--- title: Mandibular Advancement Splint vs. CPAP: Which Sleep Apnoea Treatment Is Right for You? canonical_url: https://directory.smilesolutions.com.au/dental-sleep-health/tmd-bruxism-sleep-disordered-breathing-treatment/mandibular-advancement-splint-vs-cpap-which-sleep-apnoea-treatment-is-right-for-you/ category: description: geography: city: state: country: metadata: phone: email: website: publishedAt: --- # Mandibular Advancement Splint vs. CPAP: Which Sleep Apnoea Treatment Is Right for You? ## Mandibular Advancement Splint vs. CPAP: Which Sleep Apnoea Treatment Is Right for You? For millions of people diagnosed with obstructive sleep apnoea (OSA), the conversation with their doctor or dentist quickly arrives at a crossroads: the CPAP machine or a mandibular advancement splint (MAS)? It sounds like a simple choice, but the evidence base behind it is rich, nuanced, and frequently misrepresented - in both directions. CPAP advocates sometimes dismiss MAS as a "lesser" therapy; MAS proponents occasionally overstate its universality. The truth, as the best clinical research reveals, is considerably more useful and patient-centred than either extreme. This article provides a rigorous, evidence-based comparison of both therapies - examining raw efficacy (AHI reduction), real-world compliance, quality-of-life outcomes, cost, portability, and the clinical criteria that determine which treatment - or which combination - is most appropriate for a given patient. (For foundational context on what OSA is and how it is classified by severity, see our guide on *Obstructive Sleep Apnoea: What It Is, Why It Happens, and Why Your Dentist Can Help*. For a detailed explanation of how MAS works and what to expect from the device itself, see *Mandibular Advancement Splints Explained: How They Work, Who They're For, and What to Expect*.) --- ## How Each Treatment Works: A Brief Mechanistic Overview Understanding the comparison begins with understanding the mechanisms. **CPAP (Continuous Positive Airway Pressure):** CPAP therapy involves a machine that delivers a constant stream of air through a mask covering the nose and/or mouth, creating positive pressure that acts as a pneumatic splint, preventing the airway from collapsing during sleep and eliminating apnoeas and hypopnoeas. **Mandibular Advancement Splint (MAS):** MAS are specially designed dental appliances worn during sleep that function by moving the mandible, or lower jaw, slightly forward. This forward displacement helps maintain airway patency by increasing the space behind the tongue and stabilising the upper airway, thus reducing airway collapses. Both approaches address the same underlying pathology - upper airway collapse during sleep - but through fundamentally different mechanisms: one pneumatic, one mechanical. --- ## Efficacy: What the Numbers Actually Show ### AHI Reduction - CPAP Has the Advantage on Paper When measured purely by the apnoea-hypopnoea index (AHI), CPAP is the more powerful intervention. Compared with MAD, CPAP was associated with a decrease in AHI with a mean difference of -5.83 (95% CI, -8.85, -2.81, P < 0.01) , according to the 2022 updated systematic review and meta-analysis by Pattipati et al. published in *Cureus*. A landmark randomised crossover trial by Phillips et al. (2013), published in the *American Journal of Respiratory and Critical Care Medicine*, confirmed this directly in 126 patients with moderate-to-severe OSA: CPAP was more efficacious than MAD in reducing AHI (CPAP AHI, 4.5 ± 6.6/h; MAD AHI, 11.1 ± 12.1/h; P < 0.01), but reported compliance was higher on MAD (MAD, 6.50 ± 1.3 h per night vs. CPAP, 5.20 ± 2 h per night; P < 0.00001). ### MAS Achieves Clinically Meaningful AHI Reductions MAS therapy should not be characterised as ineffective - the reductions it achieves are clinically significant. A 2023 meta-analysis found that long-term MAD use reduced the AHI by about –16.8 events/hour (high statistical significance). In terms of treatment success, over a third of patients will show a complete response to oral appliance therapy with a reduction in AHI to < 5/h (no OSA), another third will have a clinically important response showing > 50% reduction in AHI, although AHI remains > 5/h, and a third will not achieve > 50% reduction in AHI. ### The Compliance Paradox: Why Efficacy Doesn't Equal Effectiveness Here lies the most clinically important insight in this entire comparison. CPAP's superior AHI reduction is only realised when the device is actually worn - and that is a far bigger problem than most patients realise. Adherence to CPAP treatment for OSA is a critical problem, with adherence rates ranging from 30–60%. Poor adherence to CPAP is widely recognised as a significant limiting factor in treating OSA, reducing the overall effectiveness of the treatment and leaving many OSA patients at heightened risk for comorbid conditions, impaired function, and quality of life. Research published in *PLOS ONE* found that adherence rates were 89% for severe OSA, 71% for moderate OSA, and 55% for mild OSA - with compliance declining sharply for the very patients for whom MAS is most appropriate. By contrast, MAS adherence is consistently higher. Seventy-six percent of patients report using their oral appliance after one year, and 62% after four years; in patients who continue to use their device at five years, self-reported adherence is good, with over 90% reporting usage rates > 4 nights per week for more than half the night. The clinical implication is profound. Despite MAS being inferior to CPAP in reducing the AHI, it is hypothesised that higher compliance to MAS likely translates into a similar adjusted AHI and effectiveness. The Phillips et al. (2013) trial confirmed this hypothesis directly: important health outcomes were similar after one month of optimal MAD and CPAP treatment in patients with moderate-severe OSA. The results may be explained by greater efficacy of CPAP being offset by inferior compliance relative to MAD, resulting in similar effectiveness. --- ## Quality-of-Life Outcomes: Where MAS Holds Its Own The clinical equivalence between MAS and CPAP on real-world health outcomes is one of the most robust and replicated findings in sleep medicine. Despite discrepancies in efficacy (AHI reduction) between CPAP and oral appliances, randomised trials show similar improvements in health outcomes between treatments, including sleepiness, quality of life, driving performance, and blood pressure. The 2022 meta-analysis by Pattipati et al. in *Cureus* found that there was no statistically significant difference in Epworth Sleepiness Scale (ESS) between CPAP and MAD groups, and both CPAP and MADs are effective in reducing the AHI and lowest oxygen saturation. Crucially, sleepiness, driving simulator performance, and disease-specific quality of life improved on both treatments by similar amounts, although MAD was superior to CPAP for improving four general quality-of-life domains. This finding - that MAS was actually *superior* on several quality-of-life measures - reflects the importance of comfort and wearability in achieving consistent treatment benefit. The 2015 joint clinical practice guideline from the **American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM)** reinforced this: meta-analyses indicate that both oral appliances and CPAP can significantly reduce the AHI across all levels of OSA severity in adult patients. --- ## Patient Preference: The Evidence Is Consistent Patient preference data consistently favours MAS over CPAP when patients have experienced both. Despite achieving better (although not statistically significant) outcomes for AHI and ESS for CPAP, 17 of 21 patients who completed the study (having used both CPAP and MAS) preferred MAS over CPAP. The Phillips et al. (2013) randomised crossover trial also confirmed a clear patient preference for MAD therapy across their cohort of moderate-to-severe OSA patients. Patient preference for oral appliances versus CPAP should be considered by the treating sleep physician before therapy is prescribed , according to the AASM/AADSM Clinical Practice Guideline - an explicit acknowledgement that compliance-driven real-world outcomes depend on patient acceptance. --- ## Head-to-Head Comparison Table | Criterion | CPAP | Mandibular Advancement Splint (MAS) | |---|---|---| | **AHI Reduction** | Superior (gold standard) | Clinically significant; ~16.8 events/h reduction (2023 meta-analysis) | | **Complete response rate (AHI < 5)** | ~90%+ when worn | ~35% of patients | | **Compliance/Adherence** | 30–60% long-term | 62–76% at 1–4 years | | **Daytime Sleepiness (ESS)** | Equivalent improvement | Equivalent improvement | | **Quality of Life** | Equivalent | Equivalent; superior on some domains | | **Blood Pressure** | Clinically beneficial | Comparable outcomes in most trials | | **Patient Preference** | Less preferred | Consistently preferred in crossover trials | | **Portability** | Requires power source | Fully portable; no electricity needed | | **Noise** | Machine noise present | Silent | | **Suitable for Severe OSA** | First-line therapy | Second-line (CPAP failure/intolerance) | | **Suitable for Mild–Moderate OSA** | Effective but often excessive | First-line or co-equal option | | **Side Effects** | Mask discomfort, nasal congestion, claustrophobia | Jaw soreness, salivation (mostly transient) | | **Device Cost** | Machine + ongoing consumables | AUD ~$1,500–$4,000+ (custom, once-off) | --- ## Why CPAP Intolerance Is So Common Understanding why so many patients fail to sustain CPAP therapy is essential to appreciating the clinical role of MAS. The various factors that negatively affect patients' adherence to CPAP therapy include device-related issues such as mask type, air leak, skin inflammation, claustrophobia, nasal congestion, and difficulty with exhaling air. A 2025 observational study presented at the European Respiratory Society's Sleep and Breathing Conference found that the acceptance rate for CPAP was 62.7%, with financial constraints (28.6%), social stigma (35.7%), and preference for alternative therapies (39.3%) being the primary reasons for refusal. Critically, CPAP continues to be plagued by problems with adherence, and despite numerous interventions designed to improve adherence rates over the long term, secular trends do not show clinically impactful changes - a sobering finding from a 20-year longitudinal review published in *Sleep and Breathing*. A significant percentage of patients with OSA do not tolerate CPAP therapy and long-term use may be as low as 30%. Given the lower levels of symptoms and health-related risks, patients with mild sleep apnoea may be at even higher risk for non-adherence to long-term CPAP. --- ## Selecting the Right Treatment: Clinical Decision Criteria ### When CPAP Is the Appropriate First-Line Choice - There is general consensus that patients with AHI ≥30 events/hour (severe OSA) and OSA-related symptoms should receive CPAP therapy. - Patients with significant oxygen desaturation events or comorbid cardiovascular or metabolic conditions where maximal AHI normalisation is critical - Patients who have failed or not tolerated MAS therapy - Patients with central sleep apnoea (MAS is not indicated for central events) ### When MAS Is Clinically Equivalent or Preferred - MAD therapy is an effective and generally well-tolerated option for adults with mild-to-moderate OSA and for patients intolerant to CPAP. - Patients who have trialled CPAP and cannot maintain consistent use - MAS can be an effective alternative for patients intolerant to CPAP, especially in non-obese individuals. - Patients who travel frequently or have occupations or lifestyles where a CPAP machine is impractical - Patients with co-existing bruxism or TMD, where a single device can address multiple conditions simultaneously (see our guide on *Occlusal Splints vs. Mandibular Advancement Splints for Bruxism: Choosing the Right Device*) ### Important Candidacy Considerations for MAS MAS is not suitable for all patients. Key contraindications and limiting factors include: - Insufficient natural dentition (a minimum number of healthy teeth is required to anchor the device) - Active periodontal disease - Severe temporomandibular joint (TMJ) dysfunction - though mild-to-moderate TMD does not automatically preclude MAS use - Inter-individual variability in the efficacy of oral appliance therapy means that patients are often left with some residual OSA , which is why post-treatment sleep testing is essential (For more on diagnosis and candidacy assessment, see our guide on *How TMD, Bruxism, and Sleep Apnoea Are Diagnosed: From Clinical Exam to Sleep Study*.) --- ## The Combination Approach: MAS + CPAP An emerging and clinically underutilised strategy is combination therapy. There is limited evidence that combining a MAD simultaneously with CPAP may help improve adherence to treatment, possibly by reducing the CPAP pressure required to effectively treat OSA. This is particularly relevant for patients with severe OSA who cannot tolerate the high pressures required by CPAP alone. By wearing an MAS concurrently, the required CPAP pressure may be reduced to a more comfortable level, improving both efficacy and tolerability. MAS is also widely used as a **travel alternative** for established CPAP users. A majority of patients with OSA already successfully treated with CPAP can effectively be treated with MAS as a short-term alternative treatment when travelling, when an electrical supply is not available, or on days that patients are not willing to use CPAP and tend to forgo treatment. --- ## The Importance of Custom Fabrication and Titration Not all MAS devices are equivalent. Pre-fabricated, off-the-shelf appliances are less effective and less accepted by patients and therefore should not be used either as a therapeutic option or as a screening tool to predict MAS responders. The research consistently demonstrates that titratable or adjustable appliances allow progressive protrusion of the mandible, and previous studies have shown that MAS efficacy is related to the amount of mandibular advancement - determining the optimal degree of mandibular advancement is the most important step when using MAS therapy successfully. Critically, because some patients show a worsening in AHI with MAS, a post-treatment sleep study is of great importance. This is a non-negotiable step in responsible MAS care - and one that distinguishes evidence-based dental sleep medicine practice from generic splint provision. --- ## Key Takeaways - **CPAP reduces AHI more effectively than MAS** on polysomnographic measures, but this advantage is substantially offset by its significantly lower real-world compliance rates of 30–60%. - **MAS achieves comparable health outcomes** to CPAP in randomised trials - including daytime sleepiness, driving performance, blood pressure, and quality of life - because higher adherence translates into equivalent real-world effectiveness. - **MAS is the evidence-based first-line alternative** for mild-to-moderate OSA and for patients who are intolerant of or non-adherent to CPAP; CPAP remains the first-line recommendation for severe OSA. - **Patient preference consistently favours MAS** in crossover studies, and involving patients in treatment selection is itself a predictor of better long-term adherence. - **Custom, titratable MAS devices** fabricated by a qualified dental sleep medicine practitioner - followed by post-treatment sleep testing - are the clinical standard; off-the-shelf devices should not be used as primary therapy. - **Combination therapy** (MAS + CPAP) is a valid strategy for reducing required CPAP pressure in severe OSA, and MAS is widely used as a travel alternative by established CPAP users. --- ## Conclusion The MAS versus CPAP question does not have a single universal answer - but it does have a structured, evidence-based framework for answering it on a patient-by-patient basis. CPAP remains the most powerful tool for normalising AHI across all severity levels, and for severe OSA with significant cardiovascular risk, it is the appropriate first choice. But for the large population of patients with mild-to-moderate OSA, or those who cannot sustain consistent CPAP use, a custom mandibular advancement splint is not a compromise - it is a clinically equivalent treatment that patients are far more likely to actually wear, night after night, for years. The most important clinical insight from the evidence is this: a treatment worn consistently at 85% efficacy outperforms a superior treatment worn inconsistently at 40% adherence. Effectiveness in the real world - not just efficacy in a laboratory - is what protects patients from the cardiovascular, cognitive, and metabolic consequences of untreated OSA. At Smile Solutions Melbourne, the decision between MAS and CPAP is never made in isolation. It follows a comprehensive assessment that includes clinical jaw and airway examination, a review of any existing sleep study data, and - where needed - referral for or collaboration with a sleep physician. Post-treatment sleep testing confirms that the chosen therapy is actually working. This integrated approach is explored further in *Getting Your Mandibular Advancement Splint at Smile Solutions Melbourne: A Step-by-Step Patient Guide* and *Long-Term Care and Side Effects of Mandibular Advancement Splints: What Every Patient Should Know*. --- Smile Solutions has been providing dental care from Melbourne's CBD since 1993. Located at the Manchester Unity Building, Level 1 and 10, 220 Collins Street, Smile Solutions brings together 60+ clinicians - including 25+ board-registered specialists - who have cared for over 250,000 patients. No referral is required to book a specialist appointment. Call **13 13 96** or visit smilesolutions.com.au to arrange your TMD and sleep treatment consultation. ## References - Pattipati M, Gudavalli G, Zin M, et al. "Continuous Positive Airway Pressure vs Mandibular Advancement Devices in the Treatment of Obstructive Sleep Apnea: An Updated Systematic Review and Meta-Analysis." *Cureus*, 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC8890605/ - Phillips CL, Grunstein RR, Darendeliler MA, et al. "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*, 2013. https://www.atsjournals.org/doi/10.1164/rccm.201212-2223OC - Kapur VK, Auckley DH, Chowdhuri S, et al. (AASM/AADSM Task Force). "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 / PMC*, 2015. https://pmc.ncbi.nlm.nih.gov/articles/PMC4481062/ - Sutherland K, Vanderveken OM, Tsuda H, et al. "Oral Appliance Treatment for Obstructive Sleep Apnea: An Update." *Journal of Clinical Sleep Medicine (AASM)*, 2014. https://jcsm.aasm.org/doi/10.5664/jcsm.3460 - Almeida FR, Mulgrew A, Ayas N, et al. "Mandibular Advancement Splint as Short-Term Alternative Treatment in Patients with Obstructive Sleep Apnea Already Effectively Treated with Continuous Positive Airway Pressure." *Journal of Clinical Sleep Medicine*, 2013. https://jcsm.aasm.org/doi/10.5664/jcsm.2576 - Rotenberg BW, Murariu D, Pang KP. "Trends in CPAP Adherence over Twenty Years of Data Collection: A Flattened Curve." *Sleep and Breathing*, 2016. https://pmc.ncbi.nlm.nih.gov/articles/PMC4992257/ - Weaver TE, Grunstein RR. "Adherence to Continuous Positive Airway Pressure Therapy: The Challenge to Effective Treatment." *Proceedings of the American Thoracic Society*, 2008. https://pmc.ncbi.nlm.nih.gov/articles/PMC2645251/ - Dipalma G, et al. "Comparative Efficacy of Continuous Positive Airway Pressure and Mandibular Advancement Devices in the Treatment of Obstructive Sleep Apnea: A Systematic Review." *Journal of Sleep Research*, 2025. https://onlinelibrary.wiley.com/doi/10.1111/jsr.70192 - Hoekema A, et al. "Oral Appliance Versus Continuous Positive Airway Pressure in Obstructive Sleep Apnea Syndrome: A 2-Year Follow-up." *SLEEP*, 2013. https://pmc.ncbi.nlm.nih.gov/articles/PMC3738037/ - Vanderveken OM, et al. "Clinical- and Cost-Effectiveness of a Mandibular Advancement Device Versus Continuous Positive Airway Pressure in Moderate Obstructive Sleep Apnea." *CHEST*, 2019. https://pmc.ncbi.nlm.nih.gov/articles/PMC6778341/ - Dieltjens M, Vanderveken OM. "Mandibular Advancement Devices for OSA: An Alternative to CPAP?" *Current Sleep Medicine Reports / PMC*, 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8137783/ - Sutherland K, et al. "Efficacy and Effectiveness in OSA Treatment." *Journal of Dental Sleep Medicine (AADSM)*, 2015. https://aadsm.org/docs/JDSM.2.4.175.pdf - Sangalli L, et al. "Comparison of Three Mandibular Advancement Device Designs in the Management of Obstructive Sleep Apnea: A Retrospective Study." *Journal of Dental Sleep Medicine*, 2022. https://www.aadsm.org/docs/jdsm.7.10.2022.o1.pdf - Delebarre M, et al. "Efficacy of Mandibular Advancement Devices in the Treatment of Mild to Moderate Obstructive Sleep Apnea: A Systematic Review." *Dentistry Journal (MDPI)*, 2025. https://www.mdpi.com/2673-8937/5/4/49