What is the recommended dental device treatment for a patient with mild to moderate obstructive sleep apnea (OSA) who cannot tolerate continuous positive airway pressure (CPAP) therapy?

Mandibular Advancement Devices Are Recommended for Sleep Apnea Patients

For patients with mild to moderate obstructive sleep apnea, mandibular advancement devices (MADs) are recommended as first-line therapy, and for those with severe OSA who cannot tolerate CPAP, MADs serve as an effective alternative treatment. 1

Best Treatment Algorithm for Sleep Apnea

First-Line Treatment by Severity

Mild to Moderate OSA (AHI 5-30):

• MADs are recommended as first-line therapy with approximately 52% overall treatment success rate 1
• Custom-made titratable devices are more effective than prefabricated ones, with newer designs achieving up to 75% treatment success rates 1, 2
• MADs reduce AHI by 50% or to <10 events per hour in most patients 3

Severe OSA (AHI >30):

• CPAP remains the gold standard first-line treatment 1, 4
• MADs are appropriate for patients who are intolerant to CPAP, refuse CPAP, or fail CPAP treatment attempts 1, 5
• Until higher quality evidence suggests otherwise, CPAP should be attempted first in severe OSA before considering MADs 5

MAD Effectiveness and Comparative Outcomes

Clinical Efficacy:

• MADs reduce the apnea-hypopnea index, arousal index, and daytime sleepiness while improving quality of life measures 1
• While CPAP is superior in normalizing respiratory parameters on polysomnography, both treatments demonstrate comparable effects on symptoms and health-related quality of life 1
• The comparable effectiveness is attributed to significantly better adherence with MADs compared to CPAP 1, 4, 6

Device Design Matters:

• Custom-made MADs with passive mouth closing features (like SomnoDent Avant) achieve 75% treatment success versus 56% for traditional wing-based designs 2
• The passive mouth closing design encourages nasal breathing, reduces mouth breathing, and decreases vertical opening, thereby reducing tongue base collapse 2

Patient Selection Criteria for MADs

Ideal Candidates:

• Younger age, female gender, lower BMI, smaller neck circumference 1
• Position-dependent OSA and lower baseline AHI 1
• Patients with mild to moderate OSA with no significant comorbidities 1
• Primary snoring patients 1

Contraindications:

• Severe periodontal disease 7
• Severe temporomandibular disorders 7
• Inadequate dentition 7
• Severe gag reflex 7

Device Specifications and Implementation

Essential MAD Characteristics:

• Must be individualized and titratable 1
• Made of biocompatible materials 1
• Engage both maxillary and mandibular arches 1
• Stable and retentive to teeth or implants 1
• Capable of advancing the mandible in increments of 1mm or less 1

Titration Protocol:

• Initial titration should start at approximately 50% of maximum mandibular advancement 1
• Subjective titration continues for approximately 3 months until resolution of symptoms and/or achieving physical limits 2
• Follow-up sleep testing (polysomnography or Type 3 cardiorespiratory study) is mandatory to verify treatment efficacy 1, 5

Side Effects and Monitoring Requirements

Common Initial Side Effects (Generally Minor and Transient):

• Jaw discomfort and tooth tenderness 1
• Excessive salivation, dry mouth 1, 4
• Gingival irritation 4
• Myofascial pain and temporomandibular disorder discomfort 4

Long-Term Monitoring:

• Patients should be followed by a qualified dentist every 6 months for the first year, then at least annually thereafter 4
• Regular follow-up is needed to monitor treatment efficacy, device deterioration or maladjustment, and health of oral structures and occlusal integrity 1, 5
• Sleep physician evaluation through appropriate sleep testing is required to assess OSA treatment effectiveness 4
• Re-evaluation with sleep testing is necessary after MAD titration, as symptom improvement alone is an imprecise indicator of treatment success 1

Critical Pitfalls to Avoid

Do Not Rely on Symptoms Alone:

• Improvement in subjective symptoms does not guarantee adequate treatment of OSA 1
• Objective sleep testing after MAD titration is mandatory 1, 5

Ensure Proper Dental Expertise:

• MADs must be fitted by qualified dental personnel trained in oral health, temporomandibular joint care, dental occlusion, and associated oral structures 5
• A multidisciplinary approach involving sleep physicians and qualified dentists is essential for optimal outcomes 1

Monitor for Worsening OSA:

• Regular follow-up is needed to assess for signs and symptoms of worsening OSA over time 5
• Repeat sleep studies may be needed when symptoms worsen or recur 5