2026-08-02 · 7 min
I am Dr. Montserrat Ortega B., a specialist in temporomandibular disorders and orofacial pain, with training in sleep medicine. A good part of my practice is people who arrive with the same story: they were diagnosed with sleep apnea, prescribed CPAP, and simply can't use it. The mask ends up on the nightstand. The question they bring is always similar: is this my only option? The short answer is no. It has become a frequent question and it deserves an answer with nuance. For selected cases there is the mandibular advancement device, and it is worth understanding clearly when it is indicated.
The mandibular advancement device, which we abbreviate as MAD, is a custom-made intraoral appliance worn only for sleep. It looks like two splints, one for the upper arch and one for the lower, joined so they hold the jaw slightly forward through the night. That advancement pulls the base of the tongue and the soft tissues of the throat forward, and with that the upper airway stays more open and less prone to collapse while you sleep. It is not an ordinary bruxism splint, even if it resembles one: its purpose is respiratory and goes beyond protecting enamel from clenching. Imaging studies that measure the airway show that mandibular advancement increases the volume of the upper airway space DOI: 10.29271/jcpsp.2023.10.1194, which is exactly where obstructive apnea creates the problem.
Let me be clear before going on: CPAP is the first-line treatment for obstructive sleep apnea and it works very well when someone uses it all night, every night. The problem shows up in real life. A significant share of patients never get used to the mask, the noise of the machine, the air pressure, or the feeling of sleeping tethered to a device. They wear it for a couple of hours and take it off, or leave it in a drawer because it doesn't fit their needs or the way they live. And here is the line I repeat at every check-up: a treatment that gets used works. The best therapy on paper changes nothing if you never actually wear it. If you want the full picture of apnea and the dentist's role in it, I cover it in sleep apnea and dentistry.
The MAD does not replace CPAP for everyone, and I prefer to say so before raising false hopes. It is prescribed in selected cases, and that prescription comes from a specialist in temporomandibular disorders and orofacial pain. The clearest scenarios are mild to moderate obstructive apnea, and people who don't tolerate or refuse CPAP after having tried it for a reasonable period. It can also be a backup for travel or situations where the machine isn't practical.
There are limits worth being clear about too: the MAD is not the answer for every type of apnea. It doesn't work in central sleep apnea, or in cases with a high loop gain phenotype, where the problem lies in how the system regulates breathing rather than in airway collapse.
What never changes is the order of things. No intraoral device is prescribed without a prior sleep study, the polysomnogram, that confirms the diagnosis and measures severity. Without that data I can't know whether your case is a candidate, and fitting an appliance blindly can leave a severe apnea untreated.
The comparison deserves honesty, and in recent years it has become more interesting than it used to be.
CPAP reduces the apnea-hypopnea index more, meaning it eliminates more respiratory events per hour of sleep. On that number it is superior and there is no point denying it. How much less the MAD lowers it depends on the patient: in some people the reduction is considerably smaller, and in others it approaches what CPAP achieves. That is why I talk about selected cases, and why the prior evaluation is not a formality.
The finding that most changed the conversation is recent. A randomized trial published in 2025 compared both treatments over twelve months in 144 patients with severe apnea and hypertension, precisely the group where the device was traditionally ruled out. CPAP reduced the event index far more, as expected. But adherence was nearly double with the device, and the MAD group showed a significant reduction in blood pressure during sleep that the CPAP group did not achieve (Colpani 2025). Sleep-related quality of life improved with both. An earlier meta-analysis already pointed in that direction, with comparable quality-of-life improvement between the two treatments DOI: 10.1007/s11325-017-1590-6.
The way I read this in practice is straightforward: adherence is part of the clinical result, not a soft detail. And in well-selected severe cases, the device is no longer something ruled out from the start.
The process always begins with the polysomnogram and a dental evaluation in which I assess your temporomandibular joint. That part matters and is not a formality: the MAD works by generating mandibular movement, so it cannot be prescribed in patients with acute or active joint pathology. If your TMJ is inflamed or there is an ongoing condition, that gets treated first.
With the diagnosis in hand, and only if the case is a candidate, I take an intraoral scan and record how you bite and how far you can bring the jaw forward. That data is used to fabricate the custom device, because it has to fit your teeth exactly and respect your joint. The part many don't expect is titration: the advancement isn't set from day one. It is adjusted gradually, millimeter by millimeter, over successive visits, until we find the position that improves symptoms without overloading the joint or the muscles. That follow-up is what separates a properly indicated MAD from a generic splint bought without supervision. The device also gets reviewed over time, since the material wears and the fit may need corrections. Ideally we repeat a sleep study with the device in place, to confirm with numbers that it is doing its job.
I prefer to close every evaluation with realistic expectations. The MAD controls apnea in selected cases, but it doesn't cure it: it is a treatment that works while you use it, just like CPAP.
There can be an initial adjustment with more salivation or, conversely, a dry mouth, a sense of clenched teeth on waking, joint discomfort, or irritation of the lips and gums. There is one effect I want you to know about before starting rather than after: sustained use of a MAD can produce tooth movement. It is a real effect, it is managed with follow-up, and it belongs in an honest conversation before the device is prescribed. As an orofacial pain specialist I keep a close eye on the temporomandibular joint, because the movement generated by your joint all night long has effects that need monitoring over time.
On bruxism I want to correct a widely circulated idea. If you grind your teeth during sleep, that does not change the design of the device or the treatment approach. The sleep bruxism episode is generated by the apnea or hypopnea event, so by treating the obstructive apnea we are treating the sleep bruxism at its mechanism. Put another way: sleep bruxism is usually the tip of the iceberg of something considerably more serious. I review that relationship in detail in bruxism and apnea, and if you want to understand the condition on its own, in what bruxism is.
If you were diagnosed with apnea and CPAP isn't working for you in practice, don't end up without treatment by default or out of resignation. Ask about the mandibular advancement device in a proper evaluation, with a polysomnogram behind it. For some cases it is exactly the alternative that finally gets the treatment used, every single night.
It is a custom-made intraoral appliance worn for sleep. It holds the jaw slightly forward, which pulls the tongue forward and keeps the airway more open. It is prescribed in selected cases of obstructive apnea, always after a polysomnogram confirms the diagnosis and after an assessment of your temporomandibular joint.
It can. CPAP intolerance is one of the clearest indications for a mandibular advancement device, especially once you have tried it for a reasonable period. Before prescribing it I need the polysomnogram and a dental evaluation that includes your TMJ. A treatment that gets used works, so the goal is to find the one you will actually wear every night.
CPAP reduces the apnea-hypopnea index more, so on that number it is superior. How much less the device lowers it depends on the patient: in some the reduction approaches CPAP and in others it is considerably smaller, which is why we talk about selected cases and why the prior evaluation matters. A 2025 randomized trial in patients with severe apnea and hypertension showed nearly double the adherence with the device and a reduction in blood pressure during sleep that CPAP did not achieve, with quality-of-life improvement in both groups.
It is prescribed in selected cases of obstructive apnea, especially mild to moderate, and in people who don't tolerate or refuse CPAP. Also as a backup for travel. It is not the answer for every type of apnea: it doesn't work in central sleep apnea or in cases with a high loop gain phenotype. The prescription comes from a specialist in temporomandibular disorders and orofacial pain, always with the sleep study in hand.
Yes, without exception. No intraoral device is prescribed without a prior polysomnogram that confirms the diagnosis and measures severity. Fitting an appliance without that data can leave a severe apnea untreated. On top of that comes the dental evaluation of your temporomandibular joint, because the device generates mandibular movement and is not indicated if there is acute or active joint pathology.
It can. Tooth movement is one of the described adverse effects of sustained mandibular advancement device use, and I prefer to discuss it before prescribing rather than after. It is managed with periodic follow-up, reviewing the bite and the fit of the appliance throughout treatment. Other possible effects are more salivation or a dry mouth, a sense of clenched teeth on waking, joint discomfort, and irritation of the lips or gums.
