The role of the sleep-disorders dentist in the management of sleep-disordered breathing is expanding. Most medical sleep teams now include a properly trained dentist.
Duties of the dentist include:
Dr. Rogers’ and Mary Beth Rogers’ experience with oral appliance design and associated technology stretches back to its early days. They have seen the field steadily progress over the past 20 years, and are well-versed in its latest advances.
The appliances and screening/titration monitors used in Dr. Rogers’ practice have been thoroughly researched and documented to produce positive results for patients. All appliances and devices are FDA approved.
Unlike most offices that use a single appliance, Dr. Rogers offers several different oral appliances, choosing the one that is best for you. The choice of oral appliance is made after a thorough medical history and oral examination.
Oral Appliance Therapy
Of the many appliances available today, each falls under one of two categories based on mode of action.
The first and largest category is that of the “mandibular repositioning device.” The vast majority of appliances in use today fall into this category. These devices gently reposition the lower jaw forward during sleep.
The second category is that of the “tongue retaining device.” These appliances are seldom used but can be especially effective for people with few to no teeth or jaw joint problems. Tongue retaining devices function by protruding the tongue forward during sleep.
TAP -Thornton Adjustable Positioner
The Thornton Adjustable Positioner (TAP®) oral appliance is a mandibular advancement device composed of two separate arches (maxillary and mandibular) containing an advancing mechanism that permits unlimited advancement of the lower jaw. The arches are custom fitted to a patient's models. The advancing mechanism is engaged, and the screw mechanism in the upper tray is then turned to advance the mandible until the patient begins to feel any discomfort in the temporomandibular joint or in the facial muscles (maximum mechanical protrusion which is an average of 2.5mm beyond maximum protrusion). The advancing screw is then turned back until patient is comfortable.
PM Positioner
The Adjustable PM Positioner™ utilizes materials and design to minimize office chair-time and provide the patient control of adjusting the jaw position under the dentist’s supervision. Research studies have shown that this appliance is successful in treating 77% of patients with moderate OSA. The appliance fits over all maxillary and mandibular teeth and is made of a special acrylic material (Bruxeze™) that softens in hot water to provide a combination of comfort, strength, and retention. This material has proven to be very durable. Expansion screws are located on the right and left buccal areas to allow maximum space for the tongue and easy anterior-posterior positioning of the mandible to achieve optimal effectiveness. This design permits ample lateral and protrusive movement to maintain jaw comfort.
The device uses a unique method of retention consisting of small projections of acrylic within the device that comfortably grip the undercut areas of two posterior teeth in each quadrant. Therefore, no metal clasps are necessary.
Elastomeric
Constructed in a dental laboratory, this device is made of a pliable, soft, custom-injected silicone and is tooth retained. There are no clasps or wires to adjust. The flexibility of the material lends itself to a high degree of patient comfort. The Elastomeric appliance is not protrusively adjustable. The vertical opening is five mm and the mandible is afforded some limited movement due to the high flexibility of the material.
The Elastometric has been proven effective by the University of Kentucky Medical Center Sleep Apnea Laboratory, and is recommended for partially edentulous patients and non-bruxers.
TRD - Tongue Retaining Device
The TRD is lab constructed of a flexible polyvinyl material adapted to the general contours of the teeth and dental arches. It does not depend on teeth for retention. Rather, the tongue is held forward by the negative pressure created in the vacuum bulb on the front of the appliance.
The appliance is available in four tongue extensions and with or without air way tubes for patients with compromised airway patency. It is constructed in conjunction with the Kel Gauge (described in another section of this program.)
Since the mandible is not rigidly or firmly held by the appliance, freedom of movement is possible during use. This would seem to make the TRD a good choice for the edentulous patient, the patient with periodontal disease and the patient with temporomandibular joint dysfunction.
There is ample research available documenting the effectiveness for treatment of snoring and OSA in certain patients.
The Remmers Sleep Recorder (RSR) is routinely utilized to monitor the effectiveness of the jaw position during trial procedures of the oral appliance. The RSR measures snoring, breathing, blood oxygen, heart rate, pulse, tooth grinding, body position and leg movements. Use of this device allows us to accurately set the oral appliance to the proper therapeutic jaw position prior to final assessment in the sleep lab.
Sleep and Breathing
During normal breathing, air passes through the nose and the flexible structures in the back of the throat, such as the soft palate, uvula and tongue. While you are awake, the muscles in these structures hold the airway open. When you fall asleep, these muscles normally relax but still hold the airway open, and healthy sleep can occur without disruption.
What Is Sleep-Disordered Breathing?
Sleep-disordered breathing is a term that means breathing is restricted due to the sleeping process itself. When the throat muscles relax during sleep, they collapse and prevent adequate breathing. This, in turn, disrupts sleep, creating a condition in which both sleep and breathing are dangerously affected.
When breathing and sleeping are disrupted night after night, adverse health consequences are more frequently seen, including high blood pressure, heart attack, stroke and diabetes.
Snoring and Obstructive Sleep Apnea
Snoring and obstructive sleep apnea are both considered sleep-disordered breathing events. Sleep Apnea is a treatable disorder in which a person stops breathing many times during the night. OSA is associated with serious health problems and a diminished quality of life. Snoring is a strong indication that OSA may be present.
Snoring is the sound of obstructed breathing during sleep. It occurs when
As air tries to pass through the partially collapsed airway, the throat structures vibrate causing the sound we know as snoring. Large tonsils, long soft palate and uvula, certain jaw formations, and excess fat deposits contribute to the collapsibility of the airway.
Sometimes the cause of snoring can be harmless, but generally it is a danger sign that indicates a serious problem which progresses from upper airway resistance syndrome (UARS) to Sleep Apnea.
Obstructive sleep apnea (OSA) occurs when the airway completely collapses during sleep and airflow stops entirely. Because no air can be drawn into the lungs, the oxygen level in the blood drops. Eventually, this signals the brain to partially awaken so that the sleeper can stimulate the throat muscles to open and clear the obstruction. This waking usually occurs with a loud gasp or choking sensation. Once the airway is open, breathing and sleep can resume. However, the relaxing influence of sleep affects the throat muscles as before and this process starts again, repeating throughout the night.
People with OSA experience disrupted sleep and periodic drops in oxygen levels each night. This is associated with cardiovascular disease and excessive daytime sleepiness. A condition known as upper airway resistance syndrome (UARS) lies midway between snoring and true OSA. People who suffer from UARS suffer many of the symptoms of OSA but do not really have OSA.
Everybody knows someone with diabetes or asthma, but did you know that obstructive sleep apnea (OSA) is as prevalent as these common problems?
People with obstructive sleep apnea (OSA) syndrome have high rates of motor vehicle crashes. This finding is based on crash records, as well as self-reporting and poor performance on driving simulators. Because traffic safety is under governmental regulation, there are legal implications for both private and commercial drivers if OSA is a significant cause of impaired driving.
In addition, recent research shows that accidents and injuries in the workplace are increased when workers suffer from fatigue and sleepiness from obstructive sleep apnea.
According to some researchers, the airway of pregnant women narrows in the last trimester of pregnancy. It has been found that if a woman has severe snoring or sleep apnea, the health of both the mother and the fetus can suffer. In pregnant women, blood pressure rises as the airway becomes narrower. Data indicates that pregnant snorers have an increased risk for preeclampsia.
Sleepy kids
Witnessed apneas occur in approximately 5% of children. Although obesity is a less important risk factor in children than adults, symptoms of sleep-disordered breathing occur two to three times as often as they do in non-obese children. Studies suggest that a minimum prevalence of obstructive sleep apnea (OSA) of 2 to 3% is likely, with prevalence as high as 10 to 20% in children who snore habitually. Daytime sleepiness is reported in 25 to 30% of children.
According to the American Sleep Apnea Association, children may present with hyperactivity, inattentiveness, aggressive behavior, irritability and mood swings. “OSA in children is a serious disorder that, untreated, may result in health problems as well as behavior and academic problems.”
Down Syndrome
It has been reported that the incidence of upper airway obstruction may be as high as 31% in children with Down Syndrome.
ADHD
A 2002 study found that children who frequently snore or have sleep disorders are almost twice as likely to suffer from ADHD as those who sleep well.
Tonsils and Adenoids
Large tonsils and adenoids are often responsible for snoring and sleep apnea in children. When large tonsils and adenoids are removed, the snoring and apnea resolves approximately 80% of the time.
Orthodontic Treatment
In many instances, snoring and sleep apnea in children can be caused by dento-facial abnormalities. Often, the upper airway can be widened through orthodontic expansion of the dental arches (a routine procedure done in most orthodontic offices).
Prevention
Some researchers suggest that breast-feeding serves to shape the dental arches in infants in a manner which increases the likelihood that the upper airway becomes adequately formed for proper breathing and sleeping. Conversely, many clinicians feel that most commercial pacifiers and thumb-sucking serve to cause malformation of the dental arches so as to increase the risk of snoring and obstructive sleep apnea.
How do you know if you have sleep-disordered breathing (SDB)? Take the simple test below,
This self-administered test measures daytime sleepiness, not specifically snoring or sleep apnea. However, if you or someone you know snores each night and is sleepy during the day, there is an increased likelihood that OSA is present.
Whether you take the test or not, be sure to visit your physician if you think you have a problem. The only way to know for certain whether you have OSA is to have a sleep test either at home from a qualified sleep physician or in a hospital sleep center. Feel free to print this test, fill it out and take with you to your physician.
Choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
A score of nine or above indicates you may be having a problem with daytime sleepiness, but a score below nine does not necessarily mean that you don't have a problem.
See your health care professional for advice if you snore, have been told that you awake gasping for breath, or if you feel sleepy during the day.
Night after night of improper sleep and breathing takes its toll on our quality of life. Signs may include:
Unfortunately, the effects of snoring and obstructive sleep apnea expand beyond the person with the problem. Anyone who has slept with a snoring partner knows it can disrupt his or her sleep as well. This “second-hand snoring” can cause the bed-partner to suffer the same daytime sleepiness problems that their partner experiences, which may lead to marital discord and adverse health consequences.
Sleep-disordered breathing (snoring and obstructive sleep apnea) can be managed in several ways:
Modification of certain behaviors can help reduce the tendency of snoring and obstructive sleep apnea (OSA), but generally does not cure the problem unless it is very mild. These modifications include weight loss, sleeping on your side instead of your back, avoiding alcohol and sedatives before bedtime, and eliminating smoking.
Considered the “gold standard,” continuous positive airway pressure (CPAP) or bi-level positive airway pressure (Bi-PAP) work very well to manage snoring and OSA in the vast majority of people. This treatment requires the use of an air compressor at bedside to deliver forced air into the nose via a nasal mask. Air pressure keeps the airway open while you sleep. However, the treatment is intrusive and cumbersome for many people, and therefore rejected in a significant number of cases.
Learn more about CPAP problems
There are several surgical options to treat snoring and OSA ranging from relatively simple to very invasive and complex. Depending on the severity of the problem and the type of surgery done, the results can vary from person to person. The process can be painful and expensive; however, when it is successful, surgery can provide a good solution to the problem.
Oral appliances have been used since the mid-1980’s to successfully manage snoring and OSA. Many scientific studies have been published that demonstrate the effectiveness of these appliances when utilized by experienced sleep-disorders dentists.
Oral appliances are small devices placed in the mouth, much like an orthodontic retainer or athletic mouth guard. They are utilized during sleep to prevent collapse of the tongue and soft tissues in the back of the throat so that the airway stays open during sleep. The appliances promote adequate air intake, helping to provide normal sleep for those who suffer from snoring and/or OSA. Oral appliances can be used alone or in combination with CPAP or after surgery.
Although oral appliances are effective for many people, they do not work for everyone. Recent research and official medical practice parameters indicate they are best utilized for mild to moderate conditions and whenever CPAP is not tolerated. Determination of proper therapy can only be made by joint consultation between your sleep-disorders dentist and your sleep physician.
Currently, more than 40 different appliance designs are available to specially trained dentists for this use. Read more about different types of Oral Appliances.
The first step in being treated for snoring or obstructive sleep apnea (OSA) is to obtain an evaluation by a sleep physician who will provide a formal diagnosis, usually based on a medical sleep study. Following diagnosis, an evaluation by a sleep-disorders dentist will determine whether you are a good candidate for oral appliance therapy and which appliance will be most effective.
The first dental appointment will involve a discussion of the problem, the advantages and limitations of oral appliance therapy in your case, the extent to which your insurance will cover the recommended procedures, and an oral examination including an X-ray of your teeth and jaw joint. If you choose to proceed with the therapy, a simple in-home baseline dental sleep study will be done initially to compare to a second study to be done once the appliance is thought to be effective.
After the selected appliance is created, you will return for a second appointment for a custom-fitting and instructions on use and care of the oral appliance. You will return for approximately two additional follow-up visits to monitor the effect of the appliance and to make any necessary adjustments. Effectiveness will judged by resolution of your symptoms (snoring and daytime sleepiness) and a second simple in-home dental sleep study.
When the snoring and tiredness have been resolved and the second in-home dental sleep study shows good improvement, you will be referred back to your sleep physician for final evaluation. Most often it will involve another medical sleep study.
Ultimately, you will be followed by Dr. Rogers on a twice per year basis to ensure adequate treatment to monitor any possible side effects.
Continuous Positive Airway Pressure (CPAP) is generally considered the mainstay of treatment for obstructive sleep apnea. However, in almost half of the cases where it is prescribed, it is poorly tolerated or simply rejected due to its unwieldy and intrusive nature.
Other objections include:
Now there is an effective way to control snoring and obstructive sleep apnea (OSA) without resorting to cumbersome CPAP devices. A small device, similar to an orthodontic appliance, can offer an alternative to CPAP machines. In some cases, oral appliance therapy may be the first choice for treatment of mild to moderate obstructive sleep apnea.
Oral Appliance Therapy
If you or a loved one snores or has had difficulty wearing his/her medically prescribed CPAP, Dr. Robert Rogers has had the years of experience necessary to offer a unique dental solution. Dr. Rogers is happy to consult with those who feel that they are having a problem with snoring or sleep apnea but have not been diagnosed and as well as those who are unable or unwilling to wear a CPAP unit. Dr. Rogers also works closely with other dentists in the tri-state area and with family physicians and sleep specialists.
Dr. Rogers will carefully follow and guide your progress throughout your treatment. You will be seen in the office several times to ensure acceptance, comfort, and effectiveness of the therapy. Instructions will be given on proper adjustment of the appliance and any areas of discomfort will be addressed.
The objective of your treatment is to resolve snoring and daytime tiredness through gently and gradually repositioning the lower jaw. Your personal feedback and two simple in-home dental sleep studies will provide guidance.
Your oral appliance is easy to care for. Each morning, simply brush it with a toothbrush and toothpaste. Rinse it well and allow it to sit in its case all day with the top open.
Be sure your oral appliance is high above the ground, out of the way, where no curious dogs can chew on it. Also avoid extremes of temperature—especially heat, which may cause the appliance to distort.
Twice each week, your appliance should be soaked for 15 minutes in the ultrasonic cleaning container using the cleanser tablets. This will disinfect and keep the appliance looking its best.
Examine your appliance frequently and call Dr. Rogers if you observe any broken areas.
Patients often find that they are unable to close their teeth completely in the morning immediately after removing the appliance. This is normal—it is caused by a temporary jaw joint change. Generally, this will resolve on its own within 10 or 20 minutes as the joint drifts back into its normal position.
After 20 minutes, jaw exercises are helpful to re-establish joint position and good tooth contact. This can be accomplished by clenching the teeth together and holding for several seconds and then releasing and then repeating the “clench/release” for a minute or so. Or, you may “clench/release” on the soft plastic exercise tabs that were provided to you.
Most of the side effects encountered during appliance use are minor and temporary. They include tenderness to teeth, muscles and joints. Dry mouth and increased salivation is also noticed frequently. In addition, teeth will not meet properly for 10 to 20 minutes after first removing the appliance after a night’s use (see “Exercises”). Dr. Rogers will work with you to manage these occurrences and minimize any problems.
It should be noted that in many cases, a permanent bite change will occur over the years due to a small, permanent change in jaw joint position and/or minor tooth movements due to the pressures placed by the appliance each night. It is critically important to keep up with twice yearly evaluation visits allowing Dr. Rogers to monitor any possible changes in your bite. They are most easily managed if discovered in the early stages.
Please feel free to call the office any time you have a concern that you feel needs personal attention by Dr. Rogers or his staff. For most instances, however, it is most convenient to email your concerns to us at rrrogers@pittsburghdentalsleepmedicine.com. We check emails often and will respond within 24 business hours or less. In this way, we can quickly and easily answer any questions or suggest you schedule an appointment to make an office visit.
The cost of therapy may vary slightly among patients, depending upon differing circumstances. Presently, most insurance companies are covering the majority of expenses for SDB treatment. Your personal out-of-pocket expenditures should be reasonable in most cases, but is subject to your insurance policy.
An accurate determination of total cost can only be made after evaluation/consultation with Dr. Rogers. Dr. Rogers has the necessary training and experience and uses appropriate therapeutic protocol to maximize your insurance coverage.