OSTLogo

Mandibular Advancement Devices for the Treatment of Obstructive Sleep Apnea

Orofacial Pain and Oral Medicine
June 24, 2023

Obstructive Sleep Apnea (OSA) is a prevalent sleep disorder characterized by upper airway collapse during sleep. Continuous Positive Airway Pressure (CPAP) is the gold standard treatment, but its efficacy is hindered by low compliance. Oral appliances, specifically Mandibular advancement appliances (MAD), have gained prominence as an alternative to CPAP. This article explores the effectiveness of MAD therapy, its design features, and the challenges associated with its provision in clinical sleep services.

Mechanism of Action of MADs

MADs prevent upper airway collapse by protruding the mandible forward, leading to an increase in airway volume at the velopharynx level. Various studies have confirmed the efficacy of MADs in reducing apneic events, demonstrating that mandibular protrusion is the primary mechanism of action.Efficacy of MAD: MAD therapy aims to address both physiological and symptomatic aspects of OSA. Studies have reported significant reductions in the Apnea-hypopnea index (AHI), with some achieving complete resolution of OSA. MADs have also shown positive effects on oxygen saturation, arousal index, REM sleep duration, and snoring reduction. Furthermore, MAD treatment has been associated with improvements in excessive daytime sleepiness (EDS), quality of life (QoL), and blood pressure.

Like what you’re learning?  Download a brochure for our Orofacial Pain and Oral Medicine certificate or master’s degree program in partnership with the Keck School of Medicine of USC.

Download a Brochure

Health Outcomes of MAD

MAD therapy has been found to reduce EDS, as measured by the Epworth Sleepiness score and Stop-Bang Questioners , and to improve both generic and disease-specific QoL measures. Additionally, MAD treatment has shown positive effects on systolic and diastolic blood pressure, particularly in hypertensive patients.

MAD Compared to CPAP

While CPAP is more effective than MADs in reducing sleep-disordered breathing, studies have shown that MADs can achieve similar health outcomes when considering factors such as EDS and QoL. Compliance rates tend to be higher for MAD therapy, which can influence overall effectiveness and cost-effectiveness.

Design Features Influencing the Efficacy of MAD

MADs vary in design and sophistication, with options ranging from non-adjustable over-the-counter appliances to custom-made devices. The ability to adjust mandibular protrusion is a significant advantage of adjustable MADs, although evidence supporting their superiority over fixed MADs is limited. More research is needed to compare the effectiveness of different MAD designs.

Side Effects of MAD

Most side effects of MAD therapy are mild and temporary, occurring during the initial acclimatization period. These side effects include hypersalivation, dry mouth, dental pain, gingival irritation, myofascial pain, and temporomandibular joint discomfort. In a study, it was found that 51% of the sample developed a posterior open bite, characterized by the loss of occlusal contact on at least two posterior teeth. Additionally, 62% of the sample developed an anterior crossbite, with an average of four teeth involved in those cases. These findings highlight potential side effects of the treatment, but it’s important to consult with a Dental Sleep Professional for accurate diagnosis and personalized recommendations.

Mandibular advancement devices offer a viable alternative to CPAP for the treatment of OSA, with evidence supporting their efficacy and positive health outcomes. However, barriers to MAD provisions, such as uncertainty regarding effectiveness prediction and design sophistication, hinder their widespread inclusion in clinical sleep services. Further research is needed to address these uncertainties and optimize the design and selection of MAD therapy.

Earn an Online Postgraduate Degree in Orofacial Pain and Oral Medicine

Like what you’re learning? Consider enrolling in the Herman Ostrow School of Dentistry of USC’s online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine in partnership with the Keck School of Medicine of USC.

Get More Information

References:

  1. Marshall NS, Wong KK, Liu PY, et al. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep. 2008;31:1079-85. [PMC free article] [PubMed] [Google Scholar]
  2. Sleep Alliance. Sleep SOS Report: The Impact of Sleep on Society. 2004.
  3. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:136-43. doi: 10.1513/pats.200709-155MG [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  4. Stradling JR, Barbour C, Glennon J, et al. Prevalence of sleepiness and its relation to autonomic evidence of arousals and increased inspiratory effort in a community-based population of men and women. J Sleep Res. 2000;9:381-8. doi: 10.1046/j.1365-
    2869.2000.00218.x [PubMed] [CrossRef] [Google Scholar]
  5. Douglas NJ, George CFP. Treating sleep apnea is cost-effective. Thorax. 2002;57:93. doi:10.1136/thorax.57.1.93 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  6. Eckert DJ, Malhotra A, Jordan AS. Mechanisms of Apnea. Prog Cardiovasc Dis.2009;51:313-23. doi: 10.1016/j.pcad.2008.02.003 [PMC free article] [PubMed][CrossRef] [Google Scholar]
  7. National Institute for Health and Clinical Excellence. Continuous positive airway pressure for obstructive sleep apnea/hypopnea syndrome. 2008.
  8. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5:173-8. doi:10.1513/pats.200708-119MG [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  9. Scottish Intercollegiate Guidelines Network. Management of Obstructive Sleep
    Apnea/Hypopnoea Syndrome in Adults: A national clinical guideline. 2003    .
  10. Ramar K, Dort LC, Katz SG, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med. 2015;11:773-827. [PMC free article] [PubMed] [Google Scholar]
  11. Chan AS, Sutherland K, Schwab RJ, et al. The effect of mandibular advancement on upper airway structure in obstructive sleep apnea. Thorax. 2010;65:726-32. doi: 10.1136/thx.2009.131094 [PubMed] [CrossRef] [Google Scholar]
  12. Ryan CF, Love LL, Peat D, et al. Mandibular advancement oral appliance therapy for obstructive sleep apnea: effect on awake calibre of the velopharynx. Thorax. 1999;54:972-7. doi: 10.1136/thx.54.11.972 [PMC free article] [PubMed] [CrossRef]
    [Google Scholar]
  13. Brown EC, Cheng S, McKenzie DK, et al. Respiratory Movement of Upper Airway Tissue in Obstructive Sleep Apnea. Sleep. 2013;36:1069-76. doi: 10.5665/sleep.2812 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  14. Andrén A, Hedberg P, Walker-Engstrom ML, et al. Effects of treatment with an oral appliance on 24-h blood pressure in patients with obstructive sleep apnea and hypertension: a randomized clinical trial. Sleep Breath. 2013;17:705-12. doi: 10.1007/s11325-012-0746-7 [PubMed] [CrossRef] [Google Scholar]
  15. Blanco J, Zamarron C, Abeleira Pazos MT, et al. Prospective evaluation of an oral appliance in the treatment of obstructive sleep apnea syndrome. Sleep Breath. 2005;9:20-
  16. doi: 10.1007/s11325-005-0003-4 [PubMed] [CrossRef] [Google Scholar]
  17. Petri N, Svanholt P, Solow B, et al. Mandibular advancement appliance for obstructive sleep apnea: results of a randomized placebo-controlled trial using a parallel group design. J Sleep Res. 2008;17:221-9. doi: 10.1111/j.1365-2869.2008.00645.x [PubMed] [CrossRef] [Google Scholar]
  18. Vanderveken OM, Devolder A, Marklund M, et al. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med. 2008;178:197-202. doi: 10.1164/rccm.200701-114OC [PubMed] [CrossRef] [Google Scholar]
  19. Quinnell TG, Bennett M, Jordan J, et al. A crossover randomized controlled trial of oral mandibular advancement devices for obstructive sleep apnea-hypopnea (TOMADO). Thorax. 2014;69:938-45. doi: 10.1136/thoraxjnl-2014-205464 [PubMed] [CrossRef] [Google Scholar]
  20. Basyuni S, Barabas M, Quinnell T. An update on mandibular advancement devices for the treatment of obstructive sleep apnoea hypopnoea syndrome. J Thorac Dis. 2018;10(Suppl 1):S48-S56. doi:10.21037/jtd.2017.12.18
  21. Pliska BT, Nam H, Chen H, Lowe AA, Almeida FR. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med. 2014;10(12):1285-1291. Published 2014
    Dec 15. doi:10.5664/jcsm.4278
The information and resources contained on this website are for informational purposes only and are not intended to assess, diagnose, or treat any medical and/or mental health disease or condition. The use of this website does not imply nor establish any type of provider-client relationship. Furthermore, the information obtained from this site should not be considered a substitute for a thorough medical and/or mental health evaluation by an appropriately credentialed and licensed professional. Commercial supporters are not involved in the content development or editorial process.

Pin It on Pinterest

Share This