Practices that have successfully implemented snoring, sleep apnea and headache treatment programs fall into two basic categories:

1. Those that receive referrals from physicians.
2. Those that generate their own cases by developing simple, direct language around treating snoring, sleep apnea and chronic headaches as part of a custom nightguard program.

Many communities in the U.S. have a dental practice that is well entrenched with local physicians and in network with medical insurers. This article is not for them.

Rather, this article is for the rest of the dentists in the community. This includes clinicians who do not have a relationship with a local sleep physician and are not on the preferred referral list, but need to deliver sleep and headache nightguards as part of the general practice of dentistry.

An estimated 16.5% of people experience parafunctional jaw activity that results in severe tooth wear due to clenching, grinding and tapping during sleep. A patient-specific nightguard is a device that is formed to the upper or lower dentition to protect teeth from wear. It is very common for a dentist to prescribe a nightguard to protect dental restorations and to treat sleeping conditions and disorders, including the following:

• Bruxism — Clenching, grinding and tapping during sleep that can result in worn dentition, jaw pain and tension-type headaches. When wearing a nightguard like the NTI-tss Plus^® or the NTI OmniSplint^®, the patient’s teeth are separated during sleep so that the teeth are protected, and clenching force is reduced. Headaches are much less severe or do not occur.
• Snoring — While technically not a medical condition, snoring is due to a partially collapsed airway and can be very disruptive to sleep quality. Nightguards for snoring position the lower jaw forward to pull the tongue forward and support the tissues of the upper airway.
• Sleep apnea — A potentially serious sleep disorder where the tongue falls back into the airway, causing the tissues of the throat to collapse. The obstruction of airflow can be severe, and comorbid conditions may include diabetes, heart disease, stroke and, in some cases, early death. Sleep apnea is a medical condition that requires diagnosis and management by a physician.

It is relatively uncommon for neurologists to provide a dental referral for patients who suffer from headaches related to clenching and grinding due to parafunctional jaw activity. Still, the NTI-tss Plus and NTI OmniSplint have begun to gain traction for the treatment of chronic headaches and clenching. Chronic headaches can be identified with a simple questionnaire in the dental office.

Mandibular advancement devices (MAD) for the treatment of snoring and sleep apnea are much more mainstream. According to a recent CDC report, nearly 65% of adults in the U.S. see their dentist at least once a year, putting the dental office in the ideal position for timely intervention. However, the traditional model of providing this care is expensive and time consuming, and dental teams often report that it does not fit well within a dental practice. These practices often have the greatest challenge with treatment acceptance, even though patients in need of care are typically found in the existing patient population (i.e., patients who are already under care and already trust the dentist to provide the treatments they need).

Dental insurers report that only 50% of adults between the ages of 18 and 64 have coverage. It is very common for preventive care, including cleanings and annual exams, to be covered procedures, but not all dental insurers cover nightguards. It is best to plan on the patient paying out of pocket for preventive care like nightguards to protect against tooth wear.

In 2021, dentists in the U.S. were expected to deliver over 18 million nightguards, and it is customary in most states for the impressions and delivery of custom nightguards to be the responsibility of auxiliary dental team members.

Treatment acceptance tends to turn on a few basic elements, such as perceived need, cost and payment options. But most importantly, the clinician should be trusted to understand the patient’s condition and treat it effectively.

The key differences between different kinds of nightguards are subtle and often only apparent to the clinician delivering the device. Features like retention, cuspid rise, vertical dimension and titration methods are important to the dentist, but can be a bewildering distraction when patients are considering accepting a treatment.

To the patient, this is simply a nightguard, which has special capabilities such as stopping snoring, reducing clenching, preventing headaches, and protecting teeth from damage. Some very successful dental practices have a flat-fee nightguard policy to make these treatments more accessible to more patients. Flat-fee programs make case presentation by auxiliary dental team members much easier because the fee is handled outside of the clinical setting.

A script might sound like one of the following examples:

Mrs. Smith, Dr. X noticed that your teeth are showing advanced wear. She has prescribed a nightguard for you today to protect your teeth and dental work against damage. Before I scan your teeth, I noticed that you indicated that you experience headaches. Would you like us to make you the nightguard that helps prevent headaches and migraines?

Mrs. Smith, Dr. X noticed that your teeth are showing advanced wear patterns. She has prescribed a nightguard for you to protect your teeth while you sleep. Before we get started, I noticed on your health form that you have a snoring history. Would you like me to order the nightguard that treats snoring so that you sleep better at night?

The second script opens the door to a more in-depth discussion about snoring and introduces sleep apnea as a possible comorbid condition. Sleep apnea is a medical condition that requires a medical diagnosis.

When making a snoring nightguard for provisional mandibular advancement device (PMAD) therapy, it is very important to have a discussion about sleep apnea and providing a referral to a physician for medical management if necessary. This discussion needs to be documented in the patient’s records with an informed consent document.

Patients deciding on dental care tend to consider a number of parameters that they feel are important. Cost of care in the dental office is a particularly important stressor, especially if the patient does not have health insurance.

The key determining factor of whether the patient goes forward with care is based on both trust in the clinician and the communication with the dental team. This communication starts from the moment the patient arrives for treatment. Preventive care with a nightguard is perhaps the least anxiety-inducing dental treatment available in the dental office.

NTI-tss Plus is a registered trademark of Boyd Research, Inc. NTI OmniSplint is a registered trademark of James Boyd.