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Title The Use Of A Mandibular Advancement Device Decreases Systemic Hypertension In Patients With Obstructive Sleep Apnea
Clinical Question In a patient with obstructive sleep apnea, does the use of a mandibular advancement device decrease the risk of systemic hypertension compared to no treatment?
Clinical Bottom Line For patients with obstructive sleep apnea, the use of a mandibular advancement device (MAD) is more effective than no treatment in reducing systemic hypertension. This is reinforced by a randomized controlled trial and a 3-year cohort study that found a significant reduction in blood pressure with values up to -15.5+/-18.7mmHg for systolic BP and -10.3+/-10 mmHg for diastolic BP, when using a MAD. MAD is a therapy for OSA that is becoming more noteworthy in general dental practice with the new research on this medical condition and its relevance to dentistry.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 15453552Gotsopoulos/ 2004N=67; majority (54%) with moderate to severe OSA and AHI> or =10 per hour and 2 associated symptoms; predominantly middle aged overweight men; 39% (n=26) were on hypertensive medicationsRCT
Key resultsPatients with OSA showed a 50% decrease in mean apnea hypopnea index (AHI) with the mandibular advancement device compared to the control group, in a four-week period. Additionally, the patients experienced a significant reduction in the arousal index and minimum oxygen saturation. There was a reduction in the mean 24-hour diastolic blood pressure (1.8 +/-0.5mmHg), but there was no effect on the mean 24-hour systolic blood pressure while the patient was asleep. This resulted in a P-value equal to 0.001. While the patient was awake there was a reduction in both systolic and diastolic blood pressures (3.3+/- 1.1mmHg and 3.4+/-0.9mmHg) with a P value of 0.003 and <0.0001.
#2) 19678869Andren/2009N=29; non-obese patients diagnosed with mild to moderate OSA and AI>5 per hour or AHI > or =10 per hour.Cohort study
Key resultsIn this 3-year cohort study there was a positive correlation between wearing a mandibular advancement device and a reduction in blood pressure. At the third month evaluation there was a reduction in the AHI value to less than 10 (4.1 +/-2.6) in 86% of the patient population (25 of 29 patients; P<0.001). An AHI value less than 10 is within the normal range of the general population without OSA. At the 3-year follow up evaluation there was a more significant decrease in blood pressure (systolic: -15.4+/-18.7mmHg; diastolic: -10.3+/-10 mmHg). These results were obtained with the majority of the patients (n=22; 4 women, 18 men with mean age of 57) wearing their MAD 4 or more nights a week (6.5 nights per week at the 3-month follow-up and 6.4 nights per week at the 3 year follow-up).
Evidence Search ("Sleep Apnea, Obstructive"[Mesh] AND "Hypertension"[Mesh]) AND "Mandibular Advancement"[Majr]
Comments on
The Evidence
Gotsopoulos published one randomized controlled trial in 2004 with a population size of 67 patients that were diagnosed with OSA and had an AHI > or = 10 episodes per hour and at least 2 of the associated symptoms: daytime sleepiness, snoring, witnessed apneas and fragmented sleep. The patient population included individuals greater than 20 years of age and with a minimum mandibular protrusion of 3mm. Andren published the cohort study in 2009 beginning with a patient group of 29 that had mild to moderate OSA defined as an AI>5 per hour and/or an AHI > or = 10 per hour (average of 16 apneas/hypopneas per hour). In both studies the groups were similar at the start. Adren noted that there was less than an 80% completion rate by the end of the study. Gotsopoulos stated that there was more than an 80% completion rate. Furthermore, both of the studies were not double-blind in nature, there was adequate follow-up and compliance throughout the studies, and recall bias was unlikely. There was no specification of any competing interests. The randomized controlled trial had a treatment group and a control group, and the cohort study followed one group for a three-year period with an evaluation at three months and three years with no control group. Perspective: Both studies provide sound evidence that the use of MAD therapy helps to reduce systemic hypertension in patients with OSA. The randomized controlled trial is higher on the evidence hierarchy compared to the cohort study. However, the cohort study holds the strength of time. This study is able to show a correlation with an increase in time of wearing the oral appliance and a further decrease in systemic hypertension. A limiting factor of both studies was that the subject population had a middle-aged male predominance.
Applicability Mandibular advancement device therapy is a recommended treatment option for patients with obstructive sleep apnea. This treatment option may be best suited for individuals who are unable to tolerate the CPAP machine and for those who may be at risk or are diagnosed with systemic hypertension associated with OSA.
Specialty/Discipline (General Dentistry) (Oral Surgery) (Orthodontics)
Keywords Obstructive sleep apnea, hypertension, mandibular advancement therapy
ID# 2414
Date of submission: 02/28/2013spacer
E-mail casarezquint@livemail.uthscsa.edu
Author Alicia Casarez-Quintana
Co-author(s) e-mail
Faculty mentor/Co-author Marcel Noujeim, DDS, MS
Faculty mentor/Co-author e-mail partidam@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
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Comments and Evidence-Based Updates on the CAT
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by Ryushiro Sugita, DDS (San Antonio, Texas) on 11/17/2015
A PubMed search on the blood pressure changes in obstructive sleep apnea patients treated with mandibular advancement devices was performed Oct 2015. A more recent publication was found: Ramar 2015, PubMed: 26094920. The meta-analysis including seven RCTs showed that mandibular advancement devices were found to lower the systolic (2.09 mmHg), diastolic (3.15 mm Hg), and mean BP. However, these reductions were modest at best.

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