Evaluating the efficacy of a virtual care model using mandibular advancement devices for mild to moderate obstructive sleep apnea
By Steven Alvarado, Peter Balacky, DDS, Edward Kim, Daniel Moradzadeh, Julieanna Gonzalez, and Martin L. Hopp, MD, PhD
A prevalent sleep disorder affecting an estimated 54 million people in the U.S., obstructive sleep apnea (OSA) is characterized by repeated episodes of upper airway obstruction during sleep, leading to intermittent hypoxia and disrupted sleep patterns.1 If left untreated, this can lead to daytime effects like excessive daytime fatigue, morning headaches, difficulty concentrating, and low energy. Long-term health risks include cardiovascular disease, cognitive impairment, and reduced quality of life.2
While continuous positive airway pressure (CPAP) therapy remains the standard of care, its effectiveness is often limited by poor patient adherence due to discomfort and inconvenience.3 As a result, there has been growing interest in alternative therapeutic approaches, such as mandibular advancement devices (MADs), which are designed to protrude the mandible forward, enlarging the upper airway, and reducing the frequency of apneic events.4
MADs have been a well-established OSA treatment for over 30 years—with previous studies demonstrating that they can effectively reduce the apnea-hypopnea index (AHI) and alleviate symptoms associated with OSA.5 According to the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM), MADs are often a first-line treatment option for mild OSA and a strong alternative to CPAP for moderate OSA, especially if CPAP is poorly tolerated.4
However, access to timely diagnosis and treatment remains a significant challenge, particularly for individuals in rural or underserved areas who may face health care access barriers.6 The rise of virtual and telehealth technology has introduced a promising solution to these access-related challenges, transforming how OSA is diagnosed, managed, and treated.7
Through virtual platforms, patients can now consult with sleep specialists and dental professionals remotely as well as undergo ongoing monitoring and adjustments without needing an in-person appointment.8
To support clinical decision-making and optimize treatment outcomes, this case study aims to evaluate the effectiveness of diagnosing and treating mild and moderate OSA through virtual telehealth technology, guided by medical and dental professionals, using MADs.
Study Overview
In this retrospective cohort study, 200 consecutive patients with mild and moderate OSA underwent virtual evaluations by a licensed dental team to assess oral health and occlusion (bite relationship) and to screen for any contraindications. All patients underwent pre- and post-treatment sleep testing using an FDA-approved home sleep testing (HST) device.9
Upon completion of the health evaluation and sleep study, a Doctor of Dental Surgery (DDS) and team licensed in the patient’s state of residence conducted a dental screening survey to assess the patient’s suitability for at-home impression taking, oral appliance therapy (OAT), bite, and contraindications.
For relevant “Yes” responses in the dental screening survey, the DDS-directed clinical team requested further photos and communicated directly with the patient to evaluate their dental condition. This review process determined whether the individual was a suitable candidate for treatment before sending an impression kit or cheek retractor.
Via the Virtual Telehealth service, patients were guided through the process of capturing upper and lower dental impressions using polyvinyl siloxane (PVS) putty, along with intraoral photographs taken using a provided cheek retractor. The resulting dental impressions and bite were reviewed by the DDS-directed team and, if approved, they were digitized via CT scanning to generate 3D models. These models, along with the submitted intraoral photographs, were reviewed by a dentist licensed in the patient’s state of residence to determine clinical appropriateness for MAD therapy.
Eligible patients were treated with a custom-fabricated MAD and titrated weekly based on virtual assessments and symptom progression by a DDS-led clinical team. Patients completed pre- and post-treatment HST using an FDA-cleared device, along with validated snoring questionnaires.
Objective outcomes were measured by changes in AHI across established response thresholds, while subjective outcomes were assessed through patient-reported changes in snoring severity.
AHI Reduction and Treatment Response Rates
A full sleep study evaluation—consisting of both initial and post-treatment sleep testing—was completed by 185 patients (140 males and 45 females). Of those, 120 had mild OSA and 65 had moderate OSA. Completion of a post-treatment sleep test within the study’s eight-week period was considered completion of therapy. The minimum time for treatment completion was 10 days, with a median of 42 days.
Among patients with mild OSA, mean AHI decreased from 9.08 pre-treatment to 3.33 post-treatment, a 63.3% reduction in AHI. In patients with moderate OSA, mean AHI dropped from 22 pre-treatment to 8.59 post-treatment, a 60.95% decrease in AHI. (See Figure 1.)
Figure 1. AHI Reduction with MAD Therapy (Annotated)
Overall, 84% of patients with mild OSA and 80% of patients with moderate OSA patients met the Sher criteria. In addition, 88% of mild OSA patients and 31% of moderate OSA patients achieved a post-treatment AHI of < 5. Among mild OSA patients, 95% achieved a post-treatment AHI of <10. (See Figure 2.)
Figure 2. AHI Outcome Measures of Success
Pre-treatment Vs. Post-treatment Snoring Level
Of the 185 OSA patients who completed full sleep evaluations, 179 responded to the snoring-related questions. The six patients who did not respond to the snoring-related questions were excluded from this snoring analysis data.
Of the 179 respondents, two reported no snoring pre-treatment and continued to have no snoring post-treatment, excluding them from the study as well. It is important to note that 82% of the total 177 patients reported having an improvement of increase in ≥ 1 point on a 5-point scale.
Efficacy of Telehealth-Guided MAD Therapy
This study demonstrates that novel DDS team-guided MAD therapy delivered via virtual telehealth is an effective treatment modality for patients with mild-to-moderate OSA. Results showed a 63.3% reduction in AHI in patients with mild OSA and a 60.95% reduction in those with moderate OSA—with 83% of all participants meeting Sher criteria. These findings support the use of telehealth-based MAD treatment as a viable and accessible alternative to in-clinic care, especially for populations facing barriers to traditional sleep medicine services.
The high response rate in patients with mild OSA is particularly noteworthy. Overall, 88% of these individuals achieved an AHI < 5, aligning with AASM and AADSM recommendations for the use of MADs as a first-line therapy in mild OSA. This validates the potential of MAD therapy as an effective, patient-friendly, minimally invasive solution.
Among patients with moderate OSA, nearly half (48%) achieved an AHI < 5, and 80% met Sher criteria, suggesting meaningful benefit in this population as well. While CPAP remains the standard treatment for moderate-to-severe OSA, these findings underscore the utility of MADs, particularly for patients who cannot tolerate CPAP.10 The significant AHI reductions observed suggest that MADs may serve as a practical alternative or adjunctive option for moderate OSA management.
Patient-reported outcomes further support the clinical value of MAD therapy. A total of 82% of patients reported subjective improvement in snoring, a key quality-of-life factor that often impacts bed partners. Of the 185 participants, only 179 completed the snoring questionnaire (96.8% response rate). Missing responses were attributable to patients who sleep alone, making it difficult to assess snoring levels without a partner’s feedback. Per study protocol, patients without bed partners were advised to use a smartphone application to objectively measure snoring in decibels, though not all complied—an important consideration when interpreting subjective outcomes in this study.
In addition to these benefits, MADs are known for higher levels of patient comfort and compliance compared to CPAP, likely contributing to the positive outcomes observed. Improved adherence to therapy may play a key role in long-term treatment success and patient satisfaction.
These findings offer valuable insight into the feasibility and effectiveness of telehealth-guided MAD therapy. Future studies should incorporate a broader range of clinical outcomes, account for comorbid conditions, and explore additional efficacy metrics to further validate the utility of MADs across diverse OSA populations.
Note: This case study was adapted from a paper that originally appeared in the American Journal of Clinical and Medical Research. To read the original case study, see:
References
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- Ramar K, Dort LC, Katz SG, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An update for 2015. J Clin Sleep Med. 2015;11(7):773-827.
- Yu M, He D, Zhang Y, et al. Long-term efficacy of mandibular advancement devices in the treatment of adult obstructive sleep apnea: A systematic review and meta-analysis. PLoS One. 2023;18(11):e0292832.
- Andrilla CHA, Patterson DG, Garberson LA, Coulthard C, Larson EH. Geographic variation in the supply of selected behavioral health providers. Am J Prev Med. 2018;54(6 Suppl 3):S199-S207.
- American Academy of Sleep Medicine. Recommendations for permanent sleep telehealth: An American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(1):1-5.
- Alsaif SS, Kelly JL, Little SA, et al. Virtual consultations for patients with obstructive sleep apnoea: A systematic review and meta-analysis. Eur Respir Rev. 2022;31(166):220180.
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