A golden opportunity for dentists: dental sleep medicine Part 2: implementing sleep dentistry into your practice

Dr. Harold F. Menchel offers a wake-up call to clinicians to explore an evolving niche in dentistry

In last issue’s article, a general overview was presented on sleep dentistry. Part 2 will emphasize the practical aspects in implementing sleep dentistry in your practice. Discussed will be:

• Your role coordinating treatment with the sleep physician
• A flowchart for OSA patients with dental appliances
• Discussion of specific sleep appliances and criteria for selection
• Standard of care for examination and informed consent.

Sleep dentistry can be introduced into your practice in two ways:

1. As a supplement to your traditional practice
2. Growing your practice with an emphasis on sleep dentistry.

Choice 1 does not involve a significant financial or time commitment. In this case, you will be acting more as a technician for the sleep physician. You should consult with the sleep physician as to his/her preference for dental appliances as they may adjust them in the sleep lab.

Choice 2 is more involved as will be discussed later in the article.

Table 1 will describe the basic flow of patients in your practice.

It may be difficult in many instances to get a follow-up split study due to lack of insurance coverage and patient compliance.

There are dozens of dental sleep appliances on the market, all of which claim certain advantages. All dental sleep appliances do the same thing. They all advance the mandible to open the airway.

In general the following guidelines may be useful:

• No single type of sleep appliance will be appropriate for every patient. Depending on whether the patient has a full dentition, partially edentulous, or edentulous on one arch, different ones may be chosen.
• The choice of materials is important also. The softer laminates are more comfortable for the patient than hard acrylic, but not as durable and adjustable if dental restorations change the tooth configuration.
• Some appliances allow full mouth opening while others restrict it. Some sleep dentists assert that opening will tend to close the airway.
• Tongue space is a strong consideration for many patients. The appliance should minimally constrict the tongue.
• The more adjustable the appliance is and the ease of adjustment for the dentist, sleep physician, and patient are also important. Some dentists will allow the patient to adjust the appliance while others do not.
• There are patients with significant limited openings and mandibular range of motion, due to arthritis, post radiation fibrosis of the muscles of mastication, or autoimmune diseases such as scleroderma. Dental sleep appliances are contraindicated in these instances.
• At this time, Medicare only allows reimbursement for Herbst and TAP appliances.

There are devices that can aid you in taking protrusive bite records,  e.g., George Gauge^®, TAP gauge^®, that are inexpensive and simple to use.  A pulse oximeter may be helpful as a screening device that you should consider adding to your practice.¹  (Review the limitations of PO as mentioned in Part 1. TMD issues, jaw lesions, and gross dental disease should be screened with a panoramic film.) TMD is not necessarily a contraindication for dental sleep appliances, but these patients have to be relatively pain free prior to treatment. In many instances, the mandibular advancement appliance can be therapeutic.

Basic sleep dentistry courses are available to familiarize you with the more popular sleep appliances (e.g., TAP, Somnodent, Herbst, Kleerway, OASYS). There are even dental appliances available for partially edentulous patients. Patient selection will be presented as well as how to take a protrusive bite record.

If this is the depth that you prefer to take sleep dentistry in your practice, it is important that you have a good relationship with a sleep physician to help you in titrating and evaluating the benefit of the dental appliance. If you want to make sleep dentistry a significant part of your practice, it is necessary to have an in-depth understanding of sleep anatomy and physiology, diagnosis, and management. You may consider prescribing your own home sleep studies for this as a screening method.³ Contact the AASM and AADSM for information on this. This can involve a significant investment in time and money. This is not discussed in this article.

Dentists who make this choice need to have more advanced instrumentation, and, more importantly, may take the initial responsibility for titration and follow-up of their patients. Dental practice acts may vary greatly depending on the state you reside in, and it is imperative that you familiarize yourself with your state laws. Every state requires that only physicians diagnose sleep disorders, and that a physician reads the sleep study.

Informed consent for dental appliances

All patients should be made aware that CPAP is still the gold standard for treating OSA, especially severe conditions, and that the dental appliance may not be as effective.⁴

• There have also been reports of dental sleep appliances causing permanent bite changes by advancing the mandible, and creating posterior open bites due to lateral pterygoid shortening and condylar and eminence remodeling. Patients need to be informed of this possibility.⁵
• Any dental appliance can promote decay and periodontal inflammation if dental hygiene is neglected.
• Sore teeth or minor tooth movement may occur with the dental appliance.
• Rarely, the patient may develop jaw and or muscle pain.

Conclusions

Adding sleep dentistry to your practice can be of great benefit to both you and your patients. Sleep physicians should be made aware that dentists are significant referrers. This is also a good motivation for your staff to learn a new and interesting facet in the practice of dentistry. There is no downside in introducing sleep dentistry into your practice. It can be done with minimal time and financial investment to you and grow as part of your practice as you decide.

It is important to establish a good relationship with the sleep physicians in your community, and to let them know that you are available to make appliances for their patients as needed. Taking a good basic sleep course is essential. You must understand the physiology of sleep and pathophysiology of OSA, how to read a PSG, how to do basic screening, and how to make, insert, and monitor dental appliances.

Sleep dentistry is a wonderful new opportunity and should be strongly considered by all dentists.

Acknowledgements

I would like to thank Drs. Barry Glassman, Don Malizia, and Steven Bender for their assistance with this article. It is greatly appreciated.

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References

1. Netzer N, Eliasson AH, Netzer C, Kristo DA. Overnight pulse oximetry for sleep-disordered breathing in adults: a review. Chest. 2001;120(2):625-633.

2. de Almeida FR, Bittencourt LR, de Almeida CI, Tsuiki S, Lowe AA, Tufik S. Effects of mandibular posture on obstructive sleep apnea severity and the temporomandibular joint in patients fitted with an oral appliance. Sleep. 2002;25(5):507–513.

3. Gagnadoux F, Pelletier-Fleury N, Philippe C, Rakotonanahary D, Fleury B. Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial. Chest. 2002;121(3):753-758.

4. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest. 1996;109(5):1269–1275.

5. Martínez-Gomis J, Willaert E, Nogues L, Pascual M, Somoza M, Monasterio C.  Five years of sleep apnea treatment with a mandibular advancement device. Side effects and technical complications. Angle Orthod. 2010;80(1):30-36.