Dataset Information

Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis.

ABSTRACT:

Background

Obstructive sleep apnea (OSA) is an independent risk factor for the development of hypertension. However the effect of continuous positive airway pressure (CPAP) on lowering systemic blood pressure (BP) in OSA patients has been conflicting. Oral appliance (OA) therapy is an important alternative therapy to CPAP for patients with mild to moderate OSA.

Objective

To conduct a meta-analysis of studies which have evaluated the effect of OAs on BP in patients with OSA.

Data sources

Studies were retrieved by searching PubMed (all studies that were published until December 15, 2011)

Study selection

Three independent reviewers screened citations to identify trials of the effect of OA on BP.

Data extraction

Data from observational and randomized controlled trial (RCT) studies was extracted for pre- and post-treatment systolic, diastolic, and mean arterial blood pressure (SBP, DBP, and MAP).

Data synthesis

A total of 7 studies that enrolled 399 participants met the inclusion criteria. The pooled estimate of mean changes and the corresponding 95% CIs for SBP, DBP, and MAP from each trial are -2.7 mm Hg (95% CI: -0.8 to -4.6), p-value 0.04; -2.7 mm Hg (95% CI: -0.9 to -4.6), p-value 0.004; and -2.40 mm Hg (95% CI: -4.01 to -0.80), p-value 0.003 (Figures 2-4). The pooled estimate of mean changes and the corresponding 95% CIs for nocturnal SBP, DBP, and MAP from each trial are -2.0 mm Hg (95% CI: 1.1 to -5.3), p-value 0.212; -1.7 mm Hg (95% CI: -0.1 to -3.2), p-value 0.03; and -1.9 mm Hg (95% CI: 1.3 to -5.1), p-value 0.255 (Figures 5-7) respectively.

Conclusions

The pooled estimate shows a favorable effect of OAs on SBP, MAP, and DBP. Most of the studies were observational. Therefore, more RCTs are warranted involving a larger number of patients and longer treatment periods to confirm the effects of OA on BP.

SUBMITTER: Iftikhar IH

PROVIDER: S-EPMC3544387 | biostudies-literature | 2013 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis.

Iftikhar Imran H IH Hays Erin Rikard ER Iverson Michelle-Anne MA Magalang Ulysses J UJ Maas Andrea Kay AK

Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 20130201 2

<h4>Background</h4>Obstructive sleep apnea (OSA) is an independent risk factor for the development of hypertension. However the effect of continuous positive airway pressure (CPAP) on lowering systemic blood pressure (BP) in OSA patients has been conflicting. Oral appliance (OA) therapy is an important alternative therapy to CPAP for patients with mild to moderate OSA.<h4>Objective</h4>To conduct a meta-analysis of studies which have evaluated the effect of OAs on BP in patients with OSA.<h4>Dat ...[more]

PMID: 23372472

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Project description:Rationale: Oral appliance therapy is efficacious in many patients with obstructive sleep apnea (OSA), but prediction of treatment outcome is challenging. Small, detailed physiological studies have identified key OSA endotypic traits (pharyngeal collapsibility and loop gain) as determinants of greater oral appliance efficacy.Objectives: We used a clinically applicable method to estimate OSA traits from routine polysomnography and identify an endotype-based subgroup of patients expected to show superior efficacy.Methods: In 93 patients (baseline apnea-hypopnea index [AHI], ≥20 events/h), we examined whether polysomnography-estimated OSA traits (pharyngeal: collapsibility and muscle compensation; nonpharyngeal: loop gain, arousal threshold, and ventilatory response to arousal) were associated with oral appliance efficacy (percentage reduction in AHI from baseline) and could predict responses to treatment. Multivariable regression (with interactions) defined endotype-based subgroups of "predicted" responders and nonresponders (based on 50% reduction in AHI). Treatment efficacy was compared between the predicted subgroups (with cross-validation).Results: Greater oral appliance efficacy was associated with favorable nonpharyngeal traits (lower loop gain, higher arousal threshold, and lower response to arousal), moderate (nonmild, nonsevere) pharyngeal collapsibility, and weaker muscle compensation (overall R2 = 0.30; adjusted R2 = 0.19; P = 0.003). Predicted responders (n = 54), compared with predicted nonresponders (n = 39), exhibited a greater reduction in AHI from baseline (mean [95% confidence interval], 73% [66-79] vs. 51% [38-61]; P < 0.0001) and a lower treatment AHI (8 [6-11] vs. 16 [12-20] events/h; P = 0.002). Differences persisted after adjusting for clinical covariates (including baseline AHI, body mass index, and neck circumference).Conclusions: Quantifying OSA traits using clinical polysomnography can identify an endotype-based subgroup of patients that is highly responsive to oral appliance therapy. Prospective validation is warranted.

Project description:Study objectivesThe present study addresses the need for a validated tool that prospectively identifies favorable candidates for oral appliance therapy in treatment of obstructive sleep apnea. The objective of the study was to evaluate the ability of a mandibular titration study, performed with a remotely controlled mandibular positioner (RCMP), to predict treatment outcome with a mandibular repositioning appliance (MRA) and to predict an effective target protrusive position (ETPP).DesignA prospective, blinded, outcome study.SettingStandard clinical care with tests performed in the polysomnographic laboratory.ParticipantsConsecutive patients (n = 67) recruited from a sleep center or a dental practice using broad inclusion criteria (age 21-80 years; AHI > 10/h; BMI < 40 kg/m(2)).InterventionsTherapeutic outcome with a mandibular protruding oral appliance was predicted following a mandibular protrusive titration study in the polysomnographic laboratory using a remotely controlled positioner and prospectively established predictive rules. An ETPP was also prospectively determined for participants predicted to be therapeutically successful with MRA therapy. All participants were blindly treated with a MRA, at either the predicted ETPP or a sham position, and therapeutic outcome was compared against prediction.Measurements and resultsAt the final protrusive position, standard predictive parameters (sensitivity, specificity, positive and negative predictive values) showed statistically significant predictive accuracy (P < 0.05) in the range of 83% to 94%. The predicted ETPP provided an efficacious protrusive position in 87% of participants predicted to be therapeutically successful with MRA therapy (P < 0.05).ConclusionsUsing prospectively established rules for interpreting the polysomnographic data, the mandibular titration study predicted mandibular repositioning appliance therapeutic outcome with significant accuracy, particularly with regard to accurately predicting therapeutic success. As well, among the participants predicted to be therapeutically successful with mandibular repositioning appliance therapy, the effective target protrusive position provided efficacious mandibular protrusion in the majority.

Project description:BackgroundObstructive sleep apnea (OSA) is associated with increased morbidity and mortality, and decreased quality of life. Treatment with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is effective for many symptoms of OSA. However, it remains controversial whether treatment with CPAP or MAD also improves depressive symptoms.Methods and findingsWe performed a systematic review and meta-analysis of randomized controlled trials that examined the effect of CPAP or MADs on depressive symptoms in patients with OSA. We searched Medline, EMBASE, the Cochrane Central Registry of Controlled Trials, and PsycINFO from the inception of the databases until August 15, 2014, for relevant articles. In a random effects meta-analysis of 19 identified trials, CPAP treatment resulted in an improvement in depressive symptoms compared to control, but with significant heterogeneity between trials (Q statistic, p<0.001; I(2) = 71.3%, 95% CI: 54%, 82%). CPAP treatment resulted in significantly greater improvement in depressive symptoms in the two trials with a higher burden of depression at baseline (meta-regression, p<0.001). The pooled standardized mean difference (SMD) in depressive symptoms with CPAP treatment in these two trial populations with baseline depression was 2.004 (95% CI: 1.387, 2.621), compared to 0.197 (95% CI: 0.059, 0.334) for 15 trials of populations without depression at baseline. Pooled estimates of the treatment effect of CPAP were greater in parallel arm trials than in crossover trials (meta-regression, p = 0.076). Random effects meta-analysis of five trials of MADs showed a significant improvement in depressive symptoms with MADs versus controls: SMD = 0.214 (95% CI: 0.026, 0.401) without significant heterogeneity (I(2) = 0%, 95% CI: 0%, 79%). Studies were limited by the use of depressive symptom scales that have not been validated specifically in people with OSA.ConclusionsCPAP and MADs may be useful components of treatment of depressive symptoms in individuals with OSA and depression. The efficacy of CPAP and MADs compared to standard therapies for depression is unknown. Please see later in the article for the Editors' Summary.

Dataset Information

Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis.

Background

Objective

Data sources

Study selection

Data extraction

Data synthesis

Conclusions

Publications

Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis.

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