Mandibular advancement splint
A mandibular splint or mandibular advancement splint (MAS) is a device worn in the mouth that is used to treat orofacial disorders including: obstructive sleep apnea (OSA), snoring, and TMJ disorders. These devices are also known as mandibular advancement devices, sleep apnea oral appliances, oral airway dilators and sleep apnea mouth guards. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. The American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) recommend that sleep physicians should prescribe sleep apnea oral appliances for the adult patients who need treatment for their primary snoring without obstructive sleep apnea) rather than no treatment and for the patients who have obstructive sleep apnea but are intolerant to the CPAP therapy, or for those who prefer alternate therapy.
Mandibular advancement splints are widely used in the United States and are beginning to be used in the UK. According to the current American Academy of Sleep Medicine treatment guidelines, Oral appliances should be considered for patients with snoring or minor to moderate sleep apnea, or as an alternative to CPAP in non compliant patients with severe obstructive sleep apnea. 
Evidence is accumulating to support the use of oral devices in the treatment of OSA, and studies demonstrating their efficacy have been underpinned by increasing recognition of the importance of upper airway anatomy in the pathophysiology of OSA.  Elucidation of the mechanism of action of oral devices has provided insight into the factors that predict treatment response and may improve the selection of patients for this treatment modality.
A 2008 study published in Sleep on the influence of nasal resistance (NAR) on oral device treatment outcome in OSA demonstrates the need for an interdisciplinary approach between ENT surgeons and sleep physicians to treating OSA. The study suggests that higher levels of NAR may negatively affect outcome with MAS and subsequently methods to lower nasal resistance may improve the outcome of oral device treatment.
They are generally more successful at treating mild and moderate sleep apnea and less effective at treating severe sleep apnea, even though good success was measures even in severe sleep apnea. They may bring the level of apnea a patient experiences down significantly but fail to completely eliminate it.
A meta-analysis of 51 randomized controlled trials investigating the effects of CPAP and oral devices on blood pressure found that oral devices were equally effective as continuous positive airway pressure (CPAP) devices in lowering the blood pressure of patients suffering from OSA. The medical dental sleep appliance, or MDSA, was clinically proven to conclusively show in a large and complex randomized controlled study that CPAP and MAS are effective in treating sleep-disordered breathing in subjects with AHI 5–30. CPAP was thought to be more effective, but randomised control evidence (such as that reviewed in 2013) suggests splints may be as effective in patients with a range of severities of obstructive sleep apnoea. Both methods appear effective in alleviating symptoms, improving daytime sleepiness, quality of life and some aspects of neurobehavioral function, with CPAP usage being less than self-reported MAS usage. More test subjects and their domestic partners felt that CPAP was the most effective treatment, although MAS was easier to use. Nocturnal systemic hypertension was shown to improve with MAS but not CPAP, although the changes are small.
In a survey study of patients, many discontinued use because of discomfort, lack of efficacy or switching to CPAP and frequent side-effects included dry mouth, tooth pain, dental discomfort and jaw pain. Long term use is not associated with temporamandibular disorders but was associated with permanent changes in how the upper and lower teeth meet and the appliances needed about 0.8 repairs/relines per year. Some patients can find these devices somewhat uncomfortable, although many patients find them less bothersome than CPAP mask treatment, so patients are more likely to wear them consistently and comply with treatment CPAP manufacturers claim that improperly fitted devices may cause teeth to shift over time, like with CPAP, but cite no evidence to support these claims Patients may pay around $1900 out of pocket to secure these devices, and, in the USA, some health plans do not cover these costs. The high price for prescription devices has led to a proliferation of lower cost non-prescription devices that are unproven and some sleep specialists suggest may be dangerous.
Adherence to oral appliance is strongly associated with patient reservations regarding the effects of the device on teeth, possible lack of efficacy, and discomfort.
- Ramar, Kannan; Dort, Leslie C.; Katz, Sheri G.; Lettieri, Christopher J.; Harrod, Christopher G.; Thomas, Sherene M.; Chervin, Ronald D. (2015-07-15). "Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015". Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 11 (7): 773–827. doi:10.5664/jcsm.4858. ISSN 1550-9389. PMC . PMID 26094920.
- Chervin, Ramar (2015). "Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015". J Clin Sleep Med. 11: 773–827. doi:10.5664/jcsm.4858. PMC . PMID 26094920.
- Rose E. (2004). "Identifying the Ideal Oral Appliance Candidate". Journal of Orofacial Orthopedics. 65: 6.
- Chan AS, Lee RW, Cistulli PA; Lee; Cistulli (August 2007). "Dental appliance treatment for obstructive sleep apnea". Chest. 132 (2): 693–9. doi:10.1378/chest.06-2038. PMID 17699143.
- Zeng B, Ng AT, Qian J, Petocz P, Darendeliler MA, Cistulli PA (2008). "Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea". Sleep. 31 (4): 543–547. doi:10.1093/sleep/31.4.543. PMC .
- Benoliel, haviv (2015). "A 2-year mean follow-up of oral appliance therapy for severe obstructive sleep apnea: a cohort study". Oral diseases. 21: 386–92. doi:10.1111/odi.12291. PMID 25207802.
- Daniel, Bratton J; Gaisl, Thomas; Wons, Anette M.; Kohler, Malcolm (2015-12-01). "Cpap vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: A systematic review and meta-analysis". JAMA. 314 (21): 2280–2293. doi:10.1001/jama.2015.16303. ISSN 0098-7484. PMID 26624827.
- Phillips, C. L.; Grunstein, R. R.; Darendeliler, M. A.; Mihailidou, A. S.; Srinivasan, V. K.; Yee, B. J.; Marks, G. B.; Cistulli, P. A. (2013). "Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial". American Journal of Respiratory and Critical Care Medicine. 187 (8): 879–87. doi:10.1164/rccm.201212-2223OC. PMID 23413266.
- Barnes M, McEvoy RD, Banks S, et al. (September 2004). "Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea". American Journal of Respiratory and Critical Care Medicine. 170 (6): 656–64. doi:10.1164/rccm.200311-1571OC. PMID 15201136.
- FR, de Almeida; AA, Lowe; S, Tsuiki; R, Otsuka; M, Wong; S, Fastlicht; F, Ryan (2005-04-01). "Long-term compliance and side effects of oral appliances used for the treatment of snoring and obstructive sleep apnea syndrome". Journal of Clinical Sleep Medicine. 1 (2): 143–52. ISSN 1550-9389. PMID 17561628.
- Pantin, Christopher C.; Hillman, David R; Tennant, Marc (1999-03). "Dental Side Effects of an Oral Device to Treat Snoring and Obstructive Sleep Apnea". Sleep. 22 (2): 237–240. doi:10.1093/sleep/22.2.237. ISSN 1550-9109. Check date values in:
- Martínez-Gomis, Jordi; Willaert, Eva; Nogues, Lluis; Pascual, Maribel; Somoza, Maria; Monasterio, Carmen (2009-10-05). "Five Years of Sleep Apnea Treatment with a Mandibular Advancement Device". The Angle Orthodontist. 80 (1): 30–36. doi:10.2319/030309-122.1. ISSN 0003-3219.
- Fietze, Glos (1989). "Comparison of effects of OSA treatment by MAD and by CPAP on cardiac autonomic function during daytime". Arteriosclerosis. 9: 1–20. PMID 2643420.
- "Oral Appliance for Sleep Apnea". sleepassociation.org. Retrieved 28 June 2016.
- "Managing a Sleep Disorder Long-Term: Will Insurance Cover Your Expenses?". Health.com. Retrieved 28 June 2016.
- Woolston, Chris (2011-02-28). "Over-the-counter devices probably won't help sleep apnea". Los Angeles Times. ISSN 0458-3035. Retrieved 2016-08-06.
- Aframian, Haviv (2017). "Assessment of interfering factors in non-adherence to oral appliance therapy in severe sleep apnea". Oral Dis. 23: 629–635. doi:10.1111/odi.12633. PMID 28054437.
|Wikimedia Commons has media related to Anti-snore prostheses.|