Comparative effectiveness of Mandibular advancement devices and Continuous positive airway pressure in adults with obstructive sleep Apnea: A systematic review and meta-analysis.

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by recurrent upper airway collapse, intermittent hypoxia, and sleep fragmentation. Continuous positive airway pressure (CPAP) is the standard treatment, although long-term adherence is often limited. Mandibular advancement devices (MADs) are increasingly used as an alternative therapy.

OBJECTIVE

To evaluate the effectiveness of MADs compared with CPAP and sham/control interventions in improving apnea-hypopnea index (AHI) and related clinical outcomes in adults with OSA.

METHODS

A systematic search of PubMed, Scopus, and the Cochrane Library was conducted according to PRISMA guidelines. Randomized controlled trials comparing MADs with CPAP or sham/control interventions were included. Meta-analysis was performed using random-effects restricted maximum likelihood models with Generic Inverse Variance methodology. For crossover trials, paired standard deviations were imputed using the Elbourne method.

RESULTS

Eight randomized controlled trials involving 642 participants were included. Compared with CPAP, MAD therapy showed significantly higher residual AHI values, favoring CPAP (MD = 11.83 events/hour; 95% CI: 6.61-17.04; I2 = 97.75%). This estimate should be interpreted cautiously because extreme heterogeneity limits precision. Compared with sham/control devices, MADs significantly improved AHI (MD = -15.78 events/hour; 95% CI: -23.13 to -8.43; I2 = 86.47%). Secondary outcomes showed variable but generally favorable responses.

CONCLUSION

CPAP remains the most effective therapy for reducing respiratory events in OSA, while limited evidence suggests MADs may offer benefit compared with sham/control interventions and remain an alternative for patients intolerant of or poorly adherent to CPAP. Interpretation should remain cautious given substantial heterogeneity and limited sham-controlled evidence available.