Snoring and sleep apnea are common signs of disturbed sleep patterns. However, it can be difficult to talk to patients about snoring and sleep apnea treatment, particularly when patients see negative or humorous portrayals of continuous positive airway pressure (CPAP) on social media and elsewhere. Patients might assume CPAP is the only option and not realize that dental sleep apnea treatment is an effective alternative. Patients may also feel strange talking to a dentist about a medical condition that has no obvious connection to the teeth, jaws or gums.

While snoring, sleep apnea and CPAP can be characterized as humorous, sleep-disordered breathing may also be associated with conditions such as:

• Diabetes
• Heart disease
• Stroke
• High blood pressure
• Bed wetting
• Fragmented sleep patterns
• Concentration issues
• Mood changes
• Nighttime sweating
• Excessive daytime sleepiness

It is recommended that dentists speak with patients about sleep-disordered breathing during routine exams. If snoring and sleep apnea are disrupting sleep patterns, treatment may provide a significant improvement on the patient’s overall health and well-being. Here are top questions and answers that patients need to know to better understand dental sleep apnea treatment.

Dental treatment for snoring and sleep apnea has been in the literature since the early 1900s, when Dr. Pierre Robin identified that the airway size corresponds to the position of the jaw. Dr. Robin developed a simple monobloc device that held the jaw in a protrusive position. This was the first documented use of an oral appliance for the treatment of snoring.

Modern oral appliance therapy incorporates titratable devices that allow the advancement of the mandible in increments of 1 mm or less. This gives a trained dentist the ability to move the mandible forward or backward depending on the patient’s response to this treatment.

Naturally, there is more than one way to get this kind of adjustment, and as the patient’s comfort is considered, there are different functional components that achieve the desired results.

Snoring and its more serious comorbid condition sleep apnea are signs of a collapsing airway. In fact, snoring is the sound that a partially collapsed airway makes. When the patient falls asleep and the tissues of the airway relax, the jaw can fall back in the airway. As the base of the tongue approaches the wall of the hypopharynx, the rushing air vibrates soft tissue of the airway, creating the snoring sound.

When the airway completely collapses, the soft tissues can adhere to each other, creating an obstructive seal of the airway. The seal stops the patient from breathing entirely and can last for 10 seconds to more than a minute, despite the patient’s efforts to breathe. This is a serious medical condition.

If snoring is accompanied by any of the following issues, it may warrant consultation with a dentist or physician for sleep apnea evaluation:

• Witnessed breathing pauses during sleep
• Excessive daytime sleepiness
• Difficulty concentrating
• Morning headaches
• Dry mouth upon awakening
• Restless sleep
• Gasping or choking at night
• High blood pressure
• Chest pain at night
• Loud snoring that disrupts a partner’s sleep

Oral appliances for snoring and sleep apnea treatment have a very specific method of action. They are designed to cover and engage the upper and lower teeth, like a retainer or nightguard. These appliances all have some mechanism that joins the upper and lower splints, so that they are fixed together. This is how the lower jaw (mandible) is held in a position set by the dentist to apply tension to the muscles and ligaments of the upper airway and support the airway all night long.

As noted above, this position is an anterior or advanced jaw position, and it can be different for every patient. Modern oral appliances are all adjustable between 6 mm and 15 mm. This allows the dentist to adjust the lower jaw position after the appliance has been delivered, and the patient adapts to the initial jaw position.

This adjustability is key to sleep apnea treatment because the tissues of the airway can change over time. It is also important to understand that the muscles and ligaments of the jaw and airway will adapt to the protrusive jaw position over time. The slight change in jaw position that comes from this adaptation can result in more snoring. Adjusting the appliance by a millimeter or so will serve to restore airway patency.

The fit, form and function of oral appliances for snoring and sleep apnea fall into a few general categories. Among the appliances available from Glidewell, there are three simple categories of bilateral and traction hinge devices: oblique traction, oblique compression, and horizontal compression or traction.

Oblique traction devices are very popular and include the Silent Nite and EMA^® appliances. These devices feature straps or bands on the sides of the appliances that pull the jaw forward. Adjustments of 1 mm can be accomplished by changing the length of the straps or bands.

This design is favored by dentists because the oblique angle of the bands allows patients to open their mouth, yet it promotes jaw closure for patients who have their mouth open during sleep. Another reason these devices are favored is because they allow lateral mobility for patients who brux or find more constricting appliances claustrophobic. These appliances are also made from inexpensive materials, so they are value-priced and easy to deliver.

Oblique compression devices using stainless steel hinge mechanisms are based on an appliance design that was invented by Dr. Emile Herbst in 1909. Dr. Herbst contributed over 90 appliance designs to the world of modern orthodontics, but the Herbst hinge design is widely recognized as his most enduring contribution to the field. In recent years, this style of appliance has received some design changes to capitalize on over 100 years of clinical input.

This hinge design is particularly beneficial because it was selected by Medicare as an appliance design that meets the requirement for E0486, the current HCPCS (Healthcare Common Procedure Coding System) medical code for a custom-fitted mandibular sleep apnea appliance used for dental sleep medicine medical billing.

These devices are micro-adjustable by using the adjustment tool included with each appliance. Since the appliance is bilateral, it is necessary to turn the screw an equal amount on each side of the appliance. The OASYS Hinge Appliance has a scale on the arms to make balancing the titration of the appliance easy.

The position of the adjustment screw in the front of the mouth gives the clinician the option of adjusting the appliance while it is in the patient’s mouth. This appliance design is good for patients who suffer from bruxism. Patients with a claustrophobic history will respond well to this appliance because it allows freedom of movement and the ability to open their mouth.

The angle of the arms and the fact that this design pushes the jaw into protrusion can encourage an open mouth posture and mouth breathing. The addition of elastics will serve to help keep the mouth closed and the lips sealed, as well as encourage nasal breathing, which is beneficial to a good night’s sleep.

The horizontal compression or traction device is a well-known method of positioning the mandible during sleep. The control that these devices offer allows specific anterior or posterior position because of the screw mechanism that is the defining characteristic of the device. This category of device was defined by Dr. Keith Thornton in the early 1990s with his Thornton Adjustable Positioner (TAP^®) products. The dreamTAP^™ appliance is the latest iteration of this style of oral appliance.

These devices have a fixed vertical dimension of occlusion (VDO) due to the position of the hinge on top of or just behind the lateral incisors. For this reason, the splints require excellent retention to accommodate natural movements of the jaw during sleep. In order for the device to provide a therapeutic effect, it needs to stay on the teeth and hold the jaw in the dentist-prescribed position. This style of appliance has a free and luxurious lateral range of motion, which lateral bruxers tend to like.

Dentistry offers excellent options for snoring and sleep apnea treatment, and they have excellent outcomes based on clinical studies and patient feedback. Patients and their dentists may have difficulty initiating discussions about snoring and sleep apnea because they might perceive dentistry to be a discipline solely focused on the teeth, jaws, and gums, not as an important contributor to overall health and wellness.

Key to the advancement of dental sleep apnea treatment as a discipline is communication with patients, as well as primary and specialty health providers. Dentists provide custom solutions for very specific health conditions that can be managed with tooth-borne therapies. Successful treatment of sleep-disordered breathing requires devices that the patient can wear all night, every night.

To discover the simple, three-step process to screen and treat patients for snoring and sleep apnea, visit glidewell.com/pmad.

Looking for a hands-on tool to enhance your communication with patients? Available for dental practices, the Sleep Appliance Sample Kit helps patients learn about various sleep devices during consultation. For more information or to order the kit, call 888-303-3975.