Mandibular Advancement Device Sources for Sleep Apnea
Your patient should be referred to a qualified dentist with specialized training in dental sleep medicine who will fabricate a custom-made, titratable mandibular advancement device (MAD) rather than purchasing over-the-counter or prefabricated devices. 1
Why Custom Devices from Qualified Dentists Are Essential
Custom-made titratable MADs are the only recommended type of oral appliance for sleep apnea treatment. 1, 2 These devices must be:
- Fabricated by a qualified dentist trained in sleep medicine and/or sleep-related breathing disorders 1, 3
- Custom-fitted to the patient's dental anatomy, not prefabricated or over-the-counter 2
- Titratable with incremental adjustment capability of 1 mm or less and a protrusive range of at least 5 mm 2
- Capable of advancing the mandible at least 50% of maximum protrusion, as non-advanced devices are ineffective and may worsen apnea 2
The Multidisciplinary Referral Process
The treatment pathway requires coordination between the sleep physician and qualified dentist. 1
- The sleep physician maintains responsibility for OSA diagnosis via polysomnography (PSG) or home sleep apnea testing (HSAT), determines treatment appropriateness, and conducts final follow-up evaluation 1
- The qualified dentist handles MAD selection, fabrication, titration to maximize results and reduce side effects, and ongoing dental follow-up 1
- Communication between providers is mandatory, with the dentist informing the physician if annual assessment reveals worsening OSA symptoms or need for device adjustments 1
Patient Eligibility Requirements
Before referring for MAD fabrication, confirm your patient meets these criteria:
- Mild to moderate OSA (AHI 15-30 events/hour) as first-line treatment, or CPAP intolerance with moderate-to-severe OSA 1, 2
- Adequate healthy teeth for device retention 3, 2
- No significant temporomandibular joint disorder 3
- Adequate jaw range of motion and manual dexterity to insert/remove the appliance 3
- Adequate periodontal health documented with baseline occlusal analysis and intraoral/extraoral photographs 2
The Titration Protocol
A structured titration procedure is non-negotiable for treatment success. 2
- Initial fitting starts at maximal comfortable protrusion 2
- Incremental advancement occurs over approximately 3 months until symptom resolution or physical limits are reached 2
- "Trial and error" approach with Type 3 sleep tests is standard, as titrating MAD during sleep studies is expensive 1
- Final sleep study (Type 1 or 2 test) for baseline comparison is mandatory to confirm treatment effectiveness 1, 2
Required Follow-Up Schedule
Structured monitoring prevents complications and ensures ongoing efficacy. 1
- Every 6 months for the first year 1
- At least annually thereafter for ongoing assessment 1
- Regular dental follow-up to monitor for dental complications including decreases in overbite/overjet, proclination of lower incisors, retroclination of upper incisors, tooth damage, and TMD issues 1, 3
Expected Side Effects and Management
Most complications are mild and temporary, occurring during the adaptation period. 1
- Short-term effects include hypersalivation, dry mouth, dental pain, gingival irritation, myofascial pain, and TMD discomfort 1, 2
- TMD symptoms are usually transient and decrease with continued use 1
- Mandibular exercises during adaptation may improve discomfort and allow treatment continuity, potentially with physiotherapy support 1
- Long-term dental changes are identifiable but manageable with proper monitoring 1
Common Pitfalls to Avoid
Do not recommend over-the-counter or prefabricated devices as they lack the customization and titratability required for effective treatment 2. Do not bypass the sleep physician for diagnosis or final treatment evaluation—PSG or HSAT interpretation must be performed by the sleep physician 1. Do not skip objective sleep testing after MAD placement, as confirmation of treatment success is mandatory 2. Do not assume all dentists are qualified—specifically seek dentists with training in dental sleep medicine who work on referral basis with sleep physicians 1, 4.
Treatment Effectiveness Context
MADs reduce AHI and improve quality of life, though less effectively than CPAP. 5, 6 However, superior compliance with MADs compared to CPAP results in similar overall clinical effectiveness 5. Approximately one out of three patients shows negligible improvement under MAD therapy, making proper patient selection imperative 5. Compliance reports suggest only 50% of patients continue using the device after 3 years 4, emphasizing the importance of ongoing follow-up and side effect management.