If you’ve been diagnosed with mild to moderate obstructive sleep apnea (OSA), your doctor probably mentioned CPAP first. It’s the gold standard. It works. But for a significant number of patients — particularly those with milder disease — CPAP is overkill, uncomfortable, and ultimately abandoned.

This is where mandibular advancement devices (MADs) enter the picture. They’re less talked about, less prescribed, and in many cases, more appropriate for the patients who need them.

How MADs Work

A mandibular advancement device is a dental appliance worn during sleep that holds the lower jaw (mandible) in a forward position. By advancing the jaw, the device opens the airway behind the tongue and soft palate — the same area that collapses during obstructive apnea events.

Custom-fitted MADs are made by dentists with training in dental sleep medicine. They consist of upper and lower dental trays connected by a mechanism that allows titration — gradual advancement of the jaw position over weeks until the optimal therapeutic position is found. This is typically 50-75% of the patient’s maximum protrusion, though the sweet spot varies between individuals.

Off-the-shelf “boil and bite” devices exist and cost $30-100. Custom devices from a sleep-trained dentist cost $1,500-3,000. The difference in efficacy and comfort is substantial — the American Academy of Dental Sleep Medicine strongly recommends custom devices and considers over-the-counter products inadequate for therapeutic use.

What the Evidence Shows

The comparative evidence between MADs and CPAP has matured considerably over the past decade.

For mild OSA (AHI 5-15 events per hour), MADs reduce the apnea-hypopnea index by approximately 50-60%. CPAP reduces it by 80-95%. On paper, CPAP wins. But here’s the critical caveat: these figures assume full compliance.

CPAP adherence — defined as using the device for at least 4 hours per night on at least 70% of nights — hovers around 50% long-term. MAD adherence rates are consistently higher, typically 70-80% in published studies. When you factor in compliance, the real-world effectiveness gap narrows considerably.

A landmark randomised controlled trial published in JAMA compared health outcomes (blood pressure, cardiovascular events, daytime sleepiness) between CPAP and MADs in patients with moderate OSA. The outcomes were equivalent. Not because the MAD was as mechanically effective as CPAP, but because patients actually wore it.

This point deserves emphasis: the best treatment is the one the patient will consistently use. A CPAP machine gathering dust on the bedside table treats nothing.

Who Should Consider a MAD

MADs are most appropriate for:

Mild to moderate OSA (AHI 5-30). This is where the evidence for MADs is strongest. For severe OSA (AHI >30), CPAP remains the primary recommendation, though MADs can be considered when CPAP has failed or is refused.

Patients who’ve tried and abandoned CPAP. If you’ve given CPAP a genuine trial (at least 4-6 weeks with proper mask fitting and pressure optimisation) and can’t tolerate it, a MAD is a far better alternative than no treatment at all.

Position-dependent OSA. If your apnea events occur primarily when sleeping on your back, MADs often work well because supine position is also when jaw relaxation and tongue collapse are most pronounced.

Patients who travel frequently. MADs are small, silent, require no electricity, and fit in a pocket. For business travellers or campers, the portability advantage over CPAP is significant.

Simple snoring without significant OSA. If your bed partner is complaining about snoring but your sleep study doesn’t show clinically significant apnea, a MAD is often the most practical solution. CPAP is not typically prescribed for primary snoring.

Side Effects and Limitations

MADs aren’t without downsides.

Jaw discomfort and TMJ symptoms. The most common complaint in the first few weeks is jaw soreness, particularly in the morning. This usually resolves as the patient acclimatises, but a small percentage of patients (approximately 5-10%) develop persistent temporomandibular joint discomfort that limits MAD use.

Dental changes. Long-term MAD use can cause subtle changes in bite alignment. Studies tracking patients over 5-10 years show measurable reduction in overjet (the horizontal overlap of upper and lower front teeth) and small changes in molar position. These changes are usually clinically insignificant but should be monitored with regular dental reviews.

Excessive salivation or dry mouth. Some patients experience increased salivation initially as the mouth adapts to the foreign object. Others develop dry mouth if the device prevents complete lip seal. Both issues tend to improve over the first month.

Incomplete treatment for severe cases. MADs typically don’t achieve AHI normalisation in severe OSA. If your AHI is 45 and the MAD brings it to 20, you’re better than untreated but still in the moderate disease range. For severe cases, combination therapy (MAD plus positional therapy, or MAD plus upper airway surgery) may be considered.

The Assessment Process

Getting fitted for a MAD involves several steps.

First, a sleep study confirming OSA diagnosis and severity. This can be an in-lab polysomnography or a home sleep test, depending on clinical circumstances and referral pathways.

Second, a dental assessment by a dentist trained in dental sleep medicine. Not every dentist provides this service. They’ll assess your dental health (adequate dentition is required — MADs don’t work well with fewer than 8-10 teeth per arch), TMJ function, and jaw protrusion range.

Third, impressions and device fabrication. Custom MADs take 2-4 weeks to manufacture. Newer digital workflows using intraoral scanners can reduce this timeline.

Fourth, fitting and titration. The initial jaw advancement position is set conservatively and gradually increased over 4-6 weeks until symptoms resolve or the maximum comfortable protrusion is reached.

Finally, a follow-up sleep study with the device in place to objectively confirm treatment efficacy. This step is often skipped but shouldn’t be — symptom improvement doesn’t always correlate with AHI reduction, and some patients feel better subjectively while remaining inadequately treated objectively.

Cost and Access in Australia

In Australia, custom MADs are partially covered under some private health insurance dental extras policies, though coverage varies significantly between funds. The out-of-pocket cost after rebates typically ranges from $800 to $2,000.

Medicare does not directly rebate MADs, though the sleep study required for diagnosis is covered under Medicare (item 12203 for in-lab polysomnography, item 12250 for home sleep studies) with a valid referral from a GP or specialist.

The choice between MAD and CPAP shouldn’t be framed as better versus worse. It’s about matching the treatment to the patient — their disease severity, their lifestyle, their tolerance for different device types, and ultimately, their likelihood of using the treatment consistently. For mild to moderate OSA, the MAD deserves a much more prominent place in that conversation than it currently gets.