American Academy Sleep Medicine Practice Guidelines
When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, the American Academy Sleep Medicine suggests that a qualified dentist use a custom, titratable appliance over non-custom oral devices.
Furthermore, the American Academy Sleep Medicine recommends that sleep physicians consider prescription of oral appliances, rather than no treatment, for adults with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternative therapy.
Dentist, for Sleep Apnea?
- Millions of undiagnosed patients
- Most people see their dentist 2 a year
- Dental cleaning 1 hour, time to talk.
- MDs have shorter appointment time
- Screening and referral
- Provide and monitor oral appliance therapy as part of treatment team with physician
- Monitor and treat potential side effects of oral appliance therapy
- Follow up
Obstructive sleep apnea is characterized by the cessation of airflow with persistence of ventilation effort, caused by collapse of soft tissue structures in the oropharynx or hypopharynx.
Possible Sites of Obstruction
- Macroglossia (enlarged tongue)
- Acid Reflux
- Tongue Scallopping
- Narrow, high-arching hard palate
- Bicuspid tooth extraction
- Red, inflamed soft tissue
- Deviated Septum
- Enlarged Turbinates
- Enlarged adenoids
- Enlarged Tonsils
- Enlarged uvula or soft palate
- Enlarged base of the tongue
- Tongue base falling into the pharyngeal airway
- Submuccosal fat or redundant mucosa
- Larynx (voice box):
- Laryngopharyngeal reflux changes with severe posterior commissures swelling
Dr. Nugent can look in your mouth and use his CBCT 3D x-ray to evaluate for the above obstructions. The only obstruction that Dr. Nugent cannot evaluate is your Larynx.
Mandibular Advancement Device:
- Been in use since 1934
- Advances the base of the tongue to open airway
- Advances and raises the hyoid bone, tightening the pharyngeal musculature which reduces airway collapsibility
- Stretch the masseter muscles which stimulates the genioglossus muscle
- Increase the size of the airway in a lateral dimension
- Improves the patency (the condition of being open, expanded, or unobstructed) of the upper airway during sleep by increasing the dimensions and reducing its collapsibility
- Oral appliance therapy should be considered as a viable treatment alternative to continuous positive airway pressure (CPAP) in patients with mild to moderate obstructive sleep apnea
Oral Appliance Costs Considerations
Over the counter boil and bite mouthpieces are a cheaper and easier snoring solution. However, you get what you pay for. The price of TMJ treatment or much worse, the cost of treatment of untreated obstructive sleep apnea health consequences is devastating. A professional sleep apnea oral appliance is usually covered by your medical insurance. Medical insurance will only cover the oral appliance if delivered by a dentist who is trained in dental sleep medicine and whose office is experienced in documenting medical necessity and medical insurance billing.
Choosing a Sleep-Disorders Dentist
A qualified sleep-disorders dentist must:
- Work closely with physicians and other health care professionals
- Have a team approach with other healthcare professionals
- Have appropriate knowledge of sleep medicine as well as jaw joint function
- Have adequate training/education in oral appliance therapy.
- Have an in-depth knowledge of oral appliance research
- Be able to treat effectively with different appliance types
- Have an established follow-up system to ensure healthy results long-term
- Have experience with medical insurance reimbursement and documenting medical necessity
- Have an established follow-up system to ensure healthy results long-term
- Provide oral and written informed consent, explaining all possible contraindications and risks of treatment
- Understand that oral appliance therapy is not always the most advantageous treatment and should suggest alternate therapeutic modalities (CPAP, surgery) when appropriate
Sleep related breathing disorders (SRBD) are disorders characterized by disruptions in normal breathing patterns. SRBDs are potentially serious medical conditions caused by anatomical airway collapse and altered respiratory control mechanisms. Common SRBDs include snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA). OSA has been associated with metabolic, cardiovascular, respiratory, dental and other diseases. In children, undiagnosed and/or untreated OSA can be associated with cardiovascular problems, impaired growth as well as learning and behavioral problems.
Dentists can and do play an essential role in the multidisciplinary care of patients with certain sleep related breathing disorders and are well positioned to identify patients at greater risk of SRBD.
SRBD can be caused by a number of multifactorial medical issues and are therefore best treated through a collaborative model. Working in conjunction with our colleagues in medicine, dentists have various methods of mitigating these disorders. In children, the dentist’s recognition of suboptimal early craniofacial growth and development or other risk factors may lead to medical referral or orthodontic/orthopedic intervention to treat and/or prevent SRBD. Various surgical modalities exist to treat SRBD. Oral appliances, specifically custom-made, titratable devices can improve SRBD in adult patients compared to no therapy or placebo devices. Oral appliance therapy (OAT) can improve OSA in adult patients, especially those who are intolerant of continuous positive airway pressure (CPAP). Dentists are the only health care provider with the knowledge and expertise to provide OAT.
The dentist’s role in the treatment of SRBDs includes the following:
- Dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas and an evaluation for risk factors such as obesity, retrognathia, or hypertension. These patients should be referred, as needed, to the appropriate physicians for proper diagnosis.
- In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.
- Oral appliance therapy is an appropriate treatment for mild and moderate sleep apnea, and for severe sleep apnea when a CPAP is not tolerated by the patient.
- When oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient with obstructive sleep apnea, a dentist should evaluate the patient for the appropriateness of fabricating a suitable oral appliance. If deemed appropriate, a dentist should fabricate an oral appliance.
- Dentists should obtain appropriate patient consent for treatment that reviews the treatment plan and any potential side effects of using OAT and expected appliance longevity.
- Dentists treating SRBD with OAT should be capable of recognizing and managing the potential side effects through treatment or proper referral.
- Dentists who provide OAT to patients should monitor and adjust the Oral Appliance (OA) for treatment efficacy as needed, or at least annually. As titration of OAs has been shown to affect the final treatment outcome and overall OA success.
- Surgical procedures may be considered as a secondary treatment for OSA when CPAP or OAT is inadequate or not tolerated. In selected cases, such as patients with concomitant dentofacial deformities, surgical intervention may be considered as a primary treatment.
- Dentists treating SRBD should continually update their knowledge and training of dental sleep medicine with related continuing education.
- Dentists should maintain regular communications with the patient’s referring physician and other healthcare providers to the patient’s treatment progress and any recommended follow up treatment.
- Follow-up sleep testing by a physician should be conducted to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities.