To whom should a patient with snoring be referred for a mouthpiece, considering their medical history and potential sleep disorders?

Specialist Referral for Snoring Mouthpiece

Patients with snoring should be referred to a sleep physician first to confirm diagnosis and rule out obstructive sleep apnea, followed by referral to a sleep-qualified dentist for oral appliance fabrication if appropriate. 1

Initial Referral Pathway

Step 1: Sleep Physician Evaluation

• All patients with snoring must first see a sleep physician to confirm whether they have primary snoring (without OSA) or underlying obstructive sleep apnea, as this distinction is critical for determining appropriate treatment and avoiding serious cardiovascular and metabolic complications. 1
• The sleep physician will order polysomnography (sleep study) to establish the diagnosis and severity of any sleep-disordered breathing. 1
• This step is non-negotiable because approximately 80% of OSA cases remain undiagnosed, and untreated OSA carries significant risks including hypertension, coronary disease, stroke, dysrhythmias, diabetes, and motor vehicle accidents. 1

Step 2: Referral to Sleep-Qualified Dentist

Once the sleep physician confirms the diagnosis, patients appropriate for oral appliance therapy should be referred to a dentist with specialized training in dental sleep medicine. 1

Appropriate candidates include:

• Adults with primary snoring (without obstructive sleep apnea) 1
• Patients with mild to moderate OSA without significant comorbidities 1
• Patients who are CPAP intolerant or refuse CPAP therapy 1

Critical Patient Selection Criteria

The sleep-qualified dentist must verify the patient has:

• Adequate healthy teeth for device retention 2, 3
• No significant temporomandibular joint disorder 2, 3
• Adequate jaw range of motion 2, 3
• Manual dexterity to insert and remove the appliance 2, 3
• Adequate periodontal health 3

Device Specifications Required

The dentist must fabricate a custom-made, titratable mandibular advancement device (MAD) that meets these specifications:

• Custom-fitted (not prefabricated) 1, 3
• Titratable with incremental adjustment capability of 1 mm or less 3
• Capable of advancing the mandible at least 50% of maximum protrusion 3
• Protrusive adjustment range of at least 5 mm 3

Mandatory Follow-Up Protocol

This is a multidisciplinary management requirement:

• The dentist performs device titration over approximately 3 months, starting at maximal comfortable protrusion and advancing incrementally until symptom resolution or physical limits are reached. 3
• Objective sleep testing is mandatory after device fitting to confirm treatment efficacy. 1, 3
• The sleep physician must verify treatment success through follow-up polysomnography and monitor general health. 1
• Dental follow-up occurs at 6 months for the first year and at least annually thereafter to monitor for complications. 1, 2

Common Pitfalls to Avoid

Do not refer directly to a general dentist without sleep medicine training, as they lack the specialized knowledge to properly screen, fit, and monitor oral appliances for sleep-disordered breathing. 1

Do not skip the initial sleep physician evaluation, even if the patient "only snores," because undiagnosed OSA carries life-threatening cardiovascular risks and the patient may require CPAP rather than an oral appliance. 1

Do not allow patients to use over-the-counter or prefabricated devices, as these are ineffective and may worsen apnea frequency. 3

Expected Side Effects to Counsel Patients About

Initial side effects occur in slightly more than half of patients and include:

• Jaw discomfort and temporomandibular joint discomfort 2, 3
• Tooth tenderness and dental pain 2, 3
• Excessive salivation or dry mouth 2, 3
• Temporary occlusal changes 2, 3
• Gingival irritation 2, 3

Long-term use may cause dental misalignment, decreased overbite and overjet, proclination of lower incisors, and retroclination of upper incisors. 1