P, Nopmaneejumrudlers C, et al. Adjustable thermoplastic oral appliance versus positive airway pressure for obstructive sleep apnoea. Laryngoscope 2018;128(2):516–522. DOI: 10.1002/lary.26753.
30. El-Solh AA, Homish GG, Ditursi G, et al. A randomized crossover trial evaluating continuous positive airway pressure versus mandibular advancement device on health outcomes in veterans with posttraumatic stress disorder. J Clin Sleep Med 2017;13(11):1327–1335. DOI: 10.5664/jcsm.6808.
31. Mok Y, Tan A, Hsu PP, et al. Comparing treatment effects of a convenient vibratory positional device to CPAP in positional OSA: a crossover randomised controlled trial. Thorax 2020;75(4):331–337. DOI: 10.1136/thoraxjnl-2019-213547.
32. Pépin JL, Raymond N, Lacaze O, et al. Heat-moulded versus custom-made mandibular advancement devices for obstructive sleep apnoea: a randomised non-inferiority trial. Thorax 2019;74(7):667–674. DOI: 10.1136/thoraxjnl-2018-212726.
33. Basyuni S, Barabas M, Quinnell T. An update on mandibular advancement devices for the treatment of obstructive sleep apnoea hypopnoea syndrome. J Thorac Dis 2018;10(1):48–56. DOI: 10.21037/jtd.2017.12.18.
34. Cammaroto G, Galletti C, Galletti F, et al. Mandibular advancement devices vs nasal-continuous positive airway pressure in the treatment of obstructive sleep apnoea: Systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal 2017;22(4):417–424. DOI: 10.4317/medoral.21671.
35. Iftikhar IH, Bittencourt L, Youngstedt SD, et al. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnoea: a network meta-analysis. Sleep Med 2017;30(3):7–14. DOI: 10.1016/j.sleep.2016.06.001.
36. Bishop B, Verrett R, Girvan T. A randomized crossover study comparing two mandibular repositioning appliances for treatment of obstructive sleep apnoea. Sleep Breath 2014;18(1):125–131. DOI: 10.1007/s11325-013-0859-7.
37. Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnoea: a randomized controlled trial. Am J Respir Crit Care Med 2013;187(8):879–887. DOI: 10.1164/rccm.201212-2223OC.
38. Arya D, Singh SV, Tripathi A, et al. A pilot study to compare patient perception of obstructive sleep apnoea treatment with CPAP or appliance therapy. J Prosthet Dent 2014;112(5):1188–1193. DOI: 10.1016/j.prosdent.2014.05.007.
39. Eriksson EW, Leissner L, Isacsson G, et al. A prospective 10-year follow-up polygraphic study of patients treated with a mandibular protruding device. Sleep Breath 2015;19(1):393–401. DOI: 10.1007/s11325-014-1034-5.
40. Remmers JE, Topor Z, Grosse J, et al. A feedback-controlled mandibular positioner identifies individuals with sleep apnoea who will respond to oral appliance therapy. J Clin Sleep Med 2017;13(7):871–880. DOI: 10.5664/jcsm.6656.
41. Kuhn E, Schwarz EI, Bratton DJ, 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(4):786–794. DOI: 10.1016/j.chest.2017.01.020.
42. Zhou J, Li DH, Zhu PF, et al. Effect of mandibular advancement device on the stomatognathic system in patients with mild‐to‐moderate obstructive sleep apnoea‐hypopnoea syndrome. J Oral Rehabil 2020;47(7):889–890. DOI: 10.1111/joor.12982.
________________________
© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.