Oral Appliances for the Management of Snoring and Obstructive Sleep Apnea Bilal Saib, DDS
© 2001, Academy of Dental Sleep Medicine
Historical Perspective Repositioning the tongue and mandible to maintain a patent airway during sleep is not new: 1903: Micrognathic Infants benefit when the tongue is sutured forward to the lower lip. 1930: Helmets and chinstraps were used to reposition the mandible forward. 1934: Pierre Robin reports the first use of an oral appliance to reposition the mandible.
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Historical Perspective (cont’d) Repositioning the tongue and mandible to maintain a patent airway during sleep is not new: 1979: Mandible surgically advanced to open the airway. 1982: Cartwright and Samelson report on the tongue retaining device. 1984: Numerous authors publish data regarding oral appliance effectiveness.
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How Do They Work? Oral appliances are utilized in the mouth during sleep to prevent the oropharyngeal tissues and the base of the tongue from collapsing and obstructing the upper airway.
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Oral Appliances May Function In 2 Basic Ways
Repositioning the mandible, tongue, soft palate and hyoid bone Stabilizing the mandible, tongue and hyoid bone
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Airway Volume
Key Red = Tongue White = Mandible Blue = Airway
Three Dimensional reconstructions courtesy of Alan A. Lowe, DMD, FRCD ( C ) , FACD © 2001, Academy of Dental Sleep Medicine
Types of Oral Appliances
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Functional Classification of Oral Appliances
Mandibular Repositioning Appliances
Tongue Retaining Appliances
Combination Oral Appliance and CPAP
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Design Variations • Method of Retention • Flexibility of Material • Adjustability • Vertical Opening • Freedom of Jaw Movement
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The effective clinician understands the functional characteristics and design variations of MANY appliances.
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Sleep Disorders 95% of the victims remain undiagnosed, largely because health professionals have not had the opportunity to learn about sleep disorders and sleep deprivation. “There is an urgent need for all health care professionals to be able to identify patients with sleep disorders.”
National Commission on Sleep Disorders Research
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Management of Snoring & OSA
Non-surgical • • • •
Avoidance of Risk Factors/ Behavior Modification Pharmacologic Agents (MEDICATION) Positive Airway Pressure (CPAP) Oral Appliance Therapy
• • • • •
Tracheostomy Laser-Assisted Uvuloplasty Somnoplasty Uvulopalatopharyngoplasty (UPPP) Maxillary / Mandibular Advancement
Surgical
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Dentistry’s Role
Obstructive Sleep Apnea (OSA) is a lifethreatening medical disorder Dentists are not qualified nor legally permitted to diagnose sleep disorders. Diagnosis must be made by a physician
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Dentistry’s Role
Screening and referral Provide and monitor oral appliance therapy as part of team with physician Monitor and treat potential side effects of oral appliance therapy Follow-up
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American Academy of Sleep Medicine Clinical Guidelines • Diagnosis Medical Evaluation to Precede Appliance Therapy • Indications Primary Snoring Selected Patients with OSA CPAP Intolerance Surgical Contraindications Sleep, 18 (6): 501-510
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American Academy of Sleep Medicine Clinical Guidelines (cont’d) • Appliance Fitting Appliance Selection and Fitting by Attending Dentist • Follow Up Medical Assessment: PSG for Moderate and Severe OSA (MD & SLEEP LAB) Periodic Evaluation by Dentist
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American Academy of Sleep Medicine Clinical Guidelines (cont’d) • Treatment Objectives Primary Snoring: Reduce Snoring OSA: Resolution of Clinical Signs and Symptoms. Normalization of ApneaHypopnea index and O2 Saturation • Contraindications First-Line Treatment for Severe OSA, Central Apnea
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The Legal Perspective The dentist must blend education, and ethics into new protocols for the maximum benefit to patients and profession.
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Major Legal Concerns • Compliance with local licensing requirements • Issues of professional liability Due to the nature of oral appliance therapy, certain aspects of treatment fall within the scope of practice of physicians and certain others within the scope of practice of dentists.
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Medical History & Physical Examination in the Dental Office
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Patient History
Snoring • Frequency • Loudness • Effect on Sleep of others (2nd Hand sleep disorder)
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Patient History
Daytime Drowsiness • Refreshed / Un-refreshed on awakening • Effect on daily activities • Cognitive Impairment • Motor vehicle accidents or near misses while driving
Courtesy of Jonathan Parker, DDS © 2001, Academy of Dental Sleep Medicine
Patient History
Quality of Sleep • Number of times awakened during night • Wake gasping and choking • Witnessed apneas
Sleep Position • Snoring in all positions or only on back
Courtesy of Jonathan Parker, DDS © 2001, Academy of Dental Sleep Medicine
Patient History
Additional Information • • • • • • • • • •
Hours of sleep per night Hypertension Morning Headaches Sour Taste in Mouth Dry Mouth Temporomandibular Joint Symptoms Bruxism Excessive Daytime Sleepiness Change in weight Nasal congestion
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Patient History
History of previous sleep disorders evaluation • Previous physician/dentist evaluation • Previous sleep studies or other testing
Polysomnography
• History of previous treatment
CPAP Surgery Oral Appliances
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Bed-partner History History
from Bed-partner
Excessive movement during sleep
Snoring
Cessation of Breathing
Gasping for air
Bruxism
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Epworth Sleepiness Scale
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Patient Dental Examination
Study Casts Radiographs • Panoramic or Full mouth radiographs • Cephalometric
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Patient Dental Examination
Dental/occlusal relationships • Overbite and overjet • Angle classification (Jaw size discrepancy) • Position of dental midlines • Wear facets (Bruxism?) • Occlusal contacts (bite locations) • Diastemata (Spaces between teeth)
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Dental/Occlusal Relationship
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Retrognathia “Small Jaw” Note: External size of nose is no guarantee of patency and ability to breathe through the nose
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Bruxism
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Condition of Dentition At least 10 teeth in each arch are required for most mandibular repositioning appliances
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Gastroesophageal Reflux
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Patient Examination
Periodontal Condition • Gingival Recession/ Pocketing • Tooth Mobility • Periodontal Disease
Intraoral soft and hard tissue pathology
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Periodontal Disease
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Patient Examination
TMJ Evaluation • Palpation • Auscultation (ultrasound/Stethoscope)
Muscle Palpation Jaw Range of Motion • Maximum opening (40-60 mm) • Lateral and protrusive movement (> 8mm)
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Temporomandibular Joint Range of motion scale can be used to measure extent of opening and lateral excursion.
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Patient Examination
Nasal Examination • Nostril patency – airflow through each nostril • Nasal speculum evaluation Polyps Enlarged turbinates
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Patient Examination
Neck Size • Men (> 17 inches) • Women (> 15 ½ Inches)
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Obesity
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Patient Examination
Oropharyngeal tissues • Size of tongue • Scalloping of tongue • Length of soft palate • Size of uvula • Tonsils • Crowding of oropharyngeal area
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Enlarged Tongue
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Scalloping of the Tongue
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Enlarged Tonsils
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Enlarged Soft Palate & Uvula
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Obstructed Airway
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Oral Appliances for the Management of Snoring and Obstructive Sleep Apnea
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Tongue Retainers
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Indications for Tongue Retaining Device (TRD)
Lack of tooth support or edentulous Active TMD symptoms (pain/dysfunction)
Non-apneic snorers or mild OSA
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Protocol for Tongue Retaining Device (TRD)
Follow-up evaluation • Update Progress Change in symptoms Compliance Side effects Change in Epworth sleepiness score • Examination Fit of appliance Occlusal evaluation TMJ/muscle evaluation • Next follow-up evaluation
Courtesy of Jonathan Parker, DDS
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Tongue Retaining Device (TRD)
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Tongue Retaining Device (TRD) (With Airway Tubes)
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Tongue Stabilizer
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Mandibular Repositioners
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Effectiveness of MRD: Summary of Current Research (Totals) % Success
Rate
Mild OSA (5-20 events/hour)
76%
41/50
Moderate OSA (20-40 events/hour)
61%
50/82
Severe OSA (>40 events/hour)
40%
27/68
Definition of success is AHI ≤ 10 and reduced by 1/2
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Effectiveness of MRD: Summary of Current Research Study
Mild (5-20/hr)
Moderate (20-40/hr)
Severe (>40/hr)
Menn, 1996
67% (4/6)
62.5% (5/8)
22% (2/9)
81% (17/21)
60% (9/15)
25% (2/8)
Parker, 1999
100% (3/3)
78% (7/9)
0% (0/1)
Pancer, 1999
67% (9/15)
58% (14/24)
47% (16/34)
87.5% (7/8)
47% (9/19)
45% (5/11)
Marklund, 1998
Lowe, 2000
Definition of success is AHI ≤ 10 and reduced by 1/2
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Mandibular Repositioners Non-Adjustable
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Clasp Retained Mandibular Repositioner
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Elastomeric Sleep Appliance
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Nocturnal Airway Patency Appliance (NAPA)
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TheraSnore (Non-Adjustable)
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Mandibular Repositioners Adjustable
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Protocol for Adjustable Mandibular Positioning Appliance
Follow-up evaluation • Update Progress Change in symptoms Compliance Side effects Change in Epworth sleepiness score • Examination Fit of appliance Occlusal evaluation TMJ/muscle evaluation • Next follow-up evaluation
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Adjustable PM Positioner
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Elastic Mandibular Advancement (EMA® ) Appliance
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Herbst Appliance (Traditional Hardware)
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Klearway Oral Appliance
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The Silencer System
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Snore-Aid® plus
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TheraSnore (Adjustable)
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Thornton Adjustable Positioner (TAP®)
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Complications & Side Effects Occlusal Changes Jaw Pain/Discomfort Tooth Pain/Discomfort
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Occlusal Changes (self-reported) Pantin (1999): Clark (2000):
12% 26%
(always/continuous)
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Conclusions
Occlusal changes can occur with mandibular repositioning appliances. Most changes appear to be of a minor nature, and of little concern to the patients , however some patients can exhibit changes that are detrimental to their occlusion. Changes do not appear to be directly correlated to the degree of protrusion, age, gender or skeletal type. Informed consent should be given to all patients prior to treatment with mandibular repositioning appliances. Routine regular dental reviews with ongoing treatment are advised.
Courtesy of Christopher Robertson, MDS
© 2001, Academy of Dental Sleep Medicine
Jaw Pain/Discomfort Pantin (1999):
25% (severity not noted)
Pancer (1999):
14% (often)
Clark (2000):
11% (muscle pain frequently or always)
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Tooth Pain/Discomfort Pantin (1999):
26% (mostly mild)
Pancer (1999):
28% (often)
Clark (2000):
15% (frequently or always)
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Why do occlusal changes occur?
Proliferation (thickening) of posterior attachment in the TMJs that will not allow condyle to fully seat in the fossa Muscles of mastication lengthen and adapt to forward jaw position (???) Tooth movement related to use of appliance
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Why do TMD symptoms occur?
Inflammation in the TMJs Referred pain from the muscles of mastication
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Compliance with Oral Appliance Therapy Evaluated by Questionnaire Schmidt-Nowara 75% after mean 7 mos. (1991): Clark (1993): 50% after 3 years Eveloff (1994): 93% after mean 2 years Ichioka (1995): 86% after 5 years Menn (1996): 70% after mean 3.4 years Pancer (1999): 86% after 350 days Yoshida (2000): 90% after mean of 3.5 years Clark (2000): 60% after 1 year 48% after 2 years
Courtesy of Jonathan Parker, DDS
© 2001, Academy of Dental Sleep Medicine
Combination Oral Appliance and CPAP Appliance and nCPAP
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CPAP/PRO®
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Oral Pressure Appliance (OPAP®)
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Sleep Apnea Airway Management System (SAAMS™)
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Sleep Apnea Airway Management System (SAAMS™)
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Academy of Dental Sleep Medicine
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Thank you!
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