He Could Not Tolerate the CPAP Mask, and His Wife Had Stopped Sleeping

Quick answer: A mandibular advancement splint holds the lower jaw slightly forward during sleep, which opens the airway. It is a recognised treatment for mild to moderate obstructive sleep apnoea and for people who cannot tolerate CPAP — but only after a proper sleep diagnosis, never instead of one.

The call

The referral came from a sleep physician, which is the correct direction of travel and bears repeating: this treatment starts with a diagnosis, not with a dentist.

Ovadia, 56, from Nachala U'Menucha, had been diagnosed with moderate obstructive sleep apnoea eighteen months earlier following a sleep study. He had been prescribed CPAP and had used it for about five weeks before abandoning it — claustrophobia with the mask, and air leaking around it.

His sleep physician had referred him for an oral appliance as the next option.

What we found

What the referral told us, and which we could not have established ourselves: his apnoea-hypopnea index, the severity classification, his oxygen saturation levels overnight, and his daytime sleepiness score. Those numbers determine whether a splint is a reasonable option, and they come from a sleep study.

Moderate severity, no significant oxygen desaturation, no cardiac complication. Suitable.

The dental assessment, which is what a dentist actually contributes:

• Enough teeth to anchor a splint. He had a full lower arch and adequate upper teeth. An appliance grips the teeth, so a heavily restored or partially edentulous mouth may not support one.
• Healthy periodontal support. Advancing the jaw against teeth with bone loss loads them unfavourably. His pockets were 3mm with no mobility.
• Adequate jaw movement. He could protrude his lower jaw about 9mm, which is comfortably within the useful range. Someone who can barely protrude cannot benefit.
• Temporomandibular joints assessed. Mild clicking without pain or locking, which is not a contraindication and does mean monitoring.
• No untreated decay or failing restorations, which would fail under an appliance.

What we did

A custom two-piece adjustable appliance, made from impressions and a protrusive bite record taken at about 60 per cent of his maximum advancement — starting conservatively and titrating forward is the approach that patients tolerate.

Two-piece designs with an adjustment mechanism are preferable to fixed one-piece appliances: the jaw position can be advanced gradually, in small increments, which is how you find the point where the airway opens without producing jaw discomfort.

Titration over ten weeks. He advanced the appliance by small increments every two weeks, reporting on snoring, his wife's observations, morning jaw comfort and daytime alertness. We reviewed at each stage.

The side effects, described honestly beforehand, because people who are not warned stop wearing it:

• Morning jaw stiffness and tenderness for the first few weeks, which settles.
• Increased salivation initially, then dryness.
• Teeth feeling odd on waking, which resolves within an hour.
• Long-term bite change. Over years, these appliances can produce small permanent changes in tooth position and bite relationship. This is the most important one, it is not reversible, and it has to be weighed against the benefit of treating the apnoea. In someone with moderate apnoea, that trade is generally worth making — but he needed to know.

Morning exercises to reposition the bite, which reduce the day-to-day discomfort.

A repeat sleep study wearing the appliance, arranged by his physician at four months. This is the step that is most often skipped and matters most: without it, nobody knows whether the apnoea is actually being treated. Reduced snoring is not evidence of a treated airway.

His follow-up study showed his index reduced into the mild range, with normal oxygen saturation.

The outcome

Wearing it nightly at two years. His daytime sleepiness score improved substantially, and his wife sleeps in the same room.

We review him every six months, checking the appliance, the joints, and the bite relationship against records taken at the start.

What to do if this happens to you

1. Get a sleep study first. A dentist should not treat snoring or suspected apnoea without a diagnosis.
2. Bring the sleep report to the dental assessment. The numbers determine suitability.
3. Ask for an adjustable appliance, not a fixed one — titration is how it is made to work.
4. Expect jaw discomfort initially, and do the morning exercises.
5. Ask about long-term bite change. It is real and permanent, and it should be part of the decision.
6. Insist on a follow-up sleep study. Feeling better is not proof the apnoea is controlled.

Diagnosed with sleep apnoea and struggling with CPAP? Ask Ramat Beit Shemesh Urgent Dental Care about an oral appliance. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.