The Oral Sleep Appliance Patient Treatment Journey
A Diplomate walks those less familiar with the process step-by-step through oral appliance therapy.
Oral appliance therapy (OAT) provides an alternative treatment option for those with upper airway resistance syndrome and obstructive sleep apnea (OSA). The patient’s treatment journey begins with the referring physician, who will have administered a sleep test, and, either due to the patient’s noncompliance with CPAP or the patient’s preference, sends the patient to a dental sleep medicine practitioner for an oral appliance.
The dentist’s job in properly treating a sleep apnea patient with an oral appliance involves a set of processes that are undertaken with the goal of identifying the patient’s specific needs, the condition of their mouth and throat, and their systemic health. Once the patient has been thoroughly evaluated, the appropriate device can be selected and fitted, allowing the patient to begin their treatment and follow-up.
Outlined here is the standard process used in my office to guide the patient from initial consultation to successful treatment. While each dentist runs their office slightly differently, this patient journey is usually followed with the goal of selecting the appropriate appliance and treating the patient’s OSA long-term.
The Initial Appointment
In this appointment, the sleep test is reviewed and interpreted to confirm the patient’s suitability for oral appliance therapy. Disqualifiers for OAT include those with a physical condition that would make it extremely uncomfortable for the patient to wear an appliance, such as acute temporomandibular joint distress, or those with gum or dental issues that would prohibit the device’s adherence to the teeth or dental implants.
In addition to administrative and procedural paperwork, I also have my patients fill out a CPAP intolerance form. Many dental sleep medicine practitioners use similar forms, which generally serve to gather detailed information about the patient’s reason for intolerance to CPAP and their decision to turn to an oral appliance for sleep apnea treatment. On the form in my office, patients may check boxes that include an inability to get the mask to fit properly, claustrophobia, and disturbed/interrupted sleep caused by presence of the device.
If the patient is ready to move forward with treatment during the initial appointment, a digital scan or standard impression is administered by a sleep assistant. Alternatively, these records may be taken during a secondary appointment if the patient indicates during the initial consultation that s/he would like to think about the options, don’t have the time to have records taken during the initial appointment, or wants to discuss their options with a partner. Additionally, records may be taken at a secondary appointment if the patient has yet to be diagnosed with OSA or has not received treatment for a significant length of time and needs to be retested.
The purpose of taking scans/impressions is two-fold: to thoroughly scan the teeth in order to provide a full picture of the mouth, soft tissue, and throat, and to gather information that will help properly fit the appliance. The decision to use either a digital scan or standard impression will largely depend on the patient as well as the dental sleep medicine practitioner’s preference, though there are some qualifying conditions that may dictate one method over another. If the patient is prone to gagging, for example, a digital scan will reduce discomfort and be easier to complete; if the patient has a small mouth, impressions are recommended, as the scanner on many existing cameras is too large for small mouths.
After impressions are gathered, a bite record is taken. In my office, the preferred method of gathering a bite is the George Gauge. George Gauge bites are taken with a 2 mm, 3 mm, or 5 mm fork depending on how much the bite should be opened.
Selecting an Oral Appliance
With records taken, an informed decision can be made about which appliance will most appropriately treat the patient. This decision is based on several factors, including the patient’s body mass index (BMI), apnea-hypopnea index (AHI), range of motion, gender, and medical history.
In most cases, appliance selection is straightforward. Some examples of special appliance selection cases include an edentulous patient, who would benefit from a tongue retaining device, or a patient with material sensitivities, who may benefit from a device with no metal, or patients who are pilots or commercial drivers, who would benefit from an appliance with an objective compliance tracking chip.
Once the decision about the appropriate appliance is made, the information is then sent to the lab, where the appliance is developed.
Fitting and Delivery
Assuming the records appointment was accurate, the fitting appointment should go fairly smoothly. Once the model is returned from the lab, bite position is checked against the position provided to ensure they are a match. If not matched, generally the appliance has to be remade to ensure accuracy. My office also checks that the appliance has the maximum amount of retention the patient can tolerate. While a good amount of generalized retention is important, also important is the absence of localized pressure areas. If pressure spots are not relieved, orthodontic movement can occur, which all good dental sleep medicine practitioners try to avoid. Adjustments are made accordingly during this appointment to maximize patient comfort while maintaining good clinical retention.
At delivery, most offices also provide each patient with information about home care for the device and morning jaw exercises, which help maximize comfort and may reduce the chance of bite change development over time. A few examples of jaw exercises my office encourages patients to do are:
- The Thinker Position, in which the patient rests their elbow on a table or countertop and places their chin in their palm, letting the weight of their head rest on their hand, and then opens and closes their mouth. The patient alternates this movement with a side-to-side movement of the jaw.
- The AM Aligner, in which the patient takes the AM aligner provided to them at delivery and holds one end in their hand, biting slowly until the jaw feels normal.
- The Chewing Gum, in which the patient takes a pack of sugarless, soft gum with them in the shower. The hot water of the shower helps relax the muscles, and the chewing helps return the jaw to a normal position.
During delivery, my office also shows the patient how to adjust their appliance and provides them with an oral appliance calibration chart, which allows the patient to track how many turns to the right, left, and center are issued each night. In the interest of total health, my office also educates the patient about good sleep hygiene such as keeping consistent bed and wake times, maintaining a cool sleep environment, and reducing caffeine consumption.
Finally, regular check-in is conducted to ensure the patient is comfortable and receiving appropriate treatment. In my office, beginning with their one-week follow-up, at each appointment the patient completes the Epworth Sleepiness Scale to measure daytime sleepiness, and the appliance is adjusted as needed for patient comfort. Our follow-up timeline is as follows: phone check-in: 2-3 days post-delivery; 1-week follow-up; 1-month follow-up, 3-month follow-up, 6-month follow-up (usually only for severe cases), and annual follow-up.
All improvement reported is forwarded to the patient’s referring physician. At this point in the patient’s treatment journey, all that is left is continual follow-up to ensure treatment is successful, that the appliance is working as it should, and that the patient is enjoying restored sleep.
Jeff Rodgers, DMD, DABDSM, DASBA, has been in private practice for over 20 years, specializing in both general dentistry (primarily restorative, implant, and cosmetic dentistry) and dental sleep medicine. A Diplomate of both the American Board of Dental Sleep Medicine (ABDSM) and the American Sleep and Breathing Academy (ASBA), Rodgers is a board-certified expert in sleep, treating patients who suffer from sleep breathing disorders at his practice in Dunwoody, Ga. He provides seminars locally and nationally throughout the year on sleep issues and oral appliance therapy as a treatment option to raise awareness for the common, but often undiagnosed, condition of sleep apnea. Rodgers earned a BS in biology from Lee University in Cleveland, Tenn, and is a 1995 graduate of the University of Alabama School of Dentistry.
from Sleep Review http://www.sleepreviewmag.com/2019/01/oral-sleep-appliance-patient-treatment/