If you have mild to moderate obstructive sleep apnea, your sleep specialist may give you the option of choosing oral appliance therapy (OAT)—also known as a sleep apnea mouthpiece or splint—to treat your OSA.
An oral appliance or dental device (also called an anti-snoring mouthpiece) 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 specially trained and accredited to practice dental sleep medicine—currently, about 3,000 dentists worldwide—are qualified to custom fit these mouthpieces for their patients.
Oral appliances or dental devices, in use by sleep medicine dentists for years, are now FDA-approved as a first-line treatment for mild-moderate obstructive sleep apnea. In the past, physicians would only recommend these apnea mouthpieces as an alternative or secondary treatment for patients who could not tolerate CPAP therapy—and they are still recommended for this purpose.
However, if you score between 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 therapy first to see if it works for you.
Many people do prefer dental devices for their apnea instead of CPAP. Others dislike wearing a mouthpiece and prefer the traditional apnea therapy of pressurized air delivered via tubing and a mask.
Which choice is right for you? To help you get more familiar with oral appliances, we’ve assembled a pros and cons list. Below are some of the more common reasons people with sleep apnea cite for either liking or disliking oral appliance therapy.
Pros (Reasons People Like Oral Appliances for Treating Apnea)
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, nor does it supply pressurized air. When wearing the mouthpiece, your nose and mouth are free to breathe room air without assistance.
Non-irritating to facial skin or hair. A minority of users complain that repeated contact with CPAP masks or head and chin straps may cause sore spots, ingrown beard or nose hairs, chafing, skin creases, or acne breakouts. While these problems can be addressed and managed by swapping out your mask for new equipment, some people prefer to use an oral device because it comes into contact with less of the head, hair, and skin.
Sleep position doesn’t affect 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 sleep position. You can even sleepwalk with it.
Convenience. Having an oral appliance can be a helpful alternative if your CPAP is out of filters or being repaired or swapped out. On a daily basis, a mouthpiece is also easy to care for as compared to tubing and a mask, which require regular rinsing and occasional replacement parts. Oral appliances are also “analog” as compared to the “digital” therapy of using a machine that requires a power supply.
Portability. An oral appliance is a small, single piece of equipment that comes with its own carrying case. You can slip it into a pocket or carry it in your hand. The small size and ease of use make it ideal for travel, for taking extended naps in places without outlets, or for sleeping in public places like buses, airports, or airplanes. (However, today’s modern CPAP technology now allows for lightweight, portable machines that run on batteries or solar power—so you can camp or “pack light” with a CPAP, too.) Mouthpieces will not trigger a TSA inspection at airport security, which can save on time, hassle, and embarrassment.
Subtlety. 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 who don’t want to be seen as “sick.” Oral mouthpieces are less obvious, and shy users can claim that they’re for tooth-grinding, dental work, or snoring, if for some reason they don’t want to admit to apnea. Some users also like not having a large, gently whirring machine on the bedside table.
Quiet. Unlike a CPAP machine, which blows air all night, an oral appliance for apnea is silent. Light sleepers and bed partners may appreciate the lack of sound associated with this therapy.
Cost. Oral appliances are often less expensive than CPAP. For patients who are paying out of pocket for therapy, this cost savings can make a big difference.
Compliance. Whether or not you get any health benefit from your apnea therapy depends on whether you use it consistently, every night, all through the night. Your compliance also determines whether your insurance will continue to cover your apnea therapy at the same level. Yet studies show that up to 50% of CPAP users discontinue therapy within a month.
Unfortunately, many people quit their CPAP therapy before giving themselves time to get used to wearing the equipment or adjusting air pressure levels. However, there’s some evidence that early-stage compliance is higher with oral devices. Studies indicate that within the first 90 days of treatment, users of oral appliances are significantly more likely to keep using their device than those using CPAP (3). While people with moderate to severe apnea will get better results from CPAP therapy, ultimately, some benefit from an imperfect treatment is better than no benefit from a treatment you give up on too soon to see results.
Cons (Reasons Not to Use Oral Appliance Therapy)
Although oral appliance therapy boasts a number of positives, not everyone takes to it. Also, because oral appliance therapy does not automatically track usage data digitally the way a CPAP does, it’s all too easy for patients to take “breaks” from wearing their devices or to get forgetful about the therapy, with no consequences and no one to get them back on track.
In one study from earlier this year that looked at long-term usage, only 32% of participants reported using their oral appliance regularly, and 55% stopped therapy within the first year.
So while some apnea sufferers tend to prefer an oral appliance in the beginning, over time the numbers tend to drop off at rates comparable to the rates that CPAP users abandon therapy. Why might that be?
Some of the cons of using an oral appliance include:
TMJ pain and bite changes. In the same study cited above, 38% of users who abandoned using their oral appliances reported doing so because of temporomandibular joint 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 occlusion (bite); in the study, 17% of the participants claimed to have this complication. Permanent occlusion changes can lead to tooth wear, cavities, and other dental issues.
Drymouth and drooling. Wearing the splint can lead to mouth breathing, which can cause dry mouth, a dry, sore throat, and bad breath. In response, the body may produce excess saliva, which can cause drooling on one’s pillow and cracked, dry lips.
Reduced effectiveness in treating severe OSA. If you have severe apnea and can’t tolerate CPAP, oral appliances are an alternative—but they are less effective at keeping your airway open than CPAP. 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 mild-moderate OSA and a secondary treatment for severe OSA. Some people with apnea prefer their ease, convenience, and comfort, but others find them uncomfortable due to side effects related to the mouth and jaw. Over the long term, people tend to give up on each therapy at about the same rate.
One major advantage to CPAP 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 and medical supplier so that you can adjust your levels and mask on a regular basis.
David Repasky has been using CPAP treatment since 2017 and has first-hand experience with what it’s like to live with Sleep Apnea. He brings the patient’s perspective to the CPAP.com blog and has received formal training in CPAP machines, masks, and equipment.