AASM/AADSM Oral Appliance Therapy Guideline (2015): six recommendations that put the sleep physician first and the qualified dentist second

What it says#

The guideline was commissioned by the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine to replace the AASM's 2006 practice parameters on oral appliances, because the literature on clinical outcomes had grown considerably since. A seven-member task force (three sleep physicians, two dentists with expertise in oral appliances, two AASM research staff) searched PubMed and Embase from January 2004, updated the search to February 28, 2013, screened 377 citations, and used 51 articles for data extraction, meta-analysis and grading under a modified GRADE process. Strength of recommendation came from a table: STANDARD when benefits clearly outweigh harms with high or moderate quality evidence, GUIDELINE when benefits clearly outweigh harms with low quality evidence or when benefits and harms are closely balanced with high or moderate evidence, OPTION for the weaker cells, and STANDARD against a therapy whenever harms clearly outweigh benefits regardless of evidence quality.

The six recommendations, with their strengths, are these. First, sleep physicians should prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring without obstructive sleep apnea (STANDARD; quality of evidence high). Second, when oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, a qualified dentist should use a custom, titratable appliance over non-custom oral devices (GUIDELINE; evidence low). Third, sleep physicians should 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 (STANDARD; evidence moderate). Fourth, qualified dentists should provide oversight, rather than no follow-up, of oral appliance therapy in adult OSA patients, to survey for dental-related side effects or occlusal changes and reduce their incidence (GUIDELINE; evidence low). Fifth, sleep physicians should conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than follow-up without sleep testing, for patients fitted with oral appliances (GUIDELINE; evidence low). Sixth, sleep physicians and qualified dentists should instruct adult patients treated with oral appliances for OSA to return for periodic office visits, as opposed to no follow-up, with a qualified dentist and a sleep physician (GUIDELINE; evidence low). Every one of the six was judged to have benefits that clearly outweigh harms.

The numbers behind them are pooled from randomized trials in adults. Across 34 RCTs with 1,301 patients, oral appliances reduced AHI by a mean of 13.60 events per hour (95% CI 11.95 to 15.25); custom appliances by 13.89 across 33 RCTs, non-custom appliances by 6.28 across two small RCTs with wide confidence intervals; custom titratable appliances by 13.80 across 27 RCTs and custom non-titratable by 12.51 across six. Against CPAP, in 15 head-to-head RCTs (491 patients on an appliance, 481 on CPAP), the mean AHI reduction was 6.24 events per hour greater with CPAP, and CPAP also did better on minimum oxygen saturation (3.11 percentage points) and arousal index (3.57 per hour). The guideline's conclusion is direct: CPAP remains the first-line or primary therapy for adult patients with severe OSA, and oral appliance therapy should be reserved for severe OSA patients who did not benefit from or were intolerant of CPAP. Side effects are mostly dental (sore teeth, gum problems, sore jaw muscles, excessive salivation, difficulty chewing in the morning, dry mouth, change in occlusion); one two-year comparison found overbite and overjet decreased 1.2 and 1.5 mm with an appliance. Discontinuation because of side effects was less likely with an appliance than with CPAP (odds 0.54 to 1 across eight RCTs).

Two definitions matter for a dental office. An oral appliance is a device intended to protrude and stabilize the mandible to maintain a patent airway during sleep; a custom appliance is fabricated from digital or physical impressions and models of the patient's own oral structures, is not a prefabricated item that is trimmed, bent or relined, and engages both arches; titratable appliances have a mechanism that allows varying amounts of mandibular protrusion. And a qualified dentist should hold a valid state license and proof of liability coverage and have at least one of: certification in dental sleep medicine by a non-profit organization, designation as the dental director of a dental sleep medicine facility accredited by a non-profit organization, or a minimum of 25 hours of recognized continuing education in dental sleep medicine (ADA CERP or AGD PACE) from a dental sleep medicine non-profit or an accredited dental school in the last two years.

Who it applies to#

Adults with primary snoring who request treatment, and adults with OSA who cannot tolerate CPAP or prefer something else, once a sleep physician, defined as board-certified or board-eligible in sleep medicine, has made the diagnosis. The guideline is written for two clinicians at once, and it assigns the roles: the physician diagnoses, prescribes and tests; the dentist chooses and fits a custom titratable appliance, watches the teeth and the bite, and shares the follow-up.

It does not reach children (pediatric studies were excluded), central or complex sleep apnea, or tongue retaining devices, for which evidence was insufficient. It gives no guidance by OSA severity because the trials mostly did not. And it is not a mandate: the guideline says its recommendations define principles of practice that should meet the needs of most patients in most situations, should not be considered inclusive of all proper methods of care, and leave the ultimate judgment to the clinician, sleep physician and dentist, in light of the individual patient.

What changed#

Versus 2006, the change is the volume of evidence and the specificity of the roles. The 2006 parameters already supported oral appliances for primary snoring at STANDARD strength; the 2015 guideline adds the OSA recommendation at STANDARD, names custom titratable devices as the dentist's default, and makes dental oversight, physician sleep testing and periodic dual follow-up explicit recommendations. It also imported the AADSM's 2013 definition of an effective appliance and the qualified-dentist criteria.

Since 2015 the two issuers have moved at different speeds. The AASM's clinical practice guidelines index still lists Oral Appliance Therapy for the Treatment of OSA and Snoring in Adults under sleep-related breathing disorders. The AADSM has updated its definition of an effective oral appliance (2019), published its own Dental Sleep Medicine Standards for screening, treatment and management with oral appliance therapy as an update in 2025, moved the 2015 guideline to its guidelines archive, and announced for 2026 a GRADE-based process for new clinical practice guidelines that are, at the time of reading, still in development. The 2015 document remains the joint physician-dentist guideline and the one the published evidence tables belong to; the AADSM's 2025 standards are the current dental-side practice document. Quote the one you are relying on.

Where the source is#

The link under the title is the DOI for the Journal of Clinical Sleep Medicine article, 2015;11(7):773-827, which resolves to the journal's site; the full text is free on PubMed Central (PMC4481062) as a page and a PDF, and the AADSM hosts the 55-page Journal of Dental Sleep Medicine co-publication (2015;2(3):71-125) in its guidelines archive. The recommendation statements, the strength table, the pooled numbers, the qualified-dentist criteria and the side-effect data above were read from the PMC full text and the JDSM PDF; the AASM and AADSM listing status was read from their guideline pages on September 13, 2026. The article is copyright 2015 American Academy of Sleep Medicine; the journal's own page requires JavaScript and refused automated tools in this session.