The most important motif when it comes to treatment of obstructive sleep apnea in the field of dental sleep medicine is that qualified dentists need to address this condition as a serious medical problem and not something considered merely, dental. With that stated, it is essential that patients are seen as individuals coming with the potential of having multiple systemic illnesses, complex medical history and medical records & treatment history; therefore, it is critical that dentists look “beyond the teeth/mouth.” Not only are there many co-morbidities to obstructive sleep apnea, but there are many factors, such as syndromes, prior injuries, trauma, mental health, phenotypic variances, chronic/ acute pain history, TMJ/TMD/orofacial issues, and even financial aspects that dentists need to address to attain a successful outcome in treatment.
Several treatment options require patients’ commitment both in time and adherence to protocol. Furthermore, dentists need to be thoroughly active and take part of the physical adjustments, fitting, refining, and finishing of the cases at each and every appointment rather than relying on delegating. Complications, liability, experience, education, and knowledge all play an important aspect for the success of any case; thus, it is paramount all qualified dental sleep providers be prepared and planned for all the variables. The oath in the healthcare profession is to do no harm and to provide the best quality care possible.
As each patient presents with their own unique medical history, tolerance to treatment duration, level of invasiveness, expectations, and financial capabilities, the foundation of any successful case lies in carefully considering these factors. This article will break down these topics into sections for the practitioner to review and consider. If there is any lack of education, experience, or knowledge, the author highly recommends pursuing continuing education through either of the two major dental sleep academies (AADSM and ASBA), attending academy conventions, or participating in mini-residencies at universities, medical or dental schools or the dental sleep academies.
This article will begin with a discussion on the preliminary considerations (medical history/record, expectations, and financial aspects) then, the following treatment options will be discussed:
1) CPAP intolerant and Straight Forward Customized Oral Appliance Cases
2) Complex cases using Oral Appliance (such as TMD/orofacial pain patient)
3) Non Responder to Oral Appliance but using Minimally invasive bone remodeling appliances / orthotropics with myofunctional therapy and other adjuncts- Chirodontics, Rochabado Physical Therapy, etc.
4) More invasive options that involve surgery (in the dental field), MARPE, MSE II, SARPE, DOME
5) Referral for MMA or Inspire, and other options
PRELIMINARY CONSIDERATIONS TO PREPARE PATIENTS FOR TREATMENT PROCESS AND MANAGEMENT OF THEIR CASE
Patient intake
The important first step in every new case is to create a solid initial foundation by completing a thorough review and discussion of the patient’s medical history and records. This means not only current systemic illnesses and both prescription and OTC medications, but also prior and current treatments and scheduled future treatment plans, will be documented and reviewed. It is crucial that the provider understand the current conditions and to be able to rank and discuss patients goals and expectations before any new treatment is initiated. Syntax and the sequence & plan of treatment have everything to do with attaining long term successful outcomes. For example, urgent and acute conditions, pain and/or biopsies, ASA III issues, etc should all be addressed before any appliance therapy, expansion, and/or surgeries. Outlining the treatment choices and steps from the very beginning of records collection and analysis will save time and help curtail risks for failure mid-treatment.
Another example for patients wanting expansion for sleep apnea treatment, is to first assess if the patient presents with TMD and orofacial pain issues or postural and cranial problems (cranial distortions and descending/ascending disorders). Not knowing where the plan of treatment is going and for what reasons can be disastrous to the whole case and outcome. Neuromuscular issues, jaw/orofacial head/neck pain, and asymmetries when addressed and corrected can definitely help the expansion process and even improve the time frame needed and predictability. Next, proper referrals should be addressed early on in the case, too. If ENTs, pulmonologists, cardiologists, and oral surgeons are to be needed in the treatment process, proper referrals and scheduling should be made.
During the preliminary work up, it is also important to discuss commitment, adherence to protocol/ compliance, time frame and financial aspects of the case. Expectations need to be realistic and the patient needs to be informed of the entire process. Follow ups, the finishing of the case, and attaching costs for the different treatment options should be explained before initiation of any treatment. If medical insurance is involved, it is absolutely necessary that pre-authorizations, verification of benefits which include deductibles, co-pay/co-insurance and all out of pocket costs have all been reviewed and accepted by the patient before treatment begins. Explaining at times, peer-to-peer calls, GAP exceptions, and more clinical paperwork from letters of medical necessity to referral/ prescriptions are needed to successfully bill medical insurance. Finally, understanding all rules and regulations of Medicare/ PDAC and also coordination of benefits all should be well communicated to the patient during the preliminary collection of data.
TREATMENT PLAN OPTIONS AND CONSIDERATIONS FOR PATIENT CARE AND CASE MANAGEMENT:
1) CPAP Intolerant and Straight Forward Oral Appliance Cases
This first category of a dental sleep medicine case may be the most straightforward, but careful attention needs to be given to each step of the process. If the patient has been properly diagnosed by a board certified sleep physician and has been referred to the dental provider due to CPAP intolerance or failure, a thorough analysis of the patient’s occlusion, prior dental/restorative work, and TMJ with functional analysis with border movement measurements should be completed. The options for doing non-customized oral appliance therapy should be discussed in the beginning as well and acknowledgement that there are non-responders to customized oral appliances exist in the population.
Utilizing equipment such as cone beam/ CT scanning, acoustic reflection, and performing a clinical dental sleep medicine examination should all be done to establish a baseline and recorded metrics for both soft and hard tissue anatomy. The results of the sleep test should be discussed with the patient. RDI/ REI which include RERAs and ODI/oxygen saturation levels, heart rate variability, sleep staging percentage, snoring decibels, positional issues and details of the medical necessity from the sleep physician regarding the results of the sleep study should be reviewed with the patient. Goals in terms of efficacy of the oral appliance, the follow up and titrations/calibrations that may be necessary, should all be explained to the patient so they can prepare for all variables to appropriately complete the case and have long term success.
Addressing the patient’s dental history, anatomical limitations, and level of comfort are all connected to long term compliance and success. For example, if a patient is very retrognathic as in Class II Division II cases, the anterior-posterior dimension may be very sensitive and correlated to tolerance and compliance of the oral appliance. Over protrusion in these patients can create a myriad of side effects and even TMD, hypertonic muscles, and extreme orofacial pain. 3D measurements and considerations are a essential, and there really is no excuse in modern times to avoid using equipment that provide thorough analysis for this critical part of the treatment process. As in the example of a mid-face deficient patient with a class III skeletal profile and occlusion, only looking at the anterior-posterior dimension is insufficient and often lead to failed treatment. Evaluating multiple dimensions such as lateral (asymmetries), vertical, pitch/diagonal, roll, and yaw dimensions are necessary as all patients who present are three dimensional and not one or two.
Providing instructions and offering videos/links to jaw exercises are important part of the management of oral appliance therapy in dental sleep medicine. Furthermore, providing a morning occlusal guide (MOG) / AM aligner to aid the patient to attain Centric Occlusion “CO” Habitual bite, is also highly recommended.
Bite
Continuing this discussion to the steps to attain the initial bite position or “start position” of the oral appliance, it is important there are many philosophies, schools/camps of thought, and options on this topic. Some (but not all) of the various bites to consider are : Silibant Phonemes/Phonetics (Ricketts), Neuromuscular, George Gauge, Andra Gauge, Swallow, Moses, Apnea/MAD Fit, pharyngometer, Gelb 4/7, and Apnea Guard to name a few. It is very important that the practitioner understand the airway bite method they use and to thoroughly follow the steps on the chosen method. Several of the dynamic bites include kinetics and reflex testing. Some may be subjective and some measured using equipment. For example, in the neuromuscular bite method, Ultra Low Frequency (ULF) TENsing using a Myomonitor (J5) or a MicroTENs unit would be necessary to first establish an antidromic effect on the hypertonic muscles of mastication and head/neck muscles so that they can truly be at rest (without action potentials) when the bite is taken. Then, further neuromuscular equipment such as the Myotronics K7 or the BioPak (Bioresearch) equipment is used with EMGs, electrosonography, and jaw tracing mechanisms to record and find the ideal airway bite for the oral appliance. It is of paramount importance that proper training and the following of instructions is met when using and selecting whichever bite method for the oral appliance.
Delivery
After the oral appliance is delivered, it is also important to automatically schedule chair time with the patient within the first two weeks to see how the patient is doing nightly with compliance and comfort. It is important that in order for the oral appliance treatment to be effective, especially long term, the patient has to be compliant and have any side effects be mitigated. Early follow up appointments can include adjustments for tight areas to titration/ calibration for improved comfort. Patients should also be given options for future dental restorative work from new crowns to bridges and implants, and in this day and age of digital records and scanning, there should be no reason to plan well ahead so that new restorations can be made to fit the existing oral appliance. This includes implant retained dentures, overdentures and partials. It is also important to review proper cleaning and maintenance of the oral appliance as well. Understanding biogunk, bacteria, and inflammation, the dental team needs to convey the importance of proper cleaning and maintenance of the appliance. For certain flex/ soft liner material, it is also important to note the avoidance of liquids that contain alcohol—only use non-alcoholic cleaners.
Using Medicare guidelines and rules, after 90 days, there should be post titration/calibration sleep study(ies) done. The post op sleep test results are important to show efficacy and the need for titration/calibration. After final position is validated a board certified sleep physician needs to interpret and finalize the outcome of the oral appliance case.
2) Complex cases using Oral Appliance (such as TMD/orofacial pain patient)
Patients who present with complex medical/ systemic issues or orofacial pain and TMJ must be allocated differently for sequencing of treatment, time frame, follow through, and expectations compared to the first category of dental sleep medicine patients mentioned above. Again, any acute pain or urgent systemic concerns all should be stabilized before the provider proceeds with dental sleep medicine treatment. Working inter-disciplinary with all the healthcare providers taking care of the patient should be planned for. Any surgeries, medical or dental related, should coordinated well in advance.
It is important to recognize that medical concerns extend beyond the realm of Western medicine. Patients may come in having undergone naturopathic treatments or using homeopathic remedies and therapies. They may present with certain allergies and conditions; for example, some patients may require an appliance without any metal, and some may even require the provider to send in materials used for allergy testing. Several new screening tools such as thermal scanning or even brain scans, such as those done at Amen Clinics throughout the US, should also be discussed when there are mental, behavioral (i.e. insomnia-cognitive), and list of medications should be factored in with any dental sleep medicine treatment.
Pain
Patients with acute or even chronic pain who are going through therapy must forward all documentation and clinical notes from all providers so that the dental sleep medicine provider can ascertain syntax and proper treatment planning and order. For example, the patient can be already under the care of an A-O Chiropractor, SOT Chiropractor, Rochabado Physical Therapist, or Chirodontist and certain manual releases and treatment are needed to stabilize the patient. If any oral appliances are made without coordination with these healthcare providers, then treatment failure, rephase, or lack of stabilization can occur. Also, it is worthy to note that combining myofunctional therapy exercises to patients using oral appliance therapy will only help the overall outcome of the treatment case.
Patients with TMD and orofacial pain issues should have those issues evaluated and addressed for daytime issues. Oral appliance therapy for sleep apnea is focused for improved and quality sleep at night. However, TMD and pain patients often need daytime appliances. Some examples are daytime Gelb appliances, Neuromuscular daytime orthotics (removable, if fixed then careful attention for a second appliance will be needed once phase 2 is completed for fixed orthotics), and Farrah type appliances for TMJ. It is important for the provider to understand the protocol and the equipment, bite techniques used for these appliances prior to OSA treatment using customized oral appliance therapy.
Follow through and time frame expectations should be discussed prior to treatment as well. Generally, with multiple factors or systemic issues, the length of time and treatment process all should take longer periods to complete or achieve.
3) Non Responder to Oral Appliance but using Minimally invasive bone remodeling appliances / orthotropics with myofunctional therapy and other adjuncts- Chirodontics, Rochabado Physical Therapy, etc.
In the literature, it is known there are non-responders to oral appliance therapy. When they are also CPAP intolerant, then what are the treatment options remaining? It is important for these patients to have a candid discussion of invasiveness, time frame, compliance to protocol, expectations and even costs/financial considerations for the remaining treatment options.
In this category, we will review only the minimally invasive options such as osseo- bone remodeling options with orthodontics and orthotropic options for the pediatric field, and all of them should be paired with myofunctional therapy and adjunctive procedures, such as tongue tie/ ankyloglossia releases. Generally, these cases require the patient to commit from a year to two during phase 1 and 2 of treatment, and sometimes, finishing these cases can take additional year(s). Therefore, long term compliance and expectations must be agreed upon from the very beginning. Some examples of treatment types in this arena are: 3-way Schwartz, Homeoblock (as well as unilateral), DNA, mRNA, mmRNA, ALF, Hyrax palatal expanders (only transverse), Fixed Osseo-Remodeling Appliance, and for pediatrics, Myobrace, VIVOS, Removable Oseeo-Remodeling Appliance and Healthy Start-Orthotain.
These cases all begin with a proper and thorough collection of records. Adequate CT scans with enough Field of View (FOV) size is critical. A board certified oral radiologist should review the entire CT scan and give a full diagnostic report. The dental sleep medicine provider should review the report and go over the report with the patient as well as schedule for any adjunctive care recommended. For example, a discussion with parents of pediatric patients for tonsil and adenoid issues should be discussed as well as tongue tie releases and myofunctional therapy.
Patients presenting with cranial strains and orofacial pain including TMJ issues need to be given options for cranial squamous suture releases, manual releases and leveling. Patients with SI or lower back issues, SOT issues or even asymmetries in length of legs need to consider foot orthotics and leveling before expansion begins. Complete and thorough pre-treatment records collection is absolutely essential. This means proper radiographs, measurements, clinical exams, photos (in front of symmetrographs), and treatment history should all be evaluated and kept. Again, tongue tie release, nutrition, exercise and mental health issues should all be addressed at the beginning of records collection.
The rate of expansion matter with all expansion cases. It is important that expansion is done at a biomimetic rate that is unique to the patient’s own anatomy and physiology. Going beyond these forces and rate of expansion by turning barrels too rapidly, for example, can cause potential unwarranted side effects. Furthermore, these are dynamic treatment modalities, and therefore, proper adjustments and wire bending, barrel turning, etc. all have to be done with proper protocol and frequency.
If forces are used too dramatically, or too much, too soon, the complications can include:
a) Relapse
b) Inflammation
c) Dehiscence
d) Root resorption
e) Teeth flaring out of bone
f) Pain
g) Worsening periodontal prognosis
h) Worsening of the finishing of the case
It is also very important that patients understand the expansion is only one phase of the treatment. After expansion, finishing of the cases can be done with traditional orthodontics, such as controlled arch orthodontics, or clear aligners, such as Invisalign or Candid Pro, or even restorative options with veneers and crowns. These all need to be properly planned and adequately set up in advance to minimize patient management issues and failure of expectations.
4) More invasive options that involve surgery (in the dental field), MARPE, MSE II, SARPE, DOME
Patients who are CPAP intolerant, non-responders to oral appliance therapy, and either have anatomical limitations or conditions, or patients with urgent need for sleep apnea treatment (i.e. a extremely morbidly obese patient with oxygen desaturations and severe RDI/REI results) should be given these more invasive treatment options. Patients who have major skeletal issues with crossbites and arches that make it difficult for less invasive expansion appliances should consider these options.
With surgical intervention, from splitting the palatal suture to surgically assisted rapid palatal expansion, these treatment options do have good success rates in the evidence based literature, but with any invasive procedures, the risks of permanent complications are greater, and post-operative healing times, and pain tolerance will be variable from patient to patient. Generally, due to these being surgical cases, the time frame to complete these cases are shortened compared to the less invasive options. But, the pros, cons, risks, benefits and alternatives must thoroughly be explained to the patient prior to initiating treatment. Also, an oral surgeon, periodontist, and/or ENT are generally involved in the process.
Myofunctional therapy exercises, nutrition, exercise and mental health should also be discussed for long term management and success of this category of cases as well.
5) Referral for MMA or Inspire, and other options
If all the above cases are not possible, then MMA surgery is an option to consider, which in the literature, has a 95% success rate. Unlike other surgeries with lower success rates such as UPPP (40% at best and not long term due to relapse), or pillars, or genioglossus advancement procedures, the MMA option tends to have more long term success rates. This option needs to weigh in the risks, potential irreversible damages, and complications that can arise. Healing time and patients tolerance of pain and their ability to eat/function for months immediately following surgery need to be all weighed in.
Another option would be Inspire, and for central sleep apnea (phrenic nerve stimulation—by Zoll Itamar), should also be discussed. Each of these options have criteria that need to be met before they will allow the patient to proceed with treatment. For example, with Inspire, the patient’s BMI and upper airway collapsibility need to be ascertained with DICE. Patients with concentric upper airway collapse will not qualify for Inspire. Furthermore, some patients end up with more fragmented sleep as the hypoglossal nerve is stimulated, the shock actually wakes the patient during sleep and can do so multiple times. If that is an issue, often the ENT’s would ask the patients just to leave the implants in and turn them off, as risks of secondary infection for another surgery to remove the implant would not be worth the risks.
Conclusion
Proper management of the sleep apnea patient becomes easier and more predictable when adequate planning, preparation, equipment, and education/knowledge are being executed for the patient. It is only fair the provider offers all options and discuss the pros, cons, risks and benefits, including costs and time frame expectations and compliance expectations with the patient. It is the oath in healthcare to do no harm and to provide the best possible care to our patients.
Jerry Hu, DDS, DASBA, DABDSM, DACSDD