Is a mandibular advancement device such as DreamVent Pro or Exvalve appropriate for a patient with Upper Airway Resistance Syndrome, apnea‑hypopnea index <5, daytime fatigue, insomnia, forward neck posture, and inadequate response to three nights of bilevel positive airway pressure therapy (EPAP ≈9 cm H₂O, IPAP ≈15 cm H₂O)?

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Last updated: February 21, 2026 • View editorial policy

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Mandibular Advancement Device for Upper Airway Resistance Syndrome

A mandibular advancement device (MAD) such as DreamVent Pro or Exvalve is an appropriate treatment option for your case of Upper Airway Resistance Syndrome (UARS) with AHI <5, given your documented inadequate response to bilevel PAP therapy after only three nights. 1

Why MAD is Appropriate for Your Specific Case

Your Clinical Profile Matches MAD Indications

  • You have UARS with AHI <5, which falls outside the typical moderate-to-severe OSA range where CPAP is considered gold standard. 1

  • MADs are specifically indicated for patients with primary snoring and mild sleep-disordered breathing without significant comorbidities, which aligns with your presentation of daytime fatigue and insomnia rather than severe apneas. 1

  • The Portuguese Society consensus (2025) explicitly recommends custom-made, titrable MADs for patients like you who have increased upper airway resistance during sleep with frequent arousals but minimal oxygen desaturation. 1

Your Brief PAP Trial Does Not Constitute Adequate CPAP Failure

  • Three nights of bilevel PAP is insufficient to determine true PAP intolerance. The American Academy of Sleep Medicine recommends comprehensive CPAP optimization including mask refitting, pressure adjustments, heated humidification, and behavioral interventions over several weeks before declaring PAP failure. 2

  • However, for UARS specifically (AHI <5), PAP therapy is not the mandatory first-line treatment as it is for moderate-to-severe OSA. 1

  • Your case represents a clinical scenario where MAD can be considered as primary therapy rather than requiring documented CPAP failure first, since you don't meet criteria for OSA syndrome requiring CPAP as gold standard. 1

Critical Requirements for MAD Success

You Must Use a Custom-Made, Titrable Device

  • Generic, non-custom devices like over-the-counter oral appliances are significantly less effective. You must obtain a custom-made, dual-block MAD fabricated by a qualified dentist with training in dental sleep medicine. 1

  • The device must be titrable to allow gradual advancement of the mandible to find the optimal position that maintains airway patency without causing temporomandibular joint problems. 1

Dental Contraindications Must Be Ruled Out

Before proceeding with MAD, ensure you do NOT have: 1

  • Severe periodontal disease
  • Severe pre-existing temporomandibular disorders (TMD)
  • Inadequate dentition or implants for retention
  • Severe gag reflex

Follow-Up Sleep Study is Mandatory

  • You must undergo objective follow-up testing (polysomnography or home sleep apnea test) after MAD titration to document treatment efficacy and ensure your respiratory effort-related arousals have decreased. 1

  • Subjective symptom improvement alone is insufficient to confirm adequate treatment of UARS. 3, 4

Your Forward Neck Posture: An Important Consideration

Postural Factors May Contribute to UARS

  • Forward head posture can narrow the upper airway and increase resistance to airflow during sleep. 4

  • Myofunctional therapy targeting oral cavity and oropharyngeal structures, combined with postural correction exercises, may complement MAD therapy by improving mandibular positioning and nasal breathing. 1

Consider Concurrent Interventions

  • Physical therapy or exercises to correct forward neck posture should be pursued alongside MAD treatment, as this may enhance overall treatment efficacy. 1

  • Positional therapy may also be beneficial if your UARS is worse in supine position, though this requires documentation via sleep study showing position-dependent respiratory events. 1

Why Not Return to PAP Therapy First?

The Evidence Supports MAD as Reasonable Primary Treatment for UARS

  • UARS patients often have intact local neurologic systems and respond to minor changes in upper airway dimensions, making them good candidates for mechanical interventions like MAD. 4

  • The 2025 Portuguese consensus and 2013 American College of Physicians guideline both support MAD for patients with mild sleep-disordered breathing, which includes UARS with AHI <5. 1

PAP Pressures of EPAP 9/IPAP 15 May Be Excessive for UARS

  • UARS patients typically require lower CPAP pressures (mean 7.1 ± 1.1 cmH₂O in one study) compared to OSA patients, suggesting your bilevel pressures may have been unnecessarily high and contributed to intolerance. 3

  • If you were to retry PAP, starting with lower CPAP pressures (6-8 cmH₂O) with heated humidification and systematic education would be more appropriate than the bilevel settings you tried. 2, 3

Expected Outcomes with MAD Treatment

MADs Effectively Reduce Respiratory Effort-Related Arousals

  • MADs decrease the frequency and duration of respiratory effort-related arousals (RERAs), which are the hallmark of UARS, by stabilizing the lower jaw in a forward position and maintaining airway patency. 1

  • MADs also reduce daytime sleepiness and improve quality of life measures, with better adherence compared to CPAP in many patients. 1

Adherence is Superior to CPAP

  • MAD adherence is generally better than CPAP adherence, which is particularly relevant given your brief and unsuccessful PAP trial. 1

Common Pitfalls to Avoid

  • Do not use a non-custom, over-the-counter device – these lack the adjustability and precision fit needed for effective treatment. 1

  • Do not skip the follow-up sleep study – you must objectively document that your RERAs and arousals have decreased with MAD therapy. 1

  • Do not ignore potential side effects – MADs can cause temporomandibular joint discomfort, excessive salivation, or tooth movement, requiring regular dental follow-up. 1

  • Do not assume MAD alone is sufficient – address your forward neck posture, consider myofunctional therapy, and optimize sleep hygiene concurrently. 1, 4

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Upper airway resistance syndrome--one decade later.

Current opinion in pulmonary medicine, 2004

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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