Dental Sleep Medicine in Restorative Practice Part 5: Selecting Appliances 

By Todd Sander DMD 

This article is written for dentists who are thinking about or just starting a dental sleep medicine practice. I do both restorative dentistry and dental sleep medicine, and by sharing what I do, I hope to help others with their planning. 

There are many other types of appliances you can consider and I am always looking at them. But to become most efficient, I have narrowed down the types of appliances I deliver. Most commonly, these are Dorsal and Herbst appliances. Both are titratable, as the patient needs more advancement over time..  

The dorsal appliance resembles a custom-fitted mouthguard, worn only during sleep. It uses advancement blocks with an orthodontic screw to advance the jaw. There are many manufacturers, and it is easy to deliver. It doesn’t impinge on the tongue, so patients find it comfortable. It is fairly durable and repairable, especially if milled out of acrylic. This is my go-to type of appliance for most patients because patients respond favorably to them. 

A Herbst appliance is more durable for parafunctional patients and fairly comfortable. Patients are sometimes intimidated when they first look at this type of appliance but I always point out that the advancement bars are in the dead space of the cheeks, and they won’t feel them. There are many types of Herbst appliances with different types of advancement arms. 

I sometimes deliver an EMA appliance or a TAP 3 appliance. I have found that the screw and bar assembly of TAP appliances can impinge the tongue a little. My preference is to use appliances that provide more room for the tongue to move forward. Milling and 3D printing have introduced many low-profile, stable, and comfortable appliances that deserve investigation.  

Whatever appliance you decide to use, become knowledgeable and proficient with it. You want to convey confidence to your patients. The more they trust in the appliance, the more compliant they will be with wearing it and the sooner they can achieve improvement of their sleep breathing issues. Oftentimes, they will feel better within a week or two and report this during their first recall visit. When they report improved symptoms, we can move on to confirming the treatment position with a home sleep monitor and refer them back to their physician. Treatment position can also be confirmed prior to appliance fabrication by using a MyTAP temporary appliance.  This can improve the initial treatment position and is necessary for non-titratable appliances..  

With most patients, we take two steps forward and one step back as we titrate an appliance to an effective treatment position. Sometimes I need to send an appliance back, so I’ve become used to taking a bite registration myself and sending it to the lab to reset the appliance in a more forward position.  Using a MyTAP to determine treatment position ahead of time helps prevent this. We prepare our patients for this possibility and provide encouragement to stay on course. Working as a team with our patients, we will get there! 

Dental Sleep Medicine in Restorative Practice Part 4: Treatment Monitoring 

By Todd Sander DMD 

One week after a dental sleep medicine patient is given their appliance I have them return for a follow-up appointment with my clinical assistant. During this appointment, we want to determine if the patient is having any issues. It takes a little time for patients to become accustomed to wearing their appliance and most patients have questions, so this appointment is a time to reassure them and reinforce instructions for advancement if the patient has a titratable appliance. After one week, many start to experience the benefits of 50 to 60% advancement. 

We bring them back again at four to six weeks, at which time, we review their medical history and see if there have been changes. We also evaluate their compliance. We have a sleep log for patients to fill out every morning after they wake. We ask them to make notes about the quality of their sleep. We also have a report form for the patient’s bed partner if the patient has one to make note of the patient’s sleep quality. Believe it or not, spouses/bed partners are accurate 80% of the time when compared with sleep monitors. My clinical assistant reviews the sleep logs and medical history, performs a preliminary appliance check, and lets me know the highlights. Then I come in and perform a thorough examination and lead a discussion to determine how well the patient is adapting to the appliance. 

If the patient is doing well with compliance and feels the therapeutic value of the appliance is adequate, I might decide to skip the eight to ten-week appointment and go straight to confirmation of resolution of symptoms with some sort of monitor. If the patient is not doing well or cannot advance comfortably, then we work out a plan. It is important to note that there are many effective appliances that are non-titratable and fabricated in a fixed position. With these appliances, I work out the titration to the treatment position in My TAP following a similar protocol before prescribing a treatment position in a final appliance. 

Note that we often see issues that cross over into the area of facial pain and temporomandibular joint problems. Many patients doing sleep appliance therapy have these problems, so if you want to do sleep dental medicine, be prepared to also manage your patients through facial pain and TMD issues as you titrate their appliances. 

Usually, in eight to ten weeks, we have successfully taught our patients to self-titrate the appliance to a comfortable treatment position, and we can move to monitor its effectiveness. We are always available to answer questions.  

People wearing Fitbits and iWatches can use snore lab apps. By self-monitoring, they have a good sense of when their appliance is in a good treatment position. In our practice, we always confirm this with either a high-resolution pulse oximetry monitor or a peripheral arterial tone monitor. These two types of monitors provide data we give the referring physician. I always send a letter and report back to the patient’s sleep physician and general dentist (if the patient is not also a general dentistry patient), and I ask the patient’s permission to include their primary doctor in the loop.  

After this, I see my sleep dental medicine patients for a six-month visit, then once a year for an annual visit. Often there are issues to be addressed. Sometimes the appliances need to be titrated a little bit more. Sometimes patients have been seating them improperly. Sometimes we see bite changes to address and document. 

My regular examination and treatment protocols for dental sleep medicine patients are based on what I learned from mentors, but I’ve molded them for my style of practice.  

Screening—Years ago, I offered 15-minute consultations for anyone who wanted to learn about dental sleep medicine and alternatives to CPAP. I found that patients were already well-versed, so I don’t do that anymore. When my team members answer the phone, they often answer insurance-related questions, and my team members have learned to answer those questions astutely. While on the phone, they weed out those just curious about how a dentist might help them and focus on those likely to be committed to my process and accept treatment. I have team members who are knowledgeable about oral appliances and quickly answer questions about them over the phone. 

Pre-Examination Records—Referred patients scheduled for a comprehensive dental sleep medicine exam are sent paperwork to complete before their examination. My clinical assistants gather the paperwork, including a detailed medical history, the referral from a sleep physician, the letter of medical necessity, and their polysomnogram, if they have had it, and the hypnogram. We gather as much data from the physician as possible. I review this in advance of seeing the patient. 

Pre-Examination Records Created by My Clinical Assistant—When patients arrive for their initial two-hour appointment, my clinical assistant takes digital impressions (sometimes we take traditional PVS impressions) and x-rays. She also collects vitals and interviews the patient just as a medical assistant would in a medical office. 

Examination—During a thorough examination, I voice-record the information needed for the medical documentation. By the end of the exam, I know what the patient’s treatment options are going to be and the anticipated charge for treatment. Sometimes the patient is not a candidate for a sleep appliance and I refer the patient to their physician. We still get paid for the comprehensive exam. Our patients are prepared for this. Even if we can’t help them, they appreciate the time we spend. When each patient leaves the comprehensive exam, we have all the information we need, including a protrusive bite registration if the patient is to receive an appliance. 

Medical Reimbursement—In my practice, payment is due upfront for the examination. If they know this is coming in, they’re accepting of this. We have chosen to do our best to help patients seek medical reimbursement and submit the required medical documentation for their insurance. We operate on a fee-for-service model, and this requires intentional conversations with patients so they will value our care, skill, and judgment whether insurance reimburses them or not. 

Second Appointment to Start Appliance Therapy—My clinical assistant helps by initially trying in the appliance we have had lab-fabricated. She educates the patient about warming the appliance in warm water if it is a thermoplastic material and fabricates a morning repositioner. Then I come in and do a fit check, spend more time adjusting the appliance if needed, answer questions, confirm that the appliance has been fabricated correctly, and review instructions for wearing the appliance and using the morning repositioner. For titratable appliances, I usually start an appliance at 50 to 60% protrusive if it’s a mandibular advancement appliance. I ask the patient not to advance the appliance for one week. If the appliance is titratable, we educate the patient on how to advance 1-2mm every two to three days until symptoms alleviate.  

Part 4 of this series will discuss how I monitor my sleep dental medicine patients. 

Why Patients Want Early Detection

For more than a decade, there has been an increase in the occurrence of head and neck cancers in the United States. According to the American Cancer Society, over 53,000 people in the United States will be diagnosed with oral or oropharyngeal cancer in 2020. Worldwide, new cases of oral and oropharyngeal cancer exceed a devastating 640,000 people per year.

Head and neck cancers include those occurring in the lips, mouth, tongue, and throat. These cancers are often referred to as oral cancer or oropharyngeal (back of the mouth and throat) cancer. There are two distinct pathways by which most people develop these cancers. The one most familiar is through the use of tobacco and alcohol, and the other is through exposure to the HPV-16 virus (human papilloma virus, version 16). HPV-16 is a more recently identified etiology and the same one that is responsible for the vast majority of cervical cancers in women. In less than 7% of oral cancer cases, there is no known cause, and it is believed that these cancers are related to a genetic predisposition.

While oral and oropharyngeal cancers are still considered uncommon, The Oral Cancer Foundation reported in 2019 that approximately 132 people in the US are diagnosed each day and one person dies from oral cancer every hour of every day. This sobering statistic has not improved in many years. The most recent statistics reported by the American Cancer Society indicate there has been an ongoing rise in cases of oropharyngeal cancer linked to HPV infection in both men and women.

Oral cancers have an 80%-90% survival rate when found at early stages. Unfortunately, the majority of oral cancers are found in the late stages and this is the reason for the very high five-year death rate of 43%. Late-stage diagnosis is said to be a result of many complex conditions including a lack of public awareness and a lack of professional screenings in dental and medical offices.

Automatically Include Cancer Screening

Within your exam fee, I urge you to include a thorough oral cancer exam. Make sure your patients know the screening is automatically included in your new patient and regular exams. While performing the screening, talk about what you are doing and why. Patients are becoming more and more proactive about their health and are more than pleased to know about the inclusion of the screening. This is a health-centered benefit of your practice that will distinguish you. If your patients are aware that you are doing it, they will mention it to others and their confidence in you will grow.

Another Opportunity to Engage New Patients

My friend Linda Miles, co-founder of Oral Cancer Cause, says, “During the last few years of my teleconsults, I encouraged each dentist to develop a strong relationship with their local oncologists, radiologists and ENT specialists so that he or she would become the go-to dentist to do dental clearances for all cancer patients especially the head and neck cancer patients. In order to start radiation or chemo, all pending dental treatment must be completed. This ranges from hundreds to tens of thousands of dollars per patient to the practice. Dental Oncology is a growth path many should develop.”