When should an oral appliance be considered for a patient with mild to moderate Obstructive Sleep Apnea (OSA) who is intolerant or has failed Continuous Positive Airway Pressure (CPAP) therapy?

When to Consider an Oral Appliance in OSA

Oral appliances should be offered to patients with mild to moderate OSA who prefer them to CPAP, or who are intolerant of CPAP, fail CPAP therapy, or are not appropriate candidates for CPAP. 1

Primary Indications for Oral Appliance Therapy

Mild to Moderate OSA

• Oral appliances are a standard treatment option for patients with mild to moderate OSA who prefer alternate therapy to CPAP or cannot tolerate CPAP. 1
• These patients should receive custom, titratable oral appliances fitted by qualified dental personnel trained in oral health, temporomandibular joint care, and dental occlusion. 1
• While CPAP remains superior in reducing AHI, arousal index, and oxygen desaturation index, oral appliances produce quality of life improvements that are not inferior to CPAP. 1

CPAP Intolerance or Failure

• Patients who do not respond to CPAP, are not appropriate candidates for CPAP, or fail treatment attempts with CPAP should be offered oral appliances. 1
• Discontinuation of therapy due to side effects occurs less frequently with oral appliances versus CPAP, making them valuable for patients who cannot tolerate CPAP. 1
• Documented specific reasons for CPAP intolerance must be established, including mask refitting attempts, pressure adjustments, heated humidification, and behavioral interventions before proceeding to oral appliances. 2

Severe OSA Considerations

• Patients with severe OSA should have an initial trial of nasal CPAP because greater effectiveness has been shown with this intervention than with oral appliances. 1
• However, oral appliances can be considered for severe OSA patients who are intolerant of CPAP, refuse CPAP, or fail CPAP therapy. 3
• When properly titrated using custom, titratable devices with systematic adjustment based on polysomnography, oral appliances achieve approximately 69% treatment success in severe OSA patients. 3
• This compares to 84% success in non-severe patients and 82% success with CPAP in head-to-head comparisons. 3

Essential Requirements Before Initiating Oral Appliance Therapy

Diagnostic Confirmation

• The presence and severity of OSA must be determined before initiating oral appliance treatment to identify patients at risk and provide a baseline for effectiveness assessment. 1
• This diagnostic confirmation is mandatory to make appropriate treatment decisions. 1

Dental Evaluation

• Patients must undergo thorough dental examination to assess candidacy, including dental history, complete intra-oral examination, soft tissue assessment, periodontal evaluation, temporomandibular joint assessment, evaluation for nocturnal bruxism patterns, and occlusion evaluation. 1
• Dental records should be reviewed, and dental radiographs or panorex survey may be obtained to assess for dental pathology. 1

Device Selection and Titration

Custom, Titratable Devices Required

• Custom, titratable oral appliances are mandatory—non-titratable devices lack sufficient evidence, particularly for severe OSA. 3
• Mandibular repositioning appliances that cover upper and lower teeth and hold the mandible in an advanced position are the primary type used. 1
• The 69-80% success rates reported in studies apply only to custom, titratable appliances with systematic adjustment. 3, 4

Objective Verification of Efficacy

• Follow-up polysomnography or attended cardiorespiratory (Type 3) sleep study with the appliance in place is essential to confirm treatment efficacy. 1, 3, 5
• Relying on subjective symptom improvement alone is insufficient, as patients may remain suboptimally treated despite feeling better. 3
• Systematic titration and adjustment based on objective sleep testing data significantly improves outcomes. 3

Follow-Up and Monitoring

Dental Oversight

• Qualified dentists should provide ongoing oversight of oral appliance therapy to survey for dental-related side effects or occlusal changes and reduce their incidence. 1
• Regular follow-up visits are needed to monitor patient adherence, evaluate device deterioration or maladjustment, assess oral structure health and occlusion integrity, and evaluate for signs of worsening OSA. 1, 5

Sleep Medicine Follow-Up

• Regular follow-up with both a qualified dentist and sleep physician is necessary to optimize the device and monitor for side effects. 3
• Follow-up polysomnography may be needed when symptoms of OSA worsen or recur. 5

Adjunct Therapies to Enhance Outcomes

Weight Loss

• Weight loss should be recommended for all overweight OSA patients using oral appliances, as successful dietary weight loss may improve the AHI in obese patients. 6
• After substantial weight loss (10% or more of body weight), follow-up polysomnography is indicated to determine if oral appliance adjustments are necessary. 6

Positional Therapy

• Positional therapy is an effective secondary therapy for patients who have a lower AHI in non-supine versus supine positions. 1, 6
• A positioning device (alarm, pillow, backpack, tennis ball) should be used when initiating positional therapy. 1, 6
• Correction of OSA by position should be documented with polysomnography before initiating as primary therapy. 1, 6

Behavioral Modifications

• Avoidance of alcohol and sedatives before bedtime is essential as these substances worsen OSA by reducing upper airway muscle tone. 6
• Exercise can complement oral appliance therapy by improving overall sleep quality and potentially reducing OSA severity. 6

Common Pitfalls to Avoid

Inadequate Objective Assessment

• Do not rely on symptom improvement alone—objective sleep testing is mandatory to confirm adequate treatment. 3, 5
• Patients may overestimate their oral appliance use and feel subjectively better despite remaining suboptimally treated. 1, 3

Inappropriate Device Selection

• Do not use prefabricated or non-titratable devices, particularly for severe OSA—success rates apply only to custom, titratable appliances. 3
• Non-custom devices lack sufficient evidence for effectiveness. 3

Skipping Follow-Up Testing

• Do not skip follow-up sleep testing—adjustments based on polysomnography data differentiate higher success rates from lower outcomes. 3
• Initial side effects may reduce adherence and should be addressed promptly. 6

Long-Term Monitoring Neglect

• Long-term dental changes can occur with oral appliance use, necessitating regular follow-up with a qualified dentist. 1, 6
• Treatment-specific outcome indicators including self-reported compliance, objective monitoring, side effects, and symptom resolution should be continuously assessed. 1

Alternative and Combination Approaches

Combination Therapy

• Combined CPAP and oral appliance therapy reduces therapeutic CPAP requirements by 35-45% and may benefit incomplete responders to oral appliance therapy alone and those who cannot tolerate high CPAP levels. 7

When Oral Appliances Are Not First-Line

• Upper airway surgery (including tonsillectomy and adenoidectomy, craniofacial operations, and tracheostomy) may supersede use of oral appliances in patients for whom these operations are predicted to be highly effective. 1