Abstract
Aim
To assess the efficacy of positional therapy and oral appliance therapy for the management of positional obstructive sleep apnea.
Methods
We searched PubMed, Web of Science, Cochrane, and SCOPUS for relevant clinical trials. Quality assessment of the included trials was evaluated according to Cochrane’s risk of bias tool. We included the following outcomes: The apnea-hypopnea index (AHI), AHI non-supine, AHI supine, sleep efficiency, percentage of supine sleep, Adherence (≥ 4 h/night, ≥ 5 days/week), Oxygen desaturation Index, Arousal Index, Epworth Sleepiness Scale score (ESS), Mean SpO2, and Functional Outcomes of Sleep Questionnaire.
Results
The AHI non-supine and the ESS scores were significantly lower in the OAT cohort than in the PT cohort. The PT cohort was associated with a significantly decreased percentage of supine sleep than the OAT cohort (MD= -26.07 [-33.15, -19.00], P = 0.0001). There was no significant variation between PT cohort and OAT cohort regarding total AHI, AHI supine, ODI, sleep efficiency, arousal index, FOSQ, adherence, and mean SpO2.
Conclusion
Both Positional Therapy and Oral Appliance Therapy effectively addressed Obstructive Sleep Apnea. However, Oral Appliance Therapy exhibited higher efficiency, leading to increased supine sleep percentage and more significant reductions in the Apnea Hypopnea Index during non-supine positions, as well as lower scores on the Epworth Sleepiness Scale.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-024-04277-8.
Keywords: Obstructive sleep apnea, Oral appliance therapy, Positional therapy, Sleep position trainer, Mandibular advancement device therapy
Introduction
Obstructive sleep apnea (OSA) is characterized by episodes of the airway collapsing completely or partially, arousing the patient from sleep or causing a drop in oxygen saturation [1]. Fragmented, non-restorative sleep is the result of this disturbance. Positional Obstructive Sleep Apnea (POSA) has major effects on mental illness, cardiovascular health, driving safety, and quality of life [2]. A number of mechanisms are probably involved in the pathophysiology of pharyngeal narrowing and closing during sleep, which is a complex event [3]. Posterior airway dimensions which are affected by age, obesity, race, or genetic reasons may predispose to breathing disorders during sleep [4, 5]. Upper airway blockage during sleep is likely caused by diminished ventilatory drive associated with sleep, as well as anatomic and neuromuscular risk factors [6].
An in-laboratory polysomnogram is the gold standard for the diagnosis of POSA. The two most prevalent signs of POSA are daytime sleepiness and snoring [7]. Others include bed partner-reported apneas, gasping or choking when you wake up, frequent awakenings, restless sleep, erectile dysfunction, and nocturia. Patients with POSA may have restless sleep, headaches in the morning, low energy, bad mood, fatigue, or poor concentration [8]. There are different options for POSA treatment, such as behavioral treatments, including positional therapy, weight loss, and avoidance of sedatives and/or alcohol before bedtime [9]. The avoidance of sleeping in a supine position to counteract the gravitational impact of supine sleep on the tongue and airway narrowing is known as positional therapy (PT) [10]. There are several methods for attempting to remain off the back when sleeping. Tennis balls can be placed in a tube sock and attached vertically in the center of the back of a sleep shirt, or a loaded backpack can be worn to bed. There are also FDA-approved commercially accessible positional therapy devices [11, 12].
Continuous positive airway pressure (CPAP) is still regarded as the gold standard of care more than three decades after it was first used [13, 14]. Nasal CPAP (nCPAP) is very effective at treating sleep apnea-related clinical sequelae and controlling symptoms while also enhancing quality of life [15]. There are other positive airway pressure treatment options for individuals who cannot tolerate CPAP or require high amounts of positive pressure [16]. Oral appliance therapy (OAT) and mandibular advancement devices (MAD), especially if they are custom-made, are efficient in treating mild to severe POSA and offer a good substitute for patients who are unable to tolerate CPAP therapy [17, 18]. Polysomnography POSA indicators are improved with OAT. In a sleep study, oxygen saturation, respiratory event indices, sleep efficiency, and arousal index (AI) all showed improvements from their baseline values [19].
Our systematic review and meta-analysis aimed to compare the efficacy of PT with that of OAT for the management of POSA. The null hypothesis posits that there is no difference between Positional Therapy (PT) and Oral Appliance Therapy (OAT) in the management of Positional Obstructive Sleep Apnea (POSA).
Methods
We conducted our study based on the PRISMA recommendations and guidelines [20] and registered our study on PROSPERO (CRD42024517491).
Search strategy and information sources
Two authors developed a search strategy by combining these keywords: (“Obstructive sleep apnea” OR “sleep apnea” OR “positional sleep apnea” OR “POSA”) AND (“mandibular advancement” OR “oral appliance” OR “oral appliance devices” OR “OAT”) AND (“positional therapy” OR “sleep position trainer”). Concerning data sources, we searched SCOPUS, PubMed, Cochrane Library, and Web of Science databases in the search process till December 2023 for articles that matched our inclusion criteria.
Study selection
In three stages, Two authors screened the studies that were included. The first stage required using EndNote Software to import the results from electronic databases into a Microsoft Excel sheet [22]. The articles that were imported into the Excel sheet were screened for titles and abstracts as part of the second stage. The third stage was the full-text screening of the step 2 citations that were included. Furthermore, we conducted a manual review of the references of the included publications to identify any potential undiscovered research. We selected the eligible articles according to the following eligibility criteria:
Population: Adult individuals suffering from POSA.
Intervention: Patients underwent PT.
Comparator: Patients underwent OAT.
Outcomes. The apnea-hypopnea index (AHI), AHI non-supine, AHI supine, sleep efficiency, percentage of supine sleep, Adherence (≥ 4 h/night, ≥ 5 days/week), Oxygen desaturation Index (ODI), Arousal Index (AI), Epworth Sleepiness Scale score (ESS), Mean SpO2 (peripheral capillary oxygen saturation), and Functional Outcomes of Sleep Questionnaire (FOSQ).
Study design: we included only randomized clinical trials (RCTs) and excluded meta-analyses, observational studies, surveys, abstracts, and reviews.
Inclusion and exclusion criteria
Inclusion criteria for the mentioned objectives included research completed in the adult age group (above 18 years old). We included studies that were published in the English language from the year 2000 to January 2024. We only included RCTs that involved adult patients with POSA and included two comparators (PT vs. OAT). We excluded articles not in English, published before the year 2000, did not have our main outcomes, were meta-analyses, observational studies, surveys, abstracts, reviews, and single-arm RCTs that had no comparators (no control group).
Quality assessment
Since we involved only RCTs, we utilized the Cochrane risk of bias tool, which depends on assessing eight domains in each clinical trial [21]. Each domain could be categorized as high, unclear, or low risk of bias.
Data extraction
We extracted three types of data from the involved articles: the first category is the demographic characteristics of the involved patients and the baseline values of our outcomes. The second category was extracting data of the following outcomes for analysis: The apnea-hypopnea index (AHI), AHI non-supine, AHI supine, sleep efficiency, percentage of supine sleep, Adherence (≥ 4 h/night, ≥ 5 days/week), Oxygen desaturation Index (ODI), Arousal Index (AI), Epworth Sleepiness Scale score (ESS), Mean SpO2, and Functional Outcomes of Sleep Questionnaire (FOSQ). The last category was data of quality assessment. The process of data collection was conducted using Microsoft Excel [22]. Three of the authors had roles in collecting data and data extraction. Each one of them extracted the three categories, and after they finished, another author revise the extracted data of each one and compared them to find any mistakes.
Statistical analysis
We performed this meta-analysis using Review Manager Software [23]. Our study involved continuous outcomes. We used a 95% confidence interval (CI) and mean difference (MD) to analyze continuous data. When data were homogenous, the fixed-effects model was employed; when data were heterogeneous, the random-effects model was utilized. We used the I2 and p-value of the Chi-square tests to assess the degree of consistency between the studies [24]. Values of P < 0.1 or I2 > 50% were significant indicators of the presence of heterogeneity.
Results
Summary of the included studies
The literature search results are illustrated in the PRISMA flow diagram in Fig. 1. Our study involved five RCTs [25–29], which included a total of 377 patients suffering from positional POSA. The PT cohort included 130 males and 57 females, while the OAT cohort included 137 males and 53 females. The mean age of participants in the PT cohort was 46 years old, while the OAT cohort was 45.5 years old. Most of the trials we included are recent trials that were performed in different countries (China, Netherlands, Japan, and Belgium). The follow-up duration was three months in all the included studies except in Huang et al., which was six months. Tables 1 and 2 demonstrate the demographics and baseline characteristics of the involved patients and RCTs.
Fig. 1.
Shows a PRISMA flow diagram of our literature search
Table 1.
Demonstrates the demographics and baseline characteristics of the involved patients and RCTs
| Study ID | Benoist 2017 | De Ruiter 2018 | Dieltjens 2015 | |
|---|---|---|---|---|
| Location | Netherlands | Netherlands | Belgium | |
| Duration | 3 months | 3 months | 3 months | |
| Sample size, n | PT | 48 | 29 | 20 |
| OAT | 51 | 29 | ||
| Age(years), mean | PT | 47.3 ± 10.1 | 49.5 ± 9.4 | 52.5 ± 10.5 |
| OAT | 49.2 ± 10.2 | 43.8 ± 10.3 | ||
| BMI, kg/m2 | PT | 27.5 ± 2.9 | 27.7 ± 2.8 | 26.4 ± 3.0 |
| OAT | 27.7 ± 4.5 | 27.1 ± 2.9 | ||
| Male, (%) | PT | 34 (70.8) | 19 (65.5) | 12 (58) |
| OAT | 36 (70.6) | 15 (51.7) | ||
| female, (%) | PT | 14 (29.2) | 10 (34.5) | 8 (42) |
| OAT | 15 (29.4) | 14 (48.3) | ||
| Neck circumference, cm | PT | 38.0 ± 3.6 | 37.9 ± 3.8 | NR |
| OAT | 37.7 ± 3.2 | 38.3 ± 3.4 | ||
| Smoking, n (%) | PT | 11 (22.9) | 5 (17.2) | NR |
| OAT | 12 (23.5) | 6 (31.6) | ||
| Alcohol intake, n(%) ≤ 2drinks/day | PT | 45 (93.7) | 26 (89.7) | NR |
| OAT | 48 (94.1) | 19 (65.5) | ||
| AHI, events/hour | PT | 13.0 [9.7–18.5] | 13.2(10.2–19) | 20.9 (17–34) |
| OAT | 11.7 [9.0-16.2] | 12.1 (7–17.2) | ||
| AHI supine, events/hour | PT | 27.0 [18.7–43.1] | 28.5 (18.9–46.2) | 39.1 (26.4; 58.2) |
| OAT | 25.8 [17.4–35.0] | 26 (11.6–36.8) | ||
| Percentage supine sleep | PT | 44.5 [30.0-55.5] | 41 (30–54) | 20.9 (17–34) |
| OAT | 39.0 [26.0–54.0] | 47 (25.0–57) | ||
| non-supine AHI, events/hour | PT | NR | 4.1 (2.4–5.8) | 11.1 (6.3; 26.1) |
| OAT | 2.4 (0.9–5.7) | |||
| ODI, events/h | PT | NR | 9 (7–15.5) | 7.7 (6.6; 16.5) |
| OAT | 13 (7–16) | |||
| Sleep efficiency | PT | NR | 92 (84–95.5) | |
| OAT | 92 (89–94) | |||
Values are mean ± standard deviation, median (interquartile range), or number of patients (%). AHI apnea hypopnea index, OAT oral appliance therapy, ODI oxygen desaturation index, PT Positional therapy
Table 2.
Demonstrates the demographics and baseline characteristics of the involved patients and RCTs
| Study ID | Huang 2023 | Suzuki 2021 | |
|---|---|---|---|
| Location | China | Japan | |
| Duration | 6 months | 3 months | |
| Sample size, n | PT | 20 | 80 |
| OAT | 20 | 80 | |
| Age(years), mean | PT | 39.20 ± 10.92 | 45.6 ± 11.4 |
| OAT | 41.55 ± 11.79 | 47.5 ± 11.4 | |
| BMI, kg/m2 | PT | 23.91(22.97–25.75) | 25.2 ± 3.8 |
| OAT | 25.19 (23.53–26.78) | 24.9 ± 3.2 | |
| Male, (%) | PT | 17 (85) | 54 (67.5) |
| OAT | 18 (90) | 62 (77.5) | |
| female, (%) | PT | 3 (15) | 26 (32.5) |
| OAT | 2 (10) | 18 (22.5) | |
| Neck circumference, cm | PT | NR | NR |
| OAT | |||
| Smoking, n (%) | PT | 5 (25) | NR |
| OAT | 6 (30) | ||
| Alcohol intake, n(%) ≤ 2drinks/day | PT | 2 (10) | NR |
| OAT | 2 (10) | ||
| AHI, events/hour | PT | 19.21 (11.77–23.9) | 24.2 ± 17.1 |
| OAT | 18.58 (16.1-24.55) | 20.8 ± 11.2 | |
| AHI supine, events/hour | PT | 24.4 (18.13–39.05) | 37.4 ± 19.0 |
| OAT | 27.4 (21.8-36.93) | 31.6 ± 16.6 | |
| Percentage supine sleep | PT | 62.98 (42.31–83.11) | NR |
| OAT | 64.88 (49.48–73.36) | ||
| non-supine AHI, events/hour | PT | 4.72 (1.54–8.75) | 13.2 ± 12.1 |
| OAT | 4.82 (1.14–8.67) | 9.4 ± 9.1 | |
| ODI, events/h | PT | 17.5 (9.6-23.13) | NR |
| OAT | 15.85 (12.63–21.6) | ||
| Sleep efficiency | PT | 75.77 ± 13.42 | 78.6 ± 16.4 |
| OAT | 75.51 ± 11.53 | 77.5 ± 11.2 | |
Values are mean ± standard deviation, median (interquartile range), or number of patients (%). AHI apnea hypopnea index, OAT oral appliance therapy, ODI oxygen desaturation index, PT Positional therapy
Results of the quality assessment
After using Cochrane’s risk of bias tool for the evaluation of the included RCTs, we found that all the included RCTs were randomized, while three of them [26–28] were at low risk of allocation concealment. Additionally, two trials [26, 27] were at low risk of blinding participants, personnel, and outcome assessment. The overall assessment of the Risk of Bias (ROB) revealed that the included RCTs were at low ROB. Figure 2 shows the ROB assessment of the involved RCTs.
Fig. 2.
Summary of the risk of bias of included studies
Analysis of the outcomes
Total AHI, events/hour
All the included studies reported the total AHI. Our analysis proved that there was a similarity between both cohorts (MD = 1.01 [-0.38, 2.41], P = 0.15). The pooled data showed homogeneity (P = 0.1, I2 = 0%) (Fig. 3).
Fig. 3.
Heterogeneity and overall effect of total AHI that does not favor any of both groups
AHI supine, events/hour
AHI supine was reported by all the included trials. We found that there was no substantial difference between both cohorts (MD= −15.27 [−47.74, 17.20], P = 0.36). The pooled data showed homogeneity (P = 0.0001, I2 = 99%) (Fig. 4).
Fig. 4.
Heterogeneity and the overall effect of AHI supine that does not favor any of both groups
AHI non-supine, events/hour
We analyzed 208 patients from four included trials [25–27, 29] that reported this outcome. The analysis showed that the AHI non-supine was significantly lower in the OAT cohort than in the PT cohort (MD = 2.45 [1.06, 3.84], P = 0.0006). The pooled data showed homogeneity (P = 0.46, I2 = 0%) (Fig. 5).
Fig. 5.
Heterogeneity and the overall effect of AHI non-supine that favors the OAT group
Oxygen desaturation index (ODI), events/hour
We analyzed 208 patients from four included trials [25–27, 29] that reported this outcome. The analysis showed that both cohorts were similar without any substantial variations (MD= -0.61 [-1.85, 0.63], P = 0.34). The data was homogenous (P = 0.87, I2 = 0%) (Fig. 6).
Fig. 6.
Heterogeneity and the overall effect of Oxygen desaturation index that does not favor any of both groups
Percentage supine sleep
After analyzing 139 participants from two included trials [25, 29] that reported the percentage of supine sleep. The analysis revealed that the PT cohort was associated with a significantly decreased percentage of supine sleep compared to the OAT cohort (MD= -26.07 [-33.15, -19.00], P = 0.0001). The data was homogenous (P = 0.62, I2 = 0%) (Fig. 7).
Fig. 7.
Heterogeneity and the overall effect of Percentage of supine sleep that favors the OAT group
Sleep efficiency
Four studies [25, 27–29] reported the sleep efficiency of the participants. The sleep efficiency was the same in both cohorts without any significant variations (MD = 1.83 [-0.40, 4.06], P = 0.11). The data was homogenous (P = 0.59, I2 = 0%) (Fig. 8).
Fig. 8.
Heterogeneity and overall effect of sleep efficiency that does not favor any of both groups
Arousal index (AI)
The AI outcome was reported by three studies [26–28]. Our analysis revealed that both cohorts had similar arousal index without substantial differences (MD = 0.28 [-6.10, 6.67], P = 0.93). The data was heterogeneous (P = 0.02, I2 = 73%) (Fig. 9).
Fig. 9.
Heterogeneity and overall effect of the Arousal index that does not favor any of both groups
Epworth sleepiness scale (ESS) score
Three studies [25, 27, 29] reported the ESS scores of the included participants. The ESS score was significantly lower with the OAT cohort than with the PT cohort (MD = 2.06 [0.84, 3.28], P = 0.0009). The data was homogenous (P = 0.67, I2 = 0%) (Fig. 10).
Fig. 10.
Heterogeneity and the overall effect of the Epworth Sleepiness Scale (ESS) score that favors the OAT group
Functional outcomes of sleep questionnaire (FOSQ)
Three studies [25, 27, 29] reported the FOSQ outcome. The analysis showed that there were no significant variations between both cohorts (MD = 0.21 [-0.38, 0.80], P = 0.49). The data was homogenous (P = 0.79, I2 = 0%) (Fig. 11).
Fig. 11.
Heterogeneity and overall effect of Functional outcomes of sleep questionnaire (FOSQ) that does not favor any of both groups
Adherence (≥ 4 h/night, ≥ 5 days/week)
We analyzed the data of 138 participants from two included trials [25, 29]. The analysis showed that there were no significant variations between both cohorts (MD = 1.91 [-6.29, 10.11], P = 0.65). The data was homogenous (P = 0.16, I2 = 50%) (Fig. 12).
Fig. 12.
Heterogeneity and overall effect of Adherence that does not favor any of both groups
Mean SpO2
This outcome was reported by three studies [25–27]. The analysis showed that there were no significant variations between both cohorts (MD= -0.02 [-0.57, 0.53], P = 0.94). The data was homogenous (P = 0.64, I2 = 0%) (Fig. 13).
Fig. 13.
Heterogeneity and overall effect of Mean SpO2 that does not favor any of both groups
Our analysis and results rejected the null hypothesis as we found that Oral Appliance Therapy exhibited higher efficiency, leading to increased supine sleep percentage, more significant reductions in the Apnea-Hypopnea Index during non-supine positions, and lower scores on the Epworth Sleepiness Scale.
Discussion
To our knowledge, this is the first study of its kind that compares the efficacy of PT and OAT for the management of individuals suffering from POSA. Our analysis showed that the AHI non-supine and the ESS scores were significantly lower in the OAT cohort than in the PT cohort (P = 0.0006) and (P = 0.0009), respectively. The PT cohort was associated with a significantly decreased percentage of supine sleep than the OAT cohort (P = 0.0001). There was no significant variation between the PT cohort and OAT cohort regarding total AHI (P = 0.15), AHI supine (P = 0.36), ODI (P = 0.34), sleep efficiency (P = 0.11), arousal index (P = 0.93), FOSQ (P = 0.49), Adherence (P = 0.65), and mean SpO2 (P = 0.94). The OAT cohort was associated with significantly lower AHI non-supine and ESS scores and an increased percentage of supine sleep than the PT cohort.
Unlike our results, Suzuki et al. [28] found that PT reduces respiratory events and supine sleep time and enhances the percentage of deep sleep more than OAT. Their study did have some drawbacks, though, since 45.0% and 46.2% of patients in the OAT and PT cohorts, respectively, did not respond to treatment adequately. This indicates that not all patients are candidates for these devices and that patient selection is crucial when using them. Marciuc et al. [30] conducted a systematic review and meta-analysis that evaluated the efficacy of oral appliances as a POSA treatment option. They concluded that OAT is an effective treatment for POSA as it improves breathing patterns by decreasing the AHI, which is consistent with our results.
Another systematic review and meta-analysis measured the impact of OAT on the quality of life of POSA patients. They found that OAT improves the quality of life of POSA patients [31]. Trindade et al. [32] included four studies with 83 adult patients and compared their results before and after OAT. They reported that OAT achieved a 79.5% reduction in AHI and a decrease in respiratory obstruction. Ravesloot et al. [33] performed a meta-analysis that assessed the efficacy of PT for managing POSA and involved six articles. Their analysis revealed that PT is an effective, simple, reversible, and cheap option for managing POSA. PT is an easy option for both patients and clinicians, and they reported that PT causes a reduction of the AHI.
The study conducted by Eijsvogel et al. provides evidence of the significance of compliance [34]. Although the therapeutic efficacy of PT and tennis ball technique (TBT) was equivalent, PT had better compliance. A mean disease alleviation of 48.6% for TBT and 70.5% for the new generation PT, respectively, was attained when compliance was taken into account [34]. Compliance issues are a problem with CPAP and, to a lesser extent, MAD treatment. A median usage of MAD therapy for 6.4 h per night was observed after 3 months, and a mean use of 6.1 h per night after one year was observed in two prospective small-scale studies with the advent of objective monitoring [35, 36]. Between 29% and 83% of CPAP users do not follow instructions. After just one night of use, 8–15% of patients decline CPAP therapy, and 20–40% stop using it after three months [37].
In 2023, ALQarni et al. [38] conducted a systematic review and meta-analysis that included eight cohort studies and ten clinical trials. These included studies compare different choices for managing POSA, such as PT, OAT, placebo, and CPAP. The primary conclusions of this systematic review and meta-analysis demonstrated that PT successfully lowered AHI and time spent in the supine position in individuals with POSA. The pooled data also showed a decrease in daytime sleepiness and a FOSQ, although these additional findings failed to reach a clinically significant difference. Additionally, the arousal index and sleep efficiency only slightly improved. When interpreting these findings, there are several things to take into account. The first is the variety of PT devices utilized and variations in the control groups of the included clinical trials. One study didn’t use any treatment. Two studies used CPAP, one study MAD, one study TBT, and two studies inactive PT treatment. The final two studies either employed combination therapy as a control or several comparators. As a result, pooling the results at follow-up was only achievable with PT when compared to baseline.
Benoist et al. [29] compare the efficacy of OAT and PT in treating individuals with mild to moderate positional POSA. They found that PT and OAT were similar in reducing ODI and AHI, which is consistent with our findings. In an analysis of 630 OSA/snoring individuals, Marklund et al. [39] found that with an odds ratio (OR) of 2.4, treatment success (AHI < 10) following oral appliance (OA) treatment could be predicted more accurately in women regardless of sleep position. Additionally, they stated that for men, the ORs for treatment success were 6.0 for POSA over non-POSA. Thirty-two patients (17 men and 15 females) with mild to moderate OSA were included in Makihara et al. [40] Every patient was assigned randomly to have a 75% mandibular advancement with an OA or a 50% mandibular advancement alone. They compared the AI, AHI, and ESS before and after treatment. The results showed that both groups’ AHI and AI greatly improved, with the group with 50% mandibular advancement showing the greatest improvement. For either group, there were no notable improvements in the ESS.
Strengths
Our meta-analysis involved only RCTs with the exclusion of the observational studies. The analysis was double-arm analysis as all the included trials had two comparators that were the same (PT vs. OAT). We analyzed eleven outcomes that considered most of the outcomes that should be measured to assess the improvement of individuals suffering from POSA.
Limitations
The main limitation of our meta-analysis is the small sample size, as so many people worldwide suffer from POSA. Additionally, the included trials had different follow-up periods; one had a 6-month follow-up period, and the other four had a 3-month follow-up period, which may affect our analysis. Also, not all of our outcomes were homogenous; some were heterogenous, and we could not solve this heterogeneity.
Conclusion
The PT was comparable to OAT, and both were effective for managing OAs; however, OAT was more efficient and caused more reduction of AHI non-supine and ESS scores with an increase in the percentage of supine sleep than PT. Further research and more clinical trials should be conducted to get more evidence and measure both options’ effects after a long follow-up period.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Author contributions
Abdelrahman MA Mohamed: conceiving and designing the study, collecting data, data analysis, paper writing. Omar Magdy Mohammed: collecting data, data analysis. Shanshan Liu: paper writing. Maher Al-balaa: data analysis. Leena Ali Al-warafi: collecting data, Writing. Song Juan Peng: Revising and writing. Yi Qiang Qiao: conceiving and designing the study, paper reviewing. All authors have read and approved the manuscript.
Funding
This study was funded by Department of Medical Sciences, National Natural Science Foundation of China, with number: U1704187.
Data availability
The datasets used and/or analysed during the current study available from the corresponding authors on reasonable request.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Yi Qiang Qiao is the Main Corresponding Author.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Abdelrahman MA Mohamed, Email: Abdelrahman@dent.suez.edu.eg.
Yi Qiang Qiao, Email: qiaoyiqiang@126.com.
References
- 1.Chang H, Chen Y, Du J. Obstructive sleep apnea treatment in adults. Kaohsiung J Med Sci. 2020;36(1):7–12. doi: 10.1002/kjm2.12130. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Johnson KG. Obstructive sleep apnea. CONTINUUM: Lifelong Learn Neurol. 2023;29(4):1071–91. doi: 10.1212/CON.0000000000001264. [DOI] [PubMed] [Google Scholar]
- 3.Hizal M, Satırer O, Polat SE, et al. Obstructive sleep apnea in children with Down syndrome: is it possible to predict severe apnea? Eur J Pediatrics. 2022;181(2):735–43. doi: 10.1007/s00431-021-04267-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Xu L, Keenan BT, Wiemken AS, et al. Differences in three-dimensional upper airway anatomy between Asian and European patients with obstructive sleep apnea. Sleep. 2020;43(5):zsz273. doi: 10.1093/sleep/zsz273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Mohamed AMA, Chen Y, Wafaie K, et al. Cephalometric evaluation of posterior airway space in Chinese and Egyptian races. APOS. 2023;13:205–14. doi: 10.25259/APOS_17_2023. [DOI] [Google Scholar]
- 6.Roncero A, Castro S, Herrero J, Romero S, Caballero C, Rodriguez P. Apnea obstructiva de sueño. Open Respiratory Archives. 2022;4(3):100185. doi: 10.1016/j.opresp.2022.100185. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Mencar C, Gallo C, Mantero M, et al. Application of machine learning to predict obstructive sleep apnea syndrome severity. Health Inf J. 2020;26(1):298–317. doi: 10.1177/1460458218824725. [DOI] [PubMed] [Google Scholar]
- 8.Menon S. Obstructive sleep apnea syndrome. Oral and maxillofacial surgery for the Clinician. Springer Nature Singapore; 2021. pp. 1577–89.
- 9.Faber J, Faber C, Faber AP. Obstructive sleep apnea in adults. Dent Press J Orthod. 2019;24(3):99–109. doi: 10.1590/2177-6709.24.3.099-109.sar. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Bariani RCB, Bigliazzi R, Cappellette Junior M, Moreira G, Fujita RR. Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review. Braz J Otorhinolaryngol. 2022;88(2):263–78. doi: 10.1016/j.bjorl.2021.02.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Arnaud C, Bochaton T, Pépin JL, Belaidi E. Obstructive sleep apnoea and cardiovascular consequences: pathophysiological mechanisms. Arch Cardiovasc Dis. 2020;113(5):350–8. doi: 10.1016/j.acvd.2020.01.003. [DOI] [PubMed] [Google Scholar]
- 12.Bussi MT, Corrêa C, de Cassettari C. Is ankyloglossia associated with obstructive sleep apnea? Braz J Otorhinolaryngol. 2022;88:S156–62. doi: 10.1016/j.bjorl.2021.09.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Schell TG. Avoiding and managing oral Appliance Therapy Side effects. Sleep Med Clin. 2018;13(4):503–12. doi: 10.1016/j.jsmc.2018.07.003. [DOI] [PubMed] [Google Scholar]
- 14.Schell TG. Avoiding and managing oral Appliance Therapy Side effects. Sleep Med Clin. 2020;15(2):251–60. doi: 10.1016/j.jsmc.2020.02.011. [DOI] [PubMed] [Google Scholar]
- 15.Kuehne CA. Clinical evaluation for oral Appliance Therapy. Sleep Med Clin. 2018;13(4):489–501. doi: 10.1016/j.jsmc.2018.08.003. [DOI] [PubMed] [Google Scholar]
- 16.Ilea A, Timuș D, Höpken J, et al. Oral appliance therapy in obstructive sleep apnea and snoring - systematic review and new directions of development. CRANIO®. 2021;39(6):472–83. doi: 10.1080/08869634.2019.1673285. [DOI] [PubMed] [Google Scholar]
- 17.Koutsourelakis I, Kontovazainitis G, Lamprou K, Gogou E, Samartzi E, Tzakis M. The role of sleep endoscopy in oral appliance therapy for obstructive sleep apnea. Auris Nasus Larynx. 2021;48(2):255–60. doi: 10.1016/j.anl.2020.08.015. [DOI] [PubMed] [Google Scholar]
- 18.Vena D, Azarbarzin A, Marques M et al. Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow. Sleep. 2020;43(7). [DOI] [PMC free article] [PubMed]
- 19.Sutherland K, Takaya H, Qian J, Petocz P, Ng AT, Cistulli PA. Oral Appliance Treatment Response and Polysomnographic phenotypes of obstructive sleep apnea. J Clin Sleep Med. 2015;11(08):861–8. doi: 10.5664/jcsm.4934. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Moher D. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement (Chinese edition) J Chin Integr Med. 2009;7(9):889–96. doi: 10.3736/jcim20090918. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Online) 2011;343(7829):d5928–5928. doi: 10.1136/bmj.d5928. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Katz A. Microsoft Excel 2010. Style (DeKalb, IL). Published online 2010.
- 23.Lebowitz F, Endnote. Aperture. Published online 2021.
- 24.Higgins JPT, Thomas J, Chandler J, et al. editors. Cochrane Handbook for Systematic Reviews of Interventions. Wiley; 2019.
- 25.de Ruiter MHT, Benoist LBL, de Vries N, de Lange J. Durability of treatment effects of the sleep position trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial. Sleep Breath. 2018;22(2):441–50. doi: 10.1007/s11325-017-1568-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Dieltjens M, Vroegop AV, Verbruggen AE, et al. A promising concept of combination therapy for positional obstructive sleep apnea. Sleep Breath. 2015;19(2):637–44. doi: 10.1007/s11325-014-1068-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Huang W, Li C, Zou J, et al. Effects of the combination of novel eye mask sleep position therapy device and oral appliance on positional OSA: a multi-arm, parallel-group randomized controlled trial. Sleep Med. 2023;102:52–63. doi: 10.1016/j.sleep.2022.12.017. [DOI] [PubMed] [Google Scholar]
- 28.Suzuki M, Funayama Y, Homma M, Shibasaki K, Furukawa T, Yosizawa T. Effect of position therapy and oral devices on sleep parameters in patients with obstructive sleep apnea. Eur Arch Otorhinolaryngol. 2021;278(11):4545–50. doi: 10.1007/s00405-021-06817-2. [DOI] [PubMed] [Google Scholar]
- 29.Benoist L, de Ruiter M, de Lange J, de Vries N. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep Med. 2017;34:109–17. doi: 10.1016/j.sleep.2017.01.024. [DOI] [PubMed] [Google Scholar]
- 30.Marciuc D, Morarasu S, Morarasu BC, et al. Dental Appliances for the treatment of obstructive sleep apnea in children: a systematic review and Meta-analysis. Medicina. 2023;59(8):1447. doi: 10.3390/medicina59081447. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Rangarajan H, Padmanabhan S, Ranganathan S, Kailasam V. Impact of oral appliance therapy on quality of life (QoL) in patients with obstructive sleep apnea — a systematic review and meta-analysis. Sleep Breath. 2022;26(3):983–96. doi: 10.1007/s11325-021-02483-0. [DOI] [PubMed] [Google Scholar]
- 32.Trindade PAK, dos Nogueira V, Weber SN. Is maxillomandibular advancement an effective treatment for obstructive sleep apnea? Systematic literature review and meta-analysis. Braz J Otorhinolaryngol. 2023;89(3):503–10. doi: 10.1016/j.bjorl.2023.02.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Ravesloot MJL, White D, Heinzer R, Oksenberg A, Pépin JL. Efficacy of the New Generation of devices for positional therapy for patients with positional obstructive sleep apnea: a systematic review of the literature and Meta-analysis. J Clin Sleep Med. 2017;13(06):813–24. doi: 10.5664/jcsm.6622. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Eijsvogel MM, Ubbink R, Dekker J, et al. Sleep position trainer versus tennis ball technique in positional obstructive sleep apnea syndrome. J Clin Sleep Med. 2015;11(02):139–47. doi: 10.5664/jcsm.4460. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Dieltjens M, Braem MJ, Vroegop AVMT, et al. Objectively measured vs self-reported compliance during oral Appliance Therapy for Sleep-Disordered Breathing. Chest. 2013;144(5):1495–502. doi: 10.1378/chest.13-0613. [DOI] [PubMed] [Google Scholar]
- 36.Dieltjens M, Verbruggen AE, Braem MJ, et al. Determinants of objective compliance during oral Appliance Therapy in patients with sleep-disordered breathing: a prospective clinical trial. JAMA otolaryngology– head neck Surg. 2015;141(10):894–900. doi: 10.1001/jamaoto.2015.1756. [DOI] [PubMed] [Google Scholar]
- 37.Askland K, Wright L, Wozniak DR, Emmanuel T, Caston J, Smith I. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Reviews. 2020;2020(4):CD007736. doi: 10.1002/14651858.CD007736.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.ALQarni AS, Turnbull CD, Morrell MJ, Kelly JL. Efficacy of vibrotactile positional therapy devices on patients with positional obstructive sleep apnoea: a systematic review and meta-analysis. Thorax. 2023;78(11):1126–34. doi: 10.1136/thorax-2021-218402. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Marklund M, Stenlund H, Franklin KA. Mandibular Advancement Devices in 630 men and women with obstructive sleep apnea and snoring. Chest. 2004;125(4):1270–8. doi: 10.1378/chest.125.4.1270. [DOI] [PubMed] [Google Scholar]
- 40.Makihara E, Watanabe T, Ogusu H, Masumi S. The comparison of two different mandibular positions for oral appliance therapy in patients with obstructive sleep apnea. Clin Exp Dent Res. 2022;8(6):1567–74. doi: 10.1002/cre2.650. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study available from the corresponding authors on reasonable request.