Snoring and Sleep Apnea page

Snoring and Sleep Apnea pages 123456789

Page 3–Fixed Jaw appliances==>>

Page 4–Adjustable appliances==>>

Who treats OSA, and how is it treated

While a dentist may be the first practitioner to identify patients who have sleep apnea, they seldom treat these patients without medical guidance.  Pulmonologists and sleep specialists are qualified to document and treat the disorder, however dentists are becoming more and more accepted by the medical profession as qualified OSA treatment providers.  Whenever a dentist diagnoses sleep apnea  from the presenting symptoms, he or she must refer the patient to a qualified physician for a polysomnogram (PSG), or ask a physician to review the results of a home sleep test (HST) for an official diagnosis.

cpapThe standard medical treatment for OSA is “Continuous positive airway pressure” or CPAP (pronounced “C-Pap”) and a newer variation called BiPap (bilevel positive airway pressure).  These machines have a high flow fan, a hose and a sealed nasal mask to which the patient is attached while sleeping.  Clinical studies have shown that CPAP is effective in relieving most apnic episodes.  In addition to the CPAP machine, physicians prescribe a weight  loss regimen, and abstinence from tobacco and alcohol.

A more advanced machine is the APAP.  This stands for Auto Triggering Positive Airway Pressure, and compliance with this machine is somewhat better than for the CPAP.  The APAP device can be set to continuous positive airway pressure mode same as the CPAP but also offers a range of pressures that is not available on the CPAP . The APAP device automatically adjusts the pressure when a change of pressure is required, for example, when the individual with sleep apnea turns from a sleeping position on their back to a sleeping position on their side, or if the patient has a cold. With the CPAP device the pressure remains constant even if the sleeping position has changed.

Dentists, insurance and Sleep Apnea

In the early 1990’s, OSA research projects were carried out on mandibular advancement devices (airway dilators, or “anti-snoring devices”) .  These projects resulted in a 1995 review (updated in 2005) by the American Sleep Disorders Association entitled “Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances“.   The review concluded that oral appliances are a good alternative to CPAP in cases of mild to moderate obstructive sleep apnea.  More recent research has found that jaw advancement appliances (known as Mandibular Advancement Devices {MADs}) are actually MORE effective for treating MILD to MODERATE obstructive sleep apnea than is CPAP.

Patient compliance with CPAP is a problem due to the noise of the air compressor, the constriction of movement caused by the hose attachment, stuffy nose, skin irritation from the nosepiece, and having less intimacy with a bed partner. Approximately 50% of patients who are prescribed any of these respirators stop using them within a year, and many more stop over the next five years. In cases of severe OSA in which the patient SHOULD be using a CPAP or BIPAP machine, but refuses for any reason, a dental mandibular advancement device may still reduce the apnic episodes enough to greatly improve and prolong the patient’s life.

The legal and ethical status of dentists in the treatment of obstructive sleep apnea is a bit complicated. Some dentists, while quite knowlegable in all aspects of sleep apnea cannot legally diagnose the disorder. Diagnosis must be done by a qualified physician. Furthermore, sleep apnea treatment is not paid for by dental insurance. It is, however covered by medical insurance. But medical insurance will not pay anything toward this treatment unless the request is accompanied by a diagnosis code signed by a qualified physician. Therefore, while a dentist may fabricate an appliance for a patient without a medical referral, he or she would much prefer to work with a physician on OSA cases rather than “going it alone”.

The removable OSA appliances (Also known as anti-snoring devices)

withandwithout-applianceAnything that advances the lower jaw forward (brings it into protrusion) will tend to lift the tongue and epiglottis away from the back of the throat. This will relieve some of the constriction caused by the relaxation of the muscles during sleep, as shown in the illustrations above.  In order to wear such an appliance, it is imperative that the patient have sufficient numbers of healthy teeth in both upper and lower arches for the appliance to attach to. If the patient lacks healthy teeth, dental implants may still make it possible to wear a removable anti-snoring device.

Edentulous patients (i.e. patients who have no teeth at all) cannot be treated with mandibular advancement devices, but it is possible to get some limited relief from obstructive apnea through the use of a tongue retaining device. However these patients are well advised to either get implants or a CPAP machine.

Impressions are taken of both the top and bottom teeth, and models are poured in plaster.  Then the patient may be instructed to bite into a slab of wax with his lower jaw protruded as much as possible without straining.  This is called a protrusive bite registration.  Both the models and the protrusive bite registration are sent to the lab.  The laboratory returns the finished appliance which can take a number of different forms depending on  what the dentist orders.

georgegagueDentists click here to order a George gauge to help in taking a reproducible protrusive bite registration, and here to learn how to use one. A competing version of the same thing is called a TAP gague

Two general types of anti-snoring device

Dental MADs (Mandibular advancement devices) fall into two general categories. Fixed and Adjustable. Fixed appliances were popular early in the history of the dental treatment of OSA, but as our knowledge of the disorder has advanced, they have fallen out of favor.  Adjustable snoring appliances have a very serious advantage over fixed jaw appliances. As the patient’s jaw musculature and ligaments adapt over time with the jaw advancement brought about by the appliance, an adjustable appliance may be advanced further to bring about more relief.This is not possible with a fixed jaw appliance.

Page 3–Fixed Jaw appliances==>>

Page 4–Adjustable appliances==>>

Snoring and Sleep Apnea pages 123456789