Obstructive sleep apnea (OSA) is a highly prevalent yet substantially underdiagnosed condition with serious cardiovascular, cognitive, and occupational consequences. Over the past decade, oral appliance therapy (OAT)—particularly the use of mandibular advancement devices—has evolved from a secondary alternative to continuous positive airway pressure (CPAP) into a recognized primary treatment for patients who are intolerant of, or noncompliant with, CPAP or prefer an alternative therapy. Advances in digital fabrication, intraoral scanning, home sleep apnea testing, and embedded device technology have significantly improved appliance fit, titration precision, and treatment monitoring. Meanwhile, the shifting treatment landscape—including the rise of over-the-counter sleep devices, hypoglossal nerve stimulation surgery, and GLP-1–driven weight loss therapies—underscores OAT’s unique role as a safe, noninvasive, reversible, and combinable treatment modality. Looking ahead, artificial intelligence, expanded screening protocols, and stronger physician–dentist collaboration promise to extend effective care to millions of OSA patients who remain undiagnosed and untreated.
Obstructive sleep apnea (OSA) affects nearly a billion people worldwide with mild-to-severe disease; in the United States, the American Academy of Sleep Medicine estimates that more than 30 million adults have this condition, with some analyses placing the figure considerably higher.1 Despite its prevalence, approximately 80% of those living with OSA remain undiagnosed and untreated—a public health gap with serious implications for cardiovascular health, metabolic and cognitive function, and quality of life. The burden of untreated OSA contributes meaningfully to motor vehicle accidents, occupational impairment, and excess healthcare utilization.2 The current treatment landscape is both expanding and evolving, presenting dentists with a growing and well-defined role in screening, management, and long-term care.
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Evolution of Oral Appliance Therapy
The past decade has brought a fundamental reappraisal of how sleep apnea is understood and managed. The American Dental Association formalized dentistry’s role in this space in 2017, recommending that dentists and hygienists periodically screen patients for OSA risk factors3—a policy that reflects a broader shift toward whole-patient care and recognition that the oral cavity offers a meaningful window into systemic health.
Mandibular advancement devices (MADs) are custom-fit oral appliances that gently stabilize the lower jaw and tongue to maintain airway patency during sleep. They were initially developed as alternatives for patients who could not tolerate continuous positive airway pressure (CPAP). Over time, clinical evidence elevated their status. Real-world data from nearly 480,000 CPAP users shows that nearly half discontinue CPAP therapy within 3 years, primarily due to discomfort, noise, and practical barriers.4 Because MADs are more comfortable, portable, and easier to use, patients wear them more consistently, and a therapy used every night outperforms one worn only occasionally. When real-world adherence is factored in, OAT produces health outcomes equivalent to CPAP and, for many patients, superior results in practice.5
The cardiovascular evidence base for OAT has strengthened considerably. A 2024 randomized trial published in the Journal of the American College of Cardiology found that MADs were noninferior to CPAP in reducing 24-hour mean arterial blood pressure in patients with hypertension and elevated cardiovascular risk.6 These findings underscore that OAT is not merely a patient-preference option; it is a clinically rigorous treatment delivering consequential outcomes.
Advancements in Technology and Innovation
Digital dentistry has transformed the design and delivery of oral appliances. Intraoral scanning has replaced traditional impressions, enabling more precise fit and more efficient fabrication. Computer-aided design/computer-aided manufacturing, including both milling and 3D printing, has produced appliances that are more durable, more comfortable, and more easily adjusted than earlier generations. Older designs relied on metal connectors and required significant manual dexterity for titration; today’s digital-workflow devices can be delivered faster and titrated with far greater ease.
Sensor technology embedded within some appliances now captures real-world usage data and, in select systems, provides insight into sleep quality itself, enabling continuous monitoring. Home sleep apnea testing (HSAT) devices—from apps to wearable devices—have expanded access to titration and outcome verification, allowing clinicians to assess treatment efficacy across multiple nights rather than relying on a single in-lab study.
Artificial intelligence (AI) is also reshaping the diagnostic landscape. AI-driven algorithms now score home sleep apnea test results and calculate emerging metrics such as hypoxic burden, supporting more nuanced clinical decision-making. Facial recognition technology has demonstrated the ability to screen patients for OSA risk with accuracy approaching that of home sleep apnea tests.7 These tools will not displace in-center polysomnography or HSAT as the standard-of-care for diagnosis, but they promise to accelerate identification of at-risk patients—particularly women, who are historically underdiagnosed by current metrics.
The Shifting Treatment Landscape
The expanding treatment landscape for obstructive sleep apnea is a promising development for patients, offering more pathways to care than ever before. However, proper clinical oversight and personalized treatment plans remain critical, as many newer options come with limitations related to access, cost, and/or clinical suitability.
Over-the-counter (OTC): Growing consumer awareness of OSA has fueled demand for OTC devices. While this trend reflects encouraging public recognition of the condition, OTC devices may carry meaningful clinical risks when used without the oversight of a qualified dental sleep medicine provider; such risks include potential damage to teeth, gums, and temporomandibular joints, as well as inconsistent and largely unproven long-term effectiveness.8 These products may serve as a first step toward care for some patients, but those requiring more effective OSA management ultimately benefit from treatment by a qualified dental sleep medicine provider.
Hypoglossal nerve stimulation (HNS): This surgery has also attracted significant attention as a treatment alternative. While it offers genuine benefit for carefully selected candidates, the eligible patient population is limited, and the procedure carries the inherent risks of any surgical intervention. The significant cost, invasiveness, and risk of side effects of HNS surgery argue for a thorough trial of OAT before surgical options are pursued.
GLP-1s: Weight-loss therapies introduce a promising variable, as weight reduction can meaningfully decrease OSA severity. However, many patients will not qualify through insurance, and, moreover, most patients who do start the treatment will not eliminate apnea entirely.9 A more clinically sound model treats GLP-1 therapy and OAT as complementary—ie, combination therapy that enhances the effectiveness of both interventions while addressing the full spectrum of the patient’s needs.
Across this evolving landscape, OAT’s fundamental advantage remains its versatility. It is noninvasive, reversible, and uniquely compatible with other treatment modalities, making it the safest option for the broadest range of patients. More than 80% of patients can tolerate OAT successfully,10 and unlike CPAP or surgery, an oral appliance can be used alongside any other therapy. Given these advantages, OAT remains clinically relevant regardless of which other treatment(s) a patient pursues.
The Future of Dental Sleep Medicine
Dentists and hygienists will increasingly serve on the front lines of OSA screening, coordinating with physicians to ensure patients receive appropriate diagnosis and care. AI-driven tools will enable faster, more accurate identification—particularly in currently underserved populations. Expanded access to home sleep apnea testing will reduce the logistical and financial barriers that delay treatment for many patients.
The American Academy of Dental Sleep Medicine (AADSM) is furthering these efforts by establishing quality care standards that balance the use of technology while ensuring patients are receiving optimal care. An example of this is the incorporation of telehealth into oral appliance therapy. Telehealth increases access to care, allowing patients to be screened, connected with a physician for diagnosis, and monitored throughout their treatment. However, providing optimal care requires patients to be seen in person by a qualified dentist for a comprehensive dental evaluation, intraoral digital scanning, and a bite registration prior to an oral appliance being fabricated.8
The AADSM is also ensuring that there is comprehensive, unbiased education, so dentists can competently and confidently provide oral appliance therapy. The AADSM Mastery Program is offered directly through the AADSM and has also been adopted by several dental schools, expanding the pipeline of qualified dental sleep medicine providers.8 Continued investment in physician and public education, along with growing collaboration between dental and medical professionals, will be essential to closing the substantial treatment gap that still leaves the majority of OSA patients without care.
Conclusion
Oral appliance therapy has matured from a CPAP alternative to a treatment of choice for many patients with obstructive sleep apnea. As the treatment landscape continues to evolve and new therapies emerge, OAT’s noninvasive profile, broad tolerability, and compatibility with combination approaches will continue to facilitate real-world adherence and better outcomes. The dental profession has a clear and expanding role in meeting the substantial unmet need in OSA care and the evidence to support it.
About the Author
Paul Jacobs, DDS
President, American Academy of Dental Sleep Medicine
References
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