Koretsi and colleagues compared intraoral appliances (IOA, the umbrella term for the abbreviation UKPS [Unterkieferprotrusionsschiene], which is commonly used in Germany) versus placebo and versus no treatment with regard to effectiveness in terms of (1):
Apnea-hypopnea index (AHI) (up to 5=normal, up to 15=acceptable),
score achieved in the Epworth Sleepiness Scale (ESS) questionnaire, and
minimum oxygen saturation during sleep.
This comparison is almost meaningless. What should be compared instead is IOA/UKPS versus continuous positive airway pressure (CPAP) as standard treatment. This comparison is completely lacking in the studies compared. Furthermore, lowering the AHI from 60 to 30, for example, is pointless as the affected person continues to experience obstructive sleep apnea syndrome (OSAS), with the described risks for blood pressure, stroke, and reduced life expectancy.
An astonishing key message is alleged on page 2–6: “There is no robust scientific evidence to support treatment of OSA patients with […] surgical maxillomandibular advancement (MMA).”
Vicini et al. published a prospective randomized controlled study in 2010 of bilateral maxillomandibular advancement versus CPAP treatment. Their study found that both treatments were equivalent with regard to AHI and ESS (2). Such a study for OA/UKPS in comparison to the gold standard CPAP is lacking in the authors’ “umbrella” study. Koretsi et al. are dental surgeons specializing in orthodontics, and with their article title “Oral Interventions for Obstructive Sleep Apnea” they lay claim to an “umbrella study,” a meta-analysis of meta-analyses. But is uvulopalatoplasty (UPPP) in its variations, and are other interventions—such as electronically guided hypoglossal nerve stimulators (“tongue pacemakers”)—not therapeutic oral interventions? Meta-analyses in sleep medicine should be conducted in an interdisciplinary manner, by involving other medical disciplines such as abdominal surgery, otorhinolaryngology, cardiology, oromaxillofacial surgery, neurology and pulmonology.
References
- 1.Koretsi V, Eliades T, Papageorgiou SN. Oral interventions for obstructive sleep apnea—an umbrella review of the effectiveness of intraoral appliances, maxillary expansion, and maxillomandibular advancement. Dtsch Arztebl Int. 2018;115:200–207. doi: 10.3238/arztebl.2018.0200. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Vicini C, Dallan I, Campanini A, et al. Surgery vs ventilation in adult severe obstructive sleep apnea syndrome. Am J Otolaryngol. 2010;31:14–20. doi: 10.1016/j.amjoto.2008.09.002. [DOI] [PubMed] [Google Scholar]