Wake Up!

Society is attempting to address the issue as it comes to the forefront. Airlines, transportation companies, and many other businesses are instituting new policies that require employees to undergo medical evaluations to determine their at-risk status for a sleep disorder. If found positive, employees in many cases must comply with treatment protocols to maintain their jobs. The recognition of sleep apnea as a serious health issue and new initiatives to identify at-risk populations are positioning dentistry as a solution provider. Clinicians and laboratories are poised to provide a wealth of patient education, diagnosis, and successful treatment protocols and appliances to alleviate the effects of OSA.

OSA is a sleep-related disorder manifested by the collapse of the pharyngeal airway. This subsequently leads to repeated episodes of airflow cessation (decrease or complete halt in airflow), oxygen desaturation, and multiple sleep disruptions.¹ The muscles near the pharynx and the back of the throat relax during sleep, causing soft tissue to collapse and block the airway² (Figure 1). When the airway is blocked, the pause in breathing usually lasts 10 to 30 seconds; some patients, however, may exhibit breathing cessation for as much as 1 minute or longer. The result and symptom manifestation of this sleep disorder is an abrupt reduction in blood-oxygen saturation, with some cases showing a drastic reduction of as much as 40% or more. These episodes provoke the brain to respond to the lack of oxygen by alerting the body (stimulating the epinephrine hormone, also known as the fight or flight hormone), and causing a brief arousal from sleep to resume regular breathing. In patients with OSA, this scenario can occur hundreds of times a night, fragmenting the needed regenerative sleep and producing an excessive feeling of daytime fatigue or sleepiness.² However, these awakenings are typically not complete, so the sleeper might be unaware of the breathing issues during the night. These patients also produce excessively loud snoring. Furthermore, patients with OSA are at increased risk for chronic elevation in daytime blood pressure, which, in turn, leads to increased risk for stroke, a higher risk for death due to heart disease, impaired glucose tolerance, impaired concentration, mood changes, and increased risk for being involved in a deadly motor vehicle accident.³

Three known treatment protocols can treat OSA. Traditionally, the continuous positive airway pressure (CPAP) has been prescribed for moderate-to-severe cases of OSA. CPAP provides a steady stream of pressurized air to patients through a mask that the patient must wear while sleeping. However, this treatment modality often leads to ineffective results, due largely in part to noncompliance of the patient because of the mask’s bulkiness and discomfort.²

A second option is the oral appliance, or the mandible forward displacement appliance (Figure 2). This appliance widens, repositions, or stabilizes the mandible retro-palatal airway patency, as well as the base of the tongue, soft palate, or uvula in the passive pharynx, and therefore hinders the collapsibility of the pharynx during sleep4 (Figure 3). Mandibular advancement oral appliances are typically the first solution for the approximately 90% of patients diagnosed with mild and moderate OSA symptoms. These oral appliances can be significantly more effective because many patients find this treatment more comfortable, lessening patients’ hesitation in wearing them at night.

When noninvasive treatment modalities are unsuccessful, surgical options can correct or alleviate the problem.²

The dental profession is in an excellent position to recognize and tackle this epidemic because 90% of the obstruction occurs behind the maxilla and mandible and in the region of the soft palate, tongue, and lateral fat pads.³ The airway is critically significant in dentistry and medicine, because the airway, proper oxygenation, and breathing are the most important and necessary functions for humans. Statistics show about 80% to 90% of adults with OSA have not received a diagnosis.² Dentists can play an important role in testing and commencing the conversation with their patients, who concurrently may have other existing and contributory dental ailments, including the under-recognized, devastating effects of the removal of the bicuspids during orthodontic treatment, which may require restorative options to remediate symptoms.

If a patient is suspected of having OSA, the first step for the dentist is to recommend a home sleep test such as Ez Sleep SystemTM (Ez Sleep, ezsleeptest.com). This system incorporates an assessment tool designed for healthcare professionals to deploy in the office. Then, the provider can give the patient an at-home, self-administered test, which is comprised of a sensor that the patient affixes with straps onto the forehead before bedtime for one or two nights. The sensor records oxygen levels, snoring, and deep sleep disruptions. Then, the patient mails the device to the company for the results to be read and sent to the ordering dentist. The comprehensive sleep report (Figure 4) is read by a board-certified sleep specialist, the only health care providers permitted to diagnose sleep disorders. From there, the diagnosis and treatment recommendations are sent to the patient’s dentist. If desired, a dentist can consult with an ear, nose, and throat specialist and the dental laboratory for appliance fabrication. A knowledgeable team approach, utilizing clinical and laboratory experts, is optimal in finding treatment solutions for success. Self-guided home sleep studies appear as effective as in-hospital studies for diagnosis of OSA without comorbidities.⁹

The aforementioned mandibular advancement device, or oral appliance (OA), is an approved and frequently effective treatment protocol. In 2006, the American Academy of Sleep Medicine published updated OSA treatment guidelines stating that oral appliances are a reasonable alternative to CPAP. Mandibular advancement devices provide a therapeutic effect by protruding the mandible relative to the maxilla, simultaneously advancing the tongue and reducing the propensity for airway collapse during sleep^5,6 (Figure 5). Although these types of oral appliances have multiple variations, they fall into two main categories: fixed or adjustable. Both variations are fabricated from models of the patient’s dentition to fit the mandibular and maxillary teeth.⁵ The primary difference between the two types is the amount of titration, or slow addition of mandibular advancement, that can be achieved. Fixed oral appliances are usually made to advance the mandible 50% to 80% and are fabricated in a permanent position. Adjustable oral appliances can be further titrated to optimize the therapeutic efficacy (Figure 6). If the appliance is adjustable, either the patient or clinician may incrementally adjust or advance it in order to achieve an optimal position for improving sleep continuity, reducing snoring, and alleviating obstructive events.^5,7 Adjustable oral appliances enable adjustments without the need to recreate or reset the appliance. In a study of adults with sleep-disordered breathing, Kato et al8 found oral appliances successfully mitigated pharyngeal collapsibility.

Advancements in digital technologies have resulted in rapid developments in materials and techniques for fabricating oral appliances. Oral appliances are made of biocompatible materials that must engage both the maxillary and mandibular arches with great precision. This level of detail affords the patient the enhanced experience of comfort. The newer generation of oral appliances are produced from 3D-printed thermoplastic materials for both the maxillary and mandibular arches, along with their titration rods (Figure 7). Multiple titration rods allow the patient to make adjustments in 1-mm increments with a protrusive adjustment range of at least 5 mm.⁶ The patient simply replaces the titration rods to advance the mandible until obstructive sleep apnea symptoms lessen or subside.

Another recent innovation in OSA oral appliance compliance comes from Panthera Dental (pantheradental.com). The company recently launched D-SAD, or the digital sleep apnea oral device, with an integrated compliance sensor. This digital recorder has a lifetime battery and is inserted into the oral appliance with a chip providing downloadable data. Patients mandated by employers to use such a device can provide their companies, unions, associations, and insurance providers with clear and usable data regarding compliance and legal proof if such a situation should arise. Furthermore, the same digital recorder can be read at the clinician’s office to assess if the patient was compliant with the treatment protocol and goals, making needed treatment decisions more relevant and leading to an enhanced level of treatment success.

Dental laboratories can benefit greatly by gaining knowledge about this market and providing their customer bases with another dental solution, which ultimately produces a new source of business revenue. Hosting a study group or seminar on sleep medicine for existing clientele and new or prospective customers provides a relevant source of education that will differentiate your business from the competition. The dental laboratory can furthermore be the vehicle by which the dentist can provide these oral appliance solutions to their patients. Once the dentist impresses both arches, the dental laboratory can pour the impressions in gypsum material, and void any bubbles or tears that may negatively affect the fit of the mandibular advancement oral appliance. In the new age of digital dentistry, some companies also have the ability to forego the costly and time-consuming model production and fabricate these devices directly from approved intraoral scan technologies.

The problem of OSA is in epic proportions and needs to be addressed with proper care. Treatment initiatives will not only provide better overall health and well-being for afflicted individuals but could potentially save them from a catastrophic consequence, alleviate existing medical conditions, and improve quality of life. It also provides another obvious scope of treatment for the dental professional; the dentist can treat a large segment of the practice’s existing patient base and attract new patients seeking help with OSA. Furthermore, the dental laboratory can become the conduit by which the oral appliance is manufactured, making this a true win-win-win for all involved.

The author thanks Michael Gelb, DDS, MS, Owner of the Gelb Center in New York, for the images.

Daniel Alter, MSc, MDT, CDT, is a consultant and Professor at New York City College of Technology.

The author had no disclosures to report.

1. Shelton T. The Price of a Good Night’s Sleep: Insights into the US Oral Appliance Market. Vital Signs. https://www.marketresearch.com/product/sample-8745989.pdf. Accessed November 18, 2015.

2. Who Must Register, List and Pay the Fee. U.S. Food and Drug Administration web site. https://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/HowtoMarketYourDevice/RegistrationandListing/ucm053165.htm. Updated August 15, 2014. Accessed November 23, 2015.