Front Neurol. 2026 May 20;17:1846726. doi: 10.3389/fneur.2026.1846726. eCollection 2026.
ABSTRACT
BACKGROUND: Continuous positive airway pressure (CPAP) is the gold standard for obstructive sleep apnea (OSA), but its clinical effectiveness in cardiovascular risk management is often limited by suboptimal adherence.
OBJECTIVE: To systematically evaluate and compare the effects of mandibular advancement devices (MAD) vs. CPAP and inactive controls on blood pressure (BP), sleep-related respiratory events, and treatment adherence in patients with OSA.
METHODS: We systematically searched PubMed, Embase, Cochrane Library, and Web of Science from database inception to February 2026. RCTs reporting ambulatory BP outcomes pre- and post-MAD treatment were included. Secondary outcomes included the apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and objective treatment adherence. Data were pooled using mean differences (MD) and 95% confidence intervals (CIs).
RESULTS: Fourteen independent RCTs (comprising 16 reports) encompassing a total of 1,141 patients, met the inclusion criteria. Compared with inactive controls, MAD showed overall trends of BP reduction. In head-to-head comparisons with CPAP, MAD demonstrated comparable cardiovascular benefits on 24-h and nighttime BP parameters. Notably, MAD achieved a significantly greater reduction in daytime systolic BP compared with CPAP (MD = -1.99 mmHg, 95% CI: -3.82 to -0.17; p = 0.03). While CPAP demonstrated superior physiological efficacy in reducing AHI (MD = 8.45 events/h, p < 0.001), MAD and CPAP yielded comparable improvements in subjective sleepiness (ESS). Crucially, pooled objective tracking data revealed that MAD had significantly longer nightly adherence than CPAP (MD = 0.71 h/night, 95% CI: 0.30 to 1.13; p < 0.001).
CONCLUSION: Despite a physiological inferiority in reducing AHI, MAD appears to offer cardiovascular benefits comparable to CPAP and demonstrates a statistically significant reduction in daytime SBP, which may be partially facilitated by its superior objective adherence. Therefore, for OSA patients who cannot tolerate CPAP, MAD may serve as a viable alternative option for cardiovascular risk management.
SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261303916, identifier: CRD420261303916.
PMID:42246045 | PMC:PMC13229622 | DOI:10.3389/fneur.2026.1846726
