The Dentist’s Role in Treatment

of Sleep Disordered Breathing

Robbie Schaack DDS

Pathophysiology

Diagnosis

Treatment Options

Major Types of Oral Appliances

The Dentist's Treatment Protocol

Obstructive Sleep Apnea

complete collapse/blockage of upper respiratory tract

Central Sleep Apnea

brain temporarily stops sending signals to the muscles that

control breathing

Mixed/Complex Sleep Apnea

become central apneas when treated with CPAP or oral

appliance

What is Sleep Apnea?(click)

(1) Kyung SH, Park YC, Pae EK. Obstructive sleep apnea patients with the oral appliance experience pharyngeal

size and shape changes in three dimensions. Angle Orthod. Jan 2005;75(1):15-22.

Hypertension

CHF

Acute MI

Coronary Artery Disease

Stroke

Sudden death

Diabetes

Obesity

Bruxism (14)

Memory & Cognitive Problems

Motor vehicle accidents

and many more!

(3,4,5,6)

cause of sound -

symptom, not a problem in

and of itself

should be taken seriously,

sign of a very serious

underlying problem

Partners lose 1.5 hrs of

sleep/night

1 in 5 adults have mild OSA

1 in 15 adults have moderate to severe OSA

Prevalence (43 million) equal to that of asthma (20

million) and diabetes (23 million) combined

80% of those with OSA remain undiagnosed!

— Male gender

— Obesity (BMI >30)

— Diagnosis of hypertension

— Excessive use of alcohol or sedatives

— Upper airway or facial abnormalities

— Smoking

— Family history of OSA

— Large neck circumference (>17” men; >16” women)

— Endocrine and metabolic disorders

(8)

deviated septum

enlarged nasal turbinates

thickened soft palate

large uvula

large tonsils

retrognathic mandible

disproportionate size of

structures in relation to

pharyngeal opening

Screening

• Patient health questionnaire

• Epworth Sleepiness Scale

Diagnosis

• Polysomnogram

• Portable monitoring/home studies (in conjunction)

Overnight sleep study

conducted at certified sleep

center or hospital

Monitors many body functions

including brain (EEG), eye

movements (EOG), muscle

activity or skeletal muscle

activation (EMG) and heart

rhythm (ECG), respiratory

airflow, pulse oximetry

Total number of apneas & hypopneas per hour of sleep

AHI = 0–5 Normal range

AHI = 5–15 Mild sleep apnea

AHI = 15–30 Moderate sleep apnea

AHI > 30 Severe sleep apnea

Apnea: complete cessation of breathing

Hypopnea: partial obstruction of breathing

*for at least 10 seconds (20-40 seconds on average)

Behavioral therapies

• mild to severe OSA, in conjunction with other therapies

Oral appliances

• first line of therapy in mild to moderate OSA and second line of treatment in patients with

severe OSA who do not tolerate CPAP

Continous positive airway pressure (CPAP)

• first line of therapy in mild, moderate, and severe OSA

Upper airway surgery (nasal surgery, uvulopalatopharyngoplasty)

• noncompliant, or after failure of nonsurgical therapies

weight loss

avoiding alcohol and tobacco

sleeping on your side

oropharyngeal exercises (10)

(11) Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. Didgeridoo playing as

alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. BMJ

2005;332:266–270.

“gold standard”

effective vs mild, moderate, and severe OSA

Compliance ~50%

Side Effects:

• nose irritation

• nasal congestion

• headaches

• stomach bloating and discomfort

• sore or dry mouth

• runny nose

• sinusitis

• nosebleeds

• irritation and sores over the bridge of the nose

• discomfort in chest muscles.

(12) Okuno K, et al. The effect of oral appliances that advanced the mandible forward and limited mouth opening in patients with obstructive sleep apnea: a systematic review and meta

Thornton Adjustable Positioner (TAP)

Adjustable PM Positioner

SomnoDent

ResMed Narval

Silent Night

Tongue Retaining Device

and many more!

heat sensitive acrylic

two piece adjustable appliance that hooks

together

only appliance that can be adjusted easily by

the patient or practitioner while in the mouth

allows the patient to fine-tune their treatment

position at home to achieve desired results

suitable for heavy bruxers

may take longer to adapt with assembly

protruding between the lips at the front of the

tongue.

heat sensitive acrylic

Expansion screws are

located on the right and left

buccal areas to allow space

for the tongue and anterior-

posterior positioning of the

mandible.

permits some (4mm) lateral

and protrusive movement

patented fin-coupling component,

which allows normal mouth opening

and closing.

a part can be added to make the

device adjustable.

Permits normal mouth opening

Allows speech and drinking

Provides full lip-seal

covered by a two year

manufacturer''s warranty.

varying sizes of straps/connectors

Patented physiological articulation: most MRDs hold the lower

jaw in a forward position. With Narval CC, the force of retention

works along the occlusal plane to retain the mandible in a

protruded position rather than pushing it, thus relieving stress

on the TMJ. The elevated articulation point allows the

connectors to be parallel with the patient's jawline, which

complements the physiological articulation

minimize the problems of patient discomfort by decreasing bulk,

eliminating invasion of tongue space and enabling freedom of

mandibular movement

Lateral flexibility eliminates “locked-in” sensation and offers

freedom to talk discernibly or drink a glass of water while

wearing it

CADCAM Technology offers more customization, accuracy,

and a greater mechanical strength

ResMed guarantees that if your Narval™ CC breaks under

normal use within 3 years, we will repair or replace it free of

charge. (digital images of models are stored)

initial treatment of snoring

mild OSA when other

treatments are ineffective or

not desired.

soft or hard frame material is

available

flexible polyvinyl material adapted to the

general contours of the teeth and dental

arches

does not depend on teeth for retention.

Rather, the tongue is held forward by the

negative pressure created in the vacuum

bulb on the front of the appliance

Since the mandible is not rigidly or firmly

held by the appliance, freedom of

movement is possible during use.

Option for patients with edentulism, perio

disease, or TMJ dysfunction

Studies reveal prefab devices to be: (13)

less comfortable

less effective vs snoring and reducing AHI

Failure rate 69%

success rate with the custom-made oral

appliance 100% higher than with pre-

fabricated devices

Side effects such as TMJ disorder,

worsened sleep apnea, bruxism and shifting

of the tooth position may outweigh the

benefits

(13Vanderveken, O. M., A. Devolder, et al. (2008). "Comparison of a

custom-made and a thermoplastic oral appliance for the treatment

of mild sleep apnea." Am J Respir Crit Care Med 178(2): 197-202.

1st Line Treatment

Mild to moderate OSA (AHI 5–30) for patients who:

- Prefer MRDs over CPAP

- Are inappropriate candidates for or fail CPAP

- Fail behavioral measures treatment

Primary snoring for patients who do not respond or are not appropriate candidates for behavioral

measures treatment

2nd Line Treatment

Severe OSAS (AHI>30) in case of lack of compliance with CPAP

*Patients who travel

Short teeth

Insufficient undercuts to retain the device

Insufficient teeth per arch and quadrant (eg, ~4 minimum per quadrant)

TMJ pain - assess

TMJ osteoarthritis

Periodontal disease

pending extractions or prosthodontic treatments

intraoral ulcers

NOTE: Mandibular repositioners have been successfully used in edentulous patients over dentures in certain cases where the

dentures have had adequate retention. Mandibular repositioners have also been successfully used in patients with

compromised periodontal status or TMJ function. In these cases, however, the clinician needs to be especially careful in design

and follow up.

Possible Side Effects

More common/Minor:

• dry mouth

• excessive salivation

• Tooth or jaw discomfort

• temporary change in the bite (when removed in the morning)

Less Common: (primarily with non custom made/OTC oral appliances)

• TMJ pain

• permanent bite changes (teeth move)

Although it may take up to a week to get used to wearing these at night, most patients experience relief the first night.

1. Medical assessment must be made by a physician before oral

appliance therapy (OAT) is initiated. (1-4)

A. the dentist refers the patient to the physician for a complete

medical evaluation and diagnosis to determine the absence or

presence, and severity, of sleep-disordered breathing (SDB)

Following diagnosis, the dentist may provide OAT as appropriate

with a prescription provided by a physician that has had a face-to-

face evaluation. The treatment of primary snoring does not require a

physician’s prescription; or

B. The physician refers the patient directly to the dentist for OAT

as appropriate.

2. The diagnostic sleep study is interpreted by

a medical sleep specialist, who provides a copy

of the interpretation to the dentist for review.

The reviewed copy of the interpretation shall be

maintained in the patient record.

3. The dentist performs a complete clinical

examination

• determine current health and prognosis of oral tissues that

might be affected by OAT.

• recent radiographic survey

• dentist recommends the choice of appliance (1, 2, 5, 6, 7, 8)

• disclose and discuss relevant fees with the patient

• explains the rationale for OAT to the patient

• record all appropriate documentation

4. The dentist communicates the proposed

plan for OAT to the patient’s physician, and

appropriate health care providers, and the

dentist regularly provides the patient’s physician

and other health care providers with progress

and follow-up notes, as well as other pertinent

information. (1,2)

5. The dentist shall provide the patient with a

copy of the consent form prior to appliance

delivery. (9)

6. Delivery: dentist meets with the patient for an

initial calibration and adjustment.

After this initial calibration, the dentist may obtain

objective data (portable sleep monitoring at

home) during an initial trial period to verify that the

oral appliance effectively improves upper airway

patency during sleep by enlarging the upper airway

and/or decreasing upper airway collapsibility.

If necessary, the dentist makes further adjustments

to the device during a final calibration to ensure that

optimal fit and positioning have been attained. (10-13)

7. Following the final calibration, the dentist refers

the patient back to the physician for a medical

evaluation and assessment of OAT outcomes.

To ensure satisfactory therapeutic benefit, an

order may be written for the patient to undergo an

overnight sleep test with the oral appliance in

place.

If the treatment is sub-therapeutic, the physician and

dentist collaborate to discuss: the possibility of

further calibration, validated alternative treatments,

or combining positive airway pressure (PAP) therapy

with OAT. (11-13)

8. Patients diagnosed with primary snoring may

be treated without objective, follow-up data;

however, the patients should be reevaluated at

least annually.

9. Follow-up every 6 months for the first year and at least annually

thereafter.

• verify appliance efficacy; ensure resolution of symptoms such as

snoring and daytime sleepiness

• occlusion stability

• check the structural integrity of the device

• inquire about patient comfort and adherence to therapy

• screen for possible side effects

• If the patient’s annual assessment reveals symptoms of worsening

OSA or the potential need for additional adjustments to the device,

then the dentist shall communicate this information to the patient’s

physician. (1, 2, 5, 14-16)

10. Knowledge of various appliances is

strongly recommended, as no single appliance

is effective for treatment of all patients.

Dentists who treat SDB are encouraged and

have a responsibility to routinely pursue

additional education in the field and to comply

with all applicable state and federal regulations.(6, 7, 8, 17, 18)

Dentist —> Sleep Physician —> Sleep Study —> Rx

—> Dentist —> Oral Appliance —> Follow-up

Not complicating!

Billed as medical code to medical insurance instead of dental.

Custom dental appliances for sleep apnea are covered by most medical

insurance companies and Medicare.

Total fees collected from patient/insurance per case: $2000-3000

• initial evaluation and consultation

• impressions

• laboratory fabrication

• delivery

• follow-up

Literature References:(1) Kyung SH, Park YC, Pae EK. Obstructive sleep apnea patients with the oral appliance experience pharyngeal size and shape changes in three

dimensions. Angle Orthod.

Jan 2005;75(1):15-22.

(2) 2. Young et al. J Am Med Assoc 2004

(3) Kuniyoshi et al. (July 2008). "Day–Night Variation of Acute Myocardial Infarction in Obstructive Sleep Apnea". Journal of the American College of

Cardiology 52 (5): 343–346. doi:10.1016/j.jacc.2008.04.027.

(4) Claudio L. Bassetti, Milena Milanova, Matthias Gugger (6 March 2006). "Sleep-Disordered Breathing and Acute Ischemic Stroke: Diagnosis, Risk

Factors, Treatment, Evolution, and Long-Term Clinical Outcome". Stroke 37: 967–972. doi:10.1161/01.STR.0000208215.49243.c3.

(5) Horstmann et al. Sleepiness-related accidents in sleep apnea patients. Sleep 2000

(6) Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An

Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 4, Functional and Economic Impact of Sleep Loss and Sleep-

Related Disorders. Available from: http://www.ncbi.nlm.nih.gov/books/NBK19958/

(7) Young et al. The occurrence of sleep-disordered breathing among middle-aged adults. New Engl J Med 1993 Apr 29;328(17):1230-5.

(8) http://www.polarmed.no/us/assets/documents/product/narval_cc/1015550_dental-practitioner-guide_us_eng.pdf

(9) "Obstructive Sleep Apnea Syndrome (780.53-0)". The International Classification of Sleep Disorders. Westchester, Illinois: American Academy of Sleep

Medicine. 2001. pp. 52–8. Retrieved 2010-09-11.

(10) Kátia C. Guimarães, Luciano F. Drager, Pedro R. Genta, Bianca F. Marcondes, and Geraldo Lorenzi-Filho "Effects of Oropharyngeal Exercises on

Patients with Moderate Obstructive Sleep Apnea Syndrome", American Journal of Respiratory and Critical Care Medicine, Vol. 179, No. 10 (2009), pp. 962-

966.

(11) Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome:

randomised controlled trial. BMJ 2005;332:266–270.

(12) Okuno K, et al. The effect of oral appliances that advanced the mandible forward and limited mouth opening in patients with obstructive sleep apnea: a

systematic review and meta-analysis of randomised controlled trials.. J Oral Rehabil. 2014 Jul;41(7):542-54. doi: 10.1111/joor.12162. Epub 2014 Mar 21.

(13) Vanderveken, O. M., A. Devolder, et al. (2008). "Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep

apnea." Am J Respir Crit Care Med 178(2): 197-202.

(14) Bader G, Lavigne G. Sleep Bruxism; An overview of an oromandibular sleep movement disorder. Sleep Med Rev 2000;4:27-‐43 • Camparis CM, et al;

Sleep Bruxism and TMD: Clinical and polysomnographic evaluaEon. Arch Oral Biol 2006;51:721-‐728

AADSM Treatment Protocol Reference List:

1. Kushida CA, Morgenthaler TI, Littner MR, et al. American Academy of Sleep Medicine Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances:

An Update for 2005. Sleep. 2006; 29(2):240-3.

2. Epstein LJ, Kristo D, Strollo PJ Jr., et al. Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical Guidelines for the Evaluation, Management and

Long-term Care of Obstructive Sleep Apnea in Adults. J Clin Sleep Med. 2009; 5(3):263-76.

3. Comparative Effectiveness of Diagnosis and Treatment of Obstructive Sleep Apnea in Adults Tufts Evidence-based Practice Ctr., July 2011. AHRQ publication No. 11-EHCO52 80-99 and 2-

5.

4. Chan ASL, Lee RWW, Cistulli P. Dental Appliance Treatment for Obstructive Sleep Apnea. Chest. 2007; 132:693-699.

5. Marklund M, Stenhuld H, Franklin KA. Mandibular Advancement Device is in 630 Men and Women with Obstructive Sleep Apnea and Snoring. Tolerability and Predictors of Treatment

Success. Chest. 2004; 125:1270-1278.

6. Lawton HM, Battagel JM, Kotecha B. A Comparison of the Twin Block and Herbst Mandibular Advancement Splints in the Treatment of Patients with Obstructive Sleep Apnea: A Prospective

Study. Eur J Orthod. 2005; 27:82-97.

7. Gagnadoux F, Fleury B , Vielle B et al. Titrated Mandibular Advancement Versus Positive Airway Pressure for Sleep Apnoea. Eur Respir J. 2009; 34:914-920.

8. Lam B, Sam K, Mok W et al. Randomized Study of Three Non-surgical Treatments in Mild to Moderate Obstructive Sleep Apnea. Thorax. 2007; 62:354-359.

9. AMA Physician Resources: http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-hysicianrelationship-topics/informed-consent.page.

10. Collop NA, Anderson WM, Boehlecke B et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical Guidelines for the Use of Unattended Portable Monitors

in the Diagnosis of Obstructive Sleep Apnea in Adult Patients. Portable Monitoring Task Force of the AASM. J Clin Sleep Med. 2007; 3(7):737-747.

11. Campbell AJ, Reynolds G, Tengrove H, et al. Mandibular Advancement Splint Titration in Obstructive Sleep Apnea. Sleep Breath. 2009: 13:157-162.

12. Almeida FR, Parker JA, Hodges JS et al. Effect of a Titration Polysomnogram on Treatment Success with a Mandibular Repositioning Appliance. J Clin Sleep Med. 2009; 5(3):198-204.

13. Holley AB, Letteri CJ, Shah A. Efficacy of an Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome.

Chest (online). 2011; 140(6):1511-6.

14. Almeida FR, Lowe A, Sung J et al. Long-term Sequellae I of Oral Appliance Therapy in Obstructive Sleep Apnea Patients: Part 1. Cephalometric Analysis. AJODA. 2006; 195-204.

15. Almeida FR, Lowe A,Otsuka R et al. Long-term Sequellae I of Oral Appliance Therapy in Obstructive Sleep Apnea Patients: Part 2. Study-model Analysis. AJODO. 2006; 205-213.

16. Ghazal A, Sorichter S, Jonas I et al. A Randomized Prospective Long-term Study of Two Oral Appliances for Sleep Apnoea Treatment. J Sleep Res. 2009; 18:321-328.

17. Petri N, Svanholt P, Solow B et al. Mandibular Advancement Appliance for Obstructive Sleep Apnea: Results of a Randomized Placebo-controlled Trial Using Parallel Group Design. J Sleep

Res. 2008; 17:211-229.

18. Vandervecken OM, Devolder A, Marklund M et al. Comparison of a Custom-made and a Thermoplastic Oral Appliance for the Treatment of Mild Obstructive Sleep Apnea. Am J Respir Crit

Care Med. 2008; 178:187-202.

Robbie

Schaack

Doctor of Dental Surgery

www.linkedin.com/in/robbieschaack