Pros and Cons of Using an Oral Appliance for Sleep Apnea

If you have mild to moderate Obstructive Sleep Apnea (OSA), your sleep specialist may give you the option of choosing oral appliance therapy (OAT)—also known as a sleep apnea mouthguard or splint—to treat your OSA. An oral appliance or dental device is a mouthguard-like splint that you wear over your teeth when you sleep. It keeps your airway open by sliding your lower jaw forward slightly, creating extra space at the back of your throat. Dentists who are specially trained and accredited to practice dental sleep medicine are qualified to custom fit these mouthpieces. As a matter of fact, there is a trade association dedicated entirely to these matters: the American Academy of Dental Sleep Medicine (AADSM). Oral appliances or dental devices that have been used by sleep medicine dentists for years are now approved by the Federal Drug Administration (FDA) as a first-line treatment for mild to moderate Obstructive Sleep Apnea. In the past, physicians would only recommend these sleep apnea mouthpieces as an alternative or secondary treatment for those who could not tolerate CPAP therapy. However, they are still recommended for this purpose. If you score between a 5 and 30 on the apnea-hypopnea index (AHI), you may be a candidate for an oral appliance and have the option of trying that form of therapy first to see if it works for you instead of first trying CPAP therapy. Treating your sleep apnea should be what's most comfortable and effective for you! The right choice is always the one that will empower you to rest easy at night. To help you get more familiar with oral appliances, we’ve assembled a pros and cons list, outlining why some people like OAT and others don’t.

There are plenty of notches in the pro column for treating sleep apnea with oral appliances. Among them are:

• Non-Claustrophobic. A dental device is custom-fit to your mouth and jaw, and is not altogether different than sleeping while wearing a sports mouthguard. People who feel claustrophobic when using a CPAP mask sometimes prefer a dental device because it doesn’t cover the nose or mouth and nor does it supply pressurized air. When wearing the mouthpiece, your nose and mouth are free to breathe room air without assistance.
• Sleep Position Doesn’t Affect Your Therapy. If you’re a restless sleeper who tosses and turns often, CPAP tubing may get tangled up and torn loose from the machine or mask. A mouthpiece stays in your mouth, regardless of your preferred sleeping position.
• Portability. An oral appliance is a small, single piece of equipment that comes with its own carrying case. You can easily slip it into your pocket or carry it in your hand. The small size and ease of use makes it ideal for travel. It must also be said here that many travel CPAP machines on the market today are very portable and lightweight and run on batteries or solar power—so you can travel light with your CPAP equipment just the same.
• Convenience. Having an oral appliance can be a helpful alternative if your CPAP is out of filters, being repaired, or you're in the process of switching to a new machine. On a daily basis, a mouthpiece is also easy to care for in the cleaning department.
• Noise. Unlike a CPAP machine, which blows air all night, an oral appliance for sleep apnea is silent. Light sleepers and bed partners alike may appreciate this aspect.
• Cost. Oral appliances are often less expensive than a CPAP machine.

Other less-frequently cited reasons why some people with sleep apnea prefer oral appliances include:

• Does Not Irritate Facial Skin or Facial Hair. A minority of wearers complain that repeated contact with their CPAP masks or forehead and chin straps may cause sore spots, ingrown beard or nose hairs, chafing, skin creases, or acne breakouts. While these problems can be managed by swapping out your mask for Movember-friendly equipment, some people prefer to use an oral device because it does not come into contact with their head, hair, or skin as frequently.
• Aesthetics. Although CPAP use is becoming more common now that more people are being diagnosed with sleep apnea, wearing a mask to bed still carries a stigma for some people. Oral mouthpieces are less obvious and while CPAP machine designs have come a long way in terms of shape and size, some wearers also like not having their machine on their bedside table.
• Compliance. Whether or not you get any health benefit from your sleep apnea therapy, depends on whether you use it consistently, every night, all through the night. Your CPAP compliance also determines whether your insurance will continue to cover your sleep apnea therapy at the same level since a recent study shows that the abandonment rate of CPAP users is as high as 60 percent.

Many people stopped using their CPAP therapy before giving themselves time to get used to wearing the equipment or adjusting to the air pressure levels needed to keep their airway open. In a 2018 study, researchers concluded that OAT users were more compliant with their treatment than those on CPAP. While people with moderate to severe sleep apnea will get better results from CPAP therapy, sleep apnea therapy is personal and should be adapted to work with you.

Although oral appliance therapy boasts a number of positives, not everyone takes to it. Since oral appliance therapy does not automatically track usage data digitally the way a CPAP machine does, it’s all too easy for people to take “breaks” from wearing their devices or to be lax about their therapy. In a 2018 study that looked at long-term usage, only 32 percent of participants reported using their oral appliance regularly, and 55 percent claimed that they stopped oral appliance therapy within the first year. While some with sleep apnea tend to prefer an oral appliance in the beginning, over time the numbers tend to drop off. Some of the downsides of using an oral appliance include:

• Temporomandibular (TMJ) Pain and Bite Changes. In the same study cited above, 38 percent of users who abandoned OAT reported doing so because of TMJ pain. The way the splint advances the mandible can contribute to soreness and headaches for some users prone to TMJ issues. The shifts in the jaw can also lead to changes in their bite. In that study, 17 percent of the participants claimed to have this complication. Permanent bite changes can lead to tooth wear, cavities, and other dental issues.
• Dry Mouth and Drooling. Wearing the splint can lead to mouth breathing, which can cause dry mouth, sore throat, and bad breath. In response, the body may produce excess saliva, which can cause drooling and cracked, dry lips.
• Reduced Effectiveness in Treating Severe OSA. If you have severe sleep apnea and can’t tolerate CPAP therapy, oral appliances are an alternative—but they are less effective at keeping your airway open than CPAP therapy. Even if you use your oral appliance faithfully, your symptoms won’t resolve entirely—they’ll merely improve. You will still experience some apnea and hypopnea events, leaving you at risk for high blood pressure, diabetes, cardiovascular disease, and mood disorders.

Oral appliances are a first-line approved treatment for treating mild to moderate OSA and is a secondary treatment for severe OSA. Some people with sleep apnea prefer the ease, convenience, and comfort of oral appliance therapy, but others find them uncomfortable due to side effects related to the mouth and jaw. One major benefit of CPAP therapy is that unlike an oral device, your compliance data is automatically collected and delivered to your physician. This monitoring can help you keep up with your therapy and may make you more likely to enter an ongoing dialogue with your doctor to get the sleep you deserve.