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Guidelines for treating patients with oral appliances.

Insurance Company Information:

Dentists who use oral orthotics to treat patients with obstructive sleep apnea (OSA) have a moral obligation to treat only those patients who have a dentition healthy enough to withstand the forces created by use of the designated orthotic device.

 

What is the dentist’s role?

The treating dentist should have a good understanding of the signs and symptoms of OSA. He / She should understand a polysomnography report and be aware of any parasomnias which may impact resolution of symptoms with an oral orthotic. The dentist should not take it upon himself to diagnose OSA or treat patients without medical supervision. A dentist who refers patients for polysomnography should ensure that each patient has a primary care physician and that the primary care physician also gets a copy of the polysomnography report.

 

Evaluation of the patient by the dentist:

Radiographs necessary for the diagnosis of dental disease and proper evaluation of the patient’s periodontal health must be obtained, either from the patient’s dentist or taken by the sleep dentist.

Evaluation should include, but not limited to:

–Medications the patient is taking
–Review of Medical History
–History of the symptoms of OSA and previous treatments
–Dental Examination:

* Decayed, missing and filled teeth (With attention to ill-fitting restorations)
* Occlusal classification
* Open interdental contacts
* Overbite, overjet, mobility status
* Maximum interincisal opening
* Range of normal jaw protrusion
* Occlusal wear patterns, evidence of bruxism, clenching

TMJ evaluation:

* Muscle pain
* Joint noises, pain

Soft tissue Evaluation:

* Tongue size, topography and lingual extension
* Neck circumference
* Throat classification (Mallampati)
* Mucosal abnormalities
* Periodontal probing abnormalities, furcation involvement, etc.

Bony topography:

* Shape, width and depth of hard palate
* Jaw size abnormalities both front to back and side to side
* Mandibular plane angle

• History of oral appliance use Choice of Orthotic:
Patients who are to receive an appliance that holds the mandible forward in relationship to the maxilla (mandibular repositioner) should meet certain criteria to minimize negative side-effects:

–The patient must have 6 or more healthy teeth in each arch.
–At least one posterior tooth per quadrant
–The teeth should be non-mobile
–Major dental care should be completed prior to orthotic fabrication
–TMJ disease should not be acute

If the patient’s dental health does not meet the requirements for a mandibular repositioner, then a tongue retaining device may be the orthotic of choice.

Decision as to which FDA accepted oral orthotic will be used is based on:

• Patient’s medical history
E.g. If a patient has asthma and requires the use on an inhaler, the oral orthotic chosen should allow use of necessary medical devices without the need to remove the orthotic.

• History of bruxism or clenching:
I.e. will the abnormal forces created by these parafunctions be poorly withstood by a specific appliance?

• Oral anatomy:
If the patient has a large torus palatini, or very narrow arches, an orthotic with minimal intra-arch presence should be the first consideration.

Appointments Required:
Evaluation should be independent of orthotic fabrication. The patient should have a clear understanding of the various options of treatments available for OSA, be aware of the possible side-effects that oral orthotics may cause and know that the American Academy of Sleep Medicine considers nCPAP the treatment of choice in all instances of obstructive sleep apnea. The patient should be reappointed for appliance fabrication to allow proper ‘comprehension’ of all the information given at the initial visit. To not inform patients of possible side-effects or to rush a patient into one mode of therapy is inappropriate medical care.

Temporary (not FDA accepted for the treatment of OSA) oral orthotics may be used to allow immediate care of serious OSA.

All appliances accepted by the FDA for the treatment of OSA require that the dentist prepare casts of the patients dentition and, often, provide a “bite registration” that will tell the dental laboratory how to orient the upper and lower casts to allow fabrication of a well fitting orthotic. To the best of my knowledge, only licensed laboratories are allowed to fabricate FDA accepted oral appliances.

Placement of the orthotic can require from 20 -60 minutes of time with the dentist. Some dentist’s allow ancillary staff to do many of the procedures involved in appliance fabrication and placement. If so, the staff should be exceptionally well trained and the dentist should provide constant oversight of care and thoroughly examine all work done by the ancillary provider prior to the completion of the patient’s appointment.

Follow-up appointments are required frequently in the first few months after placement of the orthotic. This allows for adjustment of the appliance to improve fit, patient comfort and compliance.

The Academy of Dental Sleep Medicine recommends that patients be seen every 6 months for 2 years after placement of an orthotic and, after that time, annually for as long as the patient wears the orthotic.

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/

© 2005 - 2008 B. Gail Demko. All rights reserved

This website reflects the personal opinions of the author and does not endorse any oral appliance, professional provider, medical insurance company or dental laboratory. Making decisions about your health and medical treatment must be made in conjuction with you own medical provider. The contents of this website are not to be construed as exhaustive or complete. Any omissions or oversights is unintentional. This site does not accept advertising.