Abstract
AIM: The aim of this study was to evaluate the association between obstructive sleep apnea (OSA) and periodontitis using an umbrella meta-analysis (MA). METHODS: PubMed, MEDLINE, Web of Science, Scopus, Embase, and Google Scholar databases were systematically searched before December 2025. MAs reporting odds ratios (OR) for the association between OSA and periodontitis were included. Methodological quality was assessed using AMSTAR-2, and certainty of evidence was evaluated using GRADE. Random-effects MA was performed. Egger's test and trim-and-fill analysis were used to assess the publication bias. RESULTS: Seven MAs encompassing over 225,000 participants were included. A significant association was found between OSA and periodontitis (OR 1.96, 95% CI 1.68-2.29, p < 0.0001), with substantial heterogeneity (I(2) = 69.5%). After using trim-and-fill method to adjust for publication bias, the association strengthened (OR 2.24, 95% CI 1.92-2.60, p < 0.0001). A dose-response pattern emerged, with severe OSA showing higher odds (OR 2.25) compared to mild-moderate OSA (OR 1.82), though not statistically different (p = 0.44). The association remained consistent among different study qualities and sample sizes. The GRADE assessment rated the certainty of evidence of the main outcome as low due to heterogeneity and publication bias. Further, a high overlap ratio of 26.8% was observed among the included MAs. CONCLUSIONS: The results of this review suggest a significant association between OSA and periodontitis, with a greater association of severe OSA with periodontitis. Future studies should examine the impact of periodontal therapy on OSA severity and vice versa. PROSPERO REGISTRATION: CRD420251241137.