Oral Appliance Therapy for Sleep Apnea

Oral appliance therapy treats obstructive sleep apnea (OSA) and snoring with a custom mouthpiece worn at night. The device holds your lower jaw slightly forward, which helps keep your airway open while you sleep. It is an option for adults who cannot use CPAP or would rather try something else, and it starts with a diagnosis from a sleep physician.

What is oral appliance therapy?

An oral appliance is a small device that fits over your teeth, a bit like a sports mouthguard or a retainer. The most common type is a mandibular advancement device (MAD). "Mandibular" means the lower jaw.

Oral appliances are one of several alternatives to CPAP. They have no mask, hose or machine, so they are quiet and easy to pack for travel.

How a mandibular advancement device works

In obstructive sleep apnea, the muscles in your throat relax during sleep. The tongue and soft tissues can fall back and narrow or block the airway. That causes snoring, pauses in breathing and broken sleep.

• Two trays — one fits your upper teeth and one fits your lower teeth.
• Jaw forward — the trays are linked so your lower jaw rests a little forward.
• More room to breathe — moving the jaw also moves the tongue forward, which helps keep the airway open.
• Adjustable — the dentist can move the jaw forward in small steps until it works and feels comfortable.

A different type, the tongue-retaining device, holds the tongue forward instead of the jaw. It is used less often.

Who oral appliances can help

In 2015, the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) published a joint guideline on oral appliances.^[1]

• Adults who can't tolerate CPAP — the guideline recommends sleep physicians consider an oral appliance for adults with OSA who cannot use CPAP or prefer another treatment.
• Adults who snore without sleep apnea — oral appliances can reduce snoring once a sleep physician has ruled out sleep apnea.
• Mild to moderate sleep apnea — this is where oral appliances are most often used, though CPAP still tends to work better.
• Severe sleep apnea — CPAP remains the first choice. An oral appliance is kept for people who did not do well with CPAP.

You also need enough healthy teeth and gums to hold the device. Active gum disease, loose teeth or jaw joint problems may make an appliance a poor fit. A dentist checks this before making one.

Oral appliance vs CPAP

Studies show both CPAP and oral appliances can lower the number of breathing pauses per hour, called the AHI. CPAP usually lowers it more, and it is more likely to bring moderate or severe sleep apnea down to a normal range.

But a treatment only works if you use it. Studies show people stop treatment because of side effects less often with an oral appliance than with CPAP. That is why the guideline asks sleep physicians to weigh each patient's preference. If you have had trouble with CPAP, it may also help to read about getting used to CPAP before you switch.

The steps to getting an oral appliance

Oral appliance therapy is a team effort between a sleep physician and a qualified dentist.

• Diagnosis — a sleep physician confirms OSA or snoring with an in-lab or home sleep apnea test. A dentist should not diagnose snoring, because it often comes with sleep apnea.
• Prescription and referral — if an appliance fits your needs, the sleep physician prescribes it and refers you to a qualified dentist, ideally one with training in dental sleep medicine.
• Custom fitting — the dentist checks your teeth, gums and jaw, takes impressions or scans, and has a custom, adjustable appliance made. The guideline prefers custom devices over non-custom ones.
• Adjustment — over several visits, the dentist moves your jaw forward in small steps.
• Follow-up sleep test — the sleep physician repeats a sleep test with the appliance in to confirm it works or guide more changes.
• Regular check-ups — you keep seeing both the dentist and the sleep physician over time.

Side effects and how to manage them

Most side effects involve the teeth and jaw. Many are mild and ease as you get used to the device.

• Sore teeth, gums or jaw — often worse in the first weeks and in the morning.
• Extra saliva or dry mouth — common early on.
• Morning chewing trouble — your bite may feel "off" for a short time after you take it out.
• Bite changes — over months to years, the way your teeth meet can shift. Regular dental visits help spot this early.
• Jaw joint problems — an appliance may make an existing jaw joint (TMJ) problem worse.

Tell your dentist about pain that does not ease. Small changes to the device often help.

When to see a sleep specialist

See a sleep physician before you buy or order any mouthpiece if you have signs of sleep apnea. Our guide on when to see a sleep specialist covers more.

• Loud snoring — especially with gasping, choking or pauses someone else notices.
• Daytime sleepiness — feeling tired after a full night, or nodding off while driving.
• CPAP trouble — you have stopped using CPAP or can't wear it most nights.
• Symptoms back on an appliance — snoring or sleepiness returns while you use your device.

If your child snores most nights, talk with your pediatrician. Children are evaluated differently from adults.

Sleep care at Teddy Bear Pediatrics & Sleep Medicine

Dr. Minal Patel is board-certified in pediatrics and sleep medicine. The practice in Cedar Park offers in-lab and home sleep studies, CPAP and BiPAP therapy, Inspire therapy evaluation, and CBT-I for insomnia. If an oral appliance may be right for you, the first step is a sleep evaluation and diagnosis.

The practice is accepting new patients, Monday to Friday, 8:30 AM to 5:00 PM, by appointment only (no walk-ins). Medicaid and CHIP are accepted for sleep medicine patients.