Sleep apnea is a common breathing disorder characterized by the repeated collapse of the upper airway during sleep. This collapse causes breathing to stop or become very shallow, leading to fragmented sleep and reduced oxygen levels. Oral Appliances (OAs) have emerged as a widely accepted, non-surgical treatment alternative to address this condition. These custom-fitted devices are worn in the mouth during sleep to prevent the airway obstruction that defines obstructive sleep apnea.
Mechanism of Airway Stabilization
Oral appliances work by altering the position of the jaw and tongue to prevent the soft tissues in the throat from collapsing. The most common type is the Mandibular Advancement Device (MAD), which consists of two custom-fitted trays that snap onto the upper and lower teeth. These trays are connected by a mechanism that gently pushes the lower jaw forward.
This forward repositioning of the jaw pulls the base of the tongue and the soft palate forward as well. By advancing these structures, the MAD increases the space in the pharyngeal airway. A less common type, the Tongue Retaining Device (TRD), uses suction pressure to hold the tongue in a forward position. The key biomechanical action of both devices is to enlarge the upper airway space and reduce its collapsibility, allowing for unobstructed breathing throughout the night.
Determining Who Benefits Most
Oral appliances are a highly effective first-line treatment for patients diagnosed with mild to moderate Obstructive Sleep Apnea (OSA). Clinical guidelines often define this as an Apnea-Hypopnea Index (AHI) between five and thirty events per hour of sleep. For many in this group, a custom-fitted OA can successfully reduce the severity of their condition.
The effectiveness of an oral appliance is strongly related to the patient’s individual anatomy. Patients with a smaller lower jaw (retrognathia) or those who have a large tongue base often respond well to mandibular advancement. OAs may also be considered for patients with severe OSA who cannot tolerate Continuous Positive Airway Pressure (CPAP).
Successful treatment requires that the patient has adequate dentition to retain the appliance securely. The presence of severe temporomandibular joint (TMJ) disorders can make a patient less suitable for this therapy, as the appliance repositions the jaw. Determining the best candidate involves a comprehensive assessment by a sleep specialist and a dentist specializing in sleep medicine.
Comparing Oral Appliances to CPAP Therapy
The established standard for treating OSA is CPAP therapy, which delivers pressurized air through a mask to pneumatically hold the airway open. CPAP is objectively superior in its ability to reduce the Apnea-Hypopnea Index (AHI), especially for severe cases, by preventing airway collapse in nearly all users when consistently applied. The true value of oral appliances, however, lies in their real-world usage and patient acceptance.
Patients frequently cite the comfort, portability, and non-intrusive nature of oral appliances as reasons for higher adherence compared to CPAP. While CPAP achieves greater control over airflow, OAs often boast significantly higher compliance rates, making their overall long-term health benefits comparable to CPAP for many patients with mild to moderate OSA.
Studies show that both treatment options can lead to similar improvements in daytime sleepiness, blood pressure, and overall quality of life. The choice between an oral appliance and CPAP often becomes a decision based on patient preference and lifestyle, prioritizing the treatment a person is most likely to use. For those who travel frequently or find the mask and tubing of CPAP cumbersome, the compact oral appliance offers a practical alternative.
Practical Considerations and Potential Adjustments
Obtaining an oral appliance requires a custom-fitted device fabricated by a qualified dental professional specializing in sleep medicine. Custom devices are more effective and safer than over-the-counter options because they are tailored to the patient’s unique dental and jaw structure. The appliance is often designed to be titratable, meaning the degree of mandibular advancement can be incrementally adjusted over time to maximize effectiveness and comfort.
Patients should expect an initial adjustment period, typically lasting a few weeks, during which temporary side effects are common. These short-term effects can include mild soreness in the jaw muscles and teeth, which usually resolves as the body adapts to the new position. Other common temporary issues are excessive salivation or, conversely, dry mouth.
Long-term use requires ongoing maintenance, including regular cleaning of the appliance and follow-up visits with the dental sleep specialist. Over time, minor, gradual changes in the patient’s bite or the position of the front teeth can occur due to the constant repositioning of the jaw. These minor occlusal changes are monitored and are considered an acceptable trade-off for the substantial health benefits of consistently treating sleep apnea.