What are the implications for sleep‑medicine practice of using mandibular advancement devices as an alternative to continuous positive airway pressure in the management of obstructive sleep apnea?

Implications of Mandibular Advancement Devices for Sleep Medicine Practice

Mandibular advancement devices represent a paradigm shift in sleep medicine, establishing themselves as a legitimate first-line treatment option for mild-to-moderate OSA and the primary alternative for CPAP-intolerant patients, fundamentally expanding the therapeutic armamentarium beyond traditional positive airway pressure therapy. 1

Expanded Treatment Algorithm and Patient Selection

Custom, titratable MADs should be offered as first-line therapy for patients with mild-to-moderate OSA (AHI <30) without significant comorbidities, and as the preferred alternative for CPAP-intolerant patients across all severity levels. 1, 2

Primary Indications for MAD Therapy:

• Mild-to-moderate OSA without cardiovascular comorbidities as first-line treatment 1
• CPAP-intolerant patients regardless of OSA severity, including very severe disease (AHI ≥50) 1, 3
• Primary snoring without obstructive events 1
• Patient preference when both treatments show equivalent quality-of-life outcomes 2, 4

Predictors of MAD Success:

The evidence identifies specific patient characteristics associated with higher treatment success rates: younger age, female gender, lower BMI, smaller neck circumference, position-dependent OSA, and lower baseline AHI 1, 2. However, recent data challenges the traditional severity limitations—a 2025 study demonstrated 72.5% mean AHI reduction in very severe OSA (AHI ≥50), with 95.5% of patients achieving at least 50% AHI reduction 3. This suggests MADs can be effective even in severe disease when CPAP fails.

Multidisciplinary Care Model Requirements

Sleep medicine must now integrate qualified dentists with specialized training in dental sleep medicine as essential members of the care team, not merely consultants. 1

Dentist Role and Responsibilities:

• Screen for sleep-disordered breathing during routine dental appointments to combat underdiagnosis 1
• Order sleep tests to confirm treatment efficacy and guide MAD titration 1
• Fabricate and titrate custom MADs with incremental adjustments of ≤1mm over a protrusive range of ≥5mm 1
• Monitor for dental side effects including occlusal changes and temporomandibular disorders 2

Sleep Physician Responsibilities:

• Confirm OSA diagnosis before MAD initiation 1
• Determine treatment success through objective sleep testing with MAD in place 1
• Follow-up on cardiovascular and metabolic comorbidities that require ongoing medical management 1

This represents a fundamental shift from the traditional physician-centric model to mandatory collaborative care between sleep physicians and dental sleep medicine specialists 1, 2.

Device Specifications and Titration Protocols

Only custom-made, titratable, dual-block MADs engaging both maxillary and mandibular arches should be prescribed—prefabricated or non-titratable devices are explicitly not recommended. 1, 2, 5

Essential Device Characteristics:

• Biocompatible materials with stable retention to teeth, implants, or edentulous ridges 1
• Incremental advancement capability of ≤1mm with minimum 5mm total protrusive range 1
• Reversible adjustment mechanism allowing reduction if side effects occur 1
• Dual-arch engagement to maintain prescribed mandibular position during sleep 1, 2

Titration Strategy:

Begin at approximately 50% of maximum mandibular protrusion, then advance incrementally based on symptom response and objective sleep testing. 2 The 2025 Portuguese guidelines emphasize that "trial and error" titration remains standard due to the expense of in-laboratory titration protocols 1, though emerging research on sleep endoscopy-guided titration shows promise 1.

Objective Treatment Verification Requirements

Symptom improvement alone is insufficient to confirm MAD efficacy—follow-up sleep testing with the device in place is mandatory to verify adequate AHI reduction. 1, 2, 6

Testing Protocol:

• Type 3 portable monitoring (home sleep apnea testing) is acceptable and cost-effective for MAD efficacy verification 1
• Testing must be performed with MAD in situ after final titration adjustments 1
• Comparison to baseline diagnostic study is essential to quantify treatment response 1

This requirement addresses a critical pitfall: patients may report subjective improvement despite inadequate objective control of respiratory events, particularly in severe OSA where residual AHI may remain elevated despite partial improvement 2, 3.

Comparative Effectiveness and Treatment Outcomes

While CPAP demonstrates superior AHI reduction, MADs achieve equivalent improvements in patient-centered outcomes including daytime sleepiness, quality of life, and functional measures. 2, 4

Key Efficacy Data:

• Overall MAD treatment success rate: approximately 52% when success is defined as AHI <5 or ≥50% reduction 2
• In very severe OSA (AHI ≥50): 72.5% mean AHI reduction with 95.5% achieving ≥50% reduction 3
• Adherence typically superior to CPAP with better long-term compliance 2, 4
• Comparable symptom resolution despite less complete AHI normalization 2, 7

The 2011 European Respiratory Society guidelines established that MADs have the highest level of evidence (13 randomized controlled trials) among all non-CPAP therapies 1, a position reinforced by subsequent research 4, 8.

Optimization Strategies to Enhance Efficacy

Combining MAD with mouth-closing adhesive tape significantly improves treatment efficacy, particularly in moderate-to-severe OSA. 9

A 2022 randomized crossover trial demonstrated that MAD plus adhesive mouthpiece reduced median AHI from 10.5 to 5.6 events/hour (p=0.02) compared to MAD alone, with 76% achieving AHI <10 versus 43% with MAD alone 9. This addresses the mechanism whereby mouth breathing during sleep increases upper airway collapsibility and reduces MAD effectiveness 9.

Implementation Considerations:

• Adhesive mouthpiece alone does not reduce AHI compared to baseline 9
• Combined therapy particularly effective in moderate-to-severe OSA (AHI ≥15) 9
• Simple, low-cost intervention that can be added to existing MAD therapy 9

Clinical Pitfalls and Risk Mitigation

Common Errors to Avoid:

1. Prescribing MADs without objective follow-up testing: Symptom improvement is an imprecise indicator of treatment success, particularly in severe OSA where significant residual AHI may persist despite subjective benefit 2, 6.

2. Using non-custom or non-titratable devices: These lack evidence of efficacy and are explicitly not recommended by guidelines 2, 5.

3. Failing to assess dental suitability: Adequate dentition (number and location of teeth), periodontal health, and absence of active temporomandibular disorders must be verified before MAD fabrication 1.

4. Inadequate documentation of CPAP intolerance: When using MAD as CPAP alternative, document the patient's understanding of CPAP's superior efficacy and the increased risks of inadequately treated OSA 6.

5. Neglecting long-term monitoring: Regular follow-up is essential to monitor for occlusal changes, temporomandibular symptoms, and maintenance of treatment efficacy 2.

Side Effect Management:

Initial side effects (jaw discomfort, tooth tenderness, excessive salivation) are common but generally minor and transient 2. However, temporary occlusal changes can occur and require monitoring 2. The reversible nature of MAD advancement allows reduction if intolerable side effects develop 1.

Integration with Other Treatment Modalities

MADs should be considered within a comprehensive treatment algorithm that includes weight reduction, positional therapy, and surgical options based on disease severity and patient characteristics. 5, 6

Treatment Hierarchy for CPAP-Intolerant Patients:

Mild-to-Moderate OSA (AHI <30):

1. Custom titratable MAD as first alternative 1, 2, 5
2. Positional therapy if position-dependent OSA confirmed 5, 6
3. Weight reduction as adjunctive therapy (rarely curative as monotherapy) 5, 6

Moderate-to-Severe OSA (AHI ≥30):

1. Custom titratable MAD, recognizing less complete AHI normalization 2, 3
2. Hypoglossal nerve stimulation if BMI <32 kg/m² and AHI 15-65 5, 6
3. Maxillomandibular advancement as salvage therapy 1, 6

The 2011 European Respiratory Society guidelines established that maxillomandibular osteotomy appears as efficient as CPAP in patients refusing conservative treatment 1, though this remains a highly specialized surgical intervention.

Economic and Healthcare System Implications

The integration of MAD therapy requires healthcare systems to develop reimbursement structures for dental sleep medicine services and establish credentialing standards for qualified dentists. 1

The 2025 Portuguese consensus emphasizes that combating the high rate of OSA underdiagnosis through dental screening represents massive potential social and economic impact 1. However, this requires healthcare system focus on prevention and early diagnosis to minimize the economic and social burden of untreated sleep-disordered breathing 1.

Research Gaps and Future Directions

Despite robust evidence supporting MAD efficacy, several areas require further investigation:

• Long-term cardiovascular outcomes comparing MAD to CPAP therapy 3
• Refinement of predictive models for treatment response beyond current demographic factors 2, 4
• Cost-effectiveness of in-laboratory titration protocols versus empirical adjustment 1
• Optimal combination therapy strategies including mouth-closing devices and positional therapy 9

The evidence base continues to evolve, with recent data challenging traditional severity limitations and expanding MAD indications to include very severe OSA in CPAP-intolerant patients 3.