Dental Sleep Medicine 3

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Published: Tuesday, 26 August 2014 11:35 Written by 

Dr.Wesam Al-saadi
Treatment Modalities
Some treatments involve lifestyle changes, such as avoiding alcohol or muscle relaxants, losing weight, and quitting smoking. Many people benefit from sleeping at a 30-degree elevation of the upper body or higher, as if in a recliner. Doing so helps prevent the gravitational collapse of the airway. Lateral positions (sleeping on a side), as opposed to supine positions (sleeping on the back), are also recommended as a treatment for sleep apnea, largely because the gravitational component is smaller in the lateral position.

Some people benefit from various kinds of oral appliances to keep the airway open during sleep. Continuous positive airway pressure (CPAP) is the most effective treatment for severe obstructive sleep apnea but oral appliances are considered a first line approach equal to CPAP for mild to moderate sleep apnea. There are also surgical procedures to remove and tighten tissue and widen the airway.

Oral Appliances

Oral appliances (OA) are a front-line treatment for patients with mild to moderate Obstructive Sleep Apnea (OSA) who prefer OAs to continuous positive airway pressure (CPAP), or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep position change. This small plastic device fits in the mouth during sleep like a sports mouth guard or orthodontic retainer. Oral appliances help prevent the collapse of the tongue and soft tissues in the back of the throat, keeping the airway open during sleep and promoting adequate air intake. Oral appliance therapy (OAT) is usually successful in patients with mild to moderate obstructive sleep apnea. OAT is a relatively new treatment option for sleep apnea in the United States, but it is much more common in Canada and Europe.
Oral appliances may be used alone or in combination with other treatments for sleep-related breathing disorders, such as weight management, surgery or CPAP.

Oral Appliance Therapy

Oral appliance therapy involves the selection, fitting and use of a specially designed oral appliance that maintains an open, unobstructed airway in the throat when worn during sleep. Custom-made oral appliances are proven to be more effective than over-the-counter devices, which are not recommended as a screening tool or as a therapeutic option.

Dentists with training in oral appliance therapy are familiar with the various designs of appliances and can help determine which is best suited for patients specific needs. A board certified sleep medicine physician must first provide a diagnosis and recommend the most effective treatment approach. A dental sleep medicine specialist may then provide treatment and follow-up.

The initial evaluation phase of oral appliance therapy can take several weeks or months to complete. This includes examination, evaluation to determine the most appropriate oral appliance, fitting, maximizing adaptation of the appliance, and the function.

Ongoing care, including short- and long-term follow-up is an essential step in the treatment of snoring and Obstructive Sleep Apnea with Oral Appliance Therapy. Follow-up care serves to assess the treatment of sleep disorder, the condition of the appliance, patients physical response to his appliance, and to ensure that it is comfortable and effective.

Advantages of Oral Appliance Therapy
Oral appliances are comfortable and easy to wear. Most people find that it only takes a couple of weeks to become acclimated to wearing the appliance.
Oral appliances are small and convenient making them easy to carry when traveling.
Treatment with oral appliances is reversible and non-invasive

How Oral Appliances Work
Repositioning the lower jaw, tongue, soft palate and uvula
Stabilizing the lower jaw and tongue
Increasing the muscle tone of the tongue

Types of Oral Appliances

With so many different oral appliances available, selection of a specific appliance may appear somewhat overwhelming. Nearly all appliances fall into one of two categories. The diverse variety is simply a variation of a few major themes. Oral appliances can be classified by mode of action or design variation.

Tongue Retaining Appliances

Tongue retaining appliances hold the tongue in a forward position using a suction bulb. When the tongue is in a forward position, it serves to keep the back of the tongue from collapsing during sleep and obstructing the airway in the throat. They are custom-made using a soft, pliable material with a compartment that fits around the tongue to hold it forward by means of suction. This device is used most for patients with dentures or patients who cannot adequately advance their lower jaw. The TRD may require some time for the patient to adapt to having their tongue held in place, so a tongue exercise and adaptation program is started a few weeks prior to the date of insertion of the device. The patient must be able to breathe well through their nose or they may have difficulty tolerating this appliance.

Mandibular Repositioning Appliances

Mandibular repositioning appliances reposition and maintain the lower jaw in a protruded position during sleep. The device serves to open the airway by indirectly pulling the tongue forward, stimulating activity of the muscles in the tongue and making it more rigid. The device also holds the lower jaw and other structures in a stable position to prevent the mouth from opening. They are custom-made for each patient. The device is made of a special heat-sensitive acrylic material that will fit snugly, but comfortably over the upper and lower teeth. The MADs have an adjustment mechanism built into the device that allows the patient to gradually change the position of the bottom jaw under the dentist's supervision to improve the effectiveness of the device. Since the appropriate jaw position to achieve success with treatment is unique to each patient this is a very valuable feature.

The choice of which appliance will be used for each patient is based on many factors. These factors include severity of the apnea condition, patient's bite and jaw structure, size of the tongue and soft palate, presence of tooth clenching or grinding, jaw range of motion, health of teeth and gums, and many others.

Examples of Oral Appliances
• TAP Appliance

The Thornton Adjustable Positioner is a mandibular advancement device for the treatment of snoring and sleep apnea. Developed with advanced dental technology, the TAP improves breathing and eliminates snoring in over 95% of all patients. The TAP effectively treats sleep apnea and reduces the impact of associated health risks without the need for surgery, CPAP, or medication.. It fits more comfortably in the mouth. The smaller hardware provides more room for the tongue and allows the lips to close. The TAP gives dentists numerous options to create the best, customized treatment solution for their patients. Interchangeable hooks can accommodate Class I, II and III bites and increase the vertical distance between upper and lower teeth.
The TAP is intended to reduce or alleviate nighttime snoring and obstructive sleep apnea (OSA). The appliance is for adult patients to be used when sleeping at home or in sleep laboratories and is for single-patient use. This device is comfortable on the teeth and allows good freedom of movement of the jaw. Therefore it is used frequently for patients who tend to grind their teeth heavily. The front assembly is located near the tip of the tongue and it protrudes between the lips, so it may take a little bit more time to adapt to the device. The device is contraindicated for patients with loose teeth, loose dental work, dentures, or other oral conditions which would be adversely affected by wearing dental appliances.
In addition, the appliance is contraindicated for patients who have central sleep apnea, have severe respiratory disorders, or are under 18 years of age.
The TAP holds the lower jaw in a forward position so that it does not shift nor fall open during the night. This prevents the airway from collapsing. The TAP is the only mandibular advancement device that can be adjusted by the patient or practitioner while in the mouth. Most patients experience relief the very first night they wear their TAP. Although it may take up to a week to get used to wearing a TAP appliance, this is a small hurdle for patients. Nine in ten patients wear the device all night, every night - making the TAP a highly effective solution for both snoring and sleep apnea.
For more info:

• Somnomed

The SomnoMed MAS™ is an oral appliance, which fits over the upper and lower teeth, much like a sports mouthguard. Unlike a sports mouthguard, however, it is a precision-made, clinically-tested medical device, which is highly effective (in most cases) in preventing snoring and mild to moderate obstructive sleep apnea.
The medical term for your lower jaw is ‘mandible’ and an oral appliance worn over the teeth is a ‘splint’, hence the name SomnoMed Mandibular Advancement Splint, or SomnoMed MAS™

• Klearway Appliance :

This is a thermoplastic appliance which must be heated in hot tap water every night (to make flexible) before it is placed in the mouth. It allows for some side-to-side movement of the bottom jaw and limited opening, so that water can be sipped without removal of the appliance. The adjustment hardware is on the roof of the mouth and it takes some time to get used to swallowing with material in that location. The patient is able to adjust the bottom jaw forwarded in very tiny 25 mm increments. The appliance is completely contained within the mouth, and though it makes the lips look a bit puffy, is completely hidden when in use

• Modified Herbst Appliance :

This is a hard plastic appliance which has the adjustment hardware set on the cheek side of the molar teeth. It prevents side-to-side motion, but since the bottom jaw is held closed with small orthodontic rubber bands, opening the jaws is fairly easy. The modified Herbst is smaller than most appliances and has a long life span. It allows jaw movement in all directions but backwards. The patient can take medications, use an asthma inhaler or talk with this appliance in place. This appliance can be fabricated out of material that has no methylmethacrylate and is thus safe for patients who are allergic to this material.The modified Herbst is one of the ‘yardsticks’ used by other appliances seeking FDA acceptance. Patients who severely grind their teeth at night can crack this appliance

• E.M.A Appliance :

The E.M.A. is the thinnest and least bulky of all the appliances. It is similar to clear acrylic orthodontic retainers, and the 'hardware' (located to the cheek side of the molar teeth) consists of specially designed, patented elastic bands. This appliance moves the jaw forward in fairly significant steps, which may be difficult to tolerate. Some care must be taken to avoid breaking the lower portion when replacing the custom elastics. The EMA is well tolerated by patients who grind their teeth. It has no metal and can be used by patients with a nickel metal allergy.

• Adjustable PM Positioner

Is a custom-made appliance constructed of a heat-sensitive acrylic that fits over the upper and lower teeth. The appliance is comfortable on the teeth and leaves added space for the tongue compared to other devices. It allows a small amount of jaw movement (4mm) so that the patient does not feel "locked into position". The adjustment mechanisms are on the cheek side of the appliance near the molars and allows for easy advancement of the jaw position to improve effectiveness of the device when it is indicated its most frequently used because of its ease of use, effectiveness and durability.

• Silent Nite Appliance:

It is a smaller appliance that is very comfortable to wear and can be effective for patients who are primarily snorers or have very mild apnea. However it is less durable and has much less adjustability.

• SnoreAid and Therasnore appliances:

Snore-Aid plus is an adjustable mandibular bite plate that advances the mandible and repositions the tongue anteriorly and superiorly. The single plate orthotic utilizes an external lip shield and occlusal coverage to minimize tooth pressures. It has no components that interfere with tongue posture and vertical dimension can be altered at chair side. This appliance is constructed from special thermoplastic resins and vinyl polymers which make it comfortable, easy to fit and very retentive. The external lip shield is easily titrated and can be quickly re-adjusted. The single plate design enables the appliance to be compatible with the patient's natural articular pattern and condylar path and this renders it a suitable appliance for nocturnal bruxers and TMD sufferers. Description for Web sites (public): Snore-Aid plus is comfortable laboratory constructed oral appliance that is prescribed by the dentist for snoring and mild obstructive sleep apnea. The appliance works by advancing the mandible and positioning the tongue to open the patient's airway, thus permitting easier breathing and preventing loud snoring. Snore-Aid plus allows the patient to have their natural jaw motions while they sleep so that their jaws do not become sore from wearing the appliance all night, every night. This is particularly helpful in patients who grind their teeth (bruxism). Speaking, yawning, and swallowing are not impaired by Snore-Aid plus. Dentists value how easily the appliance can be fitted and adjusted. This durable appliance rarely needs repair.

• Therasnore appliances:

The TheraSnore is one of the few appliances that requires no laboratory construction and is easily fitted chairside from a boil and bite blank.
In the non-adjustable device the mandible is retained in a protrusive position with pliable thermoplastic material and is afforded limited movement. Protrusive adjustability is possible to a small degree.In the adjustable TheraSnore, patients are started at centric relation. Should it be necessary to protrude the mandible, it can be done in precise 1.5 mm increments without refitting the appliance.
The Adjustable TheraSnore is also available in 3 different arch sizes based on the most commonly used impression trays. This has been very important to TheraSnore patients who have a smaller or larger than average arch size. The TheraSnore also allows the mandible complete vertical and lateral freedom of movement to ensure the problems associated with TMJ/TMD are thereby avoided and the patient is comfortable.

• Reference

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