When many people think of treating sleep apnea, they consider using continuous positive airway pressure (CPAP). 

But, if CPAP doesn’t work for you, a mandibular advancement device (MAD), also called a mandibular repositioning device (MRD), mouthguard or oral appliance, could also be a possible treatment.

MADs reposition your lower jaw to open your airway as you sleep. They are not an option for everyone and cannot help with central sleep apnea (CSA), the less common form of sleep apnea, as this is a neurological rather than mechanical condition. They are effective for some people with obstructive sleep apnea (OSA) – particularly younger, lean people and those with mild-to-moderate symptoms.¹

In this article, we look at the types of MAD devices, how they work, and how they compare to CPAP therapy. 

Here’s what you need to know: 

How do MADs work? 

When you have OSA, your airway closes or partially closes while you sleep, causing snoring, small pauses in breathing, and disrupted sleep patterns. The disorder usually happens due to the narrowing of the airway, which can be caused by issues with your soft palate, tongue, nose or throat.² Snoring results from air moving through a narrowed airway and creating vibration in your soft tissue as you breathe.³ 

MADs sit inside your mouth and physically move your lower jaw forward and open your airway as you sleep. By helping to keep your airway open, they can help you breathe normally and stop or reduce snoring at the same time.

Types of MADs

Several types of MADs are available, including standard over-the-counter devices, fully customized devices (sometimes referred to as titratable or bespoke), and semi-customized devices.⁴ Most MADs are adjustable, which means you can tweak the positioning of your lower jaw with an elastic band, screw, hinge, or other mechanism. Fixed-advancement MADs are not adjustable, meaning they must be custom-fitted and replaced if you need to alter your jaw position.

Every person with sleep apnea has different MAD needs. If you have mild apnea, a non-custom, non-adjustable device may be enough to alleviate your snoring and other apnea symptoms. If you have severe symptoms or your jaw positioning is complicated, you might need an adjustable, custom-made MAD.⁵ 

Boil-and-bite 

A ‘boil-and-bite’ (or thermoplastic) MAD is a bit like a sports mouthguard. Made of moldable plastic, the device consists of upper and lower trays in standard sizes and positions. By softening the trays in hot water then biting into them, you can change the shape of the device to better fit your mouth. However, this will not compare to the fit of a custom-made MAD. 

Key takeaways 

• Boil-and-bite MADs are usually sold without a prescription. 
• Usually, these are marketed as anti-snoring devices. 
• May be used to prevent snoring, even without a sleep apnea diagnosis.

Semi-custom-made

Like boil-and-bite MADs, semi-custom versions don’t usually require a prescription. Instead, you get an impression kit in the mail and bite into it to make a mold of your teeth and gums. These impressions are sent to the manufacturer and used to create a custom-fitted MAD. Semi-custom MADs can be used to manage mild-to-moderate OSA.⁶

Key takeaways

• May not fit as well as a custom-made MAD.
• Most manufacturers will send you a new impression kit if your device does not fit.
• Some semi-custom-made MADs are adjustable. 

Custom-made 

When you get a custom-made MAD, your dentist or sleep specialist takes impressions and measurements of your teeth and jaw, which are used to create your mouthpiece. Your dentist can then adjust the device to ensure a perfect fit. Because they’re handmade with specific measurements, custom-made MADs tend to be more comfortable for the user and may be more effective for treating snoring and other symptoms of OSA.⁷

Key takeaways 

• Custom-made MADs generally require a prescription. 
• They can be adjusted gradually, giving you time to get used to them.

MADs: Pros and cons

Pros⁴

• Affordable: MADs, particularly over-the-counter and semi-custom versions, tend to be reasonably inexpensive compared with other sleep apnea treatments. 
• Accessible: You can buy some MADs, even customizable ones, over the counter and online, making them easy to access without a prescription. 
• Quick: Because you don’t need a referral or prescription, MADs can be a quick way to treat OSA symptoms in the short term. 

Cons⁸

• Less oversight: You may not have a healthcare professional overseeing your outcomes. 
• Discomfort: Depending on the type and fit of the device, it may be uncomfortable to wear. 
• Varying results: While MADs are effective for some people with sleep apnea, results vary. 
• Side effects: MADs can cause jaw pain, dry mouth, tooth pain, and excessive saliva.⁸   
• Long-term issues: MADs may cause dental problems when used long-term, so it is crucial to consult your dentist if they are your preferred treatment.

MAD vs. CPAP

Some people see MAD as a cheaper, quicker, more accessible choice and assume it may have fewer side effects than traditional CPAP therapy. However, it’s not quite that simple. 

While results vary depending on your symptoms, the type of device used, and whether you use your device consistently, CPAP is among the most common sleep apnea treatments. For most patients, consistent use of CPAP therapy will lead to better outcomes, such as improved blood oxygen levels, compared to using a MAD device.⁹

Trialing a mouthguard isn’t cheap and easy if you need to try out several devices. MADs may also cause significant dental changes in the long-term due to their placement in your mouth.⁴ 
 
 Your doctor or specialist may recommend a MAD if you’ve tried CPAP therapy, but have been unable to troubleshoot issues associated with using the treatment. 

Have a read of our CPAP Troubleshooting article if you’re struggling to adjust. 

Think you have sleep apnea? 

Noticing snoring, fatigue, night waking, or other signs of sleep apnea? The disorder is common and can be serious, so if you suspect sleep apnea, get checked out as soon as you can.¹⁰ Once you’ve spoken to your doctor, they will be able to recommend the best course of action for you – whether that’s CPAP, a MAD or another treatment 

Here’s how to get help: 

• Undergo a sleep study. Go to, What is a Sleep Study.
• Take the Fisher & Paykel Healthcare Sleep Apnea quiz.

The content is for educational purposes only. It should not be used as a substitute for the medical advice of one’s healthcare provider.