by Vicki Cohn DDS, D. ABDSM, is the Clinical Director of Sleep Apnea Dentists of New England.

Continuous positive airway pressure (CPAP) is the first line of treatment for obstructive sleep apnea (OSA) but some people have difficulty tolerating it. CPAP can be uncomfortable, and it can dry out the mouth and cause nasal congestion. Fortunately, oral appliance therapy can be a successful alternative to CPAP for some people.

What is an oral appliance?

A custom-made oral appliance is a small device that fits over the teeth and is worn while you sleep. A mandibular advancement device (MAD) is the primary oral appliance for treating OSA. Insurance may cover oral appliance therapy using the same criteria as CPAP. Be aware that some insurance companies require you to try CPAP before covering oral appliance therapy.

When is oral appliance therapy a good option?

Oral appliance therapy can be an option for those with mild to moderate OSA and those who cannot tolerate or do not want to try CPAP. It is possible to go right from diagnosis to oral appliance therapy skipping CPAP altogether if you and your doctor determine it is an appropriate choice. All oral appliance therapy requires a prescription from a treating physician who will diagnose OSA and refer you to a dental sleep provider. The success of oral appliance therapy may improve when made by a dentist with dental sleep training. Some people may find CPAP easier to tolerate with an oral appliance or when they can alternate between therapies.

How does it treat OSA?

OSA is characterized by three major areas of collapse in the airway tube— high/upper: behind the soft palate to the top of the tongue; middle: where the tongue can fall back; and low: at the level of the epiglottis (this is rarer). Most people with OSA collapse in at least two places, but currently, there is no way to know in which of the three areas the collapse occurs.

A trained dental sleep medicine provider can make a MAD which will hold the jaw and tongue in a forward position during sleep, expanding the upper airway. This targets two of the three possible areas of airway collapse. The good news is that this helps the majority of patients who try it. CPAP targets all three areas of possible collapse, so it helps to open the entire airway, but it can be more challenging to use. Studies have shown that for mild to moderate OSA, the effectiveness of MAD is similar to CPAP. One reason may be that MAD compliance is higher.

How will my dentist determine if it is working?

There is some trial and error in finding the right jaw position to improve OSA. Your dentist may start by bringing the jaw forward until there is symptomatic relief. After a few months, a sleep study may be done, and any necessary adjustments will be made. Once the appliance is fit to the optimal position, dental visits will likely continue yearly to check the fit and integrity of the appliance.

While CPAP and oral appliances are the most widely used treatments for OSA, other treatments are available if these don’t work for you. It may be as simple as changing the position of your sleep or weight loss, or as intensive as surgery. If you suspect you suffer from sleep apnea, consult a sleep specialist.