CoChat
Sign Up
Cited by 11Obstructive Sleep Apnea ResearchMeta-analysis and systematic reviewsSleep and related disorders

Quality assessment of systematic reviews on the efficacy of oral appliance therapy for adult and pediatric sleep-disordered breathing

Open access
Al-Jewair, Thikriat S., Gaffar, Balgis O., Flores-Mir, Carlos·2016·Journal of Clinical Sleep Medicine
DOI 10.5664/jcsm.6062PMC PMC4957196
Open this paper in CoChat — free accountOpen PDF

Abstract

Study objectives To assess the methodological quality of published systematic reviews (SRs) and meta-analyses (MAs) about the efficacy of oral appliances (OA) in the management of adult and pediatric sleep-disordered breathing (SDB).Methods SRs/MAs that evaluated the efficacy of OA therapy on the treatment of SDB in human subjects of all age groups were sought. Multiple electronic databases were searched for articles published in any language from the database's inception until January 2016. Two reviewers independently selected and then assessed the methodological quality of the studies using the Assessment of Multiple Systematic Reviews (AMSTAR) measurement tool.Results Thirteen reviews on adult SDB were included (2 SRs and 11 SRs with MAs). Of those, seven were medium quality and six were high quality. Only four reviews were included on pediatric SDB (3 SRs and 1 SR with MA). Three of these were of high quality and one was medium quality. The identified limitations in the included reviews were failing to reference the excluded studies or describe reasons for exclusion, lack of applying valid criteria to assess the quality of included studies, lack of publication bias assessment, and absence of conflicts of interest reporting.Conclusions Overall, SRs/MAs on OA therapy for adult and pediatric SDB were conducted with acceptable methodological quality. High AMSTAR scores should not be extrapolated as a proxy of the methodological quality of the included evidence. There is a need for more primary studies and then that information can be used to be synthesized through SRs on pediatric SDB.

AI snapshot

Written from the paper’s full text.

TL;DR

This methodological review assessed the AMSTAR quality of 17 systematic reviews/meta-analyses on oral appliance therapy for adult and pediatric sleep-disordered breathing. Overall quality was acceptable, but evidence for pediatric efficacy remains insufficient and high AMSTAR scores do not guarantee the quality of included evidence.

Key findings

  • Seventeen reviews met inclusion: 13 on adult SDB (2 SRs and 11 SRs with meta-analyses) and 4 on pediatric SDB (3 SRs and 1 SR with meta-analysis).
  • Adult reviews: 7 were medium quality and 6 high quality, with a mean AMSTAR score of 7.85 ± 1.72 (range 5–11). Pediatric reviews: 3 were high quality and 1 medium quality, with a mean score of 9 ± 1.41 (range 7–10).
  • Common limitations were failure to reference excluded studies or describe exclusion reasons, lack of valid criteria to assess included-study quality, lack of publication bias assessment, and absence of conflict-of-interest reporting. More than 23% of adult reviews failed to list/reference excluded studies or give reasons; approximately 85% of adult and 75% of pediatric reviews used a valid quality-assessment tool; none of the pediatric reviews documented conflicts of interest.
  • OAs showed superior efficacy over controls/placebo/no treatment in adult SDB, but evidence was insufficient to support efficacy in pediatric SDB/OSA.

Methods

  • PRISMA-guided methodological quality assessment; multiple databases (PubMed, Ovid MEDLINE, EMBASE, Evidence Based Medicine Reviews, CINAHL, ProQuest Digital Dissertation, Health Technology Assessment, ADA-EBD, Google Scholar) and reference lists were searched from inception until January 2016.
  • Included SRs/MAs in any language that evaluated efficacy/effectiveness of OA therapy for SDB/OSA in children and/or adults; excluded primary studies, narrative reviews, case reports, editorials, guidelines, and practice parameters.
  • Two reviewers independently selected studies and assessed methodological quality using the 11-domain AMSTAR tool; disagreements were resolved by discussion, with a third investigator consulted when required. Scores were categorized as high quality (9–11), medium/low quality (5–8), and low quality (< 4).

Limitations

  • Stated by the paper: AMSTAR, like PRISMA, assesses reporting quality of SRs rather than risk of bias among the included studies; high AMSTAR scores should not be extrapolated as a proxy for the methodological quality of the included evidence. More primary studies and then SRs are needed for pediatric SDB.
  • Evident from the text: only four pediatric reviews were identified, and only one conducted a meta-analysis; heterogeneity limited quantitative synthesis. Publication bias was assessed in only 2 of 4 pediatric reviews and 5 of 13 adult reviews (38.5%), and none of the pediatric reviews documented conflicts of interest.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.5664/jcsm.6062

Cites

69 of 69 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 7 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Four systematic reviews on pediatric sleep-disordered breathing were included: 3 systematic reviews and 1 systematic review with meta-analysis.

    “Only four reviews were included on pediatric SDB (3 SRs and 1 SR with MA).”
    • Also stated in: § R ESU LT S · plain
      “four reviews were on pediatric OSA (3 SRs and 1 SR with MA).12,15,61,62”
    Quote in the paperNot a substantial claim
  • Findingown data

    Some included reviews lacked application of valid criteria to assess the quality of included studies.

    “The identified limitations in the included reviews were failing to reference the excluded studies or describe reasons for exclusion, lack of applying valid criteria to assess the quality of included studies, lack of publication bias assessment, and absence of conflicts of interest reporting.”
    Quote in the paperSubstantial claim
  • Findingown data

    Some included reviews lacked publication bias assessment.

    “The identified limitations in the included reviews were failing to reference the excluded studies or describe reasons for exclusion, lack of applying valid criteria to assess the quality of included studies, lack of publication bias assessment, and absence of conflicts of interest reporting.”
    • Also stated in: § Adult SDB · plain
      “Only five reviews (38.5%) either assessed publication bias using funnel plots 55,[58][59][60] or described reasons for not investigating it.56”
    Quote in the paperSubstantial claim
  • Findingown data

    Some included reviews failed to reference excluded studies or describe reasons for exclusion.

    “The identified limitations in the included reviews were failing to reference the excluded studies or describe reasons for exclusion, lack of applying valid criteria to assess the quality of included studies, lack of publication bias assessment, and absence of conflicts of interest reporting.”
    • Also stated in: § References of Excluded Reviews · plain
      “More than 23% of adult reviews failed to include a list or reference the excluded studies, or provide reasons for exclusion.”
    Quote in the paperSubstantial claim
  • Findingown data

    Some included reviews lacked conflicts of interest reporting.

    “The identified limitations in the included reviews were failing to reference the excluded studies or describe reasons for exclusion, lack of applying valid criteria to assess the quality of included studies, lack of publication bias assessment, and absence of conflicts of interest reporting.”
    • Also stated in: § References of Excluded Reviews · plain
      “None of the pediatric reviews documented conflicts of interest.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 27
  • Classified as probably not a substantial claim. 30
  • The quote only partly states this claim. 5

  • May combine two claims.

    Findingown data

    Thirteen systematic reviews on adult sleep-disordered breathing were included: 2 systematic reviews and 11 systematic reviews with meta-analyses.

    “Thirteen reviews on adult SDB were included (2 SRs and 11 SRs with MAs).”
    • Also stated in: § R ESU LT S · plain
      “Thirteen reviews were on adult OSA (2 SRs and 11 SRs with MAs)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Of the 13 adult reviews, seven were of medium quality and six were of high quality according to AMSTAR.

    “Of those, seven were medium quality and six were high quality.”
    • Also stated in: § References of Excluded Reviews · plain
      “adult OSA were of medium quality 1,49,51,53,54,57,58 and six were of high quality.50,52,55,56,59,60”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Of the four pediatric reviews, three were of high quality and one was of medium quality according to AMSTAR.

    “Three of these were of high quality and one was medium quality.”
    • Also stated in: § References of Excluded Reviews · plain
      “Of the reviews on pediatric OSA, three were of high quality 15,61,62 and one was medium quality 12”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Huynh et al., 2016 received an AMSTAR total score of 7 out of 11.

    “| Huynh et al., 2016 | Y | Y | Y | Y | Y | Y | N | N | Y | N | N | 7 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    In the moderate-quality reviews, oral appliances reduced AHI/respiratory disturbance index, improved blood pressure, and were associated with greater patient compliance and satisfaction.

    “In these reviews, OAs reduced AHI/respiratory disturbance index, improved blood pressure, and were associated with greater patient compliance and satisfaction.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Li et al., 2013 received an AMSTAR total score of 11 out of 11.

    “| Li et al., 2013 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 11 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Kuhle et al. and Carvalho et al. both had the highest score, whereas Huynh et al. had the lowest score among pediatric reviews.

    “Kuhle et al. 15 and Carvalho et al. 61 both had the highest score, whereas Huynh et al. 12 had the lowest score.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The review included 4 systematic reviews on pediatric sleep-disordered breathing.

    “Table 3 - Characteristics of included SRs with and without meta-analyses on pediatric SDB (n = 4).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The assessment of publication status by searching gray literature sources was conducted in 84.6% of adult reviews and all pediatric reviews.

    “The assessment of publication status by searching gray literature sources was conducted in 84.6% of adult reviews and all pediatric reviews.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Ahrens et al., 2011 received an AMSTAR total score of 8 out of 11.

    “| Ahrens et al., 2011 | Y | Y | Y | Y | N | Y | Y | Y | Y | NA | N | 8 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Two reviews did not report the search dates and four others did not search the gray literature.

    “Two reviews, 53,54 however, did not report the search dates and four others 49,[58][59][60] did not search the gray literature.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Meta-analyses were conducted in 11 reviews.

    “Meta-analyses were conducted in 11 reviews.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Iftikhar et al., 2013 received the lowest AMSTAR total score among the included adult sleep-disordered breathing systematic reviews, 5 out of 11.

    “| Iftikhar et al., 2013 | Y | Y | N | N | N | Y | N | N | Y | Y | N | 5 |”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Li et al., 2013 was the only included systematic review to receive a perfect AMSTAR total score of 11 out of 11.

    “| Li et al., 2013 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 11 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Iftikhar et al., 2013 received an AMSTAR total score of 5 out of 11.

    “| Iftikhar et al., 2013 | Y | Y | N | N | N | Y | N | N | Y | Y | N | 5 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Lim et al., 2006 received an AMSTAR total score of 9 out of 11.

    “| Lim et al., 2006 | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | N | 9 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Sharples et al., 2016 received an AMSTAR total score of 9 out of 11.

    “| Sharples et al., 2016 Y | Y | Y | Y | N | Y | Y | Y | Y | Y | N | 9 | |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Okuno et al., 2014 received an AMSTAR total score of 9 out of 11.

    “| Okuno et al., 2014 | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | N | 9 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Randomized controlled trials were the most commonly sought and included study type.

    “As expected, RCTs was the most commonly sought and included study type.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Ahrens et al., 2010 received an AMSTAR total score of 8 out of 11.

    “| Ahrens et al., 2010 | Y | Y | Y | Y | N | Y | Y | Y | Y | NA | N | 8 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Although the authors of all the reviews documented conflicts of interest, in only one review did the authors declare conflicts of interest for the individual studies included within the review.

    “Although the authors of all the reviews documented conflicts of interest, in only one review 56 did the authors declare conflicts of interest for the individual studies included within the review.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingreasoning

    Comparisons with CPAP therapy in the moderate-quality reviews demonstrated similar or superior efficacy of CPAP.

    “Comparisons with CPAP therapy demonstrated similar or superior efficacy of CPAP.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    Most of the primary studies included within the selected systematic reviews were randomized controlled trials; however, most of these reviews reported that the quality of the included studies was moderate or low.

    “Most of the primary studies included within the selected SRs were RCTs; however, most of these SRs reported that the quality of the included studies was moderate or low.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    McDaid et al. assessed bias and allocation concealment, but the results were not presented for each study.

    “McDaid et al. 51 assessed bias and allocation concealment, but the results were not presented for each study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    McDaid et al., 2009 received an AMSTAR total score of 6 out of 11.

    “| McDaid et al., 2009 | Y | Y | Y | Y | N | Y | N | N | Y | N | N | 6 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    A total of 387 studies were identified and assessed for inclusion.

    “A total of 387 studies were identified and assessed for inclusion.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims. The quote only partly states this claim.

    Findingown data

    Huynh et al., 2016 received the lowest AMSTAR total score among the included pediatric sleep-disordered breathing systematic reviews, 7 out of 11.

    “| Huynh et al., 2016 | Y | Y | Y | Y | Y | Y | N | N | Y | N | N | 7 |”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The AMSTAR total scores of the included pediatric sleep-disordered breathing systematic reviews ranged from 7 to 10 out of 11.

    “| Huynh et al., 2016 | Y | Y | Y | Y | Y | Y | N | N | Y | N | N | 7 |”
    • Also stated in: § A BBRE V I ATI O NS · plain
      “| Carvalho, et al., 2007 Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | 10 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The number of included studies in each review ranged from 1 to 71 studies with different study designs.

    “The number of included studies in each review ranged from 1 to 71 studies with different study designs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Franklin et al., 2007 received an AMSTAR total score of 9 out of 11.

    “| Franklin et al., 2007 | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | N | 9 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Bratton et al., 2015 received an AMSTAR total score of 9 out of 11.

    “| Bratton et al., 2015 | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | N | 9 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Lie et al. had the highest quality among all reviews (11/11) and Iftikhar et al.'s review had the lowest (5/11).

    “Lie et al. 56 had the highest quality among all the reviews (11/11) and Iftikhar et al.'s 58 review had the lowest (5/11).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Wang et al., 2013 received an AMSTAR total score of 6 out of 11.

    “| Wang et al., 2013 | Y | Y | Y | Y | N | Y | Y | N | N | N | N | 6 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Approximately 85% of adult reviews and 75% of pediatric reviews used a valid tool or criteria to assess the quality of included studies.

    “Approximately 85% and 75% of adult and pediatric reviews, respectively, used a valid tool or criteria to assess the quality of included studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The total mean AMSTAR score for adult OSA reviews was 7.85 ± 1.72 and scores ranged from 5 to 11.

    “The total mean score for the adult OSA studies was 7.85 ± 1.72 and the scores ranged from 5 to 11.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    All included reviews were published between 2004 and 2016 and were in English except for one review in Chinese.

    “All the included reviews were published between 2004 and 2016 and were in English language except for one review 57 in Chinese.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Li et al., 2013 was the only included systematic review to document conflict of interest.

    “| Li et al., 2013 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 11 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    None of the pediatric reviews documented conflicts of interest.

    “None of the pediatric reviews documented conflicts of interest.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The total mean AMSTAR score for pediatric OSA reviews was 9 ± 1.41 and the range was 7 to 10.

    “the total mean score for the studies was 9 ± 1.41 and the range was 7 to 10.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Kuhle et al., 2009 received an AMSTAR total score of 10 out of 11.

    “| Kuhle et al., 2009 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | 10 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    These high-quality reviews supported a reduction in apnea-hypopnea index, minimum oxygen saturation level, blood pressure, and arousal index with oral appliances, in addition to improvement in health-related quality of life.

    “These reviews supported a reduction in apnea-hypopnea index (AHI), minimum oxygen saturation level, blood pressure, and arousal index with OAs, in addition to improvement in health-related quality of life.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Twelve systematic reviews with meta-analyses and five without meta-analyses were included.

    “Twelve SRs with MAs and five without MAs were included.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Health Quality Ontario, 2009 received an AMSTAR total score of 6 out of 11.

    “| Health Quality | Y | CA | Y | N | N | Y | Y | Y | Y | N | N | 6 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Carvalho et al., 2007 received an AMSTAR total score of 10 out of 11.

    “| Carvalho, et al., 2007 Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | 10 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Hoekema et al., 2004 received an AMSTAR total score of 7 out of 11.

    “| Hoekema et al., 2004 Y | Y | Y | Y | N | Y | Y | N | Y | N | N | 7 | |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Nazarali et al., 2015 received an AMSTAR total score of 9 out of 11.

    “| Nazarali et al., 2015 | Y | Y | Y | Y | Y | Y | Y | Y | Y | NA | N | 9 |”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The AMSTAR total scores of the included adult sleep-disordered breathing systematic reviews ranged from 5 to 11 out of 11.

    “| Iftikhar et al., 2013 | Y | Y | N | N | N | Y | N | N | Y | Y | N | 5 |”
    • Also stated in: § A BBRE V I ATI O NS · plain
      “| Li et al., 2013 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 11 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Johal et al. evaluated eight reviews/clinical practice guidelines comparing oral appliances with different modalities including no treatment and reported variable quality with only two of the systematic reviews being of high quality.

    “Johal et al. 16 evaluated eight reviews/clinical practice guidelines comparing OAs with different modalities including no treatment.They reported variable quality with only two of the SRs being of high quality.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [16] Johal A, Fleming PS, Manek S, Marinho VC. Mandibular advancement splint (MAS) therapy for obstructive sleep apnoea--an overview and quality assessment of systematic reviews. Sleep Breath 2015;19:1101–8. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Many systematic reviews have been published on the efficacy of oral appliance therapy in adult sleep-disordered breathing, but only few about pediatric sleep-disordered breathing.

    “Many SRs have been published on the efficacy of OA therapy in adult SDB, but only few about pediatric SDB.1,15”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [1] Hoekema A, Stegenga B, De Bont LG. Efficacy and co-morbidity of oral appliances in the treatment of obstructive sleep apnea-hypopnea: a systematic review. Crit Rev Oral Biol Med 2004;15:137–55. source

      Not checked in the free run.

    • cites [15] Kuhle S, Urschitz MS, Eitner S, Poets CF. Interventions for obstructive sleep apnea in children: a systematic review. Sleep Med Rev 2009;13:123–31. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Treatment success depends on the severity of the disease and the design and degree of mandibular forward repositioning of oral appliances among other factors.

    “depends on the severity of the disease and the design and degree of mandibular forward repositioning of OAs among other factors.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two independent reviewers selected the studies independently.

    “Two independent reviewers (T.J. and B.G.) selected the studies independently.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The PRISMA criteria were followed during the reporting of this methodological quality assessment study.

    “The preferred reported items for systematic reviews and metaanalyses (PRISMA) criteria 17 were followed during the reporting of this methodological quality assessment study.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 2009;6:e1000097. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Trials of shorter duration might have exaggerated the treatment efficacy as compared to trials of longer durations.

    “Trials of shorter duration might have exaggerated the treatment efficacy as compared to trials of longer durations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Disagreement in scoring between investigators was discussed openly and when required a third investigator was consulted.

    “Disagreement in scoring between investigators was discussed openly and when required, a third investigator was consulted (C.F.M).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Overall, oral appliances showed superior efficacy to no treatment/controls in the management of adult sleep-disordered breathing/obstructive sleep apnea, but evidence is insufficient to support the efficacy of those appliances in pediatric sleep-disordered breathing/obstructive sleep apnea.

    “Overall, OAs showed superior efficacy to no treatment/controls in the management of adult SDB/OSA, but evidence is insufficient to support the efficacy of those appliances in pediatric SDB/OSA.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    More studies were published since Johal et al.'s last search in 2013 and no study has evaluated the quality of systematic reviews about pediatric obstructive sleep apnea.

    “More studies were published since their last search in 2013 and no study has evaluated the quality of SRs about pediatric OSA.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The same two reviewers independently assessed the methodological quality of the studies using the AMSTAR measurement tool.

    “The same two reviewers independently assessed the methodological quality of the studies using the Assessment of Multiple Systematic Reviews (AMSTAR) measurement tool.18”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Shea BJ, Grimshaw JM, Wells GA, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Intent-to-treat analyses were not conducted in many studies, which may have introduced bias.

    “Also, intent-to-treat analyses were not conducted in many studies, which may have introduced bias.”
    Quote in the paperSubstantial claim
58 of 58

  • The paper relies on this without support.

    AMSTAR (like PRISMA) assesses only the quality of reporting in systematic reviews, not the risk of bias among the included studies inside those reviews.

    “Similar to PRISMA, which only assesses the quality of reporting in the SRs, and not the risk of bias among the included studies inside those SRs, high AMSTAR scores should not be extrapolated as a proxy for the methodological quality of the included evidence.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Pediatric conclusions cite reviews outside the pediatric high-quality group

    Minor

    The pediatric discussion identifies references 58, 11, and 57 as its three high-quality reviews. The results instead identify references 15, 61, and 62 as the three high-quality pediatric reviews; reference 58 is listed among the medium-quality adult reviews.

  • One exception does not fit the stated 84.6% rate

    Minor

    The paper reports 13 adult reviews, 11 of them with meta-analyses. If only one review used inappropriate combining methods, the appropriate-use rate would be 12/13 (92.3%) across adult reviews or 10/11 (90.9%) across their meta-analyses, not 84.6%.

  • Gray-literature search count conflicts with the reported rate

    Minor

    The discussion says four adult reviews did not search gray literature. The results say 84.6% of the 13 adult reviews did search it, leaving only two that did not.

  • Two different cutoffs are given for low-quality reviews

    Minor

    The methods define low quality as a score below 4, while the later scoring note defines it as below 5. A score of 4 is classified differently.

4 of 4

Cites

Flagged first, then by citations

3 of the 72 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. Franklin K, Rehnqvist N, Axelsson S. Obstructive sleep apnoea syndrome: a systematic literature review. Report of a Joint Nordic Project. Stockholm: SBU, 2007. http://www.sbu.se/Filer/Content0/publikationer/1/somnapne_fulltext.pdf.2007.
  2. Wang N, Tu XP, Hu K, Xiao JX, Gou Y. Effectiveness of oral appliance versus continuous positive airway pressure in treating patients with mild to moderate obstructive sleep apnea-hypopnea syndrome: a meta-analysis. CJEBM 2013;13:231–5.

Cited by

Sorted by citations

Related

Authors
Al-Jewair, T. S., Gaffar, B. O., & Flores-Mir, C.
Affiliations
Imam Abdulrahman Bin Faisal University (SA)
ORCID
Gaffar, Balgis O.
Venue
Journal of Clinical Sleep Medicine
Publisher
Springer Science and Business Media LLC
Published
2016-08-15
Volume
12
Issue
8
Pages
1175-1183
ISSN
  • 1550-9389 (ISSN-L)
  • 1550-9397
DOI
10.5664/jcsm.6062
PMC
PMC4957196
OpenAlex
W2499877824
Semantic Scholar
5277b0fe7eb00f9e5ebded0b612b7cb7a10e2b0e
Cited by
10
References
72
Citations by year
2023: 1 · 2022: 1 · 2021: 1 · 2019: 2 · 2018: 2 · 2017: 2 · 2016: 1
FWCI
0.27
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Clinical Sleep Medicine (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
  • Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
Keywords
oral appliance therapy, sleep-disordered breathing, methodological quality of systematic reviews, AMSTAR, pediatric sleep apnea, adult sleep apnea, publication bias, conflicts of interest, meta-analysis
MeSH terms
Adult, Child, Humans, Quality Assurance, Health Care, Review Literature as Topic, Sleep Apnea Syndromes, Treatment Outcome, Mandibular Advancement

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review